POLICY ISSUE

INFORMATION

April 18, 2003

FOR: The Commissioners SECY-03-0060

FROM: William D. Travers

Executive Director for Operations

SUBJECT: ANNUAL REPORT TO THE COMMISSION ON PERFORMANCE

IN THE MATERIALS AND WASTE ARENAS

PURPOSE:

This paper provides the first annual update on significant nuclear materials issues, as well as

performance trends in the Materials and Waste Arenas, pursuant to Staff Requirements

Memorandum SRM-SECY-02-0216, “Proposed Process for Providing Information on Significant

Nuclear Materials Issues and Adverse Licensee Performance,” dated February 25, 2003. 

SUMMARY:

Staff evaluated performance trends and significant issues based on aggregated information

obtained from operating experience associated with reportable events and generic issues

affecting the industry. The aggregated information, obtained through existing processes and

systems, includes the following: (1) Abnormal Occurrence (AO) data; (2) Strategic Goal and

Performance Goal data; (3) data derived through escalated enforcement actions; (4) significant

issues identified based on existing criteria; (5) generic and special event study results; and 

(6) quarterly report data based on assessment of events reported to the Nuclear Materials

Events Database (NMED). The performance data presented in this paper encompasses all

NRC Materials and Waste Arena licensees and Agreement State licensees.

CONTACTS: Samuel L. Pettijohn, NMSS/IMNS

(301) 415-6822

Anita L. Turner, Ph.D., NMSS/IMNS

(301) 415-5508
The Commissioners 2

Based on the staff’s evaluations, it was determined that: (1) there are no discernable trends

from the assessment of the overall performance data; and (2) four nuclear materials issues

have met the significant issues criteria as described in Table 2 of SECY-02-0216. Among the

four significant issues, three of them (PermaGrain, Fansteel, and Safety Light) shared a

common issue of deficiencies in the financial assurance area, which leads to a potential risk to 

public health and safety. The fourth significant issue (Schlumberger) revealed the limitations of

cytogenetic blood testing in the United States. 

BACKGROUND:

On June 28, 2002, the Commission issued SRM M020501, concerning the Agency Action

Review Meeting (AARM). In the SRM, the Commission stated the following:

The staff should propose a process for providing the Commission with annual updates

on significant nuclear materials issues (such as overexposures, medical

misadministrations, and lost or stolen sources) and on adverse licensee performance.

This information could be provided in conjunction with the Agency Action Review

Meeting results and Commission meetings, or through another appropriate mechanism.

The staff should inform the Commission of the final criteria that it will use to determine

those material licensees that will be discussed at the Agency Action Review Meeting. 

On December 11, 2002, staff issued SECY-02-0216. The SRM for SECY-02-0216, dated

February 25, 2003, approved the staff’s proposal to provide the Commission information on the

Materials and Waste Arenas’ performance in an annual report. This paper is the first in a series

of annual reports developed to keep the Commission informed of the overall performance

trends as well as significant issues among U.S. Nuclear Regulatory Commission (NRC) and

Agreement State licensees in the Materials and Waste Arenas.

DISCUSSION:

The evaluation of performance trends and significant issues is based on aggregated

information on operating experience associated with reportable events and generic issues

affecting the industry. As stated in SECY-02-0216, staff has developed an approach for

providing the Commission with annual updates on significant issues and performance trends

that: (1) builds on existing processes and systems; and (2) has minimal impact on 

staff resources. 

The aggregated information used to evaluate performance trends and significant issues was

obtained through existing processes and systems and includes the following: (1) AO data; 

(2) Strategic Goal and Performance Goal data; (3) data derived through escalated enforcement

actions; (4) significant issues identified based on existing criteria; (5) generic and special event

study results; and (6) quarterly report data based on assessment of events reported 

to NMED. 
The Commissioners 3

This paper is the first annual report and is a product of an evolving process. In the future,

evaluations may be performed through a mechanism being developed under the pilot National

Materials Program. In addition, a longer-term goal is to also use risk insights derived from the

application of NUREG/CR-6642, “Risk Analysis and Evaluation of Regulatory Options for

Nuclear Byproduct Material,” and to incorporate inspection findings data in the analysis of

trends, to perform an integrated assessment of overall safety in Materials and Waste Arenas.

The following sections discuss the evaluation of the performance trends and significant issues

using the aggregated information stated above, followed by overall conclusions of performance

in Materials and Waste Arenas. 

AO Data:

Nine events reported to NRC in Fiscal Year (FY) 2002, involving the Materials and Waste

arena, were determined by the staff to meet the criteria for AOs. The FY 2002 AO Report will

be available in the 2nd quarter of the year 2003. The AO events include four Medical Events

(i.e., misadministrations), four Personnel Overexposure events, and one event involving a loss

of package integrity for a radioactive material shipment. Although the 9 AO events proposed

for FY 2002 represent an increase from the number reported for FY 2001 (only one event was

found to meet the AO criteria in FY 2001), there is no discernable increasing trend in AO events

when 5 years of data are compared (Table 1.0 of Attachment 1).

A significant finding is that several of the AOs reported for FY 2002 exceeded the AO criteria 

by a substantial margin and resulted in, or had a high potential to result in, acute effects to

personnel involved. For example, three of the personnel overexposures involved high doses 

to radiographers. In one case, a radiographer received an extremity dose of 150 sieverts (Sv)

[15,000 (rem)]. In two other cases, one radiographer received a whole-body dose of 2.7 Sv

(270 rem) and another received a whole-body dose of 0.70 Sv (70 rem). The AO criterion for

extremity exposures is 2500 millisieverts (mSv) (250 rem), and the AO criterion for whole-body

exposure is 250 mSv (25 rem). The circumstances that led to the occurrence of these events

are the same as recorded for less serious events of the same type (i.e., a failure to perform

adequate radiation surveys and follow procedures for properly monitoring doses). The “Generic

and Special Event Study Results” section of this report and Attachment 2 contain further

discussions of personnel exposure data.

Strategic Goal and Performance Goal Data:

The Strategic Plan Performance Goal and Measures data highlighted in the report are the

values that exceed a performance goal or measure or will likely exceed a performance goal or

measure, within 80 percent of the maximum value. 

No events reported for FY 2002 met the criteria for Strategic Goal Measures. Although events

occurred in FY 2002, the Performance Goal Measures were not exceeded. However, three

Performance Goal measures were within 80 percent of the Performance Measure goal for 

FY 2002. The Measures were the following: (1) loss or theft of material; (2) loss or theft of
The Commissioners 4

sources greater than 0.37 terabecquerel (TBq) (10 Ci); and (3) release of material. Overall, the

number of reported thefts and losses of material reported for FY 2002 and through the first

quarter of FY 2003 was not substantially different from the number of events reported for

previous years. In addition, NRC has achieved all of its strategic goals and performance goals

in both Materials and Waste Arenas since 2000.

The theft of portable moisture/density gauges continue to dominate the theft of material. 

Although there appears to be a slight increase in thefts of these devices in FY 2002 and the first

quarter of FY 2003, there is no evidence that thefts of these devices are associated with

intended malevolent use of radioactive material. The loss or thefts of sources greater than 

0.37 TBq (10 Ci) in calendar years 2001 and 2002 involved the thefts of three radiography

exposure devices (two of which were recovered). There is no evidence that the thefts of these

devices are associated with intended malevolent use of radioactive material. The “Generic and

Special Event Study Results” section and Attachment 3 contain further discussions of lost and

stolen material.

Data Derived Through Escalated Enforcement Actions:

There is no apparent trend for escalated enforcement actions over the last five years. The

NRC issued an average of 61 escalated actions per year (including civil penalties, orders, and

Notices of Violation for Severity Level I, II, and III violations without civil penalties). The number

of civil penalty actions increased in FY 2001 and FY 2002, based on the Commission’s

Enforcement Policy revision addressing the loss, abandonment, or improper transfer or disposal

of sources that became effective on February 16, 2001. Over the last five years, an average of

three events per year resulted in Severity Level I or II violations, ranging from a single event 

per year to six events per year. Summaries of Severity Level I or II violations for FY 2001 and

FY 2002 are described in Attachment 4.

Significant Issues Identified Based on Existing Criteria: 

There are three nuclear materials licensee issues and one incident that meet the significant

issues criteria as described in Table 2 of SECY-02-0216. These significant issues

demonstrated a high potential to impact public health and safety, which warranted a discussion

in this paper. Event details are provided in Attachment 5, which include a discussion of issues

at PermaGrain Products, Inc., Fansteel, Inc., and Safety Light Corporation, and an incident that

occurred at Schlumberger Technology Corporation. The three licensee issues (PermaGrain,

Fansteel, and Safety Light) shared a common issue of deficiencies in the financial assurance

area, which leads to a potential risk to public health and safety. The staff is addressing the

financial assurance program as part of its analysis of the License Termination Rule

(SRM-SECY-01-0194 and SECY-02-177) as well as a draft final rule that amends financial

assurance requirements. The staff's analysis will more fully outline the issues associated with

decommissioning financial assurance and identify a number of potential improvements that may

be implemented.

In the case of the PermaGrain Products, Inc., the licensee declared bankruptcy, resulting in

potential abandonment of a substantial inventory of cobalt-60 sources. The cost of removal and
The Commissioners 5

disposal of these sources is approximately 10 times greater than the amount of financial

assurance required in current regulations. Recently, the U.S. Environmental Protection Agency

(EPA) has agreed to implement a Federal removal of the sources. A draft rulemaking (in the

final stage) will require that financial assurance for irradiators be based on site-specific

decommissioning cost, rather than a fixed amount, as specified in the current regulations. 

Due to bankruptcy, Fansteel, Inc. is not able to provide the necessary amount of financial

assurance for decommissioning activities, as required in 10 CFR 40.36. Subsequently, staff

denied the license renewal application submitted by Fansteel. To date, Fansteel has not

provided an acceptable plan to emerge from bankruptcy and fund remediation of the Muskogee

site. Safety Light Corporation is also deficient in the financial assurance needed to perform

effective remediation work. The staff, working in concert with EPA and the Commonwealth of

Pennsylvania, has approved a work plan for removal of the silo wastes from this site. Because

of the considerable shortfall in licensee funds relative to ultimate cleanup cost, EPA is also

considering adding the site to the National Priorities List and possible remediation under the

Comprehensive Environmental Response, Compensation and Liability Act. 

Staff upgraded the inspection effort concerning Schlumberger Technology Corporation to an

Augmented Inspection Team (AIT) because of the significant discrepancies between the

estimated radiation doses and the cytogenetic test results, and because of the potential for a

high radiation dose to a member of the public. The Armed Forces Radiobiology Research

Institute is the only facility in the United States that is currently available to NRC for cytogenetic

testing on an ongoing and on-demand basis for use in radiation dose assessments. There is a

need to have more than one facility available to NRC for cytogenetic testing within the United

States. The staff is working to establish additional capability so that testing results can be

compared and verified if discrepancies arise.

Generic and Special Event Study Results:

Staff performed reviews of reported data on radiography overexposures, radiopharmacy

extremity overexposures, and the loss and theft of radioactive material. The results of the

reviews of radiography exposures and radiopharmacy extremity exposures were published in an

addendum to the 4th NMED Quarterly Report (Attachment 2). A summary for each of the three

data reviews is presented below. Attachment 3 contains the full text of the data review on the

loss and theft of radioactive material.

Review of Radiography Overexposures (1997 to 2002):

A review of data, reported to NRC, that involved reportable overexposures, was performed for

the period of January 1997 through May 2002. A total of 70 individuals received doses that

exceeded regulatory limits: 67 whole-body doses and six extremity doses. Approximately 23

percent of reported causes of radiography overexposures were failures to perform surveys and 

follow procedures. Approximately 49 percent of radiography overexposures were attributed to

poor administrative practices (i.e., overexposures because of improper oversight of workers’

annual doses). These administrative doses ranged between 50 and 60 mSv (5-6 rem). 
The Commissioners 6

Review of Radiopharmacy Extremity Overexposures (1997 to 2002):

A review of data reported to NRC involving hand and finger exposures in excess of regulatory

limits at radiopharmacies was performed for the period of January 1997 through May 2002.

Events reported during this period involved exposures to 126 persons. One event, which

occurred over a 5-year period, accounted for 116 of the 126 persons. Except for the

overexposures that occurred because of this event, an average of two events was reported

annually, from 1997 through 2001. Although this number may appear low, the overall data

suggest that, in the absence of radiation safety procedures that involve the use and frequent

monitoring of dosimetry results and the use of shielding and remote-handling tools, the potential

for extremity exposures in excess of regulatory limits is high. 

Analysis of Lost and Stolen Data for Trend Identification, Calendar Years (2001-2002):

An analysis of data from NMED for calendar years 2001 and 2002 was conducted to identify a

pre-9/11 baseline and post-9/11 trends for lost and stolen moisture/density gauges and

radiographic cameras. Each moisture/density gauge contains approximately 0.3 gigabecquerel

(GBq) [8 millicuries (mCi)] of cesium-137, and 1.48 Gbq (40 mCi) of americium-241/beryllium,

in the form of sealed sources. With the exception of radiographic cameras that contain highactivity sources, the remaining percentage of stolen sources (~20 percent) have an activity in

the Ci to mCi range, and are typically contained in gauging/measuring devices, and ionization

devices used for static elimination. Because of the low-activity range, the stolen sources are

not likely to be candidates for malevolent use. Based on the analysis, staff did not identify any

trend or information indicating that reported losses and thefts of licensed material over the last

2 years represent a substantive safety risk. In addition, there was no identifiable pattern to

support the idea that individuals are stealing portable moisture/density gauges for malevolent

use. However, the theft of a portable gauge may still pose a potential risk to public health and

safety if the gauge is abandoned in the environment, is recycled in a steel mill, or is used

inappropriately. An NRC/Agreement State Working Group has developed a draft proposed rule

to reduce the opportunity for portable gauge theft. 

Assessment of Data Reported to NMED

NMED contains records of events involving nuclear materials reported to NRC by NRC

licensees, Agreement States, and non-licensees. The events are reported to NMED based on

requirements defined by Title 10 of the Code of Federal Regulations. The event reports are

evaluated to identify any safety-significant events and their causes. NMED data are reviewed

quarterly and presented in a quarterly report, in which 18 months of historical data are

aggregated for evaluation of potential trends. The NMED quarterly report is posted on the

NMED web site at http://NMED.inel.gov and is directly available to NRC and Agreement State

staff. Using event analysis and reviews published in the NMED quarterly report, trends can be

identified. The NMED format and content of the NMED quarterly report are being revised to

include statistical analysis and trending. Future fourth quarter reports will include an annual

summary of data.

Attachment 6 is a copy of the 4th Quarter FY 2002 NMED quarterly report. For the 18-month

period ending September 30, 2002, 852 events (not including fuel cycle facility events) were
The Commissioners 7

reported to NRC. Among them, 49 percent were classified as Loss of Control of Material. The

remaining 51 percent were divided among Equipment Problems (21 percent), Leaking Sources

(9 percent), Transportation (7 percent), Medical Events (6 percent), Radiation Overexposures

(4 percent), Release of Licensed Material or Contamination (2 percent), and Other (2 percent).

The event-reporting rate is about 2.7 events per 100 licensees annually, for all events, and

about 0.7 events per 100 licensees, annually, for Medical Events. The calculated reporting

rates are based on an estimate of about 21,000 materials licensees (about 5000 NRC licensees

and 16,000 Agreement-State licensees) that reported 568 events (annual rate) and about 5000

medical licensees that reported 37 Medical Events (annual rate). 

The 18-month assessment of NMED data does not reveal any overall discernable trends in

performance. Although the number of events reported annually is low, the event data do, in

some cases, highlight areas, such as radiography overexposures, for follow-up studies. Data

were reviewed for the first quarter of FY 2003 and was found to be consistent with the results of

the 18-month assessment in the 4th Quarter FY 2002 NMED Quarterly Report. 

OVERALL PERFORMANCE CONCLUSIONS:

The review of current processes for assessing performance in the Materials and Waste arenas

does not reveal any discernable trend in declining performance. These processes do identify

areas for improvement through highlighting where problems occur and also enable lessonslearned for feedback to the industry and regulatory community. Based on existing criteria, four

significant nuclear materials issues have been identified. Three of them shared a common

issue of deficiencies in the financial assurance area, and the fourth revealed the limitations of

cytogenetic blood testing in the United States. The staff is addressing the financial assurance

program as part of its analysis of the License Termination Rule as well as a draft final rule that

amends financial assurance requirements.

COORDINATION:

The Office of the General Counsel has reviewed this paper and has no legal objections.

/RA/

William D. Travers

Executive Director

 for Operations

Attachments: 

1. Annual Trend in AO Events and Summary of FY 2002 AO Events 

2. Addendum to the Fourth Quarter FY 2002 NMED Quarterly Report

3. Analysis of Lost and Stolen Data for Trend Identification, Calender Year 2001-2002

4. Summary of Severity Level I and II Enforcement Actions for FY 2001 and FY 2002

5. Significant Issues and Incident Investigations

6. Fourth Quarter FY 2002 NMED Quarterly Report
The Commissioners 7

reported to NRC. Among them, 49 percent were classified as Loss of Control of Material. The

remaining 51 percent were divided among Equipment Problems (21 percent), Leaking Sources

(9 percent), Transportation (7 percent), Medical Events (6 percent), Radiation Overexposures

(4 percent), Release of Licensed Material or Contamination (2 percent), and Other (2 percent).

The event-reporting rate is about 2.7 events per 100 licensees annually, for all events, and

about 0.7 events per 100 licensees, annually, for Medical Events. The calculated reporting

rates are based on an estimate of about 21,000 materials licensees (about 5000 NRC licensees

and 16,000 Agreement-State licensees) that reported 568 events (annual rate) and about 5000

medical licensees that reported 37 Medical Events (annual rate). 

The 18-month assessment of NMED data does not reveal any overall discernable trends in

performance. Although the number of events reported annually is low, the event data do, in

some cases, highlight areas, such as radiography overexposures, for follow-up studies. Data

were reviewed for the first quarter of FY 2003 and was found to be consistent with the results of

the 18-month assessment in the 4th Quarter FY 2002 NMED Quarterly Report. 

OVERALL PERFORMANCE CONCLUSIONS:

The review of current processes for assessing performance in the Materials and Waste arenas

does not reveal any discernable trend in declining performance. These processes do identify

areas for improvement through highlighting where problems occur and also enable lessonslearned for feedback to the industry and regulatory community. Based on existing criteria, four

significant nuclear materials issues have been identified. Three of them shared a common

issue of deficiencies in the financial assurance area, and the fourth revealed the limitations of

cytogenetic blood testing in the United States. The staff is addressing the financial assurance

program as part of its analysis of the License Termination Rule as well as a draft final rule that

amends financial assurance requirements.

COORDINATION:

The Office of the General Counsel has reviewed this paper and has no legal objections.

/RA/

William D. Travers

Executive Director

 for Operations

Attachments: 

1. Annual Trend in AO Events and Summary of FY 2002 AO Events 

2. Addendum to the Fourth Quarter FY 2002 NMED Quarterly Report

3. Analysis of Lost and Stolen Data for Trend Identification, Calender Year 2001-2002

4. Summary of Severity Level I and II Enforcement Actions for FY 2001 and FY 2002

5. Significant Issues and Incident Investigations

6. Fourth Quarter FY 2002 NMED Quarterly Report ML030920733

OFF IMNS NMSS MSIB MSIB IMNS

NAME SPettijohn* EKraus*

(by fax)

FBrown

(KHsueh)

TEssig CMiller

(PHolahan for)

DATE 4/4/03 3/27/03 4/4/03 4/4/03 4/4/03

OFF OGC CFO (by email) NMSS DEDMRS EDO

NAME STreby (nlo)* JFunches* MVirgilio* CPaperiello WTravers

DATE 4/01/03 3/31/03 4/5/03 4/17/03 4/18/03

 OFFICIAL RECORD COPY
Annual Trend in AO Events and Summary of FY 2002 AO Events

1. Trend in Abnormal Occurrence Events

Table 1.0 shows the number of events reported annually that were determined to meet the AO

criteria. A total of 35 events were found to meet the AO Criteria for the five year period 1998 -

2002. Sixty percent of the AO events were Medical events. However, the relative higher

number of Medical Events determined to be AOs is not necessarily an indication of relative

performance. The numerical dose criteria applied to Medical Events also appear to be a factor

in Medical Events meeting the AO criteria. For example, the criteria for a Medical Events is that

(1) the total dose delivered differs from the prescribed dose by greater than 20% and (2) the

dose to an organ is greater than 0.05 Sv (5 rem). Therefore, a broad range of dose deviations

can result in a Medical Event AO.

It is noteworthy that while events involving the loss or theft of material account for about 40%

(five year average) of the number of events reported to NRC, only one event in five years has

been found to meet the AO criteria.

Table 1.0 - Comparison of the Annual Number of Abnormal Occurrence Event 

Year (FY) Lost/Stolen

Material

Medical

Event

Personnel

Overexposure

Fuel Cycle

Facility

Event

Totals

1998 0 5 1 1 7

1999 0 7 2 1 10

2000 0 5 2 0 7

2001 0 0 1 0 1

2002 1 4 4 1 10

Totals 1 21 10 3 35

Attachment 1
INEEL/EXT-02-00358 (FY 2002 QTR 4) Addendum

January 2003

Addendum to

Nuclear Materials

Events Database

(NMED) Quarterly

Report

Fourth Quarter Fiscal Year 2002

Samuel L. Pettijohn, NRC

 

Attachment 2
NOTICE

This information was prepared as an account of work sponsored by an agency of the U.S.

Government. Neither the U.S. Government nor any agency thereof, nor any of their

employees, makes any warranty, express or implied, or assumes any legal liability or

responsibility for any third party’s use, or the results of such use, of any information,

apparatus, product, or process disclosed herein, or represents that its use by such third party

would not infringe privately owned rights. The views expressed herein are not necessarily

those of the U.S. Nuclear Regulatory Commission.
INEEL/EXT-02-00358 (FY 2002 QTR 4) Addendum

Addendum to

Nuclear Materials Events Database

(NMED) Quarterly Report

Fourth Quarter Fiscal Year 2002

Samuel L. Pettijohn, NRC

Published January 2003

http://nmed.inel.gov

Idaho National Engineering and Environmental Laboratory

Risk, Reliability and Regulatory Support Department

Idaho Falls, Idaho 83415

Prepared for the

U.S. Nuclear Regulatory Commission

Office of Nuclear Material Safety and Safeguards

Under DOE Idaho Operations Office

Contract DE-AC07-99ID13727
1

SAFETY HIGHLIGHTS

Review of Radiography Overexposures (1997 to 2002)

This addendum presents a Safety Highlights report that was not available in time for inclusion in the

regular quarterly report. This report represents the results of a review of data, reported to the NRC,

involving the reportable overexposures for the period of January 1, 1997, through May 2002. 

Total number of individuals who received doses that exceeded regulatory limits (70):

Whole Body dose: 67

Extremity dose: 6

(In three cases, extremity doses were exceeded but whole body doses were not exceeded.)

Approximately 23 percent of reported causes of radiography overexposures were due to failure to survey

and follow procedures. Approximately 49 percent of radiography overexposures were administrative

overexposures (i.e. overexposures due to poor oversight of workers annual dose). These administrative

doses range between 5 rem to 6 rem. Seven of the forty-one overexposures between 5 rem and 6 rem

were due to failure to survey and follow procedures.

Table 1. Whole Body Doses

Dose range for whole body doses (rem) Number of individuals exposed

5 - 6 41

6 - 10 14

10 - 25 8

>25 4

Table 2. Reported Causes for Whole Body Doses

Whole body dose

greater than 25 rem

(rem)

Reported cause Event date

39 Failure to survey and follow procedures 2/16/2001

40 Failure to survey and follow procedures 9/25/2001

70 Failure to survey; could not hear alarming

ratemeters due to high noise environment

4/10/2002

77 Possible intentional overexposure to badge 10/1/1999
2

Table 3. Reported Causes for Extremity Exposures

Extremity dose Reported cause Event date

730 rem to the hands Failure to survey and follow procedures 9/25/2001

150 rem to the left hand Unshielded source during source exchange 11/22/2000

3000 to 5000 rem to index

finger

Failure to survey; Inadequate training 12/31/1998

100 to 680 rem to fingers and

hands (contract employee)

Inattention of radiographer; radiography

was in parking garage

12/16/1998

1500 rem to left calf Failure to survey and follow procedures 6/1/2000

80 rem to hand Failure to survey; could not hear alarming

ratemeters due to high noise environment

1/13/2001

Review of Radiopharmacy Extremity Overexposures

This report represents the results of a review of data reported to NRC by radiopharmacies involving hand

and finger exposures that exceeded regulatory limits for the period of January 1, 1997, to May 2002. 

Events reported during this period involved exposures to 126 persons. One event, which occurred over

about a five year period, accounted for 116 of the 126 persons. Tables 4 through 6 below summarize the

result of the review. Except for the overexposures that occurred from 1995 - 2000 due to a common

event, an average of two events were reported annually from 1997 through 2001. While this number may

appear low, the overall data suggest that there is a high potential for extremity exposures in excess of

regulatory limits. The use of, and frequency of monitoring, dosimetry results, and the use of shielding

and remote handling tools (where required) can significantly reduce the potential for extremity

exposures. 

Table 4. Frequency of Reported Occurrences

Year Number of events Number of persons

1995 - 2000 Several events reported as one event 116

1998 1 1

1999 2 2

2000 2 2

2001 4 5

Total 9 126

A group of overexposures that occurred over the period 1995 - 2000 due to the same causal factors were

reported as one event. The overexposures were discovered during the investigation of an extremity

overexposure event that occurred March 31, 2001. The licensee reviewed other production processes at

the plant where high hand exposures might have occurred. This investigation resulted in the discovery of

a total of 116 extremity overexposures from 1995 through 2000. Sixteen of the exposures were in excess

of 250 cSv (rem) SDE, the highest of which was 453 cSv (rem) SDE. The causes of these events were
3

determined to be insufficient training, a failure to follow procedures, inadequate identification of

radiological hazards, and the failure to recognize the radiological implications of some work practices. 

Over 80 percent (103 of 126) of the extremity exposures were less than 250 rem. 

The number of extremity overexposure events reported for 2001 is at least twice the number reported for

each of the three preceding years. The reason for this increase was not apparent from a review of the

data.

Table 5. Task Being Performed by Worker and Associated Cause of Overexposure

Task Events Workers Reported cause(s) Does range

(rem)

Dispensing

routine doses

7 8 Poor handling techniques used during

the manual recapping of syringes;

Workload too high;

Radiopharmacist was new and had

slower technique; Worker was in

training

51 -151

F-18 dose

splitting

process

1 1 Instead of using of using the remote

handling tool provided, the

radiopharmacist handled syringes by

hand during preparation of F-18

doses

127

Dispensing

bulk doses of

Tc-99m

1 1 Radiopharmacist used vial shield

without a shielded top and used left

index finger to hold vial containing Tc99m

700

Reworking

radiopharmaceutical

generators

and other

production

processes

1 117 The individual used his fingers to

manipulate needles inside the

generator instead of forceps

51 - 1120

One extremity overexposure was calculated to be as high as 1120 rem. This overexposure resulted from

an employee working at the rework and packaging stations of a radiopharmaceutical generator

manufacturing line. The employee handled a Mo-99/Tc-99m column containing 703 GBq (19 Ci) of

Mo-99 and 296 GBq (8 Ci) of Tc-99m with his right hand for 10 to 20 seconds. The individual was

supposed to use forceps to manipulate needles inside the generator, but instead used his fingers. Two

other events involved specific actions that led to the overexposures. In one event, the worker failed to

use a remote handling tool. In the other event, the worker used a vial shield without a shielded top. For

70 percent of the events, workers were involved in routine dispensing of radiopharmaceuticals and

received exposures in excess of regulatory limits. These events were due mostly to generally inadequate

work procedures.
4

Table 6. Comparison of Dose Dosimetry Reading with Calculated Dose for Events Where the

Difference Was Greater than 20 Percent

Exposure Dose reported by

dosimetry (rem)

Dose determined from calculation (rem)

1 34 151

2 5.8 510 - 1120

3 Reported as low (no value) 700

In three of the reported events, the dose calculated for the extremity was substantially higher than the

dosimetry reading. In one event, the calculated dose was approximately 200 times higher.

Table 7. Common Causal Factors Related to the Occurrence of the Events 

Causal factor Number of events = Yes Number of events = No

Was extremity dosimetry

used?

8 2

Was extremity dosimetry

monitored at a sufficient

frequency?

2 8

Was overexposure event due

to specific incident?

2 8

Was worker receiving

exposures experienced?

6 4

Extremity dosimetry was reported to be used in most of the events (8 of 10), but the dosimetry was

reported to be adequately monitored in only 20 percent of the events. As a result, most of the

overexposure events (8 of 10) resulted from poor oversight of workers quarterly doses (i.e., the

overexposure dose accumulated throughout the monitoring period rather than from specific incidents). 

For 40 percent of the events, the experience of the worker was cited as a contributing factor.
Analysis Of Lost And Stolen Data For Trend Identification, 

Calendars Year 2001 - 2002

Summary

Based upon the analysis, we did not identify any trend or information indicating that reported

losses and thefts of licensed material over the last two years represent a substantive safety

risk. In addition, there was no identifiable pattern to support the idea that individuals are

stealing portable moisture density gauges for malevolent use. 

Discussion

An analysis of data from the NRC’s Nuclear Materials Event Database (NMED) for the calendar

years 2001 and 2002 was conducted to identify a pre-9/11 baseline and post-9/11 trends for

lost and stolen moisture density gauges and radiographic cameras. Each moisture density

gauge contains approximately 8 millicuries (0.3 GBq) of Cesium-137 and 40 millicuries (1.48

GBq) of Americium-241/Beryllium in the form of sealed sources. With the exception of

radiographic cameras which contain high activity sources, the remaining percentage of stolen

sources (~20%) have an activity in the microcurie to low millicurie range and are typically

contained in gauging/measuring devices, and ionization devices used for static elimination. 

Due to the low activity range, the stolen sources are not likely to be candidates for malevolent

use.

Graph (next page): Stolen versus lost moisture density gauges, CY 2001-2002

One hundred and four events involving stolen moisture density gauges occurred during

CY 01-02 as compared to 22 events involving loss of a moisture density gauge for the

same time period.

An average of 4.5 gauges were stolen per month during 2001. The same average of

4.5 stolen gauges per month continued during 2002.

An average of 1 gauge was lost per month during 2001. The same average of 1 lost

gauge per month continued during 2002.

Conclusion: The trend for lost and stolen moisture density gauges remained constant

between CY 2001 and 2002. There is no evidence of potential

accumulation of large number of these types of sources.

Attachment 3
2

0 

2 

4 

6 

8 

10 

12 

14 

Number of events

01/01 03/01 05/01 07/01 09/01 11/01 01/02 03/02 05/02 07/02 09/02 11/02

Month/Year

Stolen vs Lost Moisture Density Gauges

CY 2001 - 2002

Red: Stolen

Blue: Lost
3

Graph (next page): Stolen versus recovered moisture density gauges, CY 2001-2002

Fifty-three events involving stolen moisture density gauges occurred in 2001. Of these

53 events, 27 resulted in the recovery of the gauges (51% recovery rate).

Fifty-one events involving stolen moisture density gauges occurred in 2002. Of these 51

events, 26 resulted in the recovery of the gauges (51% recovery rate).

Conclusion: At this moment, there is not an identifiable pattern (increasing number of

events post 9/11) to support the idea that individuals are stealing

moisture density gauges for malevolent use.
4

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 Number of events

01/01 03/01 05/01 07/01 09/01 11/01 01/02 03/02 05/02 07/02 09/02 11/02

Month/Year

Stolen vs Recovered Moisture Density

Gauges, CY 2001 - 2002

Red: Stolen

Green: Recovered
5

Graph (next page): Moisture density gauges stolen along with vehicle versus recovery, 

CY 01-02

Ten events involving moisture density gauges stolen along with a vehicle occurred in

2001. Of these 10 events, 9 resulted in the recovery of the gauge (90% recovery rate).

Five events involving moisture density gauges stolen along with a vehicle occurred in

2002. Of these 5 events, 5 resulted in the recovery of the gauge (100% recovery rate).

Conclusion: There is clear indication that individuals stealing a vehicle containing a

moisture density gauge are likely to quickly dispose of the gauge (by

leaving it by the side of a road or in a garbage container), since stealing

the gauge is not their primary motive (no malevolent intention). 
6

0 

1 

2 

3 

Number of events

01/01 03/01 05/01 07/01 09/01 11/01 01/02 03/02 05/02 07/02 09/02 11/02

Month/Year

 Moisture Density Gauges Stolen Along

 With Vehicle vs. Recovery, CY 01 - 02

Red: Stolen

Green: Recovered
7

Table 1. Statistics on Stolen Gauges Reported to the NMED, CY 01-02

State Number

of stolen

gauges**

[A]

Number of

recovered

gauges**

[B]

Recovery

rate (%)

[B/A]

Number of

licensees*

Number of

gauges*

[C]

Gauges stolen

rate (%)

[A/C]

Oklahoma 4 3 75 63 130 3.1

Arizona 6 3 50 101 300 2.0

Washington 5 0 0 100 250 2.0

Louisiana 3 1 33 30-40 150-200 1.7

Tennessee 4 3 75 94 267 1.5

Puerto Rico 2 2 100 28 147 1.4

Michigan 5 2 40 125 400 1.3

New Jersey 2 1 50 61 100-200 1.3

California 15 6 40 569 1400 1.1

West Virginia 2 1 50 47 205 1.0

Idaho 1 1 100 48 100 1.0

Texas 15 7 47 348 2000 0.8

North Carolina 2 1 50 100 250 0.8

Indiana 1 0 0 40 120 0.8

Georgia 3 1 33 94 410 0.7

Mississippi 1 1 100 75 150 0.7

Alabama 2 1 50 120 300 0.6

Pennsylvania 2 1 50 143 300-400 0.6

South Carolina 1 0 0 70 200 0.5

Utah 1 0 0 80 200 0.5

Wisconsin 1 1 100 100 200 0.5

Florida 8 5 63 300 1800 0.4

Colorado 4 3 75 130 500-1500 0.4

Oregon 1 1 100 132 285 0.4

Illinois 2 0 0 250 1000 0.2

Nevada 1 0 0 140 500 0.2

Ohio 2 1 50 105 1082 0.2

Kentucky 1 1 100 200 600 0.2
8

State Number

of stolen

gauges**

[A]

Number of

recovered

gauges**

[B]

Recovery

rate (%)

[B/A]

Number of

licensees*

Number of

gauges*

[C]

Gauges stolen

rate (%)

[A/C]

Maryland 1 1 100 100 500 0.2

New Mexico 1 0 0 n/a n/a ----

Arkansas 0 ---- ---- 80 250 ----

Maine 0 --- ---- 40 75 ----

New York 1 1 100 250 n/a ----

North Dakota 0 ---- ---- 20 50 ----

* Most of these numbers are estimates based on a survey made to the Agreement States in

 October 2002, and from information collected from the NRC regions.

** The numbers of stolen and recovered gauges are obtained based on information reported

 to NMED.

Conclusions: Most States with high numbers of stolen moisture density gauges,

including high numbers of unrecovered gauges, have a large population

of gauges (opportunity for theft) and have recovery rates near the

average (~53%) of all the data presented in the above Table. This

indicates the absence of targeting for malevolent use. 

Graph (next page): Lost versus recovered moisture density gauges, CY 2001-2002 

These types of events typically result when the licensee fails to block and brace and the

gauge falls from the vehicle when the tailgate opens.

Twelve events involving loss of a moisture density gauge occurred in 2001. Of these 12

events, 10 resulted in the recovery of the gauges (83% recovery rate).

Ten events involving loss of a moisture density gauge occurred in 2002. Moisture

density gauges were recovered in all ten events (100% recovery rate). Also an

additional event resulted in the recovery of a missing gauge manufactured prior to 1975,

for a total of 11 events in which gauges were recovered in the year 2002.

Conclusion: Given the current recovery trend, lost moisture density gauges do not

represent a credible source for malevolent use material.
9

0 

1 

2 

3 

4 Number of events

01/01 03/01 05/01 07/01 09/01 11/01 01/02 03/02 05/02 07/02 09/02 11/02

Month/Year

Lost vs Recovered Moisture Density

Gauges, CY 2001 - 2002

Blue: Lost

Green: Recovered
10

Graph (next page): Lost and stolen radiographic cameras versus recovery, CY 2001-2002

Two events involving stolen radiographic cameras occurred in 2001. Of these 2 events,

1 resulted in the recovery of the camera.

One event involving a stolen radiographic cameras occurred in 2002. The radiographic

camera from this event was recovered.

Five events involving lost radiographic cameras occurred in 2001. Of these 5 events, 5

resulted in the recovery of the cameras (100% recovery rate).

One event involving a lost radiographic camera occurred in 2002. The radiographic camera

from this event was recovered (100% recovery rate).

Conclusion: There is no indication that radiographic cameras are being stolen for

malevolent use.
11

0 

1 

2 

3 Number of events

01/01 03/01 05/01 07/01 09/01 11/01 01/02 03/02 05/02 07/02 09/02 11/02

Month/Year

Lost and stolen radiographic cameras

versus recovery, CY 2001 - 2002

Blue = Lost

Red = Stolen

Green = Recovered
12

Distribution per State of stolen vs recovered stolen moisture density gauges

CY 2001-2002

State, City Stolen Recovered Remarks

Alabama, Scottsboro 1 0 Other items stolen

Alabama, Auburn 1 1

Arkansas, Little Rock 1 1

Arizona, Tempe 2 2 Vehicle also stolen

Arizona, Tempe 1 1

Arizona, Yuma 1 0

Arizona, Chandler 1 0

Arizona, Chandler 1 0 Vehicle also stolen

California, Fresno 1 1

California, San Diego 2 0

California, Hemet 1 1

California, Chino Hills 1 0

California, Redlands 1 0

California, Long Beach 2 1

California, Los Angeles 1 0

California. Diamond Bar 1 0

California, Modesto 1 0

California, Escondido 1 1

California, Stockton 1 0

California, Gardena 1 1

California, Orange 1 1

Colorado, Denver 2 1

Colorado, Brighton 1 1

Colorado, Thornton 1 1

Florida, Key Biscayne 1 0

Florida, Kissimmee 1 1

Florida, Valrico 1 1

Florida, Miami 3 1 Other items stolen in one of the events

Florida, Miami 1 1 Vehicle also stolen

Florida, Fort Lauderdale 1 1 Vehicle also stolen

Georgia, Atlanta 1 0

Georgia, Loganville 1 0 Other items stolen

Georgia, Duluth 1 1 Vehicle also stolen

Idaho, Lava Hot Springs 1 1

Illinois, Chicago 2 0

Indiana, Griffith 1 0

Kentucky, Park Hills 1 1

Louisiana, Shreveport 1 1

Louisiana, Fort Polk 1 0 Other items stolen

Louisiana, Metairie 1 0

Maryland, Columbia 1 1

Michigan, Temperance 1 1 Other items stolen

Michigan, Ferndale 1 0

Michigan, Farmington Hills 2 0

Michigan, Grand Rapids 1 1
13

State, City Stolen Recovered Remarks

Mississippi, Jackson 1 1

Missouri, Independence 1 1

Missouri, Joplin 1 1

Missouri, House Springs 1 1 Vehicle also stolen

Nevada, Las Vegas 1 0

New Jersey, Jersey City 1 1

New Jersey, Phillipsburg 1 0

New Mexico, Ponderosa 1 0

New York, Queens 1 1 Vehicle also stolen

North Carolina, Winston-Salem 2 1

Ohio, Columbus 1 1

Ohio, Toledo 1 0

Oregon, Portland 1 1 Vehicle also stolen

Oklahoma, Oklahoma City 1 0

Oklahoma, Del City 1 1

Oklahoma, Fairfax 1 1

Oklahoma, Tulsa 1 1

Pennsylvania, Philadelphia 2 1

Puerto Rico, San Juan 1 1 Vehicle also stolen

Puerto Rico, Trujillo Alto 1 1

South Carolina, North Aux. Field 1 0

Texas, Cross Roads 1 0

Texas, Rockwall 1 0

Texas, San Antonio 1 1

Texas, Austin 1 1

Texas, Houston 2 0 Other items stolen in both of the events

Texas, Houston 3 3 Vehicle also stolen

Texas, Dallas 3 1 Other items stolen in two of the events

Texas, Garland 1 0

Texas, Harlingen 1 1

Texas, Katy 1 0

Tennessee, Chattanooga 1 1

Tennessee, Memphis 1 0

Tennessee, Old Hickory 1 1

Tennessee, Corryton 1 1 Vehicle also stolen

Utah, West Valley City 1 0

Washington, Centralia 1 0

Washington, Seattle 1 0

Washington, Redmond 1 0

Washington, Issaquah 1 0

Washington, Spokane 1 0

West Virginia, Bridgeport 1 0

West Virginia, Whitesville 1 1 Vehicle also stolen

Wisconsin, Baraboo 1 1
Summary of Severity Level I and II Enforcement Actions for FY 2001 and FY 2002

Severity I:

Southeast Missouri State University

Cape Girardeau, Missouri

EA 00-201

Docket No. 030-33508

On September 13, 2001, a Notice of Violation and Proposed Imposition of Civil Penalty 

in the amount of $11,000 was issued for a Severity Level I problem involving the failure to: 

(1) control activities to limit doses in accordance with requirements, (2) make necessary

surveys to determine radiological hazards, and (3) possess only material authorized on the

University’s license.

Severity II:

Advanced Medical Imaging and Nuclear Services

Easton, Pennsylvania

EA 02-072

Docket No. 030-35594

On October 22, 2002, a Notice of Violation and Proposed Imposition of Civil Penalty in the

amount of $43,200 was issued for a Severity Level II problem involving willfully using byproduct

material without an Authorized User, failing to appoint a Radiation Safety Officer, and creating

incomplete and inaccurate records. Although the normal civil penalty assessment process

would have resulted in a base civil penalty, the NRC exercised discretion in accordance with

Section VIIA.3 of the Enforcement Policy and assessed a base civil penalty for each day the

violation continued after the licensee’s consultant raised the issue. Discretion was warranted

base on the egregiousness of the violations, the level of management involved, the economic

benefit of being in noncompliance, and the failure to take corrective action after the consultant’s

finding.

Bristol-Myers Squibb Radiopharmaceuticals, Inc.

Rio Piedras, Puerto Rico

EA 02-160

Docket No. 030-34187

On August 22, 2002, a Notice of Violation was issued for a Severity Level II problem involving

the failure to control occupational dose (two operators received extremity overexposures) and

the failure to perform adequate surveys to evaluate radiation exposure to the extremities. 

Attachment 4
2

Eastern Isotopes, Inc.

Charlotte, North Carolina

EA 02-097

Docket No. 030-32974

On July 30, 2002, a Notice of Violation and Proposed Imposition of Civil Penalty in the amount

of $4,800 was issued for a Severity Level II violation involving an overexposure to a pharmacist

in excess of NRC requirements. Although the civil penalty would have been fully mitigated

based on the normal civil penalty assessment process, the NRC exercised enforcement

discretion in accordance with Section VII.A.1 of the Enforcement Policy and proposed a base

civil penalty because the violation was assessed at Severity Level II and because it resulted in

an overexposure. 

J. L. Shepherd and Associates

San Fernando, California

EA 02-043

Docket Nos. 71-0122, 71-6280

On August 13, 2002, an Order Imposing Civil Monetary Penalty in the amount of $19,200 was

issued. The action was based on a Notice of Violation and Proposed Imposition of Civil Penalty

in the amount of $19,200 that was issued on June 11, 2002 for a Severity Level II problem

involving the willful failure to comply with a Certificate of Compliance with regard to fabrication

and shipment of packages. The licensee’s July 10, 2002, response did not deny that the

violations occurred as stated in the Notice, but requested mitigation of the penalty. After

considering the licensee’s response, the NRC concluded that the violations occurred as stated

and that there was not an adequate basis for mitigating the civil penalty.

South Pittsburgh Cancer Center

Pittsburgh, Pennsylvania

EA 01-132

Docket No. 030-34832

On August 22, 2001, a Notice of Violation and Proposed Imposition of Civil Penalty in the

amount of $8800 was issued for a Severity Level II violation involving the deliberate possession

of depleted uranium (in the form of bricks used for shielding within two linear accelerators)

without authorization in a specific license issued by the NRC. 
Significant Issues and Incident Investigations

PERMAGRAIN PRODUCTS, INC.

1.0 SITE IDENTIFICATION

Location: Karthaus, PA

License No.: 37-17860-01

Docket No.: 030-13573

License Status: Active

2.0 SITE STATUS SUMMARY

The Facility is located in the Quehanna Wild Area about 45 miles northwest of State College, PA.

License No. 37-17860-01 is issued to Permagrain Products, Inc. (PPI) for the operation of a Cobalt-60

irradiator.

While PPI is licensed to possess and use up to 2,000,000 curies of cobalt-60 to irradiate materials in an

underwater irradiator in northcentral Pennsylvania, less than 100,000 curies are actually at the facility. 

The irradiator was used to cross-link a plastic monomer in wood to make a durable flooring product used

in commercial and residential applications. Under NRC regulations in 10 CFR 30.35, PPI was required

to have financial assurance in the amount of $75,000. PPI had complied with the requirement by

providing NRC with a $75,000 letter of credit.

 

3.0 MAJOR TECHNICAL OR REGULATORY ISSUES

In response to deteriorating product demand and limits imposed on its operational line of credit, PPI

declared bankruptcy in the United State Bankruptcy Court, Eastern District of Pennsylvania, on

December 17, 2002. With the bankruptcy filing, the licensee had no resources to maintain or secure the

facility or to dispose of the sources and decommission the facility. Region I called in the letter of credit

on December 12, 2002 and coordinated with the Commonwealth of Pennsylvania to secure and maintain

the facility effective the day of the bankruptcy filing. On February 14, 2003, in recognition of the

Commonwealth’s limited funds to continue security and maintenance at the site, Region I requested that

U.S. Environmental Protection Agency (EPA) perform an emergency removal and disposal of the

sources. EPA responded to the Region I letter on February 13 indicating that they were proceeding to

gather information in support of implementing federal removal response activities at the site. 

The sealed cobalt-60 sources possessed by PPI are old and of low specific activity. New sources are

usually about 10,000 curies per source. All of the sources at PPI are less than 1000 curies and many are

less than 100 curies. Therefore, they have no economic value and probably will be disposed as

radioactive waste. 

Current estimates are that removal and disposal of the sources will cost between $1.5 million and $1.9

million, amounts considerably in excess of the financial assurance provided by the licensee.

Attachment 5
2

A soon-to-be-final rulemaking will require, among other things, that financial assurance for irradiators be

based on an actual cost estimate rather than a fixed amount specified in the regulations. As long as the

staff assures that the cost estimates for irradiators are thorough and complete (including, for example,

facility security and maintenance costs) that rulemaking should prevent similar problems at other

irradiators. However, the Permagrain case has highlighted the potential risk of financial assurance

instruments which may underestimate the actual cost of decommissioning a facility. 
3

FANSTEEL INC.

1.0 SITE IDENTIFICATION

Location: Muskogee, OK

License No.: SMB-911

Docket No.: 040-07580

License Status: Expired (possession only)

2.0 SITE STATUS SUMMARY

From 1958 until 1989, Fansteel Speciality Metals operated a process to recover tantalum,

niobium, scandium, and other metals of commercial value from ores and previous process

waste residues. Fansteel decontaminated approximately 35 acres of the 110-acre Muskogee

facility designated as the “Northwest Property,” and the NRC released this area for unrestricted

use. Fansteel has an NRC license dated March 25, 1997, to complete the processing of ore

residues, calcium fluoride residues, and wastewater treatment residues containing uranium and

thorium, in various site impoundments. In November, 2001, Fansteel notified NRC that it had

ceased operating the facility. The current license expired in September, 2002; the renewal

application was denied because Fansteel wrote off the cost of the facility in its bankruptcy and

did not provide sufficient financial assurance. 

On January 15, 2002, Fansteel and its U.S. subsidiaries filed for voluntary bankruptcy

(Chapter 11) in the U.S. Bankruptcy Court for the District of Delaware; one subsidiary in Mexico

and one in Barbados were not included in this action. On June 25, 2002, Fansteel submitted an

assessment of financial assurance (FA) in accordance with its license. The letter provided a

cost estimate and stated it could not obtain the $57 million in financial assurance -- the cost

estimate to decommission for unrestricted use filed with the bankruptcy court -- and asked

NRC to defer further consideration of FA until December 22, 2002. 

NRC engaged its financial assurance review contractor, ICF, to evaluate the Fansteel site and

develop cost estimates for decommissioning for unrestricted use and for restricted use, as

defined in Subpart E of 10 CFR 20. ICF provided a report on November 15, 2002 that showed

estimated decommissioning costs from $105 - $230 million; the differences are in disposal

costs of $5 - $17 per cubic foot. 

Fansteel submitted its decommissioning plan (DP) on January 16, 2003. In this DP, Fansteel

proposed an industrial land use scenario with the ground water pathway turned off. The

estimated cost is given as $26 million (plus $14 million for ground water and chemical

remediation for Oklahoma Dept. of Environment Quality (ODEQ); this is a significant reduction

from the $57 million estimate in the bankruptcy and the June 25 letter to NRC regarding

financial assurance. 

Staff has met several times with Fansteel to develop a plan for funding remediation of the

Muskogee site. Fansteel has not presented a plan acceptable to the NRC staff. 
4

3.0 MAJOR TECHNICAL OR REGULATORY ISSUES

Fansteel has provided a total of about $4.5 million in financial assurance. The previous

Fansteel estimate for decommissioning, by deposition to the Bankruptcy Court, is $57 million for

off-site disposal of all wastes greater than 10 pCi/g total rad, a license condition limit. The

revised estimate of $26 million is based on dose criteria of 10 CFR 20.1402 using an industrial

land use scenario with no ground water pathway. It estimates an additional $14 million for

commitments to ODEQ, primarily ground water remediation. Because it is in a bankruptcy

proceeding, Fansteel states it is not able to provide the additional assurance. The DP, except

portions of Chapter 15 - - financial assurance -- was received in January 16. The letter of

transmittal stated that the FA portion would be submitted by February 14. Staff met with

Fansteel and various counsel on December 18, February 5, and February 21 at NRC HQ. In

addition, there have been several other meetings and phone calls among the relevant parties. 

As of 26 March, 2003, Fansteel has not provided a plan to emerge from bankruptcy and fund

remediation of the Muskogee site that is acceptable to the NRC staff. 

Preliminary review of the DP indicates there are short comings in the characterization, the level

of detail about planned remedial activities, the final status survey, and, consequently, the cost

estimate. The staff is writing a letter rejecting the DP and instructing Fansteel to provide a

schedule for resubmittal. Without satisfactory site characterization and plan of activities, the

final cost to remediate cannot be reasonably estimated. 

Contaminants at the site include natural uranium and decay products, and natural thorium and

decay products. Chemical contamination in the form of metals including tantulum, niobium,

chromium, antimony, tin, barium, arsenic; ammonia fluoride and methyl isobutyl ketone are 

also present.

Groundwater contamination is non-uniformly distributed at the Fansteel site. Measurements

taken in the shallow groundwater zone during the Spring of 1993 ranged from 19 pCi/l to 2600

pCi/l gross alpha and from 59 to 1300 pCi/l gross beta. A Spring 1993, sampling and analysis

of three deep (bedrock) groundwater wells in the process area, and one in the NW property,

detected no concentrations above background levels. These wells were closed shortly

thereafter. Fansteel estimates $14 million to remediate the ground water in the shallow aquifer. 

Soil contamination is non-uniformly distributed at the Fansteel site. Gross alpha concentrations

range from 21 to 360 pCi/g; uranium concentrations range from 6.2 to 93 pCi/g; and

thorium concentrations range from 7.2 to 51 pCi/g. The depth of contamination ranges from the

ground surface to 7.9 m (26 ft) below, with the majority concentrated within the top 0.76 m (2.5

ft) of soil, but there is significant contamination deeper in the vicinity of the chemical processing

buildings and ponds 2 and 3. 

Preliminary radioactivity surveys indicate that surfaces and equipment in the following buildings

are contaminated: Chemical A, Chemical C, Thermite, Sodium Reduction, and Research &

Development Lab. 
5

Fansteel estimates that the volume of contaminated soil and other material for which metal

recovery operations are feasible and that must be transported off-site is 16,810 m3

(594,000 ft3

). “Offsite” is defined as any other area and may include areas currently owned by

Fansteel and located adjacent to the Eastern Property Area. 

There is public interest about the decommissioning of this site. There are two primary parties:

the State of Oklahoma and the Cherokee Nation. The State Office of the Attorney General has

a representative participate in the meetings with Fansteel. ODEQ is also reviewing the DP. 

The Nation is interested because the Fansteel property is within its area of influence in eastern

Oklahoma. 
6

SAFETY LIGHT CORPORATION

1.0 SITE IDENTIFICATION

Location: Bloomsburg, PA

License No.: 37-00030-02

Docket No.: 030-05980

License Status: Active

2.0 SITE STATUS SUMMARY

The Safety Light Corporation (SLC) facility is located about five miles east of Bloomsburg,

Pennsylvania. SLC is licensed (37-00030-02) to perform site characterization and

decommissioning activities. The SLC site is contaminated from manufacturing operations of

self-luminous watch and instrument dials and other items involving Ra-226, Cs-137, Sr-90, and

Am-241. The site is approximately 10 acres in size and contains about 16 buildings. Work with

radioactive materials (Ra-226) began at the site in 1948. License 37-00030-08 is still active for

H-3 exit sign work utilizing a full time staff of about 20 individuals.

Radioactive waste was disposed on site in three primary locations: silos, lagoons, and a waste

dump. In the fall of 1999, the licensee began removal of the radioactive material from the two

underground silos. This radioactive material is currently stored on site in 55 gallon drums and

B-25 boxes awaiting further processing/sorting prior to disposal.

NRC staff continue to coordinate activities with Environmental Protection Agency (EPA) and

Pennsylvania Department of Environmental Protection (PADEP) regarding remediation of the

SLC site. An EPA Administrative Order of Consent (AOC) with SLC for the sorting,

characterization, and re-packaging of the drums of mixed waste and radioactive waste that

were removed from the onsite silos, became effective on February 3, 2003. On August 15,

2002, NRC amended the SLC license to approve the work plan for this activity, as did PADEP. 

A separate EPA Order will be prepared for disposal of the waste. If disposal costs exceed the

licensee’s decommissioning funds, EPA could propose a unilateral Order and use EPA

emergency removal funds. 

With renewal of License No. 37-00030-02 in December 1994 for a five year period, SLC

entered into a settlement agreement with the NRC to place funds into a trust account and

contributed $348,000 over five years. USR Industries, a previous responsible party, contributed

an additional $48,000. The licensee also received insurance settlements in the amounts of $1.3

million and $500,000. These funds are for site maintenance and decommissioning. With the

renewal of the license in December 1999, SLC is required to contribute to the trust account a

total of $492,000 over the five year term of the renewal.
7

3.0 MAJOR TECHNICAL OR REGULATORY ISSUES

A 1995 site characterization identified primary soil contaminates as Ra-226 and Cs-137 with

small amounts of Am-241. The onsite ground water is also contaminated with H-3, Sr-90, and

Cs-137. The 1998 site decommissioning and decontamination (D&D) report submitted to the

NRC called for a “task by task” approach to decommissioning because of limited funding

availability. Estimated decommissioning costs were approximately $15 million, excluding 

H-3 waste.

A more recent decommissioning cost estimate (DCE), submitted in 2000, estimated the

decommissioning costs at $29 million, including the H-3 waste. Review by NRC found the DCE

significantly underestimated the costs for soil removal. Staff estimates DCE for unrestricted

release to be between $94-$120 million.

Lack of financial assurance remains the key issue; effective remediation work cannot be

performed because of limited funding. The licensee is proposing that the remaining funds be

used to characterize, re-package and dispose of waste that was removed from underground

silos. Other decommissioning tasks have been outlined and estimated in the licensee

Decommissioning Plan and DCEs that were submitted in 2001.

In December 2001, NRC requested that EPA Region 3 conduct a preliminary site assessment

for the purpose of scoring the site for inclusion on the National Priorities List and possible

remediation under the Comprehensive Environmental Response, Compensation and Liability

Act (CERCLA). EPA has completed the scoring package. When the package is sent to EPA

Headquarters for review, a copy will be shared with NRC. 

NRC staff submitted a claim in December 2001 against USR Industries (de jure licenses of

NRC for the Bloomsburg facility) before the US Bankruptcy Court for the Southern District of

Texas. However, in April and June 2002, the bankruptcy claims were dismissed by the Court,

because the debtor failed to prosecute.

Coordination activities continue between NRC, EPA, and PADEP staffs to develop a path

forward for this site. The last joint telephone conference was held on February 7, 2003.
8

SCHLUMBERGER TECHNOLOGY CORPORATION

1.0 SITE IDENTIFICATION

Location: Sugar Land, TX

License No.: 42-00090-03

Docket No.: 030-06388

License Status: Active

2.0 SITE STATUS SUMMARY

A Region IV well-logging licensee, Schlumberger Technology Corporation (STC), notified the

NRC Operations Center, on May 23, 2002, of an incident involving the loss of control of a

radiation source and possible unplanned exposures of 31 oil rig workers. The source was a

cesium-137 well-logging source of 44 gigabequerel (1.2 Ci) nominal activity, and the incident

occurred on an oil rig in Montana during drilling operations. Region IV conducted a special

inspection on May 25-26, 2002, to determine the facts of the event, interview the workers

involved, and calculate preliminary dose estimates for the exposed workers.

The licensee submitted its report of the event to the NRC on June 26, 2002. In its report, the

licensee estimated that the highest dose to any worker, based on time-and-motion

reconstructions of the event and some conservative assumptions, was 0.064 Sv (6.4 rem). To

support its bounding dose calculations, the licensee had blood tests performed on 10 of the

workers involved in the event. These tests were routine blood counts done at a local hospital,

and were intended to rule out high radiation exposures by showing that there were no

abnormally low blood counts. The workers were advised to forward their test results to the

Radiation Emergency Assistance Center/Training Site (REAC/TS) for interpretation, and six of

the 10 workers who took the tests sent their blood test results. 

REAC/TS did not find any indications of radiation dose based on its examination of the blood

sample results for these workers. REAC/TS did recommended that one of the workers

(Worker D) be advised that a cytogenetic test be done. Since REAC/TS currently does not

provide cytogenetic testing, the Armed Forces Radiobiology Research Institute (AFRRI) in

Bethesda conducted this test. NRC was informed of the cytogenetic test results on

August 30, 2002. The results showed a radiation dose on the order of 2 Gy (200 rad) whole

body equivalent. The radiation dose assessment completed by the NRC for this worker

indicated that the most likely dose was less than 1 cGy (1 rad). 

NRC upgraded the inspection effort to an Augmented Inspection Team (AIT) because of the

significant discrepancies between the estimated radiation doses and the cytogenetic test

results, and because of the potential for a high radiation dose to a member of the public.
9

NRC decided to repeat the cytogenetic tests for this individual and six other workers who were

exposed. In addition, NRC decided to split the blood samples three ways and send these split

samples to three different laboratories, one being AFRRI, and the others being the National

Radiological protection Board (NRPB) in England, and the Institute for Radiation Protection

(IRD) in Brazil. 

The results of this second round of testing, as reported by NRPB, were negative, that is,

showed zero radiation dose for all but Worker D who had the AFRRI reported dose of 2 Gy. 

The results from NRPB for Worker D showed a slightly elevated chromosome dicentric

frequency, which corresponded to an equivalent whole-body dose in the range of 0-14 cGy 

(0-14 rad), with a mean of 4 cGy (4 rad). The samples sent to IRD did not pass the Brazilian

customs and were not analyzed.

The cytogenetic test results from AFRRI agreed with those of NRPB for all the workers and

showed no radiation dose, except for Worker D for whom AFRRI estimated a dose of 1.3-1.5

Gy (130-140 rad). The cytogenetic test slides from NRPB for Worker D were sent to IRD in

Brazil for evaluation, and slides from AFRRI’s second test for Worker D were sent to IRD for

evaluation. Also, the slides from AFRRI’s initial cytogenetic test for Worker D were sent to

NRPB for evaluation.

Without discussing specifics of the cytogenetic results from the three labs, there appeared to be

considerable disagreements in their results. To summarize.

• Results from IRD and NRPB are in agreement, and indicate very low to zero

doses for all workers

• Results for AFRRI agreed with IRD and NRPB for all samples except for

Worker D.

• Although NRPB and IRD both found very low to zero radiations doses for Worker

D, AFRRI reported a radiation dose of 1 Gy (100 rad).

• Discussions between NRC and the three labs led to a probable cause for the

disagreements, which involved an unusual characteristic for Worker D ‘s

chromosomes, which resulted in some of Worker D’s chromosomes, viewed

under the microscope, to look like dicentrics, thus giving an erroneously high

radiation dose estimate.

Based on NRC’s radiation dose estimates, the most probable doses received by all of the

exposed workers are in the range of 0-1 cSV (0-1 rem). Most of the radiation doses are

estimated to be at or slightly above NRC’s dose limit for members of the public of 0.1 cSv

(0.1 rem) per year.
10

3.0 MAJOR TECHNICAL OR REGULATORY ISSUES

AFRRI’s cytogenetic facility is the only lab in the United States that is currently available to the

NRC for cytogenetic testing on an ongoing and on-demand basis for use in radiation dose 

assessments. Although AFRRI has been of assistance in the past, and may be able to assist

NRC in the future, there are several significant considerations including:

• The turn-around time for the results, the time from delivery of a blood sample to

the lab to receipt of the results of the cytogenetic test is currently at least

3 weeks per sample.

• It is unsatisfactory to have only one lab engaged in this activity, because this

leaves no means of verifying the validity of the one lab’s methods and results by

comparison with the results of other labs on a routine, controlled, and ongoing

basis, which is normal practice for any activity involving accurate measurements.

With only one laboratory in the United States currently available, this significantly limits the

capability to reliably perform cytogenetic blood testing.
INEEL/EXT-02-00358 (FY 2002 QTR 4)

January 2003

Nuclear Materials

Events Database

(NMED) Quarterly

Report

Fourth Quarter Fiscal Year 2002

Samuel L. Pettijohn, NRC

Stephen B. Conroy, INEEL

 Attachment 6
NOTICE

This information was prepared as an account of work sponsored by an agency

of the U.S. Government. Neither the U.S. Government nor any agency thereof,

nor any of their employees, makes any warranty, express or implied, or assumes

any legal liability or responsibility for any third party’s use, or the results of

such use, of any information, apparatus, product, or process disclosed herein, or

represents that its use by such third party would not infringe privately owned

rights. The views expressed herein are not necessarily those of the U.S. Nuclear

Regulatory Commission.
INEEL/EXT-02-00358 (FY 2002 QTR 4)

Nuclear Materials Events Database

(NMED) Quarterly Report

Fourth Quarter Fiscal Year 2002

Samuel L. Pettijohn, NRC

Stephen B. Conroy, INEEL

Published January 2003

http://nmed.inel.gov

Idaho National Engineering and Environmental

Laboratory

Risk, Reliability and Regulatory Support

Department

Idaho Falls, Idaho 83415

Prepared for the

U.S. Nuclear Regulatory Commission

Office of Nuclear Material Safety and Safeguards

Under DOE Idaho Operations Office

Contract DE-AC07-99ID13727
CONTENTS

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

PERFORMANCE MEASURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. INTRODUCTION ...................................... 1

1.1 Overview and Objectives ......................... 1

1.2 NMED Database ................................ 1

2. ANALYSIS OF NMED DATA ............................ 3

2.1 All NMED Events ............................... 3

2.2 Medical Events (MD2) ........................... 4

2.3 Radiation Overexposures (EXP) .................... 5

2.4 Release of Licensed Material or Contamination (RLM) . 6

2.5 Loss of Control of Material (LAS) .................. 7

2.6 Leaking Sealed Sources (LKS) ..................... 8

2.7 Equipment Problems (EQP) ....................... 9

2.8 Transportation (TRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.9 Other (OTH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Appendix A - Event Type Descriptions and Criteria

FIGURES

1. All NMED Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2. MD2 Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. MD2 Event Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4. MD2 Event Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . 4

5. MD2 Event Therapeutic and Diagnostic Procedures . . . . . . . . . . . . 4

6. EXP Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

7. EXP Event Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8. EXP Event Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . 5

9. EXP Event Exposures ................................... 5

10. RLM Events .......................................... 6

11. RLM Event Causes .................................... 6

12. RLM Event Reporting Requirements ...................... 6

13. RLM Event Releases ................................... 6

14. LAS Events .......................................... 7

15. LAS Event Causes ..................................... 7

16. LAS Event Reporting Requirements ....................... 7

17. LAS Event Losses ..................................... 7

18. LKS Events .......................................... 8

19. LKS Event Causes ..................................... 8

20. LKS Event Reporting Requirements ....................... 8

21. LKS Event Sealed Sources .............................. 8

22. EQP Events .......................................... 9
23. EQP Event Causes ..................................... 9

24. EQP Event Reporting Requirements ....................... 9

25. EQP Equipment ....................................... 9

26. TRS Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

27. TRS Event Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

28. TRS Event Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . 10

29. TRS Event Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

30. OTH Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ABSTRACT

This quarterly report presents information on trending and analysis of

incidents/accidents (events) reported to the Nuclear Regulatory Commission

(NRC) that involve radioactive materials. The events are reported by NRC

licensees, Agreement States, and non-licensees, and are recorded in the NRC’s

Nuclear Materials Events Database (NMED). The reported events are classified

into nine categories and “Other.” The categories are based on event reporting

requirements defined in Title 10 of the Code of Federal Regulations. The 

categories are (1) Medical Events, (2) Radiation Overexposures, (3) Release of

Licensed Material or Contamination, (4) Loss of Control of Material, (5)

Leaking Sealed Sources, (6) Equipment Problems, (7) Transportation, (8) Fuel

Cycle Facility Events, and (9) Non-Power Reactor Events. The scope of the

NMED quarterly report is limited to a discussion and evaluation of categories (1)

through (7) and “Other.” Events involving fuel cycle facilities and non-power

reactors are excluded from this report due to the significant difference in

operation of these facilities compared to the operation of other facilities licensed

by NRC and Agreement States to use by-product, source, and special nuclear

material. Data on trending and analysis of reported events are presented by

cause, reporting requirements, event type, and corrective actions for each of the

categories. Data on these events are presented for an 18-month period (trending)

covering April 1, 2001 through September 30, 2002. Data on reportable events

tracked by the NRC as performance measures under the FY 2000 - 2005

Strategic Plan are presented on page ix.

Copies of this report are available on the Internet at http://nmed.inel.gov.
EXECUTIVE SUMMARY

The Nuclear Regulatory Commission’s Nuclear Materials Events Database contains records of events

involving nuclear materials reported to the NRC by NRC licensees, Agreement States, and non-licensees.

The reported events are classified based on event reporting requirements defined by Title 10 of the Code

of Federal Regulations. The event reports are evaluated to identify any safety-significant events and

concerns, and their causes. The reported information aids understanding of why the events occurred and

in identifying any actions necessary to improve the effectiveness of the nuclear material regulatory

program. Events involving fuel cycle facilities and non-power reactor events are excluded from this

report due to the significant difference in operation of these facilities compared to the operation of other

facilities licensed by the NRC and Agreement States to use by-product, source, and special nuclear

material.

EQP - Equipment Problems

EXP - Radiation Overexposures

LAS - Loss of Control of Material

LKS - Leaking Sealed Sources

MD2 - Medical Events

OTH - Other

RLM - Release of Licensed Material

or Contamination

TRS - Transportation

Eight hundred fifty-two events were reported during the 18-month period. One hundred twenty-eight of

these events were reported during the current quarter. 

Forty-nine percent of the reported events were classified as Loss of Control of Material.

The remaining 51% of events were divided between Equipment Problems (21%), Leaking Sealed

Sources (9%), Transportation (7%), Medical Events (6%), Radiation Overexposures (4%),

Release of Licensed Material or Contamination (2%), and Other (2%).

The event reporting rate is about 2.7 events per 100 licensees annually for all events, and about 0.7

events per 100 licensees annually for Medical Events. This is based on an estimate of about 21,000

material licensees (about 6,000 NRC licensees and 15,000 Agreement State licensees) that reported 568

events (annual rate) and about 5,000 medical licensees that reported 37 Medical Events (annual rate).

This indicates that, annually, only 2.7% of all licensees report any type of incident/accident involving
licensed material. For incidents involving Medical Events, less than 1% of medical licensees report an

event annually. 

PERFORMANCE MEASURES

All NMED reportable events for Radiation Overexposures, Medical Events, Loss of Material,

Malevolent Acts (intentional violation), and Release of Material (reporting requirement 10 CFR

20.2203(a)(3)(ii) only) are tracked by the NRC as performance measures under the NRC FY 2000 - 2005

Strategic Plan. The NRC Strategic Plan is available on the NRC’s website at www.nrc.gov.

The following charts show Fiscal Year 2002 performance measures as a percentage of the annual limits.

Data for the performance measure charts represent data at the close of Fiscal Year 2002 (i.e., data 

through September 30, 2002). Slight variations between these data and data presented in the body of the

report (downloaded on January 9, 2002) may exist. 
Nuclear Materials Events Database (NMED) Quarterly

Report: Fourth Quarter Fiscal Year 2002

1. INTRODUCTION

1.1 Overview and Objectives

Nuclear materials event reports are evaluated to

identify any safety-significant events and

concerns, their causes, and corrective actions.

The reported information aids understanding of

why the events occurred and in identifying any

actions necessary to improve the effectiveness

of the nuclear material regulatory program.

A database for tracking nuclear materials events

was developed by the Nuclear Regulatory

Commission (NRC) in 1981. In 1993, using

existing materials events databases, the NRC

developed a new and more comprehensive

database for tracking materials events. This

database, designated the Nuclear Materials

Events Database (NMED), contains records of

events involving nuclear materials reported to

the NRC by NRC licensees, Agreement States,

and non-licensees. The database is maintained

by the Idaho National Engineering and

Environmental Laboratory (INEEL) and

contains almost 14,000 records of materials

events submitted to the NRC from

approximately January 1990 through

September 2002.

The reported events are classified into nine

primary categories and “Other,” based on event

reporting requirements defined by Title 10 of

the Code of Federal Regulations (CFR). The

categories are (1) Medical Events, (2) Radiation

Overexposures, (3) Release of Licensed

Material or Contamination, (4) Loss of Control

of Material, (5) Leaking Sealed Sources, (6)

Equipment Problems, (7) Transportation, (8)

Fuel Cycle Facility Events, and (9) Non-Power

Reactor Events. The scope of the NMED

quarterly report is limited to a discussion and

evaluation of categories (1) through (7) and

“Other.” Events involving fuel cycle facilities

and non-power reactors are excluded from this

report due to the significant difference in

operation of these facilities compared to the

operation of other facilities licensed by NRC

and Agreement States to use by-product, source,

and special nuclear material. A description of

categories addressed in this report and

associated screening criteria is contained in

Appendix A.

1.2 NMED Database

The NMED accommodates multiple events in a

single report to be recorded and tracked. For

example, a report may describe a loss of control

of licensed material that also resulted in an

overexposure. In such a case, both events are

recorded in the NMED and identified by the

same report number. The NMED Quarterly

Report, which provides a summary of event data

contained within the NMED, has been designed

to further enhance the usefulness of the

database. Data presented in this report were

downloaded from the NMED on

January 9, 2002. Be aware that the NMED is a

dynamic database and updated daily. Therefore,

slight variations in quarterly data may be

encountered. Also note that, even though many

events were reported and entered in the database

for record keeping, only those events required to

be reported under 10 CFR are addressed in this

report.

In summary, this report focuses on reportable

events that occurred between April 1, 2001 and

September 30, 2002 that were entered into

NMED prior to the data download on January 9,

2002. More specifically, this report includes a

depiction of selected NMED 18-month trend

data, and a breakdown of event causes, reporting

categories, and event type data.
Performance measures data are presented on

page ix. Appendix A presents a detailed

description of the NMED data categories

discussed in this report.

Reporting guidance for Agreement States is

presented in the Handbook on Nuclear Material

Event Reporting in the Agreement States. The

handbook is an appendix to the NRC Office of

State Programs Procedure SA-300, Reporting

Material Events. Access to NMED is available

to the NRC and Agreement State staff at

http://nmed.inel.gov.

For assistance on searches or to answer other

questions, contact Sam Pettijohn (slp@nrc.gov),

(301) 415-6822.
2. ANALYSIS OF NMED DATA

Event reports involving nuclear materials submitted to the NRC are reviewed, categorized, and entered

into the NMED. Eighteen-month trend charts with quarterly data points were developed to show general

data trends. For this report, Fiscal Quarter 02-4 and 18-month event data were evaluated.

Several event reports did not contain sufficient information to determine the event causes. Such events

were categorized as “Insufficient Information” concerning the event causes.

2.1 All NMED Events

Figure 1. All NMED Events (18-months)

Figure 1 displays the number of NMED events that occurred per fiscal quarter during the 18-month

period. The following observations were made concerning NMED events reported in the 18-month

period:

Eight hundred fifty-two reportable events occurred in the 18-month period.

Events averaged 142 per quarter, with 128 events occurring in Fiscal Quarter 02-4.
2.2 Medical Events (MD2)

Figure 2. MD2 Events (18-months)

Figure 4. MD2 Event Reporting

Requirements (18-months)

Figure 3. MD2 Event Causes (18-months)

Figure 5. MD2 Event Therapeutic and

Diagnostic Procedures (18-months)

Figures 2 through 5 display the number per quarter and breakdown of reportable MD2 events occurring

for the 18-month period. The following observations were noted:

Fifty-five MD2 events occurred in the 18-month period.

1.06 Events averaged nine per quarter, with six events in Fiscal Quarter 02-4.

1.07 Staff inattention to detail and procedure non-compliance were the causes of over half the events.

1.08 Most MD2 events involved prescribed dose deviations or wrong treatment sites (an event can be

associated with more than one reporting requirement).

1.09 Almost 80% of the incidents involved radiopharmaceuticals and brachytherapy treatments (one

radiopharmaceutical event involved 61 patients). (An event can involve more than one type of
procedure.)

2.3 Radiation Overexposures (EXP)

Figure 6. EXP Events (18-months)

Figure 8. EXP Event Reporting

Requirements (18-months)

Figure 7. EXP Event Causes (18-months)

Figure 9. EXP Event Exposures (18-

months)

Figures 6 through 9 display the number per quarter and breakdown of reportable EXP events occurring

for the 18-month period. The following observations were noted:

Thirty-one EXP events occurred in the 18-month period.

1.11 Events averaged five per quarter, with two events in Fiscal Quarter 02-4.

1.12 Procedure non-compliance and staff inattention to detail caused most of the events.

1.13 The majority of the EXP events involved exceeding occupational dose limits (an event can

involve more than one type of reporting requirement).

1.14 Over half of the events involved radiography (an event can involve more than one type of

exposure). A single “Other” event in Fiscal Quarter 02-3 involved the 31 individual exposures
from a well logging source.
2.4 Release of Licensed Material or Contamination (RLM)

Figure 10. RLM Events (18-months)

Figure 12. RLM Event Reporting

Requirements (18-months)

Figure 11. RLM Event Causes (18-months)

Figure 13. RLM Event Releases (18-

months)

Figures 10 through 13 display the number per quarter and breakdown of reportable RLM events

occurring for the 18-month period. The following observations were noted:

Twenty-one RLM events occurred in the 18-month period.

1.16 Events averaged four per quarter, with five events in Fiscal Quarter 02-4.

1.17 Defective/failed equipment was the largest single causal category.

1.18 The majority of the EXP events involved unplanned contamination (an event can be associated

with more than one reporting requirement).

1.19 Three-quarters of the events involved surface contamination (an event can involve more than one

type of contamination).
2.5 Loss of Control of Material (LAS)

Figure 14. LAS Events (18-months)

Figure 16. LAS Event Reporting

Requirements (18-months)

Figure 15. LAS Event Causes (18-months)

Figure 17. LAS Event Losses (18-months)

Figures 14 through 17 display the number per quarter and breakdown of reportable LAS events occurring

for the 18-month period. The following observations were noted:

Four hundred twenty LAS events occurred in the 18-month period.

1.21 Events averaged 70 per quarter, with 55 events in Fiscal Quarter 02-4.

1.22 Loss of administrative control, insufficient information reported, and malicious act were the

largest causal categories.

1.23 The majority of the LAS events involved lost or stolen material (an event can be associated with

more than one reporting requirement).

1.24 Almost half of the events involved lost material, followed by alarming gate monitors and stolen

material.
2.6 Leaking Sealed Sources (LKS)

Figure 18. LKS Events (18-months)

Figure 20. LKS Event Reporting

Requirements (18-months)

Figure 19. LKS Event Causes (18-months)

Figure 21. LKS Event Sealed Sources (18-

months)

Figures 18 through 21 display the number per quarter and breakdown of reportable LKS events occurring

for the 18-month period. The following observations were noted:

Seventy-four LKS events occurred in the 18-month period.

1.26 Events averaged 12 per quarter, with 17 events in Fiscal Quarter 02-4.

1.27 Defective or failed material and parts were the largest causal categories.

1.28 All but one of the LKS events involved either failed equipment or removable radioactive material

(an event can be associated with more than one reporting requirement).

1.29 Over half of the events involved ECDs.
2.7 Equipment Problems (EQP)

Figure 22. EQP Events (18-months)

Figure 24. EQP Event Reporting

Requirements (18-months)

Figure 23. EQP Event Causes (18-months)

Figure 25. EQP Equipment (18-months)

Figures 22 through 25 display the number per quarter and breakdown of reportable EQP events occurring

for the 18-month period. The following observations were noted:

One hundred eighty-one EQP events occurred in the 18-month period.

1.31 Events averaged 30 per quarter, with 32 events in Fiscal Quarter 02-4.

1.32 Defective or failed parts was the largest causal category.

1.33 Over three quarters of the EQP events involved equipment failing to function (an event can be

associated with more than one reporting requirement).

1.34 Over half of the events involved “Other” event types, while the remainder was split primarily

between medical sealed sources and radiography exposure devices.
2.8 Transportation (TRS)

Figure 26. TRS Events (18-months)

Figure 28. TRS Event Reporting

Requirements (18-months)

Figure 27. TRS Event Causes (18-months)

Figure 29. TRS Event Materials (18-

months)

Figures 26 through 29 display the number per quarter and breakdown of reportable EQP events occurring

for the 18-month period. The following observations were noted:

Fifty-seven TRS events occurred in the 18-month period.

1.36 Events averaged 10 per quarter, with six events in Fiscal Quarter 02-4.

1.37 Procedure non-compliance and staff inattention to detail were the largest specified causal

categories.

1.38 Over half of the events involved 10 CFR 71.5 non-compliance (an event can be associated with

more than one reporting requirement).

1.39 Most of the events involved shipping containers or unsealed material during transportation.
2.9 Other (OTH)

Figure 30. OTH Events (18-months)

Figure 30 display the number per quarter and breakdown of reportable OTH events occurring for the

18-month period. The following observations were noted:

Thirteen OTH events occurred in the 18-month period.

1.41 Events averaged two per quarter, with five events in Fiscal Quarter 02-4.
Appendix A

Event Type Descriptions and Criteria
Appendix A

Event Type Descriptions and Criteria

The NMED events covered by this report are divided into the following categories based on the event

reporting requirements defined in 10 CFR.

Medical Events (MD2)

Medical events (formerly referred to as medical misadministrations) are defined in 10 CFR Part 35 as

follows:

1. A radiopharmaceutical dosage greater than 30 microcuries of either sodium iodide I - 125 or I - 131: 

- Involving the wrong individual, or wrong radiopharmaceutical; or

- When both the administered dosage differs from the prescribed dosage by more than 20 percent of

the prescribed dosage and the difference between the administered dosage and prescribed dosage

exceeds 30 microcuries. 

2. A therapeutic radiopharmaceutical dosage, other than sodium iodide I - 125 or I - 131: 

- Involving the wrong individual, wrong radiopharmaceutical, or wrong route of administration; or

- When the administered dosage differs from the prescribed dosage by more than 20 percent of the

prescribed dosage. 

3. A gamma stereotactic radiosurgery radiation dose: 

- Involving the wrong individual, or wrong treatment site; or

- When the calculated total administered dose differs from the total prescribed dose by more than 10

percent of the total prescribed dose. 

4. A teletherapy radiation dose: 

- Involving the wrong individual, wrong mode of treatment, or wrong treatment site;

- When the treatment consists of three or fewer fractions and the calculated total administered dose

differs from the total prescribed dose by more than 10 percent of the total prescribed dose; 

- When the calculated weekly administered dose exceeds the weekly prescribed dose by 30 percent

or more of the weekly prescribed dose; or

- When the calculated total administered dose differs from the total prescribed dose by more than 20

percent of the total prescribed dose. 

5. A brachytherapy radiation dose: 

- Involving the wrong individual, wrong radioisotope, or wrong treatment site (excluding, for

permanent implants, seeds that were implanted in the correct site but migrated outside the

treatment site);

- Involving a sealed source that is leaking; 

- When, for a temporary implant, one or more sealed sources are not removed upon completion of

the procedure; or

- When the calculated administered dose differs from the prescribed dose by more than 20 percent of

the prescribed dose. 

6. A diagnostic radiopharmaceutical dosage, other than quantities greater than 30 microcuries of either

sodium iodide I - 125 or I - 131, both: 

- Involving the wrong individual, wrong radiopharmaceutical, wrong route of administration, or
A-ii

when the administered dosage differs from the prescribed dosage; and

- When the dose to the individual exceeds 5 rems effective dose equivalent or 50 rems dose

equivalent to any individual organ.

Events are not considered MD2 events if they involve: 

1. Only accelerator produced radiopharmaceuticals.

2. Only a linear accelerator.

3. A dose calculation error made by the prescribing physician that was administered as (incorrectly)

prescribed.

4. Patient intervention.

Events are considered MD2 events if they involve: 

1. A radiopharmaceutical containing by-product material was prescribed, but a radiopharmaceutical

containing accelerator produced material was administered. 

2. A radiopharmaceutical containing accelerator produced material was prescribed, but a

radiopharmaceutical containing by-product material was administered. 

3. A linear accelerator is used for therapy by mistake instead of a teletherapy unit or a teletherapy unit

instead of a linear accelerator.

MD2 events occur to patients only. Hospital patients are always considered to be patients, rather than

members of the general public, for purposes of determining whether to categorize an event as an MD2 or

EXP event. For example, if a patient was administered a radiopharmaceutical that was prescribed for

another patient, the event would be categorized as an MD2 event (radiopharmaceutical given to the

wrong patient) rather than an EXP event.

Radiation Overexposures (EXP)

The EXP event category includes all regulatory overexposures of radiation workers or exposures of

members of the public to radiation. The overexposure can be external or internal and can be whole body,

extremity, skin, lens of the eye, or internal dose. When the overexposure involves multiple individuals or

an individual with multiple overexposure types (such as whole body and extremity), the different types of

overexposures are classified into the NMED Event Table separately. Note that dosimeters record

exposure if improperly stored near a radiation source and, depending on the type of dosimeter, may react

as though they are in a radiation field when exposed to heat or humidity. It is NRC policy to classify only

those events that positively involve a personnel overexposure, and not just a dosimeter exposure, as

reportable EXP events. For example, either the licensee does not contest the personnel overexposure, or

in cases where the licensee does contest the overexposure, the State or NRC determines the event to be

personnel overexposure. EXP events are categorized as follows:

1. A total effective dose equivalent of 0.25 Sv (25 rem) or more.

2. A total effective dose equivalent exceeding 0.05 Sv (5 rem) in a period of 24 hours.

3. An eye dose equivalent of 0.75 Sv (75 rem) or more.

4. An eye dose equivalent exceeding 0.15 Sv (15 rem) in a period of 24 hours.

5. A shallow-dose equivalent to the skin or extremities of 2.5 Gy (250 rads) or more.

6. A shallow-dose equivalent to the skin or extremities exceeding 0.5 Sv (50 rem) in a period of 24
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hours.

7. A dose in excess of the occupational dose rate for adults in 20.1201.

8. A dose in excess of the occupational dose limits for a minor in 20.1207.

9. A dose in excess of the limits for an embryo/fetus of a declared pregnant woman in 20.1208.

10. A dose in excess of the limits for an individual member of the public in 20.1301

11. A dose in excess of any applicable limit in the license.

Release of Licensed Material or Contamination (RLM)

The RLM event category includes two types of events. The first type is a radioactive release to air or

water exceeding the old 10 CFR Part 20 appendix governing maximum permissible concentrations

(MPCs) or the new 10 CFR Part 20 appendix containing annual limit on intakes (ALIs). The second type

of RLM event involves contamination events such as a radioactive spill outside of work areas, removable

contamination found on equipment, or material tracked around a laboratory such that additional

radiological control measures had to be implemented. This category does not include spills inside of

laboratory hoods, radiopharmaceutical dose preparation areas, or hot cells where radioactive work

routinely requires cleanup or changing of absorbent paper after the performance of a task. Should there

be multiple release types (e.g., surface, or air, or water) or areas of contamination associated with the

release, this information is classified individually into the NMED Event Table. RLM events are

categorized as follows:

1. An unplanned contamination event that requires access to the contaminated area, by workers or the

public, to be restricted for more than 24 hours by imposing additional radiological controls or by

prohibiting entry into the area.

2. An unplanned contamination event that involves a quantity of material greater than five times the

lowest ALI specified in Appendix B of 10 CFR 20.

3. An unplanned contamination event that has access to the area restricted for a reason other than to

allow isotopes with a half-life of less than 24 hours to decay prior to decontamination.

4. The release of radioactive material, inside or outside of a restricted area, such that had an individual

been present for 24 hours, the individual could have received an intake five times the ALI (the

provisions of this paragraph do not apply to locations where personnel are not normally stationed

during routine operations, such as hot-cells or process enclosures).

5. The release of radioactive material, inside or outside of a restricted area, such that had an individual

been present for 24 hours, the individual could have received an intake in excess of one ALI (the

provisions of this paragraph do not apply to locations where personnel are not normally stationed

during routine operations, such as hot-cells or process enclosures).

6. Levels of radiation or concentrations of radioactive material in a restricted area in excess of any

applicable limit in the license.

7. Levels of radiation or concentrations of radioactive material in an unrestricted area in excess of 10

times any applicable limit set forth in 10 CFR 20 or in the license (whether or not involving

exposures of any individual in excess of the limits in 10 CFR 20.1301).
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8. For licensees subject to the provisions of the Environmental Protection Agency’s (EPA's) generally

applicable environmental radiation standards in 40 CFR 190, levels of radiation or releases of

radioactive material in excess of those standards, or of license conditions related to those standards.

9. An event that requires unplanned medical treatment at a medical facility of an individual with

spreadable radioactive contamination on the individual's clothing or body.

10. An unplanned fire or explosion damaging any licensed material or any device, container, or

equipment containing licensed material when the quantity of material involved is greater than five

times the lowest ALI specified in Appendix B of 10 CFR 20.

Loss of Control (LAS)

The LAS event category includes those events where licensed radioactive material is lost or found,

abandoned or discovered, and stolen or recovered. The radioactive material involved can be sealed or

unsealed material, specifically or generally licensed, exempt or non-exempt quantities, involve a licensee

or a non-licensee, and can be found anywhere. Abandoned well logging sources are included in this

category. LAS events are categorized as follows: 

1. Any lost, stolen, or missing licensed material in an aggregate quantity greater than or equal to 1,000

times the quantity specified in Appendix C to 10 CFR 20 under such circumstances that it appears to

the licensee that an exposure could result to persons in unrestricted areas. 

2. Any lost, stolen, or missing licensed material in a quantity greater than 10 times the quantity

specified in Appendix C to 10 CFR 20.

3. An irretrievable well logging source.

4. An attempt made, or believed to have been made, to commit a theft or unlawful diversion of more

than 10 Ci of H-3 at any one time or more than 100 Ci in any one calendar year.

5. An attempt made, or believed to have been made, to commit a theft or unlawful diversion of more

than 15 pounds of source material at any one time or more than 150 pounds of source material in any

one calendar year.

6. An attempt made, or believed to have been made, to commit a theft or unlawful diversion of special

nuclear material.

7. Any loss (other than normal operating loss), theft, or unlawful diversion of special nuclear material.

Leaking Sealed Sources (LKS)

The LKS event category includes events involving leaking sealed sources. The NRC requires that most

sealed sources be periodically leak tested to verify that the material is still sealed and that the source is

still considered safe to use without protective clothing such as gloves. A source is considered leaking if a

leak test can detect greater than 0.005 μCi of removable radioactive material. The leaking source is then

removed from service, disposed of or returned to the manufacturer for repair, and a report is sent to the

NRC or Agreement State with the details of the leaking source. For regulatory reporting purposes, a

leaking source is generally considered a failed device under 10 CFR 30. Some specific reporting criteria

are also listed in 10 CFR 31 (generally licensed material), 10 CFR 34 (radiography), and 10 CFR 35

(medical use of byproduct material).
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Equipment Problems (EQP)

The EQP event category includes all types of radiological equipment problems, including generally

licensed device problems covered in 10 CFR 31; radiography equipment problems covered in 10 CFR 34;

irradiator problems covered in 10 CFR 36; well logging problems covered in 10 CFR 39, and other types

of equipment covered in 10 CFR 30, 40, 70, and 76. EQP events are defined as the failure of, or a defect

in, any piece of equipment that either contains licensed radioactive materials as an integral part, or whose

function is to interact with such materials.

Examples of these problems include such things as a radiography source disconnect, a moisture density

gauge being run over by a bulldozer, an irradiator source rack drive cable breaking, a well logging source

being ruptured during a source recovery attempt, a fan motor failure in an exhaust hood used to store

radioiodine, failure of a glove box connector gasket, or a damaged Type B shipping container. The

radioactive material or source need not be damaged or leaking for the event to be considered an EQP

event. Damage to a device housing, shutter, operation controls, or even a version of a software containing

an error are covered in this category. 

1. A defect or non-compliance involving the construction or operation of a facility or an activity that is

subject to the licensing requirements under 10 CFR Parts 30, 40, 50, 60, 61, 70, 71, or 72.

2. A defect or non-compliance involving a basic component that is supplied for a facility or an activity

that is subject to the licensing requirements under 10 CFR Parts 30, 40, 50, 60, 61, 70, 71, 72 or 76.

3. A piece of equipment that is disabled or fails to function as designed when the equipment is required

by regulation or license condition to prevent releases exceeding regulatory limits, to prevent

exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the

consequences of an accident.

4. A piece of equipment that is disabled or fails to function as designed when the equipment is required

to be available and operable.

5. A piece of equipment that is disabled or fails to function as designed when no redundant equipment

is available and operable to perform the required safety function.

6. An unplanned fire or explosion damaging any licensed material or any device, container, or

equipment containing licensed material when the damage affects the integrity of the licensed material

or its container.

7. The actual or possible failure of, or damage to, the shielding of radioactive material or the on-off

mechanism or indicator on a generally licensed device.

8. An unintentional disconnection of a radiography source assembly from the control cable.

9. The inability to retract a radiography source assembly to its fully shielded position and secure it in

this position.

10. The failure of any radiography component (critical to safe operation of the device) to properly

perform its intended function.

11. An irradiator source stuck in an unshielded position.

12. Damage to an irradiator’s source racks.
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13. Failure of the cable or drive mechanism used to move an irradiator’s source racks.

14. Inoperability of an irradiator’s access control system.

15. Structural damage to an irradiator’s pool liner or walls.

16. Abnormal water loss or leakage from an irradiator’s source storage pool.

17. Irradiator pool water conductivity exceeding 100 microsiemens per centimeter.

18. A licensee knows, or has reason to believe, that a well logging sealed source has been ruptured.

Transportation (TRS)

The TRS category includes a variety of transportation related events as follows:

1. The presence of removable surface contamination that exceeds the limits of Section 71.87(I).

2. The presence of external radiation levels that exceed the limits of Section 71.47.

3. Any significant reduction in the effectiveness of any approved Type B or fissile packaging during

use.

4. Any defects with safety significance in Type B or fissile packaging after first use with the means

employed to repair the defects and prevent their recurrence.

5. The conditions of approval in the certificate of compliance were not observed in making a shipment.

6. An accident involving a vehicle carrying licensed material regardless of whether the licensed

material is damaged or spilled as a result of the accident.

7. Fire, breakage, spillage, or suspected contamination involving shipment of radioactive material.

Other (OTH)

The OTH event category includes a broad range of reportable events that do not specifically fit into one

of the previous categories. This event type may also include events not reportable to the NRC but are

included in the NMED program for informational purposes.