[Federal Register Volume 67, Number 79 (Wednesday, April 24, 2002)]
[Pages 20186-20187]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-9995]



Report to Congress on Abnormal Occurrences Fiscal Year 2001 
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 U.S. Nuclear Regulatory Commission (NRC) determines 
is 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 annually. During fiscal year 
2001, two events, one at a facility licensed by the NRC and the other 
at a facility licensed by an Agreement State 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. 24, ``Report to Congress on Abnormal Occurrences, Fiscal Year 
2001.'' This report will be available electronically at the NRC Web 
site http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/.

Nuclear Power Plants

    None of the events that occurred at U.S. nuclear power plants 
during this reporting period was significant enough to be reported as 
an AO.

Fuel Cycle Facilities (Other Than Nuclear Power Plants)

    None of the events that occurred at fuel cycle facilities during 
this reporting period was significant enough to be reported as an AO.

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

01-1  Occupational Overexposure at Southeast Missouri State University 
in Cape Girardeau, Missouri

    Date and Place--June 13-16, 2000, Southeast Missouri State 
University (the university), Cape Girardeau, Missouri. The information 
available to the staff prior to the publication of the FY 2000 report 
was not sufficient to determine if this event met the AO criteria.
    Nature and Probable Consequences--In 1970, the university was 
licensed by the Atomic Energy Commission, NRC's predecessor, to possess 
and use up to 185 megabecquerel (MBq) [5 millicurie (5 mCi)] of 
americium-241 (Am-241) in unsealed form. The authorized user of the Am-
241 died in 1980. In 1991, the university requested and received an 
amendment to its NRC license to remove authorization to possess and use 
certain radionuclides, including Am-241. The university disposed of 
some radionuclides in its possession but inadvertently kept the 
unsealed Am-241.
    On February 16, 2000, a routine NRC inspection at the university 
found that the radiation program had deteriorated significantly. 
Specifically, since August 1, 1999, the university had been without a 
radiation safety officer (RSO), and the university officials were not 
sure whether they had radioactive materials in their possession or what 
materials they were authorized to possess. They did not know the 
general terms and conditions of their license. During the inspection, 
the licensee and an NRC inspector found an apparently empty vial 
labeled as containing 185 MBq (5 mCi) of Am-241 in a safe, located in 
the basement of the university, along with additional unauthorized 
    After the discovery of the unauthorized material, the university 
hired a consultant to characterize the material in the safe, and assess 
contamination in and around the area. On April 19, 2000, the consultant 
inventoried the contents of the safe and found elevated radiation 
levels in the room where the safe was located. On June 13, 2000, the 
consultant began to perform surveys and decontamination activities and 
identified loose Am-241 contamination.
    Inadequate radiological surveys and poor handling techniques used 
by the consultant resulted in contamination in a number of areas in the 
    On June 21, 2000, the NRC initiated a special inspection in 
response to a report from the university on loose Am-241 contamination. 
NRC surveys independently confirmed the Am-241 contamination.
    The licensee restricted access to all contaminated areas, 
interrupted the decontamination process, and performed internal dose 
assessments of individuals potentially exposed to Am-241 contamination. 
These assessments indicated that the consultant received a calculated 
committed dose equivalent to the bone surface of 2630 millisievert (263 
rem). The consultant has seen a doctor, had one therapeutic medical 
treatment, and no adverse health effects are expected. The licensee 
hired a second consultant to complete the decontamination process.
    Cause or Causes--The licensee possessed radioactive material not 
authorized by the NRC license and failed to perform adequate radiation

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surveys, including air sampling to measure airborne radioactivity 
present during the inventory and decontamination activities. The survey 
instruments were incapable of detecting alpha activity which is needed 
to identify the presence of Am-241. In addition, from August 1, 1999, 
to July 10, 2000, the licensee had no RSO to oversee and ensure 
implementation of an effective radiation protection program.
Actions Taken To Prevent Recurrence
    Licensee--The licensee appointed a new RSO and revised its 
radiation safety program, with an emphasis on inventory control. 
Specifically, the university implemented new property control and 
surplus inventory policies and procedures that included: (1) Review and 
approval by the RSO of property transfers of potentially contaminated 
equipment, (2) surveys of surplused equipment for contamination 
control, and (3) training of personnel in the correct procedures for 
surplusing equipment containing radioactive material.
    NRC--On September 13, 2001, the NRC issued a Notice of Violation 
and Proposed Imposition of Civil Penalty against the university for the 
violation associated with the June 2000 radiation overexposure to the 
consultant. The fine was $11,000. The NRC also issued Information 
Notice 2001-01 to emphasize the importance of accurate inventory 
controls to prevent unauthorized possession of radioactive material.
    This event is closed for the purpose of this report.
* * * * *

Agreement State Licensees

AS 01-1  Industrial Radiography Occupational Overexposure at Quality 
Inspection Services, Inc., in Jacksonville, Florida

    Date and Place--February 16, 2001, Quality Inspection Services, 
Inc., Jacksonville, Florida.
    Nature and Probable Consequences--Based on discussions with the 
involved individuals, it was determined that a radiographer retracted a 
2.15 terabecquerel (58 curie) iridium-192 source into what was thought 
to be a locked, shielded, and fully retracted position inside the 
radiography camera. In setting up for the next shot, the radiographers 
noticed that the source had not been secured in the off position after 
the previous shot and that their survey meters and their pocket 
dosimeters were off scale. The radiographers immediately retracted the 
source to its fully shielded position and exited the working area. Film 
badges belonging to the radiographers indicated exposures of 29 mSv 
(2.9 rem) and 392 mSv (39.2 rem). For the radiographer with the highest 
exposure, blood tests were normal and he declined further testing. No 
adverse health effects are expected.
    Cause or Causes--The radiographers failed to perform an adequate 
survey of the radiography camera after performing radiographic 
operations. In addition, the alarming ratemeter worn by one of the 
radiographers was not turned on during radiography. The alarming 
ratemeter for the second radiographer had a low battery and did not 
produce an audible alarm.
Actions Taken To Prevent Recurrence
    Licensee--The licensee conducted a reenactment of the event and, 
based on lessons learned, the training procedures were revised to 
prevent future incidents.
    State Agency--The State of Florida Bureau of Radiation Control 
determined that the radiographer failed to follow procedures and took 
enforcement action against the licensee. The State reviewed and 
accepted the licensee's corrective actions, which included refresher 
    This event is closed for the purpose of this report.
* * * * *

    Dated at Rockville, Maryland this 18th day of April, 2002.

    For the Nuclear Regulatory Commission.
Annette L. Vietti-Cook,
Secretary of the Commission.
[FR Doc. 02-9995 Filed 4-23-02; 8:45 am]