Information Notice 1996-66, Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators: Difference between revisions

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| issue date = 12/13/1996
| issue date = 12/13/1996
| title = Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators
| title = Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators
| author name = Cool D A
| author name = Cool D
| author affiliation = NRC/NMSS/IMNS
| author affiliation = NRC/NMSS/IMNS
| addressee name =  
| addressee name =  
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| page count = 15
| page count = 15
}}
}}
{{#Wiki_filter:UNITED STATES NUCLEAR REGULATORY
{{#Wiki_filter:UNITED STATES


COMMISSION
NUCLEAR REGULATORY COMMISSION


===OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS===
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C. 20555 December 13, 1996 NRC INFORMATION


NOTICE 96-66: RECENT MISADMINISTRATIONS
WASHINGTON, D.C. 20555 December 13, 1996 NRC INFORMATION NOTICE 96-66: RECENT MISADMINISTRATIONS CAUSED BY


CAUSED BY INCORRECT
INCORRECT CALIBRATIONS OF STRONTIUM-90
                                EYE APPLICATORS


CALIBRATIONS
==Addressees==
to use


OF STRONTIUM-90
All U.S. Nuclear Regulatory Commission Medical Use Licensees authorized


===EYE APPLICATORS===
strontium-90 (Sr-90) eye applicators.
 
==Purpose==
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information


==Addressees==
notice to alert addressees to recent misadministrations caused by incorrect    that
All U.S. Nuclear Regulatory


Commission
source strength determinations of Sr-90 eye applicators. It is expected


Medical Use Licensees
facilities


authorized
recipients will review the information    for applicability  to  their


to use strontium-90 (Sr-90) eye applicators.
and consider actions, as appropriate, to avoid similar problems. However, suggestions contained in this information notice are not NRC requirements;
therefore, no specific action nor written response is required.


==Purpose==
DescriDtion of Circumstances
The U.S. Nuclear Regulatory


Commission (NRC) is issuing this information
The primary causes of two recent events have been problems with calibration  the


notice to alert addressees
and calculation of the dose rates from Sr-90 applicators. As a result, administered doses were not  within  20 percent of  the prescribed  dose.


to recent misadministrations
to use


caused by incorrect source strength determinations
Case 1. In October 1995, during an inspection of a licensee authorized        the


of Sr-90 eye applicators.
a Sr-90 eye applicator in Mayag~ez, Puerto Rico, it was determined that A


It is expected that recipients
calibration record for the  licensee's  Sr-90 eye  applicator  was missing.


will review the information
and


for applicability
previous owner of the source lost the original calibration certificate,        This


to their facilities
his medical physics consultant performed a check of the source strength.  resulted


and consider actions, as appropriate, to avoid similar problems.
check was performed with an inappropriate measurement instrument and                   0
in an incorrect determination of the source strength as 0.24 Gray (Gy)/sec the


However, suggestions
(24 rad/sec). The licensee obtained the source in 1994 and relied on source


contained
erroneous source strength determination during treatments. Also, the


in this information
had not been decay-corrected by either owner since 1990. NRC urged the                  Fc2 licensee to have the eye applicator recalibrated and to be instructed in the


notice are not NRC requirements;
D
therefore, no specific action nor written response is required.DescriDtion


of Circumstances
proper method to calculate the decay of the source.


The primary causes of two recent events have been problems with calibration
National


and calculation
The licensee subsequently had the eye applicator recalibrated by the                a


of the dose rates from Sr-90 applicators.
Institute of Standards and Technology. The resultant recalibration revealed    used


As a result, the administered
dose rate of 0.53 Gray (53 rad)/sec rather than the 0.24 Gy (24 rad)/sec to


doses were not within 20 percent of the prescribed
10
  by the licensee. The licensee had prescribed a total dose of between


dose.Case 1. In October 1995, during an inspection
25 Gy (1000 to 2500 rad) for approximately


of a licensee authorized
9-0709036    f  arr&0                                C.        Ilt, 2a


to use a Sr-90 eye applicator
Dr


in Mayag~ez, Puerto Rico, it was determined
IN 96-66 December 13, 1996 70 patients, but actually administered about twice this amount. An NRC


that the calibration
medical consultant has reviewed the cases and has recommended that the


record for the licensee's
patients be evaluated for any adverse effects.


Sr-90 eye applicator
Case 2. In November 1995, while reviewing treatment records during a routine


was missing. A previous owner of the source lost the original calibration
NRC inspection of a licensee authorized to use a Sr-90 eye applicator in


certificate, and his medical physics consultant
Honolulu, Hawaii, an NRC inspector determined that the licensee had


performed
incorrectly calculated the decay of the strength of a Sr-90 eye applicator and


a check of the source strength.
subsequently delivered doses 20 percent over the prescribed doses to 16 patients. The root cause of this event was the licensee improperly


This check was performed
calculating the decay of the Sr-90 source. Specifically, the licensee


with an inappropriate
linearly decayed the strength of the source instead of logarithmically


measurement
decaying the source strength of the eye applicator. Before May 1995, a


instrument
technologist had correctly calculated the decay of the source; however, when


and resulted in an incorrect
this technologist left, the physician incorrectly calculated the source decay


determination
based on a linear decay from the previous calculations. In addition, the


of the source strength as 0.24 Gray (Gy)/sec 0 (24 rad/sec).
incorrect half-life of Sr-90 was used in the calculation.


The licensee obtained the source in 1994 and relied on the erroneous
Following a correct determination of the source strength, the licensee


source strength determination
determined that 17 misadministrations involving 16 patients occurred, from


during treatments.
May 6, 1995 to November 16, 1995, including one patient who was treated on


Also, the source had not been decay-corrected
both eyes. The delivered doses range from 21.1 to 22.7 percent greater than


by either owner since 1990. NRC urged the licensee to have the eye applicator
the prescribed dose of 40 Gy (4000 rad).


recalibrated
Discussion


and to be instructed
10 CFR 35.32, *Quality Management Program," requires licensees to develop


in the D Fc2 proper method to calculate
written procedures to meet five objectives associated with any brachytherapy


the decay of the source.The licensee subsequently
dose, including assurance that the prescribed dose is the administered dose.


had the eye applicator
A necessary part of this is to ensure that the dose rate emitted from an


recalibrated
applicator is correct. If the manufacturer's certificate of calibration or


by the National Institute
original activity/dose rate name plate is missing, the licensee should arrange


of Standards
with a qualified expert to determine the dose rate from the Sr-90 source.


and Technology.
(For additional details, see NRC IN 94-17, NSr-90 Eye Applicators: Submission


The resultant
of Quality Management Plan, Calibration and Use," dated March 11, 1994.)
Failure to implement the Quality Management Rule and make required reports may


recalibration
subject a licensee to orders, civil penalties, and notices of violation.


revealed a dose rate of 0.53 Gray (53 rad)/sec rather than the 0.24 Gy (24 rad)/sec used by the licensee.
In view of the nature of the cited events, it appears worthwhile to review


The licensee had prescribed
some of the properties of Sr-90 eye applicators and the related processes for


a total dose of between 10 to 25 Gy (1000 to 2500 rad) for approximately
decay correction over time. New Sr-90 eye applicators typically contain a


9-0709036 f arr&0 C. Dr Ilt, 2a
2 gigabecquerel (GBq) [54 millicurie(mCi)] source, exhibiting a surface dose


IN 96-66 December 13, 1996 70 patients, but actually administered
rate of about 0.50 Gy (50 rad)/sec. The half-life of the parent Sr-90 is


about twice this amount. An NRC medical consultant
28.5 yrs [maximum beta energy equal to 0.54 mega-electron volts (MeY)], and


has reviewed the cases and has recommended
the yttrium-90 (Y-90) daughter half-life is 64.2 hrs (beta-max, 2.27 MeV);
therefore, both isotopes are in equilibrium on the eye applicator. Since


that the patients be evaluated
Sr-90 and Y-90 are in equilibrium, emissions from both isotopes must be


for any adverse effects.Case 2. In November 1995, while reviewing
accounted for in dosimetry calculations.


treatment
IN 96-66 December 13, 1996 rate


records during a routine NRC inspection
The dose rate (D,) at a time (t) can be calculated from the initial dose


of a licensee authorized
(De) at the time of the most recent calibration with the following    formula:
D = D - (e-^t)                                                                  (FI)
                                                                                -Xt


to use a Sr-90 eye applicator
where e, the base of the natural logarithm (2.718), is raised to the powerT.  is


in Honolulu, Hawaii, an NRC inspector
and is referred to as the 'decay  factor' (df), where -X  - -0.693/Tx, the half-life of the isotope, and t is the elapsed time. For Sr-90, TX-28.5 can


determined
years; therefore, X - (0.693)/(28.5 yrs) = 0.0243 yr'. The values for df


that the licensee had incorrectly
after  t


calculated
be used to determine the fraction of original activity remaining


the decay of the strength of a Sr-90 eye applicator
years. These values can then be used to calculate dose rates by using the


and subsequently
following formula:
D,= Dao df                                                                    (F2)
The fraction of activity remaining after a given number of years from the


delivered
original measurement date is given in Table 1 (Attachment 1).


doses 20 percent over the prescribed
For example


doses to 16 patients.
An eye applicator calibrated by the manufacturer on January 1, 1978, If, delivered


The root cause of this event was the licensee improperly
on contact.        on


calculating
an initial dose rate ( Do) of 0.75 Gy/sec (75 rad/sec)
                                                                            (in


the decay of the Sr-90 source. Specifically, the licensee linearly decayed the strength of the source instead of logarithmically
January 1, 1996, the eye applicator needs to be used, the elapsed time


decaying the source strength of the eye applicator.
years) since calibration is 18, and from Table 1, df = 0.646 for Sr-90.


Before May 1995, a technologist
Using formula F2:
D,= bo. df


had correctly
D18yaM  - (0.75 Gy/sec)(0.646)
          bigyea  - 0.485 Gy/sec


calculated
(48.5 rad/sec)


the decay of the source; however, when this technologist
IN 96-66 December 13, 1996 Table I may be extended using formula F1 and the value X - 0.0243 yr' for


left, the physician
Sr-90. Other values of df that need to be evaluated by licensees will need to


incorrectly
be re-calculated by using the appropriate half-life for that isotope.


calculated
Alternatively, a semi-logarithmic plot of the above data will yield a straight


the source decay based on a linear decay from the previous calculations.
line, which may be extended beyond 25 years.


In addition, the incorrect
This information notice requires no specific action nor written response. If


half-life
you have any questions about the information in this notice, please contact


of Sr-90 was used in the calculation.
one of the technical contacts listed below or the appropriate regional office.


Following
Donald A. Cool, D rector


a correct determination
Division of Industrial and


of the source strength, the licensee determined
Medical Nuclear Safety


that 17 misadministrations
Office of Nuclear Material Safety


involving
and Safeguards


16 patients occurred, from May 6, 1995 to November 16, 1995, including
Technical contacts: Jose M. Diaz-Velez, RII


one patient who was treated on both eyes. The delivered
(404) 331-7438 E-mail: jxd2@nrc.gov


doses range from 21.1 to 22.7 percent greater than the prescribed
Emilio M. Garcia, RIV


dose of 40 Gy (4000 rad).Discussion
(510) 975-0239 E-mail: emg@nrc.gov


10 CFR 35.32, *Quality Management
James A. Smith, NMSS


Program," requires licensees
(301) 415-7904 E-mail: jas4@nrc.gov


to develop written procedures
Attachments:
1. List of Recently Issued NMSS Information Notices


to meet five objectives
2. List of Recently Issued NRC Information Notices


associated
42          T7SSI        (/4e


with any brachytherapy
Attachment I


dose, including
IN 96-66 December 13, 1996 Page 1 of I


assurance
TABLE 1 FRACTION (EXPRESSED AS DECIMAL) OF ORIGINAL


that the prescribed
SR-90 ACTIVITY REMAINING AFTER (t) YEARS


dose is the administered
df      Years  (t) df      Years  (t) df    Years    (t)  df


dose.A necessary
Years  (t)
          0.994    6.5        0.854    12.75      0.734  19            0.63
.25
                    6.75      0.849    13        0.729  19.25          0.626
.5        0.988
          0.982    7          0.844    13.25      0.725  19.5          0.623
.75
          0.976    7.25      0.838    13.5      0.72  19.75          0.619
1
          0.97    7.5        0.833    13.75      0.716  20            0.615
1.25
          0.964    7.75      0.828    14        0.712  20.25          0.611
1.5
          0.958    8          0.823    14.25      0.707  20.5          0.608
1.75
          0.953    8.25      0.818    14.5      0.703  20.75          0.604
2
          0.947    8.5        0.813    14.75      0.699  21            0.6
2.25
          0.941    8.75      0.808    15        0.695  21.25          0.597
2.5
          0.935    9          0.804    15.25      0.69  21.5            0.593
2.75
          0.93    9.25      0.799    15.5      0.686  21.75          0.589
3
          0.924    9.5        0.794    15.75      0.682  22              0.586
3.25
                    9.75      0.789    16        0.678  22.25          0.582
3.5        0.918
                    10        0.784  16.25      0.674  22.5            0.579
3.75      0.913
                    10.25      0.78    16.5      0.67  22.75          0.575
4          0.907
            0.902    10.5      0.775    16.75      0.666 23              0.572
4.25
            0.896    10.75      0.77    17        0.662 23.25          0.568
4.5
                    11        0.765    17.25      0.658  23.5          0.565
4.75      0.891
                    11.25      0.761    17.5      0.654  23.75          0.562
5          0.886
                    11.5      0.756    17.75      0.65  24            0.558
5.25      0.88
            0.875    11.75      0.752    18        0.646  24.25          0.555
5.5
            0.87    12        0.747    18.25      0.642  24.5          0.551
5.75
            0.864    12.25      0.743    18.5      0.638  24.75          0.548
6
            0.859    12.5      0.738    18.75      0.634  25            0.545
  6.25


part of this is to ensure that the dose rate emitted from an applicator
Attachment 2 IN 96-66 December 13, 1996 Page 1 of I


is correct. If the manufacturer's
UST OF RECENTLY ISSUED


certificate
NMSS INFORMATION NOTICES


of calibration
Information                                  Date of


or original activity/dose
Notice No.        Subject                    Issuance    Issued to


rate name plate is missing, the licensee should arrange with a qualified
96-63      Potential Safety Issue            12/05196    All U.S. Nuclear Regulatory


expert to determine
Regarding the Shipment                        Commission licensees


the dose rate from the Sr-90 source.(For additional
of Fissile Material                          authorized to possess special


details, see NRC IN 94-17, NSr-90 Eye Applicators:
nuclear material in unsealed
Submission


of Quality Management
quantities greater than a


Plan, Calibration
critical mass


and Use," dated March 11, 1994.)Failure to implement
96-57      Incident-Reporting Require-        10/30196  All U.S. Nuclear Regulatory


the Quality Management
ments Involving Intakes,                      Commission licensees


Rule and make required reports may subject a licensee to orders, civil penalties, and notices of violation.
During a 24-Hour Period


In view of the nature of the cited events, it appears worthwhile
that May Cause a Total


to review some of the properties
Effective Dose Equivalent


of Sr-90 eye applicators
in Excess of 0.05 Sv (5 rem)
96-54      Vulnerability of Stainless        10/17/96    All material licensees


and the related processes
Steel to Corrosion When


for decay correction
Sensitized


over time. New Sr-90 eye applicators
96-53      Retrofit to Amersham 660          10115/96    All industrial radiography


typically
Posilock Radiography                          licensees


contain a 2 gigabecquerel (GBq) [54 millicurie(mCi)]
Camera to Correct Incon- sistency in 10 CFR Part 34 Compatibility
source, exhibiting


a surface dose rate of about 0.50 Gy (50 rad)/sec.
96-52      Cracked Insertion Rods            09/26/96    All U.S. Nuclear Regulatory


The half-life
on Troxler Model 3400                        Commission portable gauge


of the parent Sr-90 is 28.5 yrs [maximum beta energy equal to 0.54 mega-electron
Series Portable Moisture                      licensees and vendors


volts (MeY)], and the yttrium-90 (Y-90) daughter half-life
Density Gauges


is 64.2 hrs (beta-max, 2.27 MeV);therefore, both isotopes are in equilibrium
96-51      Residual Contamination            09/11196    All material licensees


on the eye applicator.
Remaining in Krypton-85 Handling System After


Since Sr-90 and Y-90 are in equilibrium, emissions
Venting


from both isotopes must be accounted
' >
                                                                          Attachment 3 IN 96-66 December 13, 1996 Page 1 of I


for in dosimetry
UST OF RECENTLY ISSUED


calculations.
NRC INFORMATION NOTICES


IN 96-66 December 13, 1996 The dose rate (D,) at a time (t) can be calculated
Information                                          Date of


from the initial dose rate (De) at the time of the most recent calibration
Notice No.            Subject                        Issuance      Issued to


with the following
96-65            Undetected Accumulation            1211 1/96      All holders of OLs


formula: D = D -(e-^t) (FI)where e, the base of the natural logarithm
of Gas in Reactor Coolant                          or CPs for nuclear


(2.718), is raised to the power -Xt and is referred to as the 'decay factor' (df), where -X --0.693/Tx, T. is the half-life
System and Inaccurate                              power reactors


of the isotope, and t is the elapsed time. For Sr-90, TX-28.5 years; therefore, X -(0.693)/(28.5 yrs) = 0.0243 yr'. The values for df can be used to determine
Reactor Water Level


the fraction of original activity remaining
Indication During Shutdown


after t years. These values can then be used to calculate
96-64            Modifications to Con-                12/10196      All holders of OLs


dose rates by using the following
tainment Blowout Panels                            or CPs for nuclear


formula: D,= Dao df (F2)The fraction of activity remaining
Without Appropriate                                reactors


after a given number of years from the original measurement
Design Controls


date is given in Table 1 (Attachment
96-63              Potential Safety Issue              12/05196      All U.S. Nuclear


1).For example An eye applicator
Regarding the Shipment                            Regulatory Commission


calibrated
of Fissile Material                                licensees authorized


by the manufacturer
to possess special


on January 1, 1978, delivered an initial dose rate ( Do) of 0.75 Gy/sec (75 rad/sec) on contact. If, on January 1, 1996, the eye applicator
nuclear material in


needs to be used, the elapsed time (in years) since calibration
unsealed quantities


is 18, and from Table 1, df = 0.646 for Sr-90.Using formula F2: D, = bo. df D18yaM -(0.75 Gy/sec)(0.646)
greater than a critical
bigyea -0.485 Gy/sec (48.5 rad/sec)
IN 96-66 December 13, 1996 Table I may be extended using formula F1 and the value X -0.0243 yr' for Sr-90. Other values of df that need to be evaluated


by licensees
mass


will need to be re-calculated
96-62            Potential Failure of the            11120196      All holders of OLs


by using the appropriate
Instantaneous Trip Function                        and CPs for nuclear


half-life
of General Electric RMS-9                          power plants


for that isotope.Alternatively, a semi-logarithmic
Programmers


plot of the above data will yield a straight line, which may be extended beyond 25 years.This information
96-61            Failure of a Main Steam Safety      11/20/96      All holders of OLs or


notice requires no specific action nor written response.
Valve to Reseat Caused by an                      CPs for nuclear power


If you have any questions
Improperly Installed Release                    . reactors


about the information
Nut


in this notice, please contact one of the technical
96-60            Potential Common-Mode Post-        11/14/96      All holders of OLs or


contacts listed below or the appropriate
Accident Failure of Residual                        CPs for nuclear power


regional office.Donald A. Cool, D rector Division of Industrial
Heat Removal Heat Exchangers                        reactors


and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
OL = Operating License


Technical
CP = Construction Permit


contacts:
IN 96-66
Jose M. Diaz-Velez, RII (404) 331-7438 E-mail: jxd2@nrc.gov
                                                            .       December 13, 1996 Table 1 may be extended using formula FH and the value x - 0.0243 yr1 for


Emilio M. Garcia, RIV (510) 975-0239 E-mail: emg@nrc.gov
Sr-90. Other values of df that need to be evaluated by licensees will need to


James A. Smith, NMSS (301) 415-7904 E-mail: jas4@nrc.gov
be re-calculated by using the appropriate half-life for that isotope.


Attachments:
Alternatively, a semi-logarithmic plot of the above data will yield a straight
1. List of Recently Issued NMSS Information


Notices 2. List of Recently Issued NRC Information
line, which may be extended beyond 25 years.


Notices 42 T7SS I (/4e
This information notice requires no specific action nor written response. If


Attachment
you have any questions about the information in this notice, please contact


I IN 96-66 December 13, 1996 Page 1 of I TABLE 1 FRACTION (EXPRESSED
one of the technical contacts listed below or the appropriate regional office.


AS DECIMAL) OF ORIGINAL SR-90 ACTIVITY REMAINING
Donald A. Cool, Director


AFTER (t) YEARS Years (t) df Years (t) df Years (t) df Years (t) df.25 0.994 6.5 0.854 12.75 0.734 19 0.63.5 0.988 6.75 0.849 13 0.729 19.25 0.626.75 0.982 7 0.844 13.25 0.725 19.5 0.623 1 0.976 7.25 0.838 13.5 0.72 19.75 0.619 1.25 0.97 7.5 0.833 13.75 0.716 20 0.615 1.5 0.964 7.75 0.828 14 0.712 20.25 0.611 1.75 0.958 8 0.823 14.25 0.707 20.5 0.608 2 0.953 8.25 0.818 14.5 0.703 20.75 0.604 2.25 0.947 8.5 0.813 14.75 0.699 21 0.6 2.5 0.941 8.75 0.808 15 0.695 21.25 0.597 2.75 0.935 9 0.804 15.25 0.69 21.5 0.593 3 0.93 9.25 0.799 15.5 0.686 21.75 0.589 3.25 0.924 9.5 0.794 15.75 0.682 22 0.586 3.5 0.918 9.75 0.789 16 0.678 22.25 0.582 3.75 0.913 10 0.784 16.25 0.674 22.5 0.579 4 0.907 10.25 0.78 16.5 0.67 22.75 0.575 4.25 0.902 10.5 0.775 16.75 0.666 23 0.572 4.5 0.896 10.75 0.77 17 0.662 23.25 0.568 4.75 0.891 11 0.765 17.25 0.658 23.5 0.565 5 0.886 11.25 0.761 17.5 0.654 23.75 0.562 5.25 0.88 11.5 0.756 17.75 0.65 24 0.558 5.5 0.875 11.75 0.752 18 0.646 24.25 0.555 5.75 0.87 12 0.747 18.25 0.642 24.5 0.551 6 0.864 12.25 0.743 18.5 0.638 24.75 0.548 6.25 0.859 12.5 0.738 18.75 0.634 25 0.545 Attachment
Division of Industrial and


2 IN 96-66 December 13, 1996 Page 1 of I UST OF RECENTLY ISSUED NMSS INFORMATION
Medical Nuclear Safety


NOTICES Information
Office of Nuclear Material Safety


Date of Notice No. Subject Issuance Issued to 96-63 96-57 96-54 96-53 96-52 96-51 Potential
and Safeguards


Safety Issue Regarding
Technical contacts: Jose M. Diaz-Velez, RII


the Shipment of Fissile Material Incident-Reporting
(404) 331-7438 E-mail: jxd2@nrc.gov


Require-ments Involving
Emilio M. Garcia, RIV


Intakes, During a 24-Hour Period that May Cause a Total Effective
(510) 975-0239 E-mail: emg@nrc.gov


===Dose Equivalent===
James A. Smith, NMSS
in Excess of 0.05 Sv (5 rem)Vulnerability


of Stainless Steel to Corrosion
(301) 415-7904 E-mail: jas4enrc.gov


===When Sensitized===
Attachments:
Retrofit to Amersham 660 Posilock Radiography
1. List of Recently Issued NMSS Information Notices


Camera to Correct Incon-sistency in 10 CFR Part 34 Compatibility
2. List of Recently Issued NRC Information Notices


Cracked Insertion
Official Record Copy S:\Jsmith\imns5350.JAS


Rods on Troxler Model 3400 Series Portable Moisture Density Gauges Residual Contamination
OFC        IMAB  I E    IMAB  lIMAB          I      IMOB  I      Tech Ed I


Remaining
KANE      JASmith        SLMerchant    LWCamper o    JMPiccone o      EKraus o


in Krypton-85 Handling System After Venting 12/05196 10/30196 10/17/96 10115/96 09/26/96 09/11196 All U.S. Nuclear Regulatory
DATE  1  11/26/96        11/26/96    110/28/96         10/29/96         8/01/96 OFC    J        IJE        OGC    I      DD/IMNS I      D/IMNS    I


Commission
NAME    JLiebermano        SATreby o        FCCombso              DACool


licensees authorized
DATE      08/07/96          11/07/96          11/12/96 I          11/29/96
  - COWVER    E = COVER & Attachment N  -  NO COPY o- See Previous Concurrence


to possess special nuclear material in unsealed quantities
eIN 96-##
                                                      'J November        .1996 Table 1 may be extended using formula F1 and the value A = 0.0243 yr" for


greater than a critical mass All U.S. Nuclear Regulatory
Sr-90. Other values of df that need to be evaluated by licensees will need to


Commission
be re-calculated by using the appropriate half-life for that isotope.


licensees All material licensees All industrial
Alternatively, a semi-logarithmic plot of the above data will yield a straight


radiography
line, which may extended beyond 25 years.


licensees All U.S. Nuclear Regulatory
This information notice requires no specific action nor written response. If


Commission
you have any questions about the information in this notice, please contact


portable gauge licensees
one of the technical contacts listed below or the appropriate regional office.


and vendors All material licensees
Donald A. Cool, Director


' >Attachment
Division of Industrial and


3 IN 96-66 December 13, 1996 Page 1 of I UST OF RECENTLY ISSUED NRC INFORMATION
Medical Nuclear Safety


NOTICES Information
Office of Nuclear Material Safety


Date of Notice No. Subject Issuance Issued to 96-65 96-64 96-63 96-62 96-61 96-60 Undetected
and Safeguards


===Accumulation===
Contacts:    Jose M. Diaz-Velez, RII
of Gas in Reactor Coolant System and Inaccurate


Reactor Water Level Indication
(404) 331-7438 Internet: JXD2@NRC.GOV


During Shutdown Modifications
Emilio M. Garcia, RIV


to Con-tainment Blowout Panels Without Appropriate
(510) 975-0239 Internet: EMG@NRC.GOV


Design Controls Potential
James A. Smith, NMSS


Safety Issue Regarding
(301) 415-7904 Internet:JAS4@NRC.GOV


the Shipment of Fissile Material Potential
Attachments:
1. Table of decay factors


Failure of the Instantaneous
2. List of Recently Issue(d NMSS Information Notices


Trip Function of General Electric RMS-9 Programmers
3. List of Recently Issue(d NRC Information Notices


Failure of a Main Steam Safety Valve to Reseat Caused by an Improperly
fffirial Rernrd COnY Svisrnith\imns5350JAS


Installed
OFC      IMAB  lE    IMAB lIMAB            lIMOB                j  Tech Ed


Release Nut Potential
NAME      JASmi      SLM@f@I~nt    LWCamper o JMPiccone o            EKraus  @
  DATE    it /96            i            10/8/
                                        9      6      10/29/96          8/01/96 OFC        OE      I      OGC            DD/IMNS          DlIMNS


Common-Mode
NAME    JLieberman@      SATreby @        FCCombs@    _____    __  _    _l


Post-Accident Failure of Residual Heat Removal Heat Exchangers
DATE      08/07/96          11/07/96        11/12/96            ///t11/96
  = COVER    E = COVER & Attachment N = NO COPY ?--See Previous Concurrence


1211 1/96 12/10196 12/05196 11120196 11/20/96 11/14/96 All holders of OLs or CPs for nuclear power reactors All holders of OLs or CPs for nuclear reactors All U.S. Nuclear Regulatory
N 96-Il


Commission
-November 91996 This information notice requires no specific action nor written respons . If


licensees
you have any questions about the information in this notice, please c tact


authorized
one of the technical contacts listed below or the appropriate reglo 1 office.


to possess special nuclear material in unsealed quantities
Donald A. Cool, Director, Division of Industrial and


greater than a critical mass All holders of OLs and CPs for nuclear power plants All holders of OLs or CPs for nuclear power.reactors All holders of OLs or CPs for nuclear power reactors OL = Operating
Medical Nuclear Sa ty


License CP = Construction
Office of Nuclear terial Safety


Permit
and Safeguards


IN 96-66.December 13, 1996 Table 1 may be extended using formula FH and the value x -0.0243 yr 1 for Sr-90. Other values of df that need to be evaluated
Contacts:    Jose M. Diaz-Velez, RI


by licensees
(404) 331-7438 Internet: JXD2@NRC.GOV


will need to be re-calculated
Emilio M. Garcia, RIV


by using the appropriate
(510) 975-0239 Internet: EMG@NRC.GOV


half-life
James A. Smith, NMSS


for that isotope.Alternatively, a semi-logarithmic
(301) 415-7904 Internet:JAS4@NRC.GOV
 
Attachments:
1. Table of decay factors


plot of the above data will yield a straight line, which may be extended beyond 25 years.This information
2. List of Recently Issued NMS Information Notices


notice requires no specific action nor written response.
3. List of Recently Issued MR Information Notices


If you have any questions
Official Record Copy  5: \smitinins5350.JAS


about the information
OFC      IMAB I E IMAB//1S          IMAB I          IMOB I      Tech E


in this notice, please contact one of the technical
NAME      JASmithm SL erc nt        LWCamper o    JMPiccone a      EKraus o


contacts listed below or the appropriate
DATE    t//14/96            A/96    10/28/96        10/29/96        8/01/96 OFC        OE    l        OGC          DD/IMNS          D/IMNS


regional office.Donald A. Cool, Director Division of Industrial
NAME    JLiebermanq/      SATreby o      FCCombso              DACool


and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
DATE      08/07/9          11/07/96        11/12/96              / /96 C = COVER    E M OVER h Attachment N a NO COPY o- See Previous Concurrence


Technical
N 96-##
                                                                  ;.


contacts: Jose M. Diaz-Velez, RII (404) 331-7438 E-mail: jxd2@nrc.gov
a *-i                                                              ovember        .1996 D


Emilio M. Garcia, RIV (510) 975-0239 E-mail: emg@nrc.gov
18year    (0.75 Gy/sec)(0.646)
                "
              blyrs,      0G0.485  Gy/sec


James A. Smith, NMSS (301) 415-7904 E-mail: jas4enrc.gov
Table 1 may be extended using formula F1 and the value A 0.0243 yr-.


Attachments:
Alternatively, a semi-logarithmic plot of the above dat will yield a straight
1. List of Recently 2. List of Recently Issued NMSS Information


Notices Issued NRC Information
line, which may extended beyond 20 years.


Notices Official Record Copy S:\Jsmith\imns5350.JAS
This information notice requires no specific actio nor written response. If


OFC IMAB I E IMAB lIMAB I IMOB I Tech Ed I KANE JASmith SLMerchant
you have any questions about the information in t s notice, please contact


LWCamper o JMPiccone
one of the technical contacts listed below or t              appropriate regional office.


o EKraus o DATE 1 11/26/96 11/26/96 1 10/28/96 10/29/96 8/01/96 OFC J JE I OGC I DD/IMNS I D/IMNS I NAME JLiebermano
Donald . Cool. Director


SATreby o FCCombso DACool DATE 08/07/96 1 1/07/96 11/12/96 I 11/29/96-COWVER E = COVER & Attachment
Divis on of Industrial and


N -NO COPY o- See Previous Concurrence
M ical Nuclear Safety


eIN 96-##'J November .1996 Table 1 may be extended using formula F1 and the value A = 0.0243 yr" for Sr-90. Other values of df that need to be evaluated
Ofice of Nuclear Material Safety


by licensees
and Safeguards


will need to be re-calculated
Contacts:        Jose M. Diaz-Velez,
                  (404) 331-7438 Internet:JMD2@NRC. V


by using the appropriate
Emilio M. Garci    , RIV


half-life
(510) 975-0239/
                  Internet:EM      C.GOV


for that isotope.Alternatively, a semi-logarithmic
James A. S      ,thNMSS


plot of the above data will yield a straight line, which may extended beyond 25 years.This information
(301) 415- 904 Internet- AS4@NRC.GOV


notice requires no specific action nor written response.
Attachments:
  1. List of Recent y Issued NMSS Information Notices


If you have any questions
2. List of Rece ly Issued NRC Information Notices


about the information
Official Recordo S:\jsmith\imns5350.JAS


in this notice, please contact one of the technical
OFC


contacts listed below or the appropriate
NAME


regional office.Donald A. Cool, Director Division of Industrial
DATE    /
                IMA


and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
/1*196 E


Contacts: Jose M. Diaz-Velez, RII (404) 331-7438 Internet:
I IMAB
JXD2@NRC.GOV


Emilio M. Garcia, RIV (510) 975-0239 Internet:
le/6///96 ant
EMG@NRC.GOV


James A. Smith, NMSS (301) 415-7904 Internet:JAS4@NRC.GOV
jI    I


Attachments:
LWCamper o
1. Table of decay factors 2. List of Recently Issue(3. List of Recently Issue(fffirial Rernrd COnY Svisr d NMSS Information


Notices d NRC Information
10/28/96 II    MOB


Notices nith\imns5350JAS
JMPiccone


OFC IMAB lE IMAB lIMAB lIMOB j Tech Ed NAME JASmi SLM@f@I~nt
10/29/96
                                                                        @
                                                                                Techi Ed


LWCamper o JMPiccone
EKraus o


o EKraus @DATE it /96 i 10/8/ 9 6 10/29/96 8/01/96 OFC OE I OGC DD/IMNS DlIMNS NAME JLieberman@
8/01/96 OFC/      OE       I       OGC           DD/IMNS           D/IMNS l
SATreby @ FCCombs@ _____ __ _ _l DATE 08/07/96 11/07/96 11/12/96 ///t11/96= COVER E = COVER & Attachment


N = NO COPY ?--See Previous Concurrence
AM      JLiebermano          SATreby o        FCCombso                DACool


N 96-Il-N ovember 91996 This information
D0/07/96                        11/07/96        11/12/96                /  /96
      ,COVER E = COVER & Attachment N = NO COPY          @- See Previous Concurrence


notice requires no specific action nor written respons .If you have any questions
N 96-ft


about the information
<iovember                                            ,1996 D (0.75 Gy/sec)(0.646)
                    .0.485  Gy/sec


in this notice, please c tact one of the technical
1 Table 1 may be etended using formula F1 and the value X - 0.0243 yr .


contacts listed below or the appropriate
Alternatively, a mi-logarithmic plot of the above data will yield a straight


reglo 1 office.Donald A. Cool, Director, Division of Industrial
line, which may ext nded beyond 20 years.


and Medical Nuclear Sa ty Office of Nuclear terial Safety and Safeguards
This information noti      requires no specific action nor written response. If


Contacts:
you have any questions bout the information inthis notice, please contact
Jose M. Diaz-Velez, RI (404) 331-7438 Internet:
JXD2@NRC.GOV


Emilio M. Garcia, RIV (510) 975-0239 Internet:
(one of) the technical c tact(s) listed below or the appropriate regional
EMG@NRC.GOV


James A. Smith, NMSS (301) 415-7904 Internet:JAS4@NRC.GOV
office.


Attachments:
Donald A. Cool, Director
1. Table of decay factors 2. List of Recently Issued NMS Information


Notices 3. List of Recently Issued MR Information
Division of Industrial and


Notices Official Record Copy 5: \smitinins5350.JAS
Medical Nuclear Safety


OFC IMAB I E IMAB//1S IMAB I IMOB I Tech E NAME JASmithm SL e rc nt LWCamper o JMPiccone
Office of Nuclear Material Safety


a EKraus o DATE t/ /14/96 A/ 96 10/28/96 10/29/96 8/01/96 OFC OE l OGC DD/IMNS D/IMNS NAME JLiebermanq/
and Safeguards
SATreby o FCCombso DACool DATE 08/07/9 11/07/96 11/12/96 / /96 C = COVER E M OVER h Attachment


N a NO COPY o- See Previous Concurrence
Contacts:      Jose M. Diaz-Velez, RII


;. N 96-##a *-i ovember .1996 D 18year " (0.75 Gy/sec)(0.646)
(404) 331-7438 Internet:JMD2@NRC.GOY
blyrs, 0G 0.485 Gy/sec Table 1 may be extended using formula F1 and the value A 0.0243 yr-.Alternatively, a semi-logarithmic


plot of the above dat will yield a straight line, which may extended beyond 20 years.This information
Emilio M. Garcia, RIV


notice requires no specific actio nor written response.
(510) 975-0239 Internet:EMG@NRC.GOV


If you have any questions
James A. Smith, NMSS


about the information
(301) 415-7904 Internet:JAS4@NRC.GOV


in t s notice, please contact one of the technical
Attachments:
1. List of Recently Issued NMSS Information Notices


contacts listed below or t appropriate
2. List of Recently Issued NRC Information Notices


regional office.Donald .Cool. Director Divis on of Industrial
Official Record Copy S:\Jsmith\imns5350.JAS                        \
  OFC  qIMABiLW                B        IM4AB -          l


and M ical Nuclear Safety Ofice of Nuclear Material Safety and Safeguards
IMOB    E\Tech Ed


Contacts:
NAME      JASm1i        SL      chant  LWCamper a    JMPiccone c      EKraus o
Jose M. Diaz-Velez, (404) 331-7438 Internet:JMD2@NRC.


V Emilio M. Garci , RIV (510) 975-0239/Internet:EM
DATE  I  I 1/96 _        /      j      10/28/96      10/29/96        8/01/96 OFC        OE              OGC              DD/IMNS        D/IMNS


C.GOV James A. S ,th NMSS (301) 415- 904 Internet- AS4@NRC.GOV
NAME    JLiebermano        SATreby a          F(Cm                DACool


Attachments:
DATE      08/07/96            11/07/96                              /    /96 C a COVER      E a CUVLK & Attacnment    N  = mU LUr1'u- aee rrevmuUs IA0ICUIIrCLM.
1. List of Recent y Issued NMSS Information


Notices 2. List of Rece ly Issued NRC Information
,N96-##
'                  "-'-6ctober                                      ,1996 ble8..  - (0.75 Gy/sec)(0.646)
                  l 0.4  y/sec


Notices Official Recordo S:\jsmith\imns5350.JAS
Table 1 may be extended using fo ula F1 and the value X - 0.0243 yre.


OFC IMA E IMAB jI I I MOB I Tech Ed i NAME I ant LWCamper o JMPiccone
Alternatively, a semi-logarithmic lot of the above data will yield a straight


@ EKraus o DATE / /1196 le /6///96 10/28/96 10/29/96 8/01/96 OFC / OE I OGC DD/IMNS D/IMNS lAM JLiebermano
line, which may extended beyond 20 ars.


SATreby o FCCombso DACool D0/07/96 11/07/96 11/12/96 / /96 ,COVER E = COVER & Attachment
This information notice requires no sp ific action nor written response. If


N = NO COPY @- See Previous Concurrence
you have any questions about the infrma ion inthis notice, please contact


N 96-ft<iovember
(one of) the technical contact(s) listed elow or the appropriate regional


,1996 D (0.75 Gy/sec)(0.646)
office.
.0.485 Gy/sec Table 1 may be etended using formula F1 and the value X -0.0243 yr 1.Alternatively, a mi-logarithmic


plot of the above data will yield a straight line, which may ext nded beyond 20 years.This information
Donald A. -ool, Director


noti requires no specific action nor written response.
Division o Industrial and


If you have any questions
Medical Ntclear Safety


bout the information
Office of N clear Material Safety


in this notice, please contact (one of) the technical
and Safegu rds


c tact(s) listed below or the appropriate
Contacts:    Jose M. Diaz-Velez, RII


regional office.Donald A. Cool, Director Division of Industrial
(404) 331-7438 Internet:JMD2@NRC. GOY


and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
Emilio M. Garcia, RIV


Contacts:
(510) 975-0239 Internet:EMG@NRC.GOV
Jose M. Diaz-Velez, RII (404) 331-7438 Internet:JMD2@NRC.GOY


Emilio M. Garcia, RIV (510) 975-0239 Internet:EMG@NRC.GOV
James A. Smith, NMSS


James A. Smith, NMSS (301) 415-7904 Internet:JAS4@NRC.GOV
(301) 415-7904 Internet:JAS4@NRC .GOV


Attachments:
Attachments:
1. List of Recently Issued NMSS Information
1. List of Recently Issued NMSS Information Notices


Notices 2. List of Recently Issued NRC Information
2. List of Recently Issued NRC Information Notices


Notices Official Record Copy S:\Jsmith\imns5350.JAS
Official Record Copy S:\Jsmithi\mns5350.JAS                       \
  OFCIMAB                  AB            IMAB I      l IMOB    l    \l,TechEdl


\OFC qIMABiLW B IM4AB -IMOB l E\Tech Ed NAME JASm1 i SL chant LWCamper a JMPiccone
NAME     JASai R      SUM      nt    LWCamper a   JMPiccone o      EKraus o


c EKraus o DATE I I 1/96 _ / j 10/28/96 10/29/96 8/01/96 OFC OE OGC DD/IMNS D/IMNS NAME JLiebermano
DATE     /       -J/                   10/28/96     10/29/96       8/01/96 OFC       OE                             DD/IMNS         D/IMNS


SATreby a F (Cm DACool DATE 08/07/96 11/07/96 / /96 C a COVER E a CUVLK & Attacnment
KANE    JLiebermano        Sireb  NIL      FCCombs              DACool


N = mU LUr1'u- aee rrevmuUs IA0ICUIIrCLM.
DATE      08/07/96        l/ /1/96            / /96                / /96 aCOVER E a COVER & Attachment K = ND COPY o- See Previous Concurrence        \


,N 96-##' "-'-6ctober
C,6 I                                                      <  ~N96-#t


,1996 ble8.. -(0.75 Gy/sec)(0.646)
4 October    ,1996 We have Dlew. - (0.75 Gy/sec)(0.646)
l 0.4 y/sec Table 1 may be extended using fo ula F1 and the value X -0.0243 yre.Alternatively, a semi-logarithmic
    Table I may be extended using formula FH and the value X - 0.0243 yr1 .


lot of the above data will yield a straight line, which may extended beyond 20 ars.This information
Alternatively, a semi-icgarithmic plot of the above data will yield a straight


notice requires no sp ific action nor written response.
line, which may extended be~yond 20 years.


If you have any questions
This information notice requires no specific action nor written response. If


about the in frma ion in this notice, please contact (one of) the technical
you have any questions about the information in this notice, please contact


contact(s)  
(one of) the technical contact(s) listed below or the appropriate regional
listed elow or the appropriate


regional office.Donald A. -ool, Director Division o Industrial
office.


and Medical Ntclear Safety Office of N clear Material Safety and Safegu rds Contacts:
Donald A. Cool, Director
Jose M. Diaz-Velez, RII (404) 331-7438 Internet:JMD2@NRC.


GOY Emilio M. Garcia, RIV (510) 975-0239 Internet:EMG@NRC.GOV
Division of Industrial and


James A. Smith, NMSS (301) 415-7904 Internet:JAS4@NRC .GOV Attachments:
Medical Nuclear Safety
1. List of Recently Issued NMSS Information


Notices 2. List of Recently Issued NRC Information
Office cf Nuclear Material Safety


Notices Official Record Copy S:\Jsmithi\mns5350.JAS
and Safrguards


\OFC IMAB AB IMAB I l IMOB l \l,Tech EdlNAME JASai R SUM nt LWCamper a JMPiccone
Contacts:      Jose M. Diaz-Velez, RII


o EKraus o DATE / -J/ 10/28/96 10/29/96 8/01/96 OFC OE DD/IMNS D/IMNS KANE JLiebermano
(404) 331-7438 Internet:JMD2@NRC.60V


S ireb NIL FCCombs DACool DATE 08/07/96 l/ /1/96 / /96 / /96 aCOVER E a COVER & Attachment
Emilio M. Garcia, RIV


K = ND COPY o- See Previous Concurrence
(510) 975-0239 Internet:EMG@NRC.GOY


\
James A. Smith, NMSS
C, 6 I< ~N 96-#t 4 October ,1996 We have Dlew. -(0.75 Gy/sec)(0.646)
Table I may be extended using formula FH and the value X -0.0243 yr 1.Alternatively, a semi-icgarithmic


plot of the above data will yield a straight line, which may extended be~yond 20 years.This information
(301) 415-7904 Internet:JAS4@NRC.GOV


notice requires no specific action nor written response.
Attachments:
      1. List of Recently Issued NMSS Information Notices


If you have any questions
2. List of Recently Issued NRC Information Notices


about the information
Official Record CODY SA:smithkimtns535GJAS


in this notice, please contact (one of) the technical
OFC      IMAB      E    IMAB                                    Tech


contact(s)
NAME      JASmi        S    rchant    C rer            on        EKraus o
listed below or the appropriate


regional office.Donald A. Cool, Director Division of Industrial
DATE  It/1 /96              /96          96      /09 /96          8/01/96 OFC        OE    lOGC            lDD/IMNS l            D/IMNS  l~
      KANE  JLiebermano        SATreby        FCCombs              DACool


and Medical Nuclear Safety Office cf Nuclear Material and Safrguards
DATE    08/07/96              / /96        I /96                / /96
      :* COVER E a COVER & Attachment N    = NO COPY e- See Previous Concurrence


Safety Contacts: Jose M. Diaz-Velez, RII (404) 331-7438 Internet:JMD2@NRC.60V
A '
                                                                  IN 96-##
                                                                  August  ,1996 This informat n not1ce requires no specific action nor written response. If


Emilio M. Garcia, RIV (510) 975-0239 Internet:EMG@NRC.GOY
you have any qu tions about the information in this notice, please contact


James A. Smith, NMSS (301) 415-7904 Internet:JAS4@NRC.GOV
(one of) the techn cal contact(s) listed below or the appropriate regional


Attachments:
office.
1. List 2. List Official of Recently of Recently Record CODY Issued NMSS Information
 
Donald A. Cool, Director
 
Division of Industrial and
 
Medical Nuclear Safety


Notices Issued NRC Information
Office of Nuclear Material Safety


Notices SA:smithkimtns535GJAS
and Safeguards


OFC IMAB E IMAB Tech NAME JASmi S on rchant C rer EKraus o DATE It /1 /96 /96 96 /09 /96 8/01/96 OFC OE lOGC lDD/IMNS l D/IMNS l~KANE JLiebermano
Contacts:      Jose M. Diaz-Velez, RII


SATreby FCCombs DACool DATE 08/07/96 / /96 I /96 / /96:* COVER E a COVER & Attachment
(404) 331-7438 Emilio M. Garcia, RIV


N = NO COPY e- See Previous Concurrence
(510) 975-0239 James A. Smith, NMSS


A 'IN 96-##August ,1996 This informat n not1ce requires no specific action nor written response.
(301) 415-7904 Attachments:
    1. List of Recently Issued NMSS Information Notices


If you have any qu tions about the information
2. List of Recently Issued NRC Information Notices


in this notice, please contact (one of) the techn cal contact(s)  
Official Record Copy G:\imns5350.JAS ,                                 )
listed below or the appropriate
      OFC      IMABl      E                          IlTech


regional office.Donald A. Cool, Director Division of Industrial
OGC          Ed


and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
NAME        JASmi'W                per                  SATreby        EKraus a


Contacts:
DATE    *in /96        __  /________ \___96            / /96        8/01/96 OFC      \        IlI  DD/IMNS l          D/IMNS l
Jose M. Diaz-Velez, RII (404) 331-7438 Emilio M. Garcia, RIV (510) 975-0239 James A. Smith, NMSS (301) 415-7904 Attachments:
1. List of Recently Issued NMSS Information


Notices 2. List of Recently Issued NRC Information
NAME  Q jeerman            FCCombs          DACool


Notices Official Record Copy G:\imns5350.JAS , )OFC IMAB l E I OGC lTech Ed NAME JASmi'W per SATreby EKraus a DATE *in /96 __ /________
DATE   ___9_
\___96 / /96 8/01/96 OFC \ lI I DD/IMNS l D/IMNS lNAME Q jeerman FCCombs DACool DATE ___9_ / /96: w COVER 'E i. COVER & Attachment
    : w COVER


N = NO COPY o- See Previous Concurrence}}
/  /96
                  'E i. COVER & Attachment N   = NO COPY o- See Previous Concurrence}}


{{Information notice-Nav}}
{{Information notice-Nav}}

Latest revision as of 04:40, 24 November 2019

Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators
ML031050494
Person / Time
Site: Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant  Entergy icon.png
Issue date: 12/13/1996
From: Cool D
NRC/NMSS/IMNS
To:
References
IN-96-066, NUDOCS 9612090360
Download: ML031050494 (15)
v • d • e


UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 December 13, 1996 NRC INFORMATION NOTICE 96-66: RECENT MISADMINISTRATIONS CAUSED BY

INCORRECT CALIBRATIONS OF STRONTIUM-90

EYE APPLICATORS

Addressees

to use

All U.S. Nuclear Regulatory Commission Medical Use Licensees authorized

strontium-90 (Sr-90) eye applicators.

Purpose

The U.S. Nuclear Regulatory Commission (NRC) is issuing this information

notice to alert addressees to recent misadministrations caused by incorrect that

source strength determinations of Sr-90 eye applicators. It is expected

facilities

recipients will review the information for applicability to their

and consider actions, as appropriate, to avoid similar problems. However, suggestions contained in this information notice are not NRC requirements;

therefore, no specific action nor written response is required.

DescriDtion of Circumstances

The primary causes of two recent events have been problems with calibration the

and calculation of the dose rates from Sr-90 applicators. As a result, administered doses were not within 20 percent of the prescribed dose.

to use

Case 1. In October 1995, during an inspection of a licensee authorized the

a Sr-90 eye applicator in Mayag~ez, Puerto Rico, it was determined that A

calibration record for the licensee's Sr-90 eye applicator was missing.

and

previous owner of the source lost the original calibration certificate, This

his medical physics consultant performed a check of the source strength. resulted

check was performed with an inappropriate measurement instrument and 0

in an incorrect determination of the source strength as 0.24 Gray (Gy)/sec the

(24 rad/sec). The licensee obtained the source in 1994 and relied on source

erroneous source strength determination during treatments. Also, the

had not been decay-corrected by either owner since 1990. NRC urged the Fc2 licensee to have the eye applicator recalibrated and to be instructed in the

D

proper method to calculate the decay of the source.

National

The licensee subsequently had the eye applicator recalibrated by the a

Institute of Standards and Technology. The resultant recalibration revealed used

dose rate of 0.53 Gray (53 rad)/sec rather than the 0.24 Gy (24 rad)/sec to

10

by the licensee. The licensee had prescribed a total dose of between

25 Gy (1000 to 2500 rad) for approximately

9-0709036 f arr&0 C. Ilt, 2a

Dr

IN 96-66 December 13, 1996 70 patients, but actually administered about twice this amount. An NRC

medical consultant has reviewed the cases and has recommended that the

patients be evaluated for any adverse effects.

Case 2. In November 1995, while reviewing treatment records during a routine

NRC inspection of a licensee authorized to use a Sr-90 eye applicator in

Honolulu, Hawaii, an NRC inspector determined that the licensee had

incorrectly calculated the decay of the strength of a Sr-90 eye applicator and

subsequently delivered doses 20 percent over the prescribed doses to 16 patients. The root cause of this event was the licensee improperly

calculating the decay of the Sr-90 source. Specifically, the licensee

linearly decayed the strength of the source instead of logarithmically

decaying the source strength of the eye applicator. Before May 1995, a

technologist had correctly calculated the decay of the source; however, when

this technologist left, the physician incorrectly calculated the source decay

based on a linear decay from the previous calculations. In addition, the

incorrect half-life of Sr-90 was used in the calculation.

Following a correct determination of the source strength, the licensee

determined that 17 misadministrations involving 16 patients occurred, from

May 6, 1995 to November 16, 1995, including one patient who was treated on

both eyes. The delivered doses range from 21.1 to 22.7 percent greater than

the prescribed dose of 40 Gy (4000 rad).

Discussion

10 CFR 35.32, *Quality Management Program," requires licensees to develop

written procedures to meet five objectives associated with any brachytherapy

dose, including assurance that the prescribed dose is the administered dose.

A necessary part of this is to ensure that the dose rate emitted from an

applicator is correct. If the manufacturer's certificate of calibration or

original activity/dose rate name plate is missing, the licensee should arrange

with a qualified expert to determine the dose rate from the Sr-90 source.

(For additional details, see NRC IN 94-17, NSr-90 Eye Applicators: Submission

of Quality Management Plan, Calibration and Use," dated March 11, 1994.)

Failure to implement the Quality Management Rule and make required reports may

subject a licensee to orders, civil penalties, and notices of violation.

In view of the nature of the cited events, it appears worthwhile to review

some of the properties of Sr-90 eye applicators and the related processes for

decay correction over time. New Sr-90 eye applicators typically contain a

2 gigabecquerel (GBq) [54 millicurie(mCi)] source, exhibiting a surface dose

rate of about 0.50 Gy (50 rad)/sec. The half-life of the parent Sr-90 is

28.5 yrs [maximum beta energy equal to 0.54 mega-electron volts (MeY)], and

the yttrium-90 (Y-90) daughter half-life is 64.2 hrs (beta-max, 2.27 MeV);

therefore, both isotopes are in equilibrium on the eye applicator. Since

Sr-90 and Y-90 are in equilibrium, emissions from both isotopes must be

accounted for in dosimetry calculations.

IN 96-66 December 13, 1996 rate

The dose rate (D,) at a time (t) can be calculated from the initial dose

(De) at the time of the most recent calibration with the following formula:

D = D - (e-^t) (FI)

-Xt

where e, the base of the natural logarithm (2.718), is raised to the powerT. is

and is referred to as the 'decay factor' (df), where -X - -0.693/Tx, the half-life of the isotope, and t is the elapsed time. For Sr-90, TX-28.5 can

years; therefore, X - (0.693)/(28.5 yrs) = 0.0243 yr'. The values for df

after t

be used to determine the fraction of original activity remaining

years. These values can then be used to calculate dose rates by using the

following formula:

D,= Dao df (F2)

The fraction of activity remaining after a given number of years from the

original measurement date is given in Table 1 (Attachment 1).

For example

An eye applicator calibrated by the manufacturer on January 1, 1978, If, delivered

on contact. on

an initial dose rate ( Do) of 0.75 Gy/sec (75 rad/sec)

(in

January 1, 1996, the eye applicator needs to be used, the elapsed time

years) since calibration is 18, and from Table 1, df = 0.646 for Sr-90.

Using formula F2:

D,= bo. df

D18yaM - (0.75 Gy/sec)(0.646)

bigyea - 0.485 Gy/sec

(48.5 rad/sec)

IN 96-66 December 13, 1996 Table I may be extended using formula F1 and the value X - 0.0243 yr' for

Sr-90. Other values of df that need to be evaluated by licensees will need to

be re-calculated by using the appropriate half-life for that isotope.

Alternatively, a semi-logarithmic plot of the above data will yield a straight

line, which may be extended beyond 25 years.

This information notice requires no specific action nor written response. If

you have any questions about the information in this notice, please contact

one of the technical contacts listed below or the appropriate regional office.

Donald A. Cool, D rector

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 E-mail: jxd2@nrc.gov

Emilio M. Garcia, RIV

(510) 975-0239 E-mail: emg@nrc.gov

James A. Smith, NMSS

(301) 415-7904 E-mail: jas4@nrc.gov

Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

42 T7SSI (/4e

Attachment I

IN 96-66 December 13, 1996 Page 1 of I

TABLE 1 FRACTION (EXPRESSED AS DECIMAL) OF ORIGINAL

SR-90 ACTIVITY REMAINING AFTER (t) YEARS

df Years (t) df Years (t) df Years (t) df

Years (t)

0.994 6.5 0.854 12.75 0.734 19 0.63

.25

6.75 0.849 13 0.729 19.25 0.626

.5 0.988

0.982 7 0.844 13.25 0.725 19.5 0.623

.75

0.976 7.25 0.838 13.5 0.72 19.75 0.619

1

0.97 7.5 0.833 13.75 0.716 20 0.615

1.25

0.964 7.75 0.828 14 0.712 20.25 0.611

1.5

0.958 8 0.823 14.25 0.707 20.5 0.608

1.75

0.953 8.25 0.818 14.5 0.703 20.75 0.604

2

0.947 8.5 0.813 14.75 0.699 21 0.6

2.25

0.941 8.75 0.808 15 0.695 21.25 0.597

2.5

0.935 9 0.804 15.25 0.69 21.5 0.593

2.75

0.93 9.25 0.799 15.5 0.686 21.75 0.589

3

0.924 9.5 0.794 15.75 0.682 22 0.586

3.25

9.75 0.789 16 0.678 22.25 0.582

3.5 0.918

10 0.784 16.25 0.674 22.5 0.579

3.75 0.913

10.25 0.78 16.5 0.67 22.75 0.575

4 0.907

0.902 10.5 0.775 16.75 0.666 23 0.572

4.25

0.896 10.75 0.77 17 0.662 23.25 0.568

4.5

11 0.765 17.25 0.658 23.5 0.565

4.75 0.891

11.25 0.761 17.5 0.654 23.75 0.562

5 0.886

11.5 0.756 17.75 0.65 24 0.558

5.25 0.88

0.875 11.75 0.752 18 0.646 24.25 0.555

5.5

0.87 12 0.747 18.25 0.642 24.5 0.551

5.75

0.864 12.25 0.743 18.5 0.638 24.75 0.548

6

0.859 12.5 0.738 18.75 0.634 25 0.545

6.25

Attachment 2 IN 96-66 December 13, 1996 Page 1 of I

UST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

96-63 Potential Safety Issue 12/05196 All U.S. Nuclear Regulatory

Regarding the Shipment Commission licensees

of Fissile Material authorized to possess special

nuclear material in unsealed

quantities greater than a

critical mass

96-57 Incident-Reporting Require- 10/30196 All U.S. Nuclear Regulatory

ments Involving Intakes, Commission licensees

During a 24-Hour Period

that May Cause a Total

Effective Dose Equivalent

in Excess of 0.05 Sv (5 rem)

96-54 Vulnerability of Stainless 10/17/96 All material licensees

Steel to Corrosion When

Sensitized

96-53 Retrofit to Amersham 660 10115/96 All industrial radiography

Posilock Radiography licensees

Camera to Correct Incon- sistency in 10 CFR Part 34 Compatibility

96-52 Cracked Insertion Rods 09/26/96 All U.S. Nuclear Regulatory

on Troxler Model 3400 Commission portable gauge

Series Portable Moisture licensees and vendors

Density Gauges

96-51 Residual Contamination 09/11196 All material licensees

Remaining in Krypton-85 Handling System After

Venting

' >

Attachment 3 IN 96-66 December 13, 1996 Page 1 of I

UST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

96-65 Undetected Accumulation 1211 1/96 All holders of OLs

of Gas in Reactor Coolant or CPs for nuclear

System and Inaccurate power reactors

Reactor Water Level

Indication During Shutdown

96-64 Modifications to Con- 12/10196 All holders of OLs

tainment Blowout Panels or CPs for nuclear

Without Appropriate reactors

Design Controls

96-63 Potential Safety Issue 12/05196 All U.S. Nuclear

Regarding the Shipment Regulatory Commission

of Fissile Material licensees authorized

to possess special

nuclear material in

unsealed quantities

greater than a critical

mass

96-62 Potential Failure of the 11120196 All holders of OLs

Instantaneous Trip Function and CPs for nuclear

of General Electric RMS-9 power plants

Programmers

96-61 Failure of a Main Steam Safety 11/20/96 All holders of OLs or

Valve to Reseat Caused by an CPs for nuclear power

Improperly Installed Release . reactors

Nut

96-60 Potential Common-Mode Post- 11/14/96 All holders of OLs or

Accident Failure of Residual CPs for nuclear power

Heat Removal Heat Exchangers reactors

OL = Operating License

CP = Construction Permit

IN 96-66

. December 13, 1996 Table 1 may be extended using formula FH and the value x - 0.0243 yr1 for

Sr-90. Other values of df that need to be evaluated by licensees will need to

be re-calculated by using the appropriate half-life for that isotope.

Alternatively, a semi-logarithmic plot of the above data will yield a straight

line, which may be extended beyond 25 years.

This information notice requires no specific action nor written response. If

you have any questions about the information in this notice, please contact

one of the technical contacts listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 E-mail: jxd2@nrc.gov

Emilio M. Garcia, RIV

(510) 975-0239 E-mail: emg@nrc.gov

James A. Smith, NMSS

(301) 415-7904 E-mail: jas4enrc.gov

Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Official Record Copy S:\Jsmith\imns5350.JAS

OFC IMAB I E IMAB lIMAB I IMOB I Tech Ed I

KANE JASmith SLMerchant LWCamper o JMPiccone o EKraus o

DATE 1 11/26/96 11/26/96 110/28/96 10/29/96 8/01/96 OFC J IJE OGC I DD/IMNS I D/IMNS I

NAME JLiebermano SATreby o FCCombso DACool

DATE 08/07/96 11/07/96 11/12/96 I 11/29/96

- COWVER E = COVER & Attachment N - NO COPY o- See Previous Concurrence

eIN 96-##

'J November .1996 Table 1 may be extended using formula F1 and the value A = 0.0243 yr" for

Sr-90. Other values of df that need to be evaluated by licensees will need to

be re-calculated by using the appropriate half-life for that isotope.

Alternatively, a semi-logarithmic plot of the above data will yield a straight

line, which may extended beyond 25 years.

This information notice requires no specific action nor written response. If

you have any questions about the information in this notice, please contact

one of the technical contacts listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 Internet: JXD2@NRC.GOV

Emilio M. Garcia, RIV

(510) 975-0239 Internet: EMG@NRC.GOV

James A. Smith, NMSS

(301) 415-7904 Internet:JAS4@NRC.GOV

Attachments:

1. Table of decay factors

2. List of Recently Issue(d NMSS Information Notices

3. List of Recently Issue(d NRC Information Notices

fffirial Rernrd COnY Svisrnith\imns5350JAS

OFC IMAB lE IMAB lIMAB lIMOB j Tech Ed

NAME JASmi SLM@f@I~nt LWCamper o JMPiccone o EKraus @

DATE it /96 i 10/8/

9 6 10/29/96 8/01/96 OFC OE I OGC DD/IMNS DlIMNS

NAME JLieberman@ SATreby @ FCCombs@ _____ __ _ _l

DATE 08/07/96 11/07/96 11/12/96 ///t11/96

= COVER E = COVER & Attachment N = NO COPY ?--See Previous Concurrence

N 96-Il

-November 91996 This information notice requires no specific action nor written respons . If

you have any questions about the information in this notice, please c tact

one of the technical contacts listed below or the appropriate reglo 1 office.

Donald A. Cool, Director, Division of Industrial and

Medical Nuclear Sa ty

Office of Nuclear terial Safety

and Safeguards

Contacts: Jose M. Diaz-Velez, RI

(404) 331-7438 Internet: JXD2@NRC.GOV

Emilio M. Garcia, RIV

(510) 975-0239 Internet: EMG@NRC.GOV

James A. Smith, NMSS

(301) 415-7904 Internet:JAS4@NRC.GOV

Attachments:

1. Table of decay factors

2. List of Recently Issued NMS Information Notices

3. List of Recently Issued MR Information Notices

Official Record Copy 5: \smitinins5350.JAS

OFC IMAB I E IMAB//1S IMAB I IMOB I Tech E

NAME JASmithm SL erc nt LWCamper o JMPiccone a EKraus o

DATE t//14/96 A/96 10/28/96 10/29/96 8/01/96 OFC OE l OGC DD/IMNS D/IMNS

NAME JLiebermanq/ SATreby o FCCombso DACool

DATE 08/07/9 11/07/96 11/12/96 / /96 C = COVER E M OVER h Attachment N a NO COPY o- See Previous Concurrence

N 96-##

.

a *-i ovember .1996 D

18year (0.75 Gy/sec)(0.646)

"

blyrs, 0G0.485 Gy/sec

Table 1 may be extended using formula F1 and the value A 0.0243 yr-.

Alternatively, a semi-logarithmic plot of the above dat will yield a straight

line, which may extended beyond 20 years.

This information notice requires no specific actio nor written response. If

you have any questions about the information in t s notice, please contact

one of the technical contacts listed below or t appropriate regional office.

Donald . Cool. Director

Divis on of Industrial and

M ical Nuclear Safety

Ofice of Nuclear Material Safety

and Safeguards

Contacts: Jose M. Diaz-Velez,

(404) 331-7438 Internet:JMD2@NRC. V

Emilio M. Garci , RIV

(510) 975-0239/

Internet:EM C.GOV

James A. S ,thNMSS

(301) 415- 904 Internet- AS4@NRC.GOV

Attachments:

1. List of Recent y Issued NMSS Information Notices

2. List of Rece ly Issued NRC Information Notices

Official Recordo S:\jsmith\imns5350.JAS

OFC

NAME

DATE /

IMA

/1*196 E

I IMAB

le/6///96 ant

jI I

LWCamper o

10/28/96 II MOB

JMPiccone

10/29/96

@

Techi Ed

EKraus o

8/01/96 OFC/ OE I OGC DD/IMNS D/IMNS l

AM JLiebermano SATreby o FCCombso DACool

D0/07/96 11/07/96 11/12/96 / /96

,COVER E = COVER & Attachment N = NO COPY @- See Previous Concurrence

N 96-ft

<iovember ,1996 D (0.75 Gy/sec)(0.646)

.0.485 Gy/sec

1 Table 1 may be etended using formula F1 and the value X - 0.0243 yr .

Alternatively, a mi-logarithmic plot of the above data will yield a straight

line, which may ext nded beyond 20 years.

This information noti requires no specific action nor written response. If

you have any questions bout the information inthis notice, please contact

(one of) the technical c tact(s) listed below or the appropriate regional

office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 Internet:JMD2@NRC.GOY

Emilio M. Garcia, RIV

(510) 975-0239 Internet:EMG@NRC.GOV

James A. Smith, NMSS

(301) 415-7904 Internet:JAS4@NRC.GOV

Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Official Record Copy S:\Jsmith\imns5350.JAS \

OFC qIMABiLW B IM4AB - l

IMOB E\Tech Ed

NAME JASm1i SL chant LWCamper a JMPiccone c EKraus o

DATE I I 1/96 _ / j 10/28/96 10/29/96 8/01/96 OFC OE OGC DD/IMNS D/IMNS

NAME JLiebermano SATreby a F(Cm DACool

DATE 08/07/96 11/07/96 / /96 C a COVER E a CUVLK & Attacnment N = mU LUr1'u- aee rrevmuUs IA0ICUIIrCLM.

,N96-##

' "-'-6ctober ,1996 ble8.. - (0.75 Gy/sec)(0.646)

l 0.4 y/sec

Table 1 may be extended using fo ula F1 and the value X - 0.0243 yre.

Alternatively, a semi-logarithmic lot of the above data will yield a straight

line, which may extended beyond 20 ars.

This information notice requires no sp ific action nor written response. If

you have any questions about the infrma ion inthis notice, please contact

(one of) the technical contact(s) listed elow or the appropriate regional

office.

Donald A. -ool, Director

Division o Industrial and

Medical Ntclear Safety

Office of N clear Material Safety

and Safegu rds

Contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 Internet:JMD2@NRC. GOY

Emilio M. Garcia, RIV

(510) 975-0239 Internet:EMG@NRC.GOV

James A. Smith, NMSS

(301) 415-7904 Internet:JAS4@NRC .GOV

Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Official Record Copy S:\Jsmithi\mns5350.JAS \

OFCIMAB AB IMAB I l IMOB l \l,TechEdl

NAME JASai R SUM nt LWCamper a JMPiccone o EKraus o

DATE / -J/ 10/28/96 10/29/96 8/01/96 OFC OE DD/IMNS D/IMNS

KANE JLiebermano Sireb NIL FCCombs DACool

DATE 08/07/96 l/ /1/96 / /96 / /96 aCOVER E a COVER & Attachment K = ND COPY o- See Previous Concurrence \

C,6 I < ~N96-#t

4 October ,1996 We have Dlew. - (0.75 Gy/sec)(0.646)

Table I may be extended using formula FH and the value X - 0.0243 yr1 .

Alternatively, a semi-icgarithmic plot of the above data will yield a straight

line, which may extended be~yond 20 years.

This information notice requires no specific action nor written response. If

you have any questions about the information in this notice, please contact

(one of) the technical contact(s) listed below or the appropriate regional

office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office cf Nuclear Material Safety

and Safrguards

Contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 Internet:JMD2@NRC.60V

Emilio M. Garcia, RIV

(510) 975-0239 Internet:EMG@NRC.GOY

James A. Smith, NMSS

(301) 415-7904 Internet:JAS4@NRC.GOV

Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Official Record CODY SA:smithkimtns535GJAS

OFC IMAB E IMAB Tech

NAME JASmi S rchant C rer on EKraus o

DATE It/1 /96 /96 96 /09 /96 8/01/96 OFC OE lOGC lDD/IMNS l D/IMNS l~

KANE JLiebermano SATreby FCCombs DACool

DATE 08/07/96 / /96 I /96 / /96

  • COVER E a COVER & Attachment N = NO COPY e- See Previous Concurrence

A '

IN 96-##

August ,1996 This informat n not1ce requires no specific action nor written response. If

you have any qu tions about the information in this notice, please contact

(one of) the techn cal contact(s) listed below or the appropriate regional

office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Contacts: Jose M. Diaz-Velez, RII

(404) 331-7438 Emilio M. Garcia, RIV

(510) 975-0239 James A. Smith, NMSS

(301) 415-7904 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Official Record Copy G:\imns5350.JAS , )

OFC IMABl E IlTech

OGC Ed

NAME JASmi'W per SATreby EKraus a

DATE *in /96 __ /________ \___96 / /96 8/01/96 OFC \ IlI DD/IMNS l D/IMNS l

NAME Q jeerman FCCombs DACool

DATE ___9_

w COVER

/ /96

'E i. COVER & Attachment N = NO COPY o- See Previous Concurrence


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