ML18067A175
| ML18067A175 | |
| Person / Time | |
|---|---|
| Site: | 03013426 |
| Issue date: | 02/22/2018 |
| From: | Honeycutt R Providence Alaska Medical Ctr |
| To: | Document Control Desk, NRC Region 4 |
| References | |
| EA-17-182 IR 2017001 | |
| Download: ML18067A175 (4) | |
Text
February 22, 2018 Attention:
U.S. Nuclear Regulatory Commission Address: ATTN: Document Control Desk Washington, D.C. 20555-0001
Subject:
Reply to a Notice of Violation; EA-17-182
Dear Mr. Morris,
I DENCE Health & Services Alaska RECEIVED Vi~R o s 10,~ DNMS Providence Alaska Medical Center is in receipt of your letter dated February 2, 2018 that cites a violation of NRC requirements identified during a special inspection conducted June 27-30, 2017. The purpose of this letter is to provide the NRC with proper response to the requirement pursuant to the provisions of 10 CFR 2.201 that a written statement or explanation be provided to the U.S. Nuclear Regulatory Commission within 30 days of receipt of the notice of violation.
Providence Alaska Medical Center continues to be extremely committed to cooperating in all aspects of the NRC review, including addressing any errors or violations that the NRC may identify.
As such, we are taking the results of our recent review seriously and have taken appropriate actions necessary to address the deficiency noted by the NRC. We have reviewed the Notice of Violation and we are currently cited for a Severity Level IV violation of NRC requirements:
failing to have our Radiation Safety Committee meet quarterly during 2016. In fact, our committee only met twice that calendar year out of the minimum four meetings as required by NRC licensing.
Providence Alaska Medical Center's Response to required parameters of response:
(1) The reason for the violation, or, if contested, the basis for disputing the violation or severity level The root cause for this violation was that, although the next quarterly meeting date was suggested in the previous meeting minutes, when it was time to schedule the quarterly meeting the members of the committee found that schedule conflicts presented.
Efforts were made to accommodate scheduling conflicts as to achieve a quorum, however, the meeting ultimately did not occur in the first and third quarter of 2016. Per the Radiation Safety Committee Charter (attachment A), the committee will meet at least once in each calendar quarter and maintain written records.
I DENCE Health & Services Alaska (2) The corrective steps that have been taken and the results achieved
- a. The Radiation Safety Committee will set meetings on the Outlook calendar and will meet regardless of if it is determined that a quorum will be met or not in advance of the meeting. b. It was established that the Radiation Safety Committee would report out meeting minutes, on a quarterly basis, to the larger PAMC Environment of Care Committee.
- c. The Radiation Safety Committee has subsequently met quarterly since the initial NRC review in July 2017. (3) The corrective steps that will be taken Providence Alaska Medical Center recognizes the importance of the quarterly meetings of the Radiation Safety Committee and will require that these meetings occur as required by the NRC. Furthermore, the Radiation Safety Committee will report quarterly minutes to the PAM C Environment of Care Committee to assure meeting are occurring as required.
To date, all corrective actions in regard to this violation have been implemented. ( 4) The date when full compliance will be achieved PAM C has already fulfilled steps to improve compliance and have been in compliance with the requirement since July 2017. Providence Alaska Medical Center respectfully requests that the NRC consider our responses above the required parameters as satisfactorily addressing the concern raised in the Notice of Violation.
Si~~ M/) Robert Honeycutt, COO~ Chief Operating Officer Providence Alaska Medical Center Anchorage, AK. CC: Mr. Scott A Morris United States Nuclear Regulatory Commission Region IV 1600 East Lamar Boulevard Arlington, TX 76011-4511 ATTACHMENT A Page3 Radiation Safety Committee Responsibility The Radiation Safety Committee
(" the Committee"}
oversees the use of radiation and radioactive material throughout the institution.
The Committee ensures that radioactive material is used safely and in accordance with applicable federal, state, and local regulations.
Authority The Committee has the authority to review and regulate all use of radioactive material.
The Committee evaluates the training and experience of users of radioactive material and the approval of the Committee must be obtained for all new uses and new users of radioactive material.
Membership The Committee shall include:
- the Radiation Safety Officer
- an authorized user of each type of radioactive material use permitted by the license
- a representative of management, who is neither an authorized user nor the RSO.
- a representative of the nursing service A quorum shall consist of three members, including the RSO or alternate, and the management representative or alternate.
Duties The Committee shall:
- Be familiar with the requirements of the regulations and of the license.
- Review the training and experience of radioactive material users.
- Review all new proposed uses of radioactive material.
- Establish precautions to be required for all new uses of radioactive material.
- Establish training programs to satisfy the requirements of and the license.
- Review the Radiation Protection Program annually in accordance with the ALARA Program, and make recommendations for corrective action when deficiencies are discovered.
The Committee has other specific duties under the ALARA program. (See ALARA.}
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- Meet at least once in each calendar quarter and maintain written records of meetings and correspondence.
- Review radiation exposure reports at each meeting.