ML20004A062
| ML20004A062 | |
| Person / Time | |
|---|---|
| Site: | 07002032 |
| Issue date: | 03/06/1981 |
| From: | Eckert D, Mark Miller, Soyugenc M WELBORN MEMORIAL BAPTIST HOSP., EVANSVILLE, IN |
| To: | Fisher W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20004A059 | List: |
| References | |
| NUDOCS 8105110633 | |
| Download: ML20004A062 (6) | |
Text
.-'
lfyCIs
/
~ LQJ
/
W6lDOfn 4ot 6 cath 6tect cete hdcno4770. (em 426 8o00 bcptrd<npbl March 6, 1981 M
United States Nuclear Regulatory Commission MV/
Region III 799 Roosevelt Road Glen Ellyn, IL 60137 ATTENTION:
W.
L.
FISHER, ACTING CHIEF FUEL FACILITY & MATERIALS SAFETY BRANCH
Dear Mr. Fisher:
This is in response to your letter received on February 12, 1981, regarding our recent NRC inspection.
Welborn Baptist Hospital, License No. 13-01674-01 VIOLATIONS 1.
Item 10 of the application states the procedures in Appendix D, Section 2 in regulatory guide 10.8 will be used for calibration of the dose calibrator.
Section 2 of Appendix D requires linearity, accuracy and geometrical variation checks upon installation of the dose calibrator.
Violation:- Contrary to the above requirement, it was determined through statements of licensee representatives and review of records that this requirement was not met.
Specifically, linearity, accuracy and geometrical variation checks were not performed on your Capintec dose calibrator received on December 15, 1980.
Corrective Action:
A.
The following tests were performed on January 26, 1981.
Instrument linearity Geometrical variation Instrument accuracy All three tests showed that the Caninte: CRC-30 was functioning properly.
8105110 8 MAR 2 61981 j
x~
u_m z
.n
.a__
-. - - ~
a B.
. Instrument linearity test will be performed quarterly.
Geometrical variation test - completed (Janua ry 26,. 1981) d Instrument accuracy test at installation.(completed January 26,-1981) and annually as outlined in Appendix D, Section 2 in regulatory.
C.
In compliance as of January 26, 1981.
2.
Item 15 of the application states each dose will be assayed prior to administration.
4 Violation:
Contrary to the above requirement,.it was determined
.through the NRC inspectors' observation that this condition is not being met.
Specifically on the date i
of the inspection, a technologist on several o,ccasions failed to perform a dose assay prior to patients administration.
I Corrective Action:
A.
It has been a routine practice in our department to assay all doses prior to ' administering to patients.
On the day of the inspection, the technologist working in the hot lab became very nervous when she was being observed by the inspectors and forgot to assay the doses before leaving the area.
The incident was discussed with the technologist and'the error has not been-repeated.
B.
Periodic inservices will be held with all technologists to reinforce all NRC requirements.
C.
As of January 20, 1981.
3.
10 CFR 35.14 (e) (1) (i) requires each license who possesses sealed sources as calibration or ference sources shall cause each scaled source to be tested for leakage and/or contamination at intervals not to exceed six months.
Violation:
Contrary to the above requirement, it was determined through the NRC inspectors' review of leak test records that this requirement is not being met.
Specifically, records indicate leak test were not performed from October 11, 1978, to the date of this inspection on 224 uCi, Cs-137 and 283 uCi Ba-133 sealed calibration sources.
Corrective Action:
A.
Wipe tests were performed on the following sealed sources to check for contamination, January 20, 1981.
Cs-137 224 uCi Ba-133 283 uCi Co-57 350 uCi B.
Wipe tests will be performed every six mo ths as of January 20, 1981, on sealed sources used for calibration.
A record of when the leak i
tests were performed and the results will be kept in the nuclear medicine department.
n-
C,.
As of January 20, 1981.
4.
10 CFR 3 5.14 (f ) (2 ) regaires each license who possesser and uses calibration and reference cources shall conduct a quarterly physical inventory to account for all sources received and possessed.
Violation:
Cont.-a:/ to the above requirement, it was determined through s ta ten.ents of licensee representatives that this is not being met.
Specifically, physical inventories were not performed from 1spril 12, 1977, to the date of this inspection.
Correc tive Action:
A.
A complete inventory of all scaled sources was done on February 26, 1931.
B.
Quarterly inventory will be performed on all scaled sources that are not being used for calibration.
A record of the sealed source and the date of inspection will be kept in the nuclear medicine department.
C.
As of Jan;ary 26, 1931.
During the inspection, a comment was made by Mr. Wiedeman regarding our surveys performed in the hot lab.
We were measuring different areas in the hot lab daily with a cutie pie survey meter.
lie felt this was not the best way tc check for contamination since other radioactive materials in the immediate areas could mask any contamination that cc 21d be present, v;c are now performing wipe tests weekly in the hot lab and counting them in the well counter to check for contamination.
Readings less than 100 dp:r/em2 wi] 1 be conc.2 derou background.
If you have any questions regarding this letter, please feel free to contact us.
Sincerely,
.,r e, d t' db0' 'Wh/T j.
~
Dennis Eckert, NMT Supervisor Nuclear Medicine EM/ T SL hm Dr. Marshall Miller V
Director of Muclear Medicine I have reviewed the above information subnitted to NRC and I hereby verify that this inforration is accurate.
W w.)
'f W Marjorie Z #
Associate Director Welborn Baptis enc,tal spi STATE OF INDIANA
)
7M., ; -r
, 9 9, My Camission/,Exp, ires:
) SS:
Resident of t
,/;,(,,7,L Count 9 VANDERRTXII ODUIEY
)
>o SUBSCRIBED AND STRN to before nn, a Notary Public in and for said County and State, this a d day of turch,1981.
-%, e, dd_,,7. f/ a, J.:
Notary Public
/
f a e,g
,n
.on,
WebOfn 401 SE 6ixth 6treet EvomdcIndono 47/O - (8G 42t>8000 boGidhcyld March 6, 1981 United States Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137 ATTENTION:
W.
L. FISHER, ACTING CHIEF FUEL FACILITY & MATERIALS SAFETY BRANCH
Dear Mr. Fisher:
This is in response to your letter received on February 12, 1981, regarding our recent NRC inspection.
Welborn Baptist Hospital, License No. 13-01674-01 VIOLATIONS 1.
Item 10 of the application states the procedures in Appendix D, Section 2 in regulatory guide 10.8 will be used for calibration of the dose calibrator.
Section 2 of Appendix D requires linearity, accuracy and geometrical variation checks upcn installation of the dose calibrator.
Violation:
Contrary to the above requirement, it was determined through statements of licensee representatives and review of records that this requirement was not met.
Specifically, linearity, accuracy and geometrical variation checks were not performed on your Capintec dose calibrator received on December 15, 1980.
Corrective Action:
A.
The following tests were performed on January 26, 1981.
Instrument linearity Geometrical variation Instrument accuracy All three tests showed that the Capintec CRC-30 was functioning properly.
MMR 12 G81 B.
Instrument linearity test will be performed quarterly.
Geometrical variation test - completed (January 26, 1981)
Instrument accuracy test at installation (completed JanJary 26, 1981) and annually as outlined in Appendix D, Section 2 in regulatory.
C.
In compliance as of January 26, 1981.
2.
Item 15 of the application states each dose will be assayed prior to administration.
Violation:. contrary to the above requirement, it was determined through the NRC inspectors' observation that this condition is not being met.
Specifically on the date-of the inspection, a technologist on several occasions failed to perform a dose assay prior to patients administration.
Corrective Action:
A.
It has been a routine practice in our department to assay all doses prior to administering to patients.
On the day of the inspection, the technologist working in the hot lab became very nervous when she was being observed _by the inspectors and forgot to assay the doses before leaving the area.
The incident was discussed with the technologist and the error has not been repeated.
B.
Periodic inservices will be held with all technologists to reinforce all NRC requirements.
C.
As of January 20, 1981.
3.
10 CFR 35.14 (e) (1) (i) requires each license who possesses sealed sources as calibration or ference sources shall cause each sealed source to be tested for leakage and/or contamination at intervals not to exceed six months.
Violation:
Contrary to the above requirement, it was determined through the NRC inspectors' review of leak test records that this requirement is not being met.
Specifically, records indicate leak test were not performed from l
October 11, 1978, to the date of this inspection on 224 uCi, Cs-137 and 283 uCi Ba-133 sealed calibration sources.
Corrective Action:
A.
Wipe tests were performed on the following sealed sources to check for contamination, January 20, 1981.
Cs-137 224 uCi Ba-133 283 uCi Co-57 350 uCi B.
Wipe tests will be performed every six months as of January 20, 1981, on sealed sources used for calibration.
A record of when the leak l
tests were performed and the results will be kept in the nuclear i
medicine departnent.
i
=.
- C.
As of January 20, 1981.
s 4.
10 CFR 35.14 (f) (2) requires each license who possesses and uses calibration and reference sources shall conduct a quarterly physical inventory to account for all sources received and possessed.
' Violation:
Contrary to the above requirement, it was determined through statements of licensee r,aesentatives that this is not being met.
Specifically, physical inventories were not performed from April -12, 1977, to the date of this inspection.
Corrective Action:
A.
A complete inventory of all sealed sources was done on February 26, 1981.
B.
Quarterly inventory will be performed on all sealed sources that are not being used for calibration.
A record of the sealed source and the date of inspection will be kept in the nuclear medicine department.
C.
As of January 26, 1981.
I During the inspection, a comment was made by Mr. Wiedeman regarding our surveys performed in the hot lab.
We were measuring different areas in the hot lab daily with a cutie pie survey meter.
He felt this was not the best way to check for contamination since other radioactive materials in the immediate areas could mask any contamination that could be present.
We are now performing wipe tests weekly in the het lab and counting them in the well counter to check for contamination.
Readings less than 100 dpm/cm2 will be considered background.
If you have any questions regarding this letter, please feel free to 4
Contact us.
Sincerely, muh hkttY WT Dennis Eckert, NMT Supervisor Nuclear Medicine Y~
T k
lI ll}
l Dr. M'arshall Miller Director of Nuclear' Medicine MM vudrao v
Marjorie Soyugenc Associate Director Welborn Baptist Hospital i
bo