occur from a postulated transient or accident (e.g., loss of emergency
core cooling system, loss of control rod system).

B. Design or Safety Analysis Deficiency, Personnel Error, or Procedural or
Administrative Inadequacy

1. Discovery of a major condition not specifically considered in the safety
analysis report (SAR) or TS that requires immediate remedial action.

2. Personnel error or procedural deficiencies that result in loss of plant
capability to perform essential safety functions so that a release of
radioactive materials, which could result in exceeding the dose limits of
10 CFR Part 100 or 5 times the dose limits of 10 CFR Part 50,

Appendix A, GDC 19, could occur from a postulated transient or accident
(e.g., loss of emergency core cooling system, loss of control rod drive

mechanism).
Cc. Any reactor events or conditions that are determined to be of high safety
significance.8
D. Any operating reactor plants that are determined to have overall unacceptable

performance or that are in a shutdown condition as a result of significant
performance problems and/or operational event(s).9

Events at Facilities Other Than Nuclear Power Plants and All Transportation Events

A. Events Involving Design, Analysis, Construction, Testing, Operation, Transport,
Use, or Disposal of Licensed Facilities or Regulated Materials
1. An accidental criticality [10 CFR 70.52(a)]
2. A major deficiency in design, construction, control, or operation having
significant safety implications that require immediate remedial action.
3. A serious safety-significant deficiency in management or procedural
controls.

The NRC reactor oversight process (ROP) uses four colors to describe the safety significance of licensee
performance. As defined in NRC Management Directive 8.13, “Reactor Oversight Process,” green is used
for very low safety significance, white is used for low to moderate safety significance, yellow is used for
substantial safety significance, and red is used for high safety significance. Reactor conditions or
performance indicators evaluated to be red are considered abnormal occurrences. Additionally,

Criterion II.C also includes any events or conditions evaluated by the NRC ASP program to have a
conditional core damage probability (CCDP) or change in core damage probability (ACDP) of greater than
1x10"

Any plants assessed by the ROP to be in the unacceptable performance column, as described in NRC
Inspection Manual Chapter 0305, "Operating Reactor Assessment Program.” This assessment of safety

performance is based on the number and significance of NRC inspection findings and licensee performance
indicators.


DRAFT

Report to Congress on Abnormal
Occurrences

Fiscal Year 2014

United States Nuclear Regulatory Commission
Washington, DC 20555-0001


NRC14-01 Medical Event at Camden-Clark Memorial Hospital in Parkersburg,
West Virginia

Criterion III.C.1.b and III.C.2.b(iii), “For Medical Licensees,” of Appendix A to this report provide,
in part, that a medical event shall be considered for reporting as an AO if it results in a dose
equal to or greater than 10 gray (Gy) [1,000 rad] to any organ or tissue (other than a major
portion of the bone marrow, the lens of the eye, or the gonads) and represents a prescribed
dose or dosage that is delivered to the wrong treatment site.

Date and Place—February 25, 2011 (reported on March 5, 2012), Parkersburg, West Virginia

Nature and Probable Consequences—Camden-Clark Memorial Hospital (the licensee), per the
request of NRC Region I, performed a reassessment of the records associated with a prostate
radioactive seed implantation procedure performed on February 25, 2011. The record review
indicated that the patient treated with permanent implant palladium-103 seeds received roughly
53 percent of the prescribed dose. Additionally, the record review indicated that 50 percent of
the tissue located adjacent to the prostate volume being treated (wrong treatment site) received
a dose between 275 Gy (27,500 rad) and 375 Gy (37,500 rad). The attending physician did not
notify the patient because he felt it would be of no benefit to the patient.

The licensee concluded that the medical event would not have a significant adverse effect on
the patient.

Cause(s)—The cause of the medical event was that the licensee failed to develop and
implement effective procedures to ensure that treatments were performed in accordance with
written directives.

Actions Taken To Prevent Recurrence

Licensee—The licensee's corrective actions included developing a detailed procedure specific
to the prostate brachytherapy program and providing additional training to personnel involved in
the program.

NRC—An NRC inspection was conducted from January 18, 2012 through April 22, 2013, which
identified several programmatic weaknesses associated with the prostate brachytherapy
program. On August 8, 2013, the NRC issued a notice of violation (NOV) to the licensee for
failure to implement procedures to provide high confidence that each administration was
performed in accordance with the written directive.

This event is closed for the purpose of this report.



The NRC adheres to the philosophy that the health and safety of the public are best ensured by
establishing multiple levels of protection. The agency achieves and maintains these levels
through regulations specifying requirements that ensure the safe use of radioactive materials.
Those regulations contain design, operation, and quality assurance criteria appropriate for the
various activities regulated by the NRC. Licensing, inspection, investigations, and enforcement
programs provide a regulatory framework to ensure compliance with the regulations. In
addition, the NRC is making the regulatory system more risk-informed and performance-based,
where appropriate.

REPORTABLE EVENTS.

The NRC initially issued the AO criteria in a Commission policy statement published in the
Federal Register on February 24, 1977 (42 FR 10950), followed by several revisions in
subsequent years. The most recent revision to the AO criteria was published in the

Federal Register on October 12, 2006 (71 FR 60198), and became effective on that date. That
revision established the criteria presented in Appendix A of this report, which the NRC used to
define AOs for the report.

Review of, and responses to, operating experience are essential to ensure that licensees
conduct their activities safely. Toward that end, the regulations require that licensees report
certain incidents or events to the NRC. Such reporting helps to identify deficiencies and ensure
that corrective actions are taken to prevent recurrence.

The NRC and its licensees review and evaluate operating experience to identify safety
concerns. The NRC responds to risk-significant issues through licensing reviews, inspections,
and enhancements to regulations. In addition, the agency maintains operational data in
computer-based data files for more effective collection, storage, retrieval, and evaluation.

The NRC routinely makes information and records on reportable events at licensed facilities
available to the public. The agency also disseminates information through public
announcements and special notifications to licensees and other stakeholders. The NRC issues
a Federal Register notice describing AOs that occurred in the previous FY at facilities licensed
or otherwise regulated by the NRC or Agreement States. In addition, the NRC routinely informs
Congress of significant events, including AOs that occur at licensed or regulated facilities.

AGREEMENT STATES

Section 274 of the AEA authorizes the Commission to enter into agreements with States
whereby the Commission relinquishes and the States assume certain regulatory authority over
byproduct, source, and certain quantities of special nuclear materials. States that enter into
such agreements with the NRC are known as Agreement States. Agreement States must
maintain programs that are adequate to protect public health and safety and are compatible with
the Commission's program for such materials. At the end of FY 2014, there were 37 Agreement
States.

Agreement States report event information to the NRC in accordance with compatibility criteria
established by the “Policy Statement on Adequacy and Compatibility of Agreement State
Programs,” which the agency published in the Federal Register on September 2, 1997

(62 FR 46517). The NRC also has implemented procedures for evaluating materials events to

viii


ABSTRACT

Section 208 of the Energy Reorganization Act of 1974, as amended (Public Law 93-438),
defines an “abnormal occurrence” (AO) as an unscheduled incident or event that the

U.S. Nuclear Regulatory Commission (NRC) determines to be significant from the standpoint of
Public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (Public

Law 104-66) requires that the NRC report AOs to Congress annually.

This report describes one event involving an NRC licensee that the NRC identified as an AO
during fiscal year (FY) 2014 based on the criteria defined in Appendix A, “Abnormal Occurrence
Criteria and Guidelines for Other Events of Interest.” This event occurred at an NRC-licensed
medical institution and is a medical event, as defined in Part 35 of Title 10 of the Code of
Federal Regulations (10 CFR), “Medical Use of Byproduct Material.”

In addition, this report describes twelve events that Agreement States identified as AOs during
FY 2014 based on the criteria defined in this report's Appendix A. Agreement States are those
States that have entered into formal agreements with the NRC, pursuant to Section 274 of the
Atomic Energy Act of 1954 (AEA) (Public Law 83-703), to regulate certain quantities of AEA
material at facilities located within their borders. Currently, there are 37 Agreement States.
One event involved radiation exposure to an embryo/fetus and the other eleven events were
medical events, as defined in 10 CFR Part 35. It should be noted that the number of identified
AOs is small in comparison to the high-numbermillions of medical procedures performed
annually.

Appendix A to this report presents the NRC's criteria for determining AOs, as well as the
guidelines for selecting “other events of interest.” Appendix B, “Updates of Previously Reported
Abnormal Occurrences,” provides updated information for two events previously updated in past
years’ “Report to Congress on Abnormal Occurrences.” The update includes a medical event at
Lovelace Medical Clinic in Albuquerque, New Mexico and a commercial nuclear power plant
event at Browns Ferry Nuclear Plant, Unit 1, in Athens, Alabama. During FY 2014, the NRC
identified no events that met the guidelines for inclusion in Appendix C, “Other Events of
Interest,” either as an update to previously reported information or as a new event that received
significant public interest. Appendix D, “Glossary,” presents definitions of terms used
throughout this report. Appendix E, “Conversion Table,” presents conversions commonly used
when calculating doses.

iii


I COMMERCIAL NUCLEAR POWER PLANT LICENSEES

During this reporting period, no events at commercial nuclear power plants in the United States
were significant enough to be reported as AOs based on the criteria in Appendix A to this report

lll. EVENTS AT FACILITIES OTHER THAN NUCLEAR POWER PLANTS AND
ALL TRANSPORTATION EVENTS

During this reporting period, one event at an NRC licensee and 12 events involving Agreement
State licensees were significant enough to be reported as AOs, based on Criterion III in
Appendix A to this report.

AS14-02 Medical Event at an Unspecified Licensee in New York State

Criteria III.C.1.b and III.C.2.b(iii), “For Medical Licensees,” of Appendix A to this report provide,
in part, that a medical event shall be considered for reporting as an AO if it results in a dose
equal to or greater than 10 Gy (1,000 rad) to any organ or tissue (other than a major portion of
the bone marrow, the lens of the eye, or the gonads) and represents a prescribed dose or
dosage that is delivered to the wrong treatment site.

Date and Place—December 17, 2007 (reported on March 13, 2009), Unspecified City,
New York

Nature and Probable Consequences—The unspecified licensee reported a medical event to the
New York State Department of Health (DOH). The DOH reported the event to the NRC but has
only recently provided the NRC with required information for this report. The DOH did not
specify the name of the licensee for this medical events in-an-effert to-complyin compliance with
New York state law designed to protect the privacy of the patient. This event occurred during a
brachytherapy seed implant treatment for prostate cancer. The patient was prescribed to
receive a total dose of 144 Gy (14,400 rad) to the prostate using 50 seeds of iodine-125.
However, it was determined during post implant seed count that many of the seeds were
implanted in the rectum and urethra (wrong treatment site). The calculated dose to the wrong
treatment site is 144 Gy (14,400 rad), assuming the same volume of tissue was treated as was
expected to be treated during treatment planning.

Ultrasound and fluoroscopy systems were used to aid with positioning the seeds; however, the
radiation oncologist misidentified the prostate, resulting in the incorrect placement of many of
the 50 seeds. On April 16, 2008, the Radiation Safety Officer performed a review of the
patient's chart, including all films and images taken, and identified that many seeds had not
been properly placed. It was determined that the tumor was under-dosed but additional
radiation treatment of the prostate was not recommended. The patient and referring physician
were informed of this event. The licensee concluded that the medical event would not have a
significant adverse effect on the patient.

Cause(s}—The cause of the medical event was human error in that the medical staff did not
follow the licensee's policies to properly image the patient's prostate.


UNITED STATES

NUCLEAR REGULATORY COMMISSION
WASHINGTON, D.C. 20555-0001

April 7, 2015
SECRETARY COMMISSION VOTING RECORD
DECISION ITEM: SECY-15-0029
TITLE: REPORT TO CONGRESS ON ABNORMAL

OCCURRENCES: FISCAL YEAR 2014
The Commission (with all Commissioners agreeing) approved the subject paper as recorded in
the Staff Requirements Memorandum (SRM) of April 7, 2015.

This Record contains a summary of voting on this matter together with the individual vote
sheets, views and comments of the Commission.

Annette L. Vietti-Cook
Secretary of the Commission

Enclosures:
1. Voting Summary
2. Commissioner Vote Sheets

cc: Chairman Burns
Commissioner Svinicki
Commissioner Ostendorff

Commissioner Baran released to the public five working
OGC days after dispatch of the report to
EDO Congress.

PDR

SECY NOTE

This Voting Record will be



3. Any radiation exposure that has resulted in unintended permanent
functional damage to an organ or a physiological system as determined
by a physician.

B. Discharge or dispersal of radioactive material from its intended place of
confinement which-that results in the release of radioactive material to an
unrestricted area in concentrations which, if averaged over a period of
24 hours, exceeds 5,000 times the values specified in Table 2 of
Appendix B, “Annual Limits on Intake (ALIs) and Derived Air
Concentrations (DACs) of Radionuclides for Occupational Exposure;
Effluent Concentrations; Concentrations for Release to Sewerage,”
to Part 20 of Title 10 of the Code of Federal Regulations (10 CFR),
“Standards for Protection against Radiation,” unless the licensee has
demonstrated compliance with 10 CFR 20.1301, “Dose Limits for
Individual Members of the Public,” using 10 CFR 20.1302(b)(1) or
10 CFR 20.1302(b)(2)ii)

This criterion does not apply to transportation events.
Cc. Theft, Diversion, or Loss of Licensed Material, or Sabotage or Security Breach'2

1 Any unrecovered lost, stolen, or abandoned sources that exceed the
values listed in Appendix P to 10 CFR Part 110, “Category 1 and 2
Radioactive Material.” Excluded from reporting under this criterion are
those events involving sources that are lost, stolen, or abandoned under
the following conditions: sources abandoned in accordance with the
requirements of 10 CFR 39.77(c); sealed sources contained in labeled,
rugged source housings; recovered sources with sufficient indication that
doses in excess of the reporting thresholds specified in AO criteria |.A.1
and I.A.2 did not occur while the source was missing; and unrecoverable
sources (sources that have been lost and for which a reasonable attempt
at recovery has been made without success) lost under such conditions
that doses in excess of the reporting thresholds specified in AO
criteria |.A.1 and I.A.2 are not known to have occurred and the agency
has determined that the risk of theft or diversion is acceptably low.

Information pertaining to certain incidents may be either classified or under consideration for classification
because of national security implications. Classified information will be withheld when formally reporting
these incidents in accordance with Section 208 of the Energy Reorganization Act of 1974, as amended. Any
classified details regarding these incidents would be available to the Congress, upon request, under
appropriate security arrangements.

Due to increased terrorist activities worldwide, this report does not disclose specific classified information
and sensitive information, the details of which are considered useful to a potential terrorist. Classified

information is defined as information that would harm national security if disclosed in an unauthorized
manner.


AS14-11 Medical Event at Unspecified Licensee in Unspecified City, Texas

Criteria III.C.1.b and III.C.2.b(iii), “For Medical Licensees,” of Appendix A to this report provide,
in part, that a medical event shall be considered for reporting as an AO if it results in a dose
equal to or greater than 10 Gy (1,000 rad) to any organ or tissue (other than a major portion of
the bone marrow, the lens of the eye, or the gonads) and represents a prescribed dose or
dosage that is delivered to the wrong treatment site.

Date and Place—June 5, 2014, Unspecified City, Texas

Nature and Probable Consequences—The unspecified licensee reported a medical event to the
Texas Department of State Health Services (DSHS). The DSHS reported the event and
provided the NRC with the required information for the report. The DSHS has redacted the
name of the licensee in an-effertte compliancey with Texas state law designed to protect the
privacy of the patient. This event occurred during a brachytherapy procedure for prostate
cancer treatment. The patient was prescribed to receive a total dose of 14,400 cGy (rad) to the
prostate using 58 iodine-125 (I-125) seeds. Instead, the seeds were implanted 3.5 centimeters
inferior (below) to the target volume, resulting in 14,400 cGy to a small volume of the rectum
and other normal tissue below the target volume (wrong treatment site). The patient and
referring physicians were informed of the event.

During the treatment, the I-125 seeds were manually being implanted with ultrasound guidance.
After the implantation began, the imaging deteriorated and it was difficult to determine the
boundary between the prostate and bladder. After discussion, the radiologist and urologist
decided to continue with the procedure as they thought they had identified the bladder base.
After the procedure was completed, it was discovered that the Foley bulb used to visualize the
bladder had been pierced and deflated. During the post-plan evaluation using a post-implant
computed tomography (CT) acquired on August 7, 2014, it was discovered that the seeds were
positioned 3.5 centimeters inferior to the target volume. Rectal and bladder doses were not
significantly impacted by the seed misplacements and remained within typical doses for prostate
impacts. The patient is receiving external beam radiation therapy to boost areas of the prostate
that did not receive the prescribed dose. The licensee concluded that there were no acute
medical effects to the patient and no long-term significant complications are expected.

Cause(s)—The application needle used to manually implant the seeds is believed to have
punctured the Foley bulb, resulting in reduced visibility of the bladder and misplacement of the
seeds. Additionally, the radiation oncologist had not performed a prostate seed implant in

5 years and was not an authorized user on the license.

Actions Taken To Prevent Recurrence

Licensee—The licensee has revised its procedures to ensure that physicians are authorized
users on its license before radioactive material therapy use. Additionally, the licensee has
instituted the practice that if at any time during the procedure adequate visualization is
compromised, the procedure will be interrupted until visualization is reestablished. The
radiation oncologist who performed this procedure has decided to discontinue performing the
prostate seed implant procedure.

State—The State cited the licensee for failure to report a medical event within the required time
and for the performing physician not being on the license as an authorized user.

14


ABNORMAL OCCURRENCES IN FISCAL YEAR 2014

Appendix A provides the specific criteria for determining whether an event is an abnormal
occurrence (AO) and provides the guidelines for reporting other events of interest that may not
meet the AO criteria, but which the Commission has determined should be in this report.
Appendix A contains four major categories: |. All Licensees, II. Commercial Nuclear Power
Plant Licensees, III. Events at Facilities Other Than Nuclear Power Plants and All
Transportation Events, and IV. Other Events of Interest. Categories |, II, and III are discussed in
this section and Category IV events are discussed in Appendix C to this report.

IL ALL LICENSEES

During this reporting period, one event involving an Agreement State licensee was significant
enough to be reported as an AO based on criteria in Appendix A, Criterion |, to this report.
Although the event occurred at a medical facility, it involved unintended exposure of an
individual who was not the patient. Therefore, this event belongs under the Criterion |.A, “All
Licensees,” category, as opposed to the Criterion III.C, “Medical Licensees,” category.

AS14-01 Human Exposure to Radiation Event at Adventist Health Systems in
Altamonte Springs, Florida

Criterion |.A.2, “Human Exposure to Radiation from Licensed Material,” of Appendix A to this
report provides that any unintended radiation exposure to any minor (an individual less than 18
years of age) resulting in an annual total effective dose equivalent of 50 millisieverts (mSv) [5
roentgen equivalent man (rem)] or more, or to an embryo/fetus resulting in a dose equivalent of
50 mSv (5 rem) or more, shall be considered for reporting as an AO.

Date and Place—June 26, 2014, Altamonte Springs, Florida

Nature and Probable Consequences— Adventist Health Systems (the licensee) reported that a
pregnant patient received 3.7 gigabecquerels (GBq) [100 millicuries (mCi)] of iodine-131 for
thyroid ablation therapy. On June 25, 2014, the patient tested negative for pregnancy
Subsequent to the procedure, her physician requested a re-test, which confirmed that she was
Pregnant. The estimated date of conception was June 23, 2014. The licensee calculated an
estimated dose of 250 mSv (25 rem) to the fetus from the procedure.

The patient and referring physician were informed of this event. The dose was received during
the first week of pregnancy, before the formation of any internal organs in the fetus. The
administered iodine-131 was out of the patient's body before critical development of the fetus
occurred; therefore, this exposure should not cause any developmental effects. The only effect
noted in the licensee's report was the possibility the fetus might not have been viable, however,
the patient was still pregnant as of August 3, 2014, and the licensee believes that the effect of
the exposure to the fetus was minimal.

Cause(s)—The patient became pregnant immediately (a few days) prior to the procedure and
the pregnancy was not detected via a standard HCG (human chorionic gonadotropin)
pregnancy test until July 7, 2014.

«~~~ {Formatted: indent: Left: 0



NOTATION VOTE

RESPONSE SHEET

TO: Annette Vietti-Cook, Secretary
FROM: COMMISSIONER SVINICKI
SUBJECT: SECY-15-0029: REPORT TO CONGRESS ON

ABNORMAL OCCURRENCES: FISCAL YEAR 2014

Approved _XX Disapproved Abstain

Not Participating

COMMENTS: Below _XX__ Attached XX None___

| approve the draft Fiscal Year 2014 Report to Congress on Abnormal Occurrences,
subject to the attached edits.

NATURE

03/ 15
DATE

Entered on “STARS” Yes \/No___



Commercial Nuclear Power Plant Event at Browns Ferry Nuclear Plant, Unit 1, in Athens,
Alabama (previously reported as NRC11-02 in NUREG-0090, Volume 34, with updates in
Appendix B of NUREG-0090, Volume 35)

Date and Place—October 23, 2010, Athens, Alabama

Background—The Tennessee Valley Authority (TVA) (the licensee) reported a commercial
nuclear power plant event at Browns Ferry Nuclear Plant, Unit 1, a boiling-water reactor
designed by General Electric. During a refueling outage, it was discovered that a residual heat
removal (RHR) low pressure coolant injection (LPCI) flow control valve failed while the licensee
was attempting to establish shutdown cooling. The NRC reviewed this event under its
significance determination process and determined that the licensee's history with regard§ t
this valve performance issue represented a finding of high safety significance (Red finding).
The NRC determined that this event did not represent an immediate safety concern, because
the licensee staff had, as part of its immediate corrective actions, implemented repairs and
modifications that returned the flow control valve to an operational condition.

Update on Actions Taken To Prevent Recurrence

NRC—NRC staff initiated a supplemental inspection per Inspection Procedure 95003 (ADAMS
Accession No. ML102020551), which was implemented in three parts beginning on September
12, 2011. The three parts of the inspection were completed and documented in inspection
reports (Part 1 documented November 17, 2011 (ADAMS Accession No. ML113210602); Part 2
documented February 28, 2012 (ADAMS Accession No. ML12059A314); and Part 3
documented August 22, 2013 (ADAMS Accession No. ML13234A539)). The NRC used the
results of these inspections to determine the breadth and depth of safety, organizational, and
programmatic issues at Browns Ferry Nuclear Power Plant and to assess the adequacy of their
Integrated Improvement Plan (IIP) submitted to the NRC on August 23, 2012 (available at
ADAMS Accession No. ML12240A106). The NRC reviewed the TVA committed IP actions and
issued a Confirmatory Action Letter (CAL) (ADAMS Accession No. ML13232A105) on August
22, 2013. This letter confirmed TVA's actions, which when completed by TVA and verified to be
adequate by the NRC, would reasonably serve to inform the NRC's decision regarding closure
of the Red finding and the transition of Browns Ferry Nuclear Plant Unit 1 out of the
Multiple/Repetitive Degraded Cornerstone Column (Column 4) consistent with the NRC's
Reactor Oversight Process. The NRC verified and documented, in an inspection report issued
January 27, 2014 (ADAMS Accession No. ML14027A742), the conclusion that TVA had taken
sufficient actions to support closure of the Red finding. Browns Ferry Nuclear Plant, Unit 1, was
moved to the Licensee Response Column (Column 1) of the NRC Action Matrix on October 1,
2014 (ADAMS Accession No. ML14289A458).

This event is closed for the purpose of this report.

B-2


NOTATION VOTE

RESPONSE SHEET

TO: Annette Vietti-Cook, Secretary
FROM: Commissioner Baran
SUBJECT: SECY-15-0029: REPORT TO CONGRESS ON

ABNORMAL OCCURRENCES: FISCAL YEAR 2014

Approved _XX Disapproved Abstain
Not Participating

COMMENTS: Below _XX Attached None

| approve the draft Fiscal Year 2014 Report to Congress on Abnormal Occurrences. | am
concerned that two states withheld from NRC the licensee names and locations associated
with reported abnormal occurrences. Staff should continue to work with the Agreement States
to improve the timeliness, consistency, and completeness of the information that is reported.

bye bo ~
SIGNATURE

3/279le
DATE

Entered on “STARS” Yes _X No__


NOTATION VOTE

RESPONSE SHEET

TO: Annette Vietti-Cook, Secretary
FROM: Chairman Burns
SUBJECT: SECY-15-0029: REPORT TO CONGRESS ON

ABNORMAL OCCURRENCES: FISCAL YEAR 2014

Approved _ XX Disapproved Abstain
Not Participating

COMMENTS: Below _XX_ Attached None___

| approve the draft Fiscal Year 2014 Report to Congress on Abnormal Occurrences.

( ; "Ws les Sarr aa
SIGHAYURE

2% March 2015
DATE

Entered on “STARS” Yes J No


VOTING SUMMARY - SECY-15-0029

RECORDED VOTES

NOT
APRVD DISAPRVD ABSTAIN PARTICIP COMMENTS DATE

CHRM. BURNS Xx X 3/23/15
COMR. SVINICKI X X 3/31/15
COMR. OSTENDORFF X X 3/9/15

COMR. BARAN X X 3/27/15


2. A substantiated? case of actual theft or diversion of licensed,
risk-significant radioactive sources or a formula quantity* of special
nuclear material; or act that results in radiological sabotage.>

3. Any substantiated? loss of a formula quantity4 of special nuclear material
or a substantiated? inventory discrepancy of a formula quantity‘ of special
nuclear material that is judged to be caused by theft or diversion or by a
substantial breakdown$ of the accountability system.

4 Any substantial breakdown® of physical security or material control
(.e., access control containment or accountability systems) that
significantly weakened the protection against theft, diversion, or
sabotage.

5 Any significant unauthorized disclosures (loss, theft, and/or deliberate) of
classified information that harms national security or safeguards
information that harms the public health and safety.

D. Initiation of High-Level NRC Team Inspection.”
For Commercial Nuclear Power Plant Licensees
A Malfunction of Facility, Structures, or Equipment

1 Exceeding a safety limit of license technical specification (TS)
[10 CFR 50.36(c)].

& Serious degradation of fuel integrity, primary coolant pressure boundary,
or primary containment boundary

3. Loss of plant capability to perform essential safety functions so that a
release of radioactive materials, which could result in exceeding the dose
limits of 10 CFR Part 100, “Reactor Site Criteria,” or 5 times the dose
limits of 10 CFR Part 50, “Domestic Licensing of Production and
Utilization Facilities,” Appendix A, “General Design Criterion for Nuclear
Power Plants,” General Design Criterion (GDC) 19, “Control Room,” could

“Substantiated’ means a situation where an indication of loss, theft, or unlawful diversion such as: an
allegation of diversion, report of lost or stolen material, statistical processing difference, or other indication of
loss of material control or accountability cannot be refuted following an investigation; and requires further
action on the part of the agency or other proper authorities.

A formula quantity of special nuclear material is defined in 10 CFR 70.4, “Definitions.”

Radiological sabotage is defined in 10 CFR 73.2, “Definitions.”

A substantial breakdown is defined as a red finding in the security inspection program, or any plant or facility
determined to have overall unacceptable performance, or in a shutdown condition (inimical to the effective
functioning of the nation's critical infrastructure) as a result of significant performance problems and/or
operational events.

Initiation of any Incident Investigation Teams, as described in NRC Management Directive (MD) 8.3, “NRC
Incident Investigation Program,” or initiation of any accident review groups, as described in MD 8.9,
“Accident Investigation.”


NOTATION VOTE

RESPONSE SHEET

TO: Annette Vietti-Cook, Secretary
FROM: COMMISSIONER OSTENDORFF
SUBJECT: SECY-15-0029: REPORT TO CONGRESS ON

ABNORMAL OCCURRENCES: FISCAL YEAR 2014

Approved _X Disapproved Abstain
Not Participating

COMMENTS:  Below_X_ Attached __ None_

| approve the draft Fiscal Year 2014 Report to Congress on Abnormal Occurrences (AO). Prior
to the next report to Congress, the staff should identify an estimate of the number of byproduct
medical procedures, both tests and treatments, performed in the United States to put into
context the number of AOs reported in future reports to Congress on AOs.

SIGNATURE

sh
DATE

Entered on “STARS” Yes___ No