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April 3, 2001

The Commission has approved the contents of the proposed Report to Congress on Abnormal Occurrences for Fiscal Year 2000 subject to the changes indicated in the attachment. The staff should perform a thorough scrub prior to submission of the report to Congress.

ATTACHMENT

Changes to the Report to Congress on Abnormal Occurrences for Fiscal Year 2000

1. In the Abstract, paragraph 2, revise sentences 2 and 3 to read ' ... the second event resulted in overexposures of occupational workers at a radiopharmaceutical manufacturing plant, and the third event involved a medical brachytherapy misadministration. The report also discusses six medical AOs ....'
   
   
2. On page 1, Event 00-1, under Nature and Probable Consequences, paragraph 2, revise the last sentence to read ' ... did not impact the public ....'
   
   
3. On page 1, revise the last paragraph to read ' ... that Consolidated Edison Corporation Company had not performed an adequate examination of the steam generator tubes during its their 1997 outage. As a result, degraded tubes were allowed to remain in service during plant operation , which and ultimately led to ....'
   
   
4. On page 2, paragraph 1, revise lines 4 and 5 to read ' ... licensee did not identify and correct the presence of PWSCC flaws in steam generator tubes and remove these tubes from service, despite opportunities ....'
   
   
5. On page 2, paragraph 3, revise line 8 to read ' ... and/or the industry.'
   
   
6. On page 4, paragraph 4, revise line 5 to read ' ... safety aspects of its their radioactive material ....' Revise line 8 to read ' ... reasonably achievable (ALARA); ....' Revise line 10 to read ' ... corrective action program into its their license.'
   
   
7. On page 4, next to last paragraph, revise line 2 to read ' ... through May 26, 2000, and a follow ....'
   
   
8. On page 6, Event AS 00-1, under Nature and Probable Consequences, paragraph 2, revise sentence 3 to reflect that the dose was delivered at the wrong treatment site within the patient's skull since GSR treatments are always intended to be inside the patient's skull. Also, the report should clarify that intervention prevented a related misadministration for patient B, if this was the case.
   
   
9. On page 7, Event AS 00-2, under Date and Place, revise the last sentence to read ' ... to the NRC resulted from was due to a computer error.'
   
   
10. On page 7, Event AS 00-2, under Nature and Probable Consequences, line 2, the abbreviation for gamma stereotactic radiosurgery should be corrected to 'GSR'. Similarly, the abbreviation of 'GRS' should be corrected to 'GSR' in the following places in the report:
    
    
1. page 7, next to last paragraph - 2 places
2. page 8, 2^nd full paragraph - 2 places
3. page 8, last paragraph
4. page 10, paragraphs 2, 3, and 5
5. page 11, line 1
   
   
11. On page 7, revise the last line to read ' ... under-dose to of a portion of the ....'
    
    
12. On page 20, APPENDIX C, OTHER EVENTS OF INTEREST, the description of the first event, the unplanned high radiation field at the University of Missouri Research Reactor, states that the event resulted in unplanned high radiation levels in the basement floor level of the reactor containment, which triggered a radiation alarm, and that the calculated maximum dose rate at the opening in the shielding was 400 rem/hr for about 3 minutes. That is, if it were possible for anyone to be at that location, they would have received a 20 rem dose. Later the report states that radiation overexposures had not occurred and that the event did not affect members of the public. Although the report clarifies that members of the public were not affected, questions arise regarding possible exposures to workers at the reactor. The answers to the following questions should be clarified in the report:
    
    

Were there any workers in the basement floor level at the time of the event?

Did any of them receive radiation exposures, given the high levels reported? (It is clear from the report that no overexposures occurred; thus, if there were exposures they were less than 5 rems.)


 

13. On page 21, NRC AND AGREEMENT STATE MATERIALS LICENSEES, paragraph 1 of this section states that there were 230 events resulting "in licensed material entering the public domain in an uncontrolled manner...." The report further states, "In some cases, the material caused radioactive contamination or radiation exposures." The report should be amplified to better describe the risk perspective on these events. In paragraph 3, revise sentence 2 to read ' ... are (1) radioactive sources used in medical treatments....'
    
    
14. On page 22, Loss of a Radioactive Camera Owned by Welding Testing X-Ray, Inc., paragraph 2, line 2 correct the spelling of 'State'. Sentence 5 states, "The sheriff's department found the radiography camera by the fire department near Canyon Lake, Texas." This sentence is not clear. Region IV staff recalls that either fire department personnel or sheriff's personnel found the camera and reported it to the licensee.

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