[Federal Register Volume 63, Number 90 (Monday, May 11, 1998)]
[Notices]
[Pages 25880-25883]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-12390]


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NUCLEAR REGULATORY COMMISSION


Report to Congress on Abnormal Occurrences Fiscal Year 1997 
Dissemination of Information

    Section 208 of the Energy Reorganization Act of 1974 (Pub. L. 93-
438) identifies an abnormal occurrence (AO) as an unscheduled incident 
or event that the Nuclear Regulatory Commission (NRC) determines to be 
significant from the standpoint of public health or safety. The Federal 
Reports Elimination and Sunset Act of 1995 (Pub. L. 104-66) requires 
that AOs be reported to Congress on an annual basis. During fiscal-year 
1997, six events that occurred at facilities licensed or otherwise 
regulated by the NRC and the Agreement States were determined to be 
AOs. These events are discussed below. As required by Section 208, the 
discussion for each event includes the date and place, the nature and 
probable consequences, the cause or causes, and the action taken to 
prevent recurrence. Each event is also being described in NUREG-0090, 
Vol. 20, ``Report to Congress on Abnormal Occurrences, Fiscal Year 
1997.'' This report will be available at NRC's Public Document Room, 
2120 L Street N.W. (Lower Level), Washington, D.C., about three weeks 
after the publication date of this Federal Register Notice.
97-1  Loss of Two of Three High Pressure Injection Pumps at Oconee 
Nuclear Station Unit 3
    One of the AO reporting criteria notes that a major deficiency in 
design, construction, control, or operation having significant safety 
implications requiring immediate remedial action can be considered an 
AO.
    Date and Place--May 3, 1997; Oconee Unit 3, a pressurized water 
nuclear reactor plant designed by Babcock and Wilcox Company, operated 
by the Duke Energy Corporation (formerly known as Duke Power Company), 
and located about 8 miles north of Clemson, South Carolina.
    Nature and Probable Consequences--On May 3, 1997, the Oconee Unit 3 
reactor was shut down and the reactor coolant system (RCS) was being 
cooled down for inspection of the high pressure injection (HPI) 
discharge piping. The need for the inspection resulted from RCS leakage 
from a weld crack in the HPI makeup piping on Unit 2. Reactor pressure 
was approximately 270 psig, RCS temperature was approximately 205 deg. 
F, one reactor coolant pump (RCP) was running, and the Low Pressure 
Injection System was being used to cool down the RCS. Makeup water to 
the RCS to compensate for the temperature decrease was being supplied 
from the letdown storage tank (LDST) by one of the three HPI pumps. 
Makeup to the LDST consisted of periodic batch additions as needed. 
These plant conditions were below the point where the technical 
specifications required that the HPI system must be operable; that is, 
required to mitigate a small-break loss-of-coolant accident.
    Plant cool-down evolutions appeared to be normal until the ``B'' 
HPI pump started to cavitate and makeup flow to the reactor coolant 
system was lost. A RCP seal water (which is also supplied by the HPI 
pump) low-flow signal automatically started the ``A'' HPI pump. 
However, it also began to cavitate. (The third HPI pump is not designed 
to automatically start on this signal and remained in the standby 
condition.) The operators stopped both pumps and began troubleshooting 
the problem. A Notification of Unusual Event was declared when it was 
recognized that the pumps would be inoperable past the shift that was 
on duty. Unit 3 pressure and temperature were stabilized and there was 
no immediate concern that conditions would worsen.
    Later investigations revealed that the potential for a more serious 
situation existed if there had been a small break loss-of-coolant 
accident, which is the design basis for the HPI system, prior to this 
event. If such an accident had occurred, all three of the HPI pumps 
would have automatically started and become inoperable very quickly. In 
addition, the pumps may have become air bound and unavailable when the 
pump suction was transferred to the Borated Water Storage Tank to 
inject into the RCS. This would have significantly complicated recovery 
from the accident, but would have been within the Emergency Operating 
Procedure guidance and training provided to the operators. It would, 
however, increase the probability of core damage. The length of time 
that Unit 3 was in this degraded status could not be accurately 
determined, but the condition may have existed since start-up in March 
1997, when plant conditions required that the HPI system be operable.
    Cause or Causes--Loss of the HPI pumps occurred when all of the 
water was inadvertently pumped from the LDST because of faulty level 
indication. The erroneous level indication was caused by the loss of 
approximately one-half of the water in the level detector reference leg 
because of a slight leak in the instrument fitting. This loss of the 
reference leg water caused the tank level instrument to indicate a 
water level higher than the actual level, a condition that may have 
existed since February 1997, the last time the reference leg was 
verified to be full. It also caused the loss of the low-level alarm. As 
a result of these conditions, the operators did not provide makeup 
water to the tank when it was needed, resulting in the HPI pump 
continuing to run until the tank was empty. The LDST level detection 
system consists of two level instruments connected to a common 
reference leg. Thus, the condition affected both level detectors 
equally.
    In addition, the control room operators did not properly monitor 
and detect the inaccurate LDST level indications. They did not notice 
that for a short period of time the indicated level stopped decreasing 
and continuously showed the tank to be approximately half-full at the 
same time water was being pumped from the tank.

Actions Taken to Prevent Recurrence

    Licensee--Corrective actions included (1) the addition of a second 
reference leg to the LDST to provide separate level indications, (2) 
enhanced operator training and procedures, and (3) the performance of 
an HPI System Reliability Study that is to be completed by December 31, 
1997.

[[Page 25881]]

    NRC--Escalated enforcement, which incorporated this issue, resulted 
in the determination that a Severity Level II violation existed, and 
the licensee was assessed a $330,000 civil penalty. Information Notice 
97-38, ``Level-Sensing System Initiates Common-Mode Failure of High-
Pressure-Injection Pumps,'' was issued on June 24, 1997, to alert other 
licensees to this event.
    This event is closed for the purpose of this report.
* * * * *

Other NRC Licensees--(Industrial Radiographers, Medical 
Institutions, Industrial Users, etc.)

97-2  Overexposure of a Worker at Mallinckrodt, Inc., in Maryland 
Heights, Missouri
    One of the AO criteria notes that any unintended radiation exposure 
to an adult (any individual 18 years of age or older) resulting in an 
annual shallow-dose equivalent to the skin or extremities of 2500 mSv 
(250 rem) or more will be considered for reporting as an AO.
    Date and Place--May 14-15, 1997; Mallinckrodt, Inc.; Maryland 
Heights, Missouri.
    Nature and Probable Consequences--On May 14, 1997, an employee was 
removing radioactive waste from the hot cell where rhenium-186 (Re-186) 
was used. The employee was performing this task manually, using gloves, 
instead of remotely. When he left the area, he attempted to perform a 
personal contamination survey but the survey meter immediately went off 
the scale. He assumed that the high count rate was due to background 
radiation from an adjacent radioactive material transport cart and, 
subsequently, forgot to resurvey himself in a low background area 
before he left the facility that evening. Upon arrival at work the next 
day, he was told that his urine sample, which he had submitted before 
going home the previous night, indicated iodine-131 (I-131) radiation 
contamination and that he was restricted from working with radioactive 
material. At that time, he performed a personal contamination survey 
and detected significant levels of contamination on his left thumb 
which subsequently was identified as Re-186. The I-131 contamination 
level did not exceed the AO criteria for exposure to radiation from 
licensed material.
    The licensee estimates that the individual received a shallow-dose 
equivalent of 6090 millisievert (609 rem) to an area of about 0.75 
square centimeters (0.12 square inches) on the palm side of the thumb 
of his left hand. Lower levels of contamination were found on the back 
of his right hand and fingers. On May 15, 1997, the employee had 
undergone decontamination to the extent that only approximately 4 
percent of the activity remained.
    The licensee surveyed the offsite locations where the employee had 
been after leaving work on May 14, 1997. Low levels of Re-186 
contamination were found on three locations inside the employee's 
vehicle and on various items in the bathroom and kitchen of his home. 
The employee's vehicle and home were decontaminated. The employee was 
examined by a physician who identified no immediate health effects. 
However, according to a report from an NRC consultant, a small 
possibility exists for skin cancer to develop in the exposed area of 
the thumb.
    Cause or Causes--The cause of the event was a procedural deficiency 
in handling waste from the Re-186 hot cell. Normally, radioactive waste 
in other hot cells at the facility was handled with remote tools. 
However, in this case, procedural controls did not require remote 
handling of the waste. Once the employee completed the work, poor 
radiation work practices were exhibited as he cross-contaminated his 
hands when he removed his gloves. In addition, the worker did not 
investigate the detection of high count rates during his first attempt 
to perform a contamination survey.

Actions Taken to Prevent Recurrence

    Licensee--The staff was instructed on the importance of conducting 
proper personal contamination surveys and the proper use of protective 
clothing. The use of Re-186 was suspended until improvements to 
existing waste disposal procedures could be evaluated and implemented. 
Plans were made (1) to compile all existing contamination protection 
procedures into one contamination protection procedure, (2) to evaluate 
the use of a portal type monitoring system, and (3) to post personal-
monitoring reminder signs at all laboratory exits.
    NRC--NRC conducted a special safety inspection, proposed a $55,000 
civil penalty on December 17, 1997, and the licensee paid the civil 
penalty on January 20, 1998.
    This event is closed for the purpose of this report.
* * * * *
Agreement State Licensees
AS 97-1  Multiple Transuranic Overexposures to a Worker at Isotope 
Products Laboratories in Burbank, California
    One of the AO criteria notes that any unintended radiation exposure 
to an adult (any individual 18 years of age or older) resulting in an 
annual total effective dose equivalent (TEDE) of 250 millisievert (mSv) 
(25 rem) or more; or an annual sum of the deep dose equivalent (DDE) 
(external dose) and committed dose equivalent (CDE) (intake of 
radioactive material) to any individual organ or tissue other than the 
lens of the eye, bone marrow, and the gonads of 2500 mSv (250 rem) or 
more will be considered for reporting as an AO. In addition, another AO 
criterion states that a serious deficiency in management or procedural 
controls in major areas will be considered for reporting as an AO.
    Date and Place--Between January 1 and December 31, 1995; Isotope 
Products Laboratories; Burbank, California.
    Nature and Probable Consequences--A radiochemist was assigned to 
make transuranic and other types of sources. The transuranics utilized 
included the isotopes of plutonium-238 (Pu-238), Pu-239, Pu-240, 
americium-241 (Am-241), and curium-244 (Cm-244). During January 1995, 
while making a Cm-244 source, it was discovered that the exhaust fan of 
the fume hood where the source was being fabricated was not working. An 
analysis of room air samples confirmed the loss of Cm-244 into the 
working area.
    Bioassay results disclosed that the fecal and urine samples 
provided by the radiochemist contained Cm-244 and Am-241. The licensee 
hired dosimetry and radiation protection consultants as directed by the 
State Agency. Careful analysis of the bioassay data by these 
consultants, which included dose summation and retrospective time 
correction for various intakes, suggested that during 1995 the 
radiochemist received a TEDE of 383.20 mSv (38.32 rem) and a CDE of 
6900 mSv (690 rem) to the bone surfaces. The specific exposures were as 
follows: (1) committed effective dose equivalent (CEDE) of 271.8 mSv 
(27.18 rem) from Cm-244, (2) CEDE of 80 mSv (8 rem) from Am-241, (3) 
CEDE of 4.4 mSv (0.44 rem) from Pu-238, Pu-239, and Pu-240, and (4) DDE 
of 27.0 mSv (2.70 rem) from external radiation.
    The State Agency discovered this incident during a routine 
inspection on December 5, 1995, and was initially reported to NRC in 
January 1996. During

[[Page 25882]]

a follow-up inspection, the State Agency learned that another Cm-244 
incident took place and was significant. The State Agency also learned 
of other exposure incidents that indicated the licensee had a deficient 
contamination control program, an inability to conduct internal dose 
assessments, and inadequate management oversight. The State provided 
additional information on these events to NRC in 1997.
    Cause or Causes--The licensee's radiation protection program was 
inadequate and lacked important elements needed to ensure the radiation 
safety of its workers. Some of these inadequacies were the lack of (1) 
work permits, (2) glove boxes for certain types of work, and (3) 
radiation procedural controls.

Actions Taken To Prevent Recurrence

    Licensee--After the licensee's consultants conducted their review 
and comprehensive audit of the existing radiation protection program, 
they made recommendations to ensure future compliance with the license 
and regulations. The licensee hired a competent radiation safety 
officer, and the radiochemist was assigned duties that did not involve 
the handling or processing of radioactive materials.
    State Agency--The State Agency completed its investigation and is 
committed to closely tracking the licensee's radiation protection 
program to ensure continued compliance.
    This event is closed for the purpose of this report.
* * * * *
AS 97-2  Overexposure of a Radiographer and an Untrained Technician at 
Wolf Creek Mine in Walker County, Alabama
    One of the AO criteria notes that any unintended radiation exposure 
to an adult (any individual 18 years of age or older) resulting in an 
annual total effective dose equivalent (TEDE) of 250 millisievert (mSv) 
(25 rem) or more; or an annual sum of the deep dose equivalent (DDE) 
(external dose) and committed dose equivalent (CDE) (intake of 
radioactive material) to any individual organ or tissue other than the 
lens of the eye, bone marrow, and the gonads of 2500 mSv (250 rem) or 
more will be considered for reporting as an AO. In addition, another AO 
criterion states that a serious deficiency in management or procedural 
controls in major areas will be considered for reporting as an AO.
    Date and Place--July 1, 1996; Wolf Creek Mine, Walker County, 
Alabama.
    Nature and Probable Consequences--A radiographer, employed by 
Certified Testing and Inspection of Cottondale, Alabama, and a 
technician, employed by Ultron, Inc., of Mt. Vernon, Illinois, were 
performing industrial radiography at the Wolf Creek Mine in Walker 
County, Alabama, when they became so distracted by problems with 
excessively exposed film that they forgot they had an exposure in 
progress and entered the high radiation area without making a survey 
and changed the film with the source in the unshielded exposed 
position. The radiographer had received prior radiation safety 
training, however, the technician, an employee of Ultron, Inc., had not 
received prior radiation safety training. The radiography film and the 
device used to support the source and the film during exposures were 
being supplied to the radiographer by Ultron, Inc.
    Consequently, both individuals received unintended radiation 
exposure. The State Agency estimated that the radiographer received a 
dose of 530 millisievert (mSv) (53 rem) to his head and 48 mSv (4.8 
rem) to the center of his body and the Ultron, Inc., technician 
received a dose of 110 mSv (11 rem) to his head and 28 mSv (2.8 rem) to 
the center of his body. Neither individual reported any acute radiation 
symptoms.
    The radiography film supplied by Ultron, Inc., had faster and 
different exposure characteristics than the film usually used by 
Certified Testing and thus was being overexposed during processing in 
the darkroom. The darkroom, which was supplied by Certified Testing, 
utilized a homemade ``safe light,'' which had been made a safe light by 
the application of red spray paint. The radiographer did not realize 
beforehand that the light would not be ``safe'' for the film supplied 
by Ultron, Inc.
    Cause or Causes--The radiographer entered a designated high 
radiation area with his alarm ratemeter turned off and without 
following his normal practice of cranking in the source and surveying 
the guide tube and camera. The radiographer interpreted the silence 
from the alarm ratemeter as an indication of safe conditions. 
Unfortunately, when turned off, the alarm ratemeter gives the same 
indication as it does when indicating safe conditions. In addition, the 
radiographer did not utilize a collimator to reduce the exposure to 
himself and the Ultron, Inc., technician.

Actions Taken To Prevent Recurrence

    Licensee--The licensee stated that the radiographer did not develop 
any symptom of acute radiation exposure and that its personnel were 
reinstructed in the importance of performing surveys and using a 
collimator. The licensee committed to the State Agency to verify the 
training of all technicians, including those of the company that hires 
the licensee to perform radiography.
    State Agency--The State Agency cited the Licensee for the following 
four violations: (1) excessive exposure to a radiation worker, (2) 
excessive exposure to a member of the public (the Ultron, Inc., 
technician representative), (3) failure to prevent unauthorized entry 
into the High Radiation Area, and (4) failure to exercise ALARA by 
using a collimator. A civil penalty was considered but not imposed. The 
State Agency recommended that both individuals contact the State and 
seek medical attention if any symptoms of acute exposure should appear.
    This event is closed for the purpose of this report.
* * * * *
AS 97-3  Radiopharmaceutical Misadministration at Mad River Community 
Hospital in Arcata, California
    One of the AO criteria states that a medical misadministration that 
results in a dose that is equal to or greater than 10 gray (Gy) (1000 
rad) to any organ (other than a major portion of the bone marrow, to 
the lens of the eye, or to the gonads) and represents a dose or dosage 
that is at least 50 percent greater than that prescribed in a written 
directive will be considered for reporting as an AO.
    Date and Place--February 28, 1996; Mad River Community Hospital; 
Arcata, California. The State initially reported this event to NRC in 
December 1996.
    Nature and Probable Consequences--A patient was prescribed a dosage 
of 3.7 megabecquerel (MBq) (0.1 millicurie [mCi]) of iodine-131 (I-131) 
for a thyroid scan and uptake procedure. However, the patient was 
administered a dosage of 262.7 MBq (7.1 mCi) of I-131. As a result, the 
patient's thyroid received a dose of about 9100 centigray (cGy) (9100 
rad), instead of the prescribed dose of 130 cGy (130 rad).
    The licensee stated that such a dose may induce a hypothyroid state 
requiring the patient to take thyroid hormone.
    Cause or Causes--The wrong dosage was administered on the 
assumption that the patient was prescribed a whole body thyroid scan 
for a cancer metastatic disease evaluation.

Actions Taken To Prevent Recurrence

    Licensee--Procedures for scheduling a whole body scan for thyroid 
cancer metastases were revised to include a detailed patient 
preparation and history.

[[Page 25883]]

The revised procedures required that the approving radiologist sign the 
I-131 administration policy before ordering a radiopharmaceutical. In 
addition, the nuclear medicine technologist attended a continuing 
education program at San Francisco General Hospital, which included a 
segment on the effects of studies involving therapy dosages.
    State Agency--The State Agency conducted numerous follow-up 
inspections to ensure that the licensee's actions taken to prevent 
recurrence had been implemented.
    This event is closed for the purpose of this report.
* * * * *
AS 97-4  Radiopharmaceutical Misadministration at Tuomey Regional 
Medical Center in Sumter, South Carolina
    One of the AO criteria notes that a medical misadministration that 
results in a dose that is equal to or greater than 10 gray (Gy) (1000 
rad) to any organ (other than a major portion of the bone marrow, to 
the lens of the eye, or to the gonads) and represents a dose or dosage 
that is at least 50 percent greater than that prescribed in a written 
directive will be considered for reporting as an AO.
    Date and Place--December 11, 1996; Tuomey Regional Medical Center; 
Sumter, South Carolina.
    Nature and Probable Consequences--A patient was prescribed a dosage 
of 74 megabecquerel (MBq) (2.0 millicurie [mCi]) of iodine-131 (I-131) 
for a treatment of Graves disease. However, the patient was 
administered a 388.5 MBq (10.5 mCi) dosage of I-131. As a result, the 
patient's thyroid received a dose of 40,400 centigray (cGy) (40,400 
rad) instead of the prescribed dose of 7700 cGy (7700 rad).
    The licensee stated that the administered dose of I-131 to the 
patient's thyroid is not expected to have major health effects.
    Cause or Causes--The wrong dosage was administered to the patient 
because the written order for the I-131 procedure was misread by the 
administering technologist.

Actions Taken To Prevent Recurrence

    Licensee--The licensee will have the written order on hand before 
ordering radiopharmaceuticals from the pharmacy and will have a second 
person verify the dosage before administration to the patient.
    State Agency--The State Agency accepted the licensee's report and 
corrective action as appropriate. No further action was requested.
    This event is closed for the purpose of this report.
* * * * *
    Dated at Rockville, Maryland this 5th day of May, 1998.

    For the Nuclear Regulatory Commission.
John C. Hoyle,
Secretary of the Commission.
[FR Doc. 98-12390 Filed 5-8-98; 8:45 am]
BILLING CODE 7590-01-P