NRC NEWS

 U.S. NUCLEAR REGULATORY COMMISSION 

 Office of Public Affairs, Region I

 475 Allendale Road, King of Prussia, Pa.

www.nrc.gov

 

No. I-07-040 July 13, 2007

Contact: Diane Screnci, 610/337-5330 Email: opa1@nrc.gov

Neil Sheehan, 610/337-5331

NRC CITES UNIVERSITY OF PITTSBURGH FOR VIOLATION

The Nuclear Regulatory Commission has cited the University of Pittsburgh for a violation of

agency requirements involving radiation therapy in its gamma stereostatic radiosurgery (GSR)

program. The violation stems from a failure to ensure that radiation safety activities adhered to

regulatory requirements as well as the university’s own procedures. Under the enforcement action –

the details of which were determined during the NRC’s Alternate Dispute Resolution (ADR) process –

the university is required to take several actions to prevent recurrence.

GSR uses radiation therapy to treat tumors and other abnormalities. 

In a letter sent to the university on Feb. 27, 2007, the NRC provided the results of an

investigation conducted by the agency’s Office of Investigations in 2006. The investigation was

undertaken to determine whether the university and a neurosurgeon had willfully violated requirements

with regard to the use of GSR.

The university was offered the option of a predecisional enforcement conference or ADR. 

University officials requested ADR, which, in this context, refers to a process in which a neutral

mediator with no decision-making authority assists the NRC and license-holders in reaching an

agreement resolving any differences regarding an enforcement action. Toward that end, an ADR

mediation session involving NRC and University of Pittsburgh officials took place on May 17, 2007 at

the agency’s Region I Office in King of Prussia, Pa.

As a result of that session, a settlement agreement was reached. The terms have now been

confirmed by the NRC via a Confirmatory Order issued to the university. Under the agreement, the

NRC and the university agree that a non-compliance with regulatory requirements occurred. The

violation has been classified as Severity Level III. The NRC classifies violations from Severity Level I

to IV, with I being the most significant. 

“This demonstrates that the Alternate Dispute Resolution Process can work and achieve a result

that protects the public health and safety. The extensive commitments made by the university provide

the NRC with confidence that radiation safety activities will be performed according to NRC

requirements,” said NRC Region I Deputy Regional Administrator Marc L. Dapas. 
Specifically, the university did not meet physical presence requirements consistently from May

13, 2004 through March 10, 2005. (Those requirements state that for GSR units, an authorized user

and an authorized medical physicist must be physically present throughout all patient treatments.) 

Further, the university failed to ensure that between 1998 and 2000 written directives (detailed

instructions regarding radiation treatments) were consistently signed by the authorized user prior to the

administration of GSR treatments. The NRC and the university have agreed to disagree whether any

aspects of the violation were willful.

Both before and during the ADR mediation session, the university described corrective actions

it has taken to prevent a recurrence. They include: ensuring that an authorized medical physicist and

authorized user are present during each GSR treatment; having the radiation safety officer initiate a

requirement for a physical presence log; having the radiation safety office staff provide annual

radiation safety training to the GSR staff; having an outside independent consultant conduct an audit of

the radiation safety program, with special emphasis on the GSR program and management oversight;

and, increasing surveillance of GSR treatments by radiation safety office staff.

As a result of the ADR session, the university has agreed to: (1) enhance its 40-hour GSR

training course provided to GSR users at other facilities throughout the U.S., including an expansion of

the lecture on NRC regulations to encompass physical presence requirements and a description of this

experience as part of the training; and (2) submit a lessons-learned article for several trade publications

that describes these occurrences.

In light of the actions that the university has taken and committed to take, as well as the fact

that the violation did not result in any known safety consequences to patients, workers or the public,

the NRC agreed to issue a Notice of Violation without an accompanying civil penalty. 

The agreement requires that the university complete the additional steps within 1 year of the

issuance of the Confirmatory Order. The university must provide the NRC with a letter within 30 days

of completion of all actions stating that all commitments have been met.

A copy of the enforcement action will be posted on the NRC web site at:

http://www.nrc.gov/reading-rm/doc-collections/enforcement/actions.

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