DRAFT 

Report to Congress on Abnormal 

Occurrences 

Fiscal Year 2014 

United States Nuclear Regulatory Commission 

Washington, DC 20555-0001 

iii 

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 number 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. 

 
 
v 

CONTENTS 

ABSTRACT .................................................................................................................................. iii

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

INTRODUCTION ............................................................................................................. vii

THE LICENSING AND REGULATORY SYSTEM........................................................... vii

REPORTABLE EVENTS ................................................................................................. viii

AGREEMENT STATES .................................................................................................. viii

FOREIGN INFORMATION ............................................................................................... ix

UPDATES OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES ................... ix

OTHER EVENTS OF INTEREST .................................................................................... ix

ABBREVIATIONS ......................................................................................................................... x

ABNORMAL OCCURRENCES IN FISCAL YEAR 2014 ............................................................... 1

I. ALL LICENSEES ................................................................................................... 1

AS14-01 Human Exposure to Radiation Event at Adventist Health Systems 

in Altamonte Springs, Florida ......................................................... 1

II. COMMERCIAL NUCLEAR POWER PLANT LICENSEES .................................... 3

III. EVENTS AT FACILITIES OTHER THAN NUCLEAR POWER PLANTS AND ALL 

TRANSPORTATION EVENTS .............................................................................. 3

AS14-02 Medical Event at an Unspecified Licensee in New York State ...... 3

NRC14-01 Medical Event at Camden-Clark Memorial Hospital in 

Parkersburg, West Virginia ............................................................ 5

AS14-03 Medical Event at Baptist Health Madisonville in Madisonville, 

Kentucky ........................................................................................ 6

AS14-04 Medical Event at Radiotherapy Clinics of Georgia in Snellville, 

Georgia .......................................................................................... 7

AS14-05 Medical Event at Central Arkansas Radiation Therapy Institute 

Inc. in Conway, Arkansas .............................................................. 8

AS14-06 Medical Event at the Cleveland Clinic Foundation in Cleveland, 

Ohio ............................................................................................... 9

AS14-07 Medical Event at Emory University in Atlanta, Georgia ............... 10

AS14-08 Medical Event at Miami Neuroscience Center, Larkin Community 

Hospital in Miami, Florida ............................................................. 11

AS14-09 Medical Event at the Cedars Sinai Medical Center in Los Angeles, 

California ...................................................................................... 12

AS14-10 Medical Event at Watson Clinic in Lakeland, Florida ................... 13

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

 ..................................................................................................... 14

AS14-12 Medical Event at University of Virginia in Charlottesville, Virginia 15

Appendix A ABNORMAL OCCURRENCE CRITERIA AND GUIDELINES FOR OTHER 

EVENTS OF INTEREST ................................................................................... A-1 

Appendix B UPDATES OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES .... B-1 

 

Appendix C OTHER EVENTS OF INTEREST ...................................................................... C-1 
vi 

Appendix D GLOSSARY ....................................................................................................... D-1

Appendix E CONVERSION TABLE ...................................................................................... E-1 
vii 

EXECUTIVE SUMMARY 

INTRODUCTION 

Section 208 of the Energy Reorganization Act of 1974 (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 those events that the NRC or an Agreement State identified as AOs 

during fiscal year (FY) 2014, based on the criteria defined in this report’s Appendix A, “Abnormal 

Occurrence Criteria and Guidelines for Other Events of Interest.” 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. The NRC has determined that, of the incidents 

and events reviewed for this reporting period, only those that are described here meet the 

criteria for being reported as AOs. For each AO, this report documents the date and place, 

nature and probable consequences, cause(s), and actions taken to prevent recurrence. 

It should be noted that two of the thirteen AOs included in this report occurred in previous FYs. 

The NRC completed its evaluation for these AOs in FY 2014. The NRC requires that 

information about AOs be complete to allow for adequate evaluation. Occasionally, all the 

required information is not available in time to report an AO in the FY of its occurrence. 

Appendix A to this report presents the NRC’s criteria for selecting 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 NUREG-0090, 

Volume 35, Revision 1, “Report to Congress on Abnormal Occurrences—FY 2012,” dated 

August 2013 (the NRC’s Agencywide Documents Access and Management System (ADAMS) 

Accession No. ML13198A165). The updates are on 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. 

THE LICENSING AND REGULATORY SYSTEM

The system of licensing and regulation that the NRC uses to carry out its responsibilities is 

implemented through the rules and regulations in Title 10 of the Code of Federal Regulations

(10 CFR). The agency informs and involves stakeholders to ensure openness in the agency’s 

regulatory process, consistent with the NRC’s “Strategic Plan: Fiscal Years 2014–2018,” 

(NUREG-1614, Volume 6, dated August 2014, Accession No. ML14246A439). The NRC 

regularly conducts licensing reviews, inspections, enforcement, investigations, operating 

experience evaluations, incident response, and confirmatory research. In addition, the agency 

involves the public in the regulatory process. 
viii 

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 
ix 

identify those that meet the AO criteria. Toward that end, the NRC uniformly applies the AO 

criteria (in Appendix A to this report) to events involving licensees regulated by either the NRC 

or the Agreement States. In addition, in 1977, the Commission determined that the annual 

report to Congress should include events that meet the criteria for AOs at licensees regulated 

by Agreement States. The Federal Register notice that the NRC issues to disseminate 

AO-related information to the public includes those AOs that occurred at licensees regulated by 

the Agreement States. 

FOREIGN INFORMATION 

The NRC exchanges information with various foreign governments that regulate nuclear 

facilities and materials. This foreign information is reviewed and considered in the NRC’s 

research and regulatory activities, as well as in its assessment of operating experience. 

Although the NRC may occasionally refer to such foreign information in its AO reports to 

Congress, the agency generally reports only domestic AOs.

UPDATES OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES 

The NRC provides updates of previously reported AOs if significant new information becomes 

available. Appendix B provides updated information for two events reported or updated in 

NUREG-0090, Volume 35, Revision 1, “Report to Congress on Abnormal Occurrences—

FY 2012,” dated August 2013 (ADAMS Accession No. ML13198A165). The updates include a 

commercial nuclear power plant event at Browns Ferry Nuclear Plant, Unit 1, in Athens, 

Alabama and a medical event at Lovelace Medical Center in Albuquerque, New Mexico. 

OTHER EVENTS OF INTEREST 

The NRC provides information concerning other events of interest that are not reportable to 

Congress as AOs but are included in this report based on the Commission’s guidelines, listed in 

Appendix A. 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. 
x 

ABBREVIATIONS 

ADAMS the NRC’s Agencywide Documents Access and Management System 

AEA Atomic Energy Act of 1954, as amended 

AO abnormal occurrence 

AS Agreement State 

CAL confirmatory action letter 

CFR Code of Federal Regulations

Ci curie 

cm centimeter 

CT computed tomography 

DOH Department of Health 

DSHS Department of State Health Services 

FR Federal Register 

FY fiscal year 

GBq gigabecquerel 

Gy gray 

HCG human chorionic gonadotropin 

HDR high dose rate 

IIP integrated improvement plan 

LDR low dose rate 

LPCI low pressure coolant injection 

MBq megabecquerel 

μCi microcurie 

mCi millicurie 

mm millimeter 

mSv millisievert 

NOV notice of violation 

NRC U.S. Nuclear Regulatory Commission 

OSHA Occupational Safety and Health Administration 

rem roentgen equivalent man 

RHR residual heat removal 

RSO radiation safety officer 

Sv sievert 

TBq terabecquerel 

TEDE total effective dose equivalent 

TVA Tennessee Valley Authority
1 

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: I. 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 I, II, and III are discussed in 

this section and Category IV events are discussed in Appendix C to this report. 

I. 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 I, 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 I.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 I.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 

occured; 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. 
2 

Actions Taken To Prevent Recurrence

Licensee—Given that an HCG pregnancy test has a delayed response of approximately 

10 days, patients will be advised to abstain from sexual intercourse for 2 weeks prior to the 

thyroid ablation procedure. The licensee also added this advisory to its patient interview 

worksheet that is used to screen patients. 

State—The State of Florida did not cite any violations and the licensee’s corrective actions were 

adequate. No further action will be taken for this event. 

This event is closed for the purpose of this report. 
3 

II. 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. 

III. 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 medical events in an effort to comply 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. 
4 

Actions Taken To Prevent Recurrence

Licensee—The corrective action taken by the licensee includes developing and implementing 

written procedures for improved prostate imaging and requiring that the urologist document the 

verification and the identification of the prostate. 

State—At the DOH’s next routine inspection of the licensee, the DOH reviewed the licensee’s 

response to this event, and noted no violations. 

This event is closed for the purpose of this report. 
5 

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. 

 
6 

AS14-03 Medical Event at Baptist Health Madisonville in Madisonville, Kentucky 

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—October 10, 2013, Madisonville, Kentucky 

Nature and Probable Consequences—Baptist Health Madisonville (the licensee) reported that a 

medical event occurred associated with an intra-vaginal low dose rate (LDR) brachytherapy 

treatment for cervical cancer. Two sources contained approximately 1.95 GBq (52.7 millicuries 

(mCi)) of cesium-137 each and a third source contained approximately 1.08 GBq (29.1 mCi) of 

cesium-137. The patient was prescribed a total dose of 7,000 centigray (cGy) [rad] to the 

vaginal area. However, the patient received a dose of approximately 1,509 cGy (rad) to the 

surface of the patient’s inner thighs (wrong treatment site). The patient and referring physician 

were informed of this event. Daily checks of the skin of the inner thighs in December 2013 have 

shown no adverse effects since the event occurred. 

Cause(s)—The intra-vaginal applicator became dislodged as a result of the patient tossing and 

turning during the night. Due to the patient’s partial paralysis below the waist, she was not 

aware that the applicator had become dislodged. The nursing procedures did not include 

instructions to check the position of the applicator; therefore, no check of the applicator position 

was made between the evening of October 9, 2013, when the applicator was last noted by 

nursing personnel to be in the correct position and the morning of October 10, 2013, when it 

was discovered to be dislodged by the prescribing physician and authorized medical physicist. 

Actions Taken To Prevent Recurrence

Licensee—The licensee revised the nursing instructions and post-operative orders to include a 

check of the implant position every shift, after bowel movements, and as necessary, and to 

document those checks in the patient’s clinical record. Nursing staff received instruction in the 

use of these new procedures prior to the next brachytherapy procedure. 

State—The Kentucky Radiation Health Branch conducted an inspection on January 13, 2014, to 

verify that the corrective measures had been developed and implemented by the licensee. 

Results of that inspection verified that revised nursing instructions and post-operative orders 

had been developed and were being implemented by the nursing staff.

This event is closed for the purpose of this report. 

 
7 

AS14-04 Medical Event at Radiotherapy Clinics of Georgia in Snellville, Georgia 

Criteria III.C.1.b, III.C.2.b(iii), and III.C.2.b(vi), “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 or is delivered to the 

wrong individual. 

Date and Place—December 16, 2013, Snellville, Georgia 

Nature and Probable Consequences—Radiotherapy Clinics of Georgia (the licensee) reported 

that a medical event occurred associated with a 296 GBq (8 Ci) iridium-192 high dose rate 

(HDR) brachytherapy treatment for basal cell carcinoma on the patient’s right temple. The 

patient was prescribed 4,000 cGy (rad) to be delivered in eight fractions of 99.61 seconds each 

to the skin on the temporal region of the patient’s head. However, the physicist inadvertently 

selected a different patient's treatment plan and initiated the treatment. An area adjacent to the 

intended site (wrong treatment site) received a maximum dose of 2,300 cGy (rad) to a single 

point and 1,000 cGy (rad) to a 1 centimeter (cm) radius and 4.5 millimeter (mm) depth. 

The physicist identified the error after 113.9 seconds and manually interrupted the procedure. 

The erroneous selection of the wrong treatment plan caused the iridum-192 source to stop short 

of the intended treatment area due to a shorter channel length. The physicist believes the 

source was in that position for nearly the entire treatment time. In addition to the dose to the 

wrong treatment site, this error resulted in the intended treatment site receiving less than half of 

the intended dose for the first fraction. 

The referring physician and patient were notified of the error. The patient opted to proceed with 

a new treatment plan and the dose to the tumor volume was corrected on the subsequent 

treatments. 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, which resulted in loading the 

wrong patient’s treatment plan into the HDR control console. 

Actions Taken To Prevent Recurrence

Licensee—The licensee’s corrective actions included procedure modifications to require that a 

pretreatment checklist be physically signed by two independent qualified HDR operators/users. 

The licensee will now print the treatment parameters at the HDR control console after the 

treatment plan is loaded. The printout is then verified and signed by both the radiation 

oncologist and the physicist prior to initiating treatment. 

State— The Georgia Department of Natural Resources performed a reactive investigation on 

December 18, 2013. The State has incorporated the licensee corrective action plan into the 

licensee licensing conditions/commitments and will review the implementation of this plan during 

future inspections. 

This event is closed for the purpose of this report. 

 
8 

AS14-05 Medical Event at Central Arkansas Radiation Therapy Institute Inc. in 

Conway, Arkansas 

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 31, 2013, Conway, Arkansas 

Nature and Probable Consequences—Central Arkansas Radiation Therapy Institute (the 

licensee) reported that a medical event occurred associated with a brachytherapy seed implant 

procedure for prostate cancer treatment. The patient was prescribed a dose of 16,786 cGy 

(rad), but only received a dose of 2,531 cGy (rad) to the intended treatment site. The procedure 

was performed using 128 iodine-125 brachytherapy seeds, which contained a total activity of 

1.592 GBq (43.036 mCi). Out of the 128 seeds, only 34 seeds were implanted into the patient’s 

prostate gland (intended treatment site). The remaining seeds were implanted outside the 

prostate and resulted in estimated average doses of 1,399 cGy (rad) to the seminal vesicles, 

4,580 cGy (rad) to the rectum, 389 cGy (rad) to the bladder, and 18,524 cGy (rad) to the penile 

bulb (wrong treatment sites). 

The patient and referring physician were informed of this event. The patient received an 

additional seed implant on April 4, 2014, to complete the treatment for prostate cancer. No 

adverse health effects from this medical event have been reported to the State. 

Cause(s)—The cause of the medical event was determined to be failure to accurately identify 

the treatment site. 

Actions Taken To Prevent Recurrence

Licensee—The corrective actions taken by the licensee included centralizing prostate seed 

implant programs such that fewer facilities will be performing these implants, ensuring 

consistent adherence to the implant procedures and policies, evaluating implant procedures, 

requiring quality assurance on ultrasound equipment, and requiring training and proficiency 

records for operating room staff assisting with implants. 

State—The Arkansas Department of Health performed an investigation on January 16, 2014. In 

addition, routine compliance inspections were performed on February 27, 2014, and 

July 24, 2014. The licensee’s corrective actions were determined to be effective. 

This event is closed for the purpose of this report. 

 
9 

AS14-06 Medical Event at the Cleveland Clinic Foundation in Cleveland, Ohio 

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 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—January 24, 2014, Cleveland, Ohio 

Nature and Probable Consequences —The Cleveland Clinic Foundation (the licensee) reported 

that a medical event occurred associated with an yttrium-90 (Y-90) microsphere procedure to 

treat liver metastases from colorectal cancer. The licensee prescribed a patient dose of 

0.53 GBq (14 mCi) of Y-90 microspheres to the left liver lobe for a planned dose of 989.8 Gy 

(98,980 rad) to the tumor and a resultant 11.99 Gy (1199 rad) to the liver. The licensee 

prescribed a patient dose of 0.92 GBq (25 mCi) of Y-90 microspheres to the right liver lobe for a 

planned dose of 446.7 Gy (44,670 rad) to the tumor and a resultant 12.97 Gy (1,297 rad) to the 

liver. The left liver lobe was treated as planned. 

Due to unanticipated shunting while treating the right liver lobe, a dose of 11 Gy (1100 rad) from 

21.57 MBq (0.58 mCi) Y-90 was delivered to the duodenum (wrong treatment site). The 

licensee uses contrast dye between vials to ensure the continued proper treatment and 

immediately discontinued the procedure when the shunting was identified. The final activity of 

Y-90 microsphere delivered to the right liver lobe was 0.55 GBq (15 mCi) for a dose of 265.9 Gy 

(26,590 rad) to the tumor and 7.7 Gy (770 rad) to the liver. The patient and referring physician 

were informed of this event. 

The consequence of the event is the potential generation of a duodenal ulcer caused by the 

radiation. The licensee is treating the patient to minimize radiation damage to the duodenum 

and will continue to monitor the patient’s condition. The prognosis of the patient will be 

determined by the underlying cancer and spread of the tumors. The licensee identified the 

event during the procedure and discontinued treatment. 

Cause(s)—The cause of the medical event was the development of collateral vessels around 

the tumor between the time of the initial patient treatment planning and delivery of the Y-90 

microspheres. The licensee was not able to identify the small change of vasculature with its 

routine checks at the time of the procedure. 

Actions Taken To Prevent Recurrence

Licensee—The licensee did not identify corrective actions to add to its current procedures to 

preclude a recurrence of the event. 

State —The Ohio Department of Health conducted an inspection on February 20, 2014, to 

review the incident and initial reports. The Department concluded that the licensee had applied 

due diligence in performing the medical procedure. The Department did cite the licensee for 

failing to report the event within 1 day after determining this was a reportable event. 

This event is closed for the purpose of this report. 

 
10 

AS14-07 Medical Event at Emory University in Atlanta, Georgia 

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 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 27, 2014, Atlanta, Georgia 

Nature and Probable Consequences—Emory University (the licensee) reported that a medical 

event occurred associated with an yttrium-90 (Y-90) microsphere procedure to treat liver cancer. 

The licensee prescribed a patient dose of 6,900 cGy (rad) with 2 GBq (54.05 mCi) of Y-90 to the 

left lobe of the liver. However, the medical team could not properly position the catheter due to 

anatomical issues not previously anticipated. A post-delivery scan revealed that approximately 

0.81 GBq (21.8 mCi) went to the left lobe of the liver and 0.91 GBq (24.5 mCi) went to the right 

lobe of the liver, resulting in doses of 2,783 and 3,128 cGy (rad) to the left and right lobes, 

respectively. Since this was a bilateral disease that would eventually require the treatment of 

both lobes of the liver, the authorized user intended to treat the right lobe next. The team 

reported that the treatment plan would be adjusted to take into account the diseased areas that 

were already treated and no unintended adverse effects were expected due to this event. The 

patient and referring physician were notified of this event. 

Cause(s)—Anatomy changes in arterial formation prevented navigation of the hepatic artery as 

intended by the initial shunt study on February 5, 2014. The patient’s medical team decided to 

proceed with the catheter orifice at an earlier branching of the artery since they ultimately 

intended to treat both impacted regions of the liver. The resulting shunt fractions were different 

from the originally intended treatment for that day. 

Actions Taken To Prevent Recurrence

Licensee—Corrective actions included revising procedures to have written directives reflect the 

dose to the entire target organ as opposed to segmenting the written directives for each 

treatment region. The licensee also instructed the medical team to immediately report events 

with microspheres to extra-hepatic organs above the acceptable levels of anticipated shunting.

State—Telephone investigations were held with the medical team at the time of reporting and 

follow-up discussions were held during a routine inspection a couple months after the incident. 

This event is closed for the purpose of this report. 

 
11 

AS14-08 Medical Event at Miami Neuroscience Center, Larkin Community Hospital in 

Miami, Florida 

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 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—April 8, 2014, Miami, Florida 

Nature and Probable Consequences—Miami Neuroscience Center, Larkin Community Hospital 

(the licensee) reported that a medical event occurred associated with cobalt-60 gamma knife 

stereotactic radiosurgery procedure for palliative treatment of trigeminal neuralgia. On April 8, 

2014, the patient was prescribed a dose of 20,000 cGy (rad) to the left side of the brain, but the 

treatment was started on the right side of the brain. The treatment planner started the treatment 

on the right side because the planner knew that the patient had been previously treated on the 

right side of the brain in 2007 and 2008 and did not realize the new treatment site was now on 

the left side of the brain. The error was recognized by a nurse and she notified the doctors to 

stop the treatment. The treatment was stopped at 1.72 minutes into the planned 19.14 minute 

procedure. This resulted in a dose to the right side of the brain (wrong treatment site) of 

approximately 1,800 cGy (rad). 

The patient and referring physician were informed of this event. After the error was identified, a 

new treatment plan was made and the patient received the prescribed treatment to the left side 

of the brain. The licensee determined the medical event would not have a significant adverse 

effect on the patient.

Cause(s)—The cause of the medical event was determined to be deficient Quality Management 

Program protocols. 

Actions Taken To Prevent Recurrence 

Licensee—Corrective actions taken by the licensee included procedure modifications requiring 

the doctor to mark on the side of the patient’s head to be treated the day before the treatment. 

State—Corrective actions were found to be adequate and no fines were imposed. 

This event is closed for the purpose of this report. 

 
12 

AS14-09 Medical Event at the Cedars Sinai Medical Center in Los Angeles, California 

Criterion III.C.1.b and III.C.2.a, “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 at least 50 percent greater than that prescribed. 

Date and Place—April 30, 2014, Los Angeles, California 

Nature and Probable Consequences—Cedars Sinai Medical Center (the licensee) reported that 

a medical event occurred associated with an yttrium-90 (Y-90) microsphere procedure to treat 

liver cancer. The event took place during the second phase of a liver treatment when the 

patient was prescribed a maximum of 0.463 GBq (12.5 mCi) of Y-90 to deliver a maximum dose 

of 102 Gy (10,200 rad) to the liver, but instead was administered 1.59 Gbq (43 mCi) of Y-90 and 

received a dose of 363 Gy (36,300 rad) (256 percent greater than the maximum dose 

prescribed). 

Local traffic congestion resulted in shipment delays and the Y-90 radiopharmaceutical arrived 

after the patient was anesthetized. An ambiguous written directive was misinterpreted by the 

radiopharmacist, who prepared an incorrect dosage. In its rush to get the Y-90 ready for 

administration, the licensee failed to have an authorized user present during dosage preparation 

to verify the correct dosage prior to administering it to the patient. The patient and referring 

physician were informed of the medical event. No unintended medical effects have been 

identified. The patient will continue to be medically monitored. 

Cause(s)—A pre-anesthetized patient and a shipment delay of the Y-90 caused the licensee to 

rush and not follow written procedures requiring the authorized user to be present during the 

dosage preparation to verify that the correct dosage was prepared by the radiopharmacist. 

Additionally, inadequate training of the radiopharmacist and a recent treatment planning 

software revision resulted in the preparation of the incorrect dosage. 

Actions Taken To Prevent Recurrence

Licensee—Corrective actions included changes to the written directive format to reduce the 

potential for misinterpretation, changes to scheduling Y-90 microsphere procedures so that 

anesthetization of patients does not occur until the radiopharmaceutical is onsite, updates to 

treatment planning software, strengthening the verification process for written procedures, and 

training of radiopharmacists and authorized users concerning the lessons learned from this 

event.

State—Enforcement action was taken by the State of California to address the authorized user’s 

failures to: 1) follow the treatment plan and written directive, 2) comply with procedures to be 

physically present when the radiopharmacist prepared the radiopharmaceutical, and 3) correctly 

confirm the radiopharmaceutical and dosage before administration to the patient. 

This event is closed for the purpose of this report. 
13 

AS14-10 Medical Event at Watson Clinic in Lakeland, Florida 

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 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—May 19, 2014, Lakeland, Florida 

Nature and Probable Consequences—Watson Clinic (the licensee) reported that a medical 

event occurred that was associated with a patient receiving high dose rate (HDR) brachytherapy

intra-vaginal cancer treatment. The patient was prescribed a dose of 700 cGy to the tumor site 

during three treatment fractions using a 342.25 GBq iridium-192 (I-192) source on March 31, 

April 7, and April 14, 2014. However, it was determined that the skin on the patient’s thighs and 

labia (wrong treatment site) received an estimated dose of 4,200 cGy (rad). 

During the follow-up visit on May 19, 2014, the patient had burns on the thighs and the labia. 

Investigation of the treatment planning revealed that an error occurred while entering the short 

source reference length into the treatment planning software, resulting in the source being 

positioned 10 cm short of the intended treatment site for all fractions of the treatment. The 

patient and prescribing physician were informed of the event. 

Cause(s)—The cause of the medical event was an error in entering the reference source length 

into the treatment planning software and failure to identify the error during quality assurance 

checks.

Actions Taken To Prevent Recurrence

Licensee—The licensee’s corrective actions include modifying procedures to incorporate a 

second-person check of the source reference length, performing pre-treatment imaging checks 

using a dummy source, posting the expected reference length for applicators used, and adding 

a step to the HDR treatment check list to ensure review of the source reference length.

State—The State of Florida imposed an administrative fine of $1,000.

This event is closed for the purpose of this report. 

 
14 

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 effort to comply with Texas state law. 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. 

This event is closed for the purpose of this report. 
15 

AS14-12 Medical Event at University of Virginia in Charlottesville, Virginia 

Criterion III.C.1.b and III.C.2.a, “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 dose or dosage that is at 

least 50 percent greater than that prescribed. 

Date and Place—September 4, 2014, Charlottesville, Virginia 

Nature and Probable Consequences— University of Virginia (the licensee) reported that a 

medical event occurred associated with an yttrium-90 (Y-90) microsphere procedure to treat 

lesions in the liver. On September 4, 2014, the patient received the prescribed activity of 

1,499.61 MBq (40.53 mCi). Based on evaluation of pre-treatment imaging, this activity was 

expected to deliver the prescribed dose of 11,700 cGy (rad) to the left lobe of the liver and 370 

cGy (rad) to the lungs. However, following the treatment, the licensee determined the patient 

had higher than expected Y-90 activity shunt into the lungs due to patient specific complicated 

shunting pathways, resulting in a dose of 6,700 cGy (rad) to the liver and 3,450 cGy (rad) (832 

percent greater than the prescribed) to the lungs. The patient and referring physician were 

informed of this event. During the week of February 2, 2015, the patient was admitted to a 

hospital with acute respiratory distress like symptoms with lung infiltrates consistent with 

radiation pneumonitis. The patient passed away over the following weekend. However, the 

cause of death and any potential association with the medical event are being evaluated. 

Cause(s)—Complications in the patients’ shunting pathways resulted in two different lung shunt 

pathways that were not identified during pre-treatment imaging because the licensee did not 

evaluate both the left and right arteries located in the liver for lung shunting. The complicated 

shunting pathway resulted in higher than expected Y-90 activity to move to the patient’s lungs 

during the treatment. 

Actions Taken To Prevent Recurrence

Licensee—Corrected procedures to measure shunting from both left and right arteries located in 

the liver when appropriate, measure lung volumes for lung mass calculations when appropriate, 

review lung shunting calculations, and clarify the locations of the arterial injections for the 

treatments. 

State—A member of the Virginia Radioactive Materials Program observed a Y-90 microsphere 

procedure on September 23, 2014. The observation included viewing the dose being drawn 

and delivered to the operating room, patient injection, surveys performed and patient release. 

Licensee staff utilized the new procedures during this implantation. Licensee staff was 

observed verbally describing each step of the procedure and a discussion was held regarding 

the written directive and lung shunt calculations. 

This event is closed for the purpose of this report. 
A-1 

APPENDIX A 

ABNORMAL OCCURRENCE CRITERIA AND 

GUIDELINES FOR OTHER EVENTS OF INTEREST 

An incident or event will be considered an abnormal occurrence (AO) if it involves a major 

reduction in the degree of protection of public health or safety. This type of incident or event 

would have a moderate or severe impact on public health or safety and could include, but need 

not be limited to, the following: 

(1) moderate exposure to, or release of, radioactive material licensed by or otherwise 

regulated by the Commission; 

(2) major degradation of essential safety-related equipment; and 

(3) major deficiencies in design, construction, use of, or management controls for facilities 

or radioactive material licensed by or otherwise regulated by the Commission. 

The U.S. Nuclear Regulatory Commission (NRC) identified the following criteria for determining 

an AO and the guidelines for “other events of interest” in a policy statement published in the 

Federal Register on October 12, 2006 (71 FR 60198). 

Abnormal Occurrence Criteria

The NRC uses the following criteria to determine whether to consider events for reporting as 

AOs: 

I. For All Licensees 

A. Human Exposure to Radiation from Licensed Material 

1. Any unintended radiation exposure to an adult (any individual 18 years of 

age or older) resulting in an annual total effective dose equivalent (TEDE) 

of 250 millisievert (mSv) [25 roentgen equivalent man (rem)] or more; or 

an annual sum of the deep dose equivalent (external dose) and 

committed dose equivalent (intake of radioactive material) to any 

individual organ other than the lens of the eye, the bone marrow, and the 

gonads of 2,500 mSv (250 rem) or more; or an annual dose equivalent to 

the lens of the eye of 1 sievert (Sv) (100 rem) or more; or an annual sum 

of the deep dose equivalent and committed dose equivalent to the bone 

marrow of 1 Sv (100 rem) or more; or a committed dose equivalent to the 

gonads of 2,500 mSv (250 rem) or more; or an annual shallow-dose 

equivalent to the skin or extremities of 2,500 mSv (250 rem) or more. 

2. Any unintended radiation exposure to any minor (an individual less than 

18 years of age) resulting in an annual TEDE of 50 mSv (5 rem) or more, 

or to an embryo/fetus resulting in a dose equivalent of 50 mSv (5 rem) or 

more. 
A-2 

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 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. 

C. Theft, Diversion, or Loss of Licensed Material, or Sabotage or Security Breach1,2 

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 I.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 I.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. 

 

1 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. 

2 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. 
A-3 

2. A substantiated3 case of actual theft or diversion of licensed, 

risk-significant radioactive sources or a formula quantity4 of special 

nuclear material; or act that results in radiological sabotage.5

3. Any substantiated3 loss of a formula quantity4 of special nuclear material 

or a substantiated3 inventory discrepancy of a formula quantity4 of special 

nuclear material that is judged to be caused by theft or diversion or by a 

substantial breakdown6 of the accountability system. 

4. Any substantial breakdown6 of physical security or material control 

(i.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.7

II. 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)]. 

2. 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 

 

3 “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. 

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

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

6 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. 

7 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.” 
A-4 

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). 

C. 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

III. 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. 

 

8 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 (ΔCDP) of greater than 

1x10-3. 

9 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. 
A-5 

4. A series of events (in which the individual events are not of major 

importance), recurring incidents, or incidents with implications for similar 

facilities (generic incidents) that raise a major safety concern. 

B. For Fuel Cycle Facilities 

1. Absence or failure of all safety-related or security-related controls 

(engineered and human) for an NRC-regulated lethal hazard (radiological 

or chemical) while the lethal hazard is present. 

2. An NRC-ordered safety-related or security-related immediate remedial 

action. 

C. For Medical Licensees 

 A medical event that: 

1. Results in a dose that is 

a. Equal to or greater than 1 gray (Gy) (100 rad) to a major portion of 

the bone marrow or to the lens of the eye; or equal or greater than 

2.5 Gy (250 rad) to the gonads; or 

b. Equal to or greater than 10 Gy (1,000 rad) to any other organ or 

tissue; and 

2. Represents either 

a. A dose or dosage that is at least 50 percent greater than that 

prescribed, or 

b. A prescribed dose or dosage that 

(i) Uses the wrong radiopharmaceutical or unsealed 

byproduct material; or 

(ii) Is delivered by the wrong route of administration; or 

(iii) Is delivered to the wrong treatment site; or 

(iv) Is delivered by the wrong treatment mode; or 

(v) Is from a leaking source or sources; or 

(vi) Is delivered to the wrong individual or human research 

subject. 

IV. Other Events of Interest 

The Commission may determine that events other than AOs may be of interest to 

Congress and the public and should be included in an appendix to the AO report as 
A-6 

“Other Events of Interest.” Such events may include, but are not necessarily limited to, 

events that do not meet the AO criteria but that have been perceived by Congress or the 

public to be of high health and safety significance, have received significant media 

coverage, or have caused the NRC to increase its attention to or oversight of a program 

area, or a group of similar events that have resulted in licensed materials entering the 

public domain in an uncontrolled manner. 
B-1 

APPENDIX B 

UPDATES OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES

During this reporting period, updated information became available for two abnormal occurrence 

(AO) events that the U.S. Nuclear Regulatory Commission (NRC) had previously reported or 

updated in NUREG-0090, Volume 35, Revision 1, “Report to Congress on Abnormal 

Occurrences: Fiscal Year (FY) 2012,” dated August 2013 (the NRC’s Agencywide Documents 

Access and Management System (ADAMS) Accession No. ML13198A165). These events 

involved a medical event at Lovelace Medical Clinic in Albuquerque, New Mexico and a 

commercial nuclear power plant event at Browns Ferry Nuclear Power Plant, Unit 1, in Athens, 

Alabama. 

Medical Event at Lovelace Medical Clinic in Albuquerque, New Mexico (previously reported 

as AS11-09 in NUREG-0090, Volume 34, with updates in Appendix B of NUREG-0090, Volume 

35) 

Date and Place—May 4, 2010, Albuquerque, NM 

Background—The Lovelace Medical Clinic (the licensee) reported that a medical event occurred 

with a high dose rate (HDR) brachytherapy treatment for endometrial carcinoma. The patient 

was prescribed a total radiation dose of 21 gray (Gy) (2,100 rad) in three fractions of 7 Gy (700 

rad) each to a distance of 0.5 cm from the surface of an applicator of diameter 2.3 cm to the 

treatment site, but instead, the skin tissue on the patient’s thigh received 30.6 Gy (3,060 rad) 

and received a dose to the thigh at 2.5 cm depth of 4.08 Gy (408 rad). 

The licensee determined that the medical event was caused by either improper placement or by 

workers inadvertently moving the catheter while adjusting the patient for better alignment with 

the treatment device. The licensee’s corrective actions included revising the procedures to 

ensure that the catheter is correctly positioned before the start of the treatment. In addition, the 

licensee required staff training to address the procedure updates. The licensee concluded that 

no long-term adverse effects are expected for the patient. The FY 2011 AO report discusses 

the full details of the event under AS11-09. 

Update on Actions Taken To Prevent Recurrence

State—The New Mexico Environment Department’s long-term enforcement action has been 

ongoing through calendar year 2014. 

This event is closed for the purpose of this report. 
B-2 

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 regards to 

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 IIP 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.
C-1 

APPENDIX C 

OTHER EVENTS OF INTEREST 

This appendix discusses other events of interest that do not meet the abnormal occurrence 

(AO) criteria in Appendix A but have been perceived by Congress or the public to be of high 

health and safety significance, have received significant media coverage, or have caused the 

U.S. Nuclear Regulatory Commission to increase its attention to or oversight of a program area. 

This appendix includes updates to other events of interest reported in previous AO reports to 

Congress. 

There are no other events of interest that meet the above criteria to report in FY 2014. 
D-1 

APPENDIX D 

GLOSSARY 

Act—the Atomic Energy Act of 1954 (Public Law 83-703), including any amendments. 

Acute respiratory distress syndrome1—respiratory failure in adults or children that results 

from diffuse injury to the endothelium of the lung (as in sepsis, chest trauma, massive blood 

transfusion, aspiration of the gastric contents, or pneumonia) and is characterized by pulmonary 

edema with an abnormally high amount of protein in the edematous fluid and by difficult rapid 

breathing and hypoxemia. 

Authorized User—as defined in § 35.2 of Title 10 of the Code of Federal Regulations

(10 CFR), “Definitions,” a physician, dentist, or podiatrist who: (1) meets the requirements in 

10 CFR 35.59, “Recentness of Training,” and 10 CFR 35.190(a), 10 CFR 35.290(a), 

10 CFR 35.390(a), 10 CFR 35.392(a), 10 CFR 35.394(a), 10 CFR 35.490(a), 10 CFR 35.590(a), 

or 10 CFR 35.690(a); or (2) is identified as an authorized user on: (i) a Commission or 

Agreement State license that authorizes the medical use of byproduct material; (ii) a permit 

issued by a Commission master material licensee that is authorized to permit the medical use of 

byproduct material; (iii) a permit issued by a Commission or Agreement State specific licensee 

of broad scope that is authorized to permit the medical use of byproduct material; or (iv) a 

permit issued by a Commission master material license broad scope permittee that is 

authorized to permit the medical use of byproduct material. 

Basal cell carcinoma1

—a skin cancer derived from and preserving the form of the basal cells 

of the skin. 

Brachytherapy—as defined in 10 CFR 35.2, a method of radiation therapy in which sources 

are used to deliver a radiation dose at a distance of up to a few centimeters by surface, 

intracavitary, intraluminal, or interstitial application. 

Brachytherapy Seed Implantation for Prostate Cancer2

—Radioactive seed implants are a 

form of radiation therapy for prostate cancer. The radioactive seeds are loaded into the 

designated number of needles, in a specific order, and each needle is inserted through the skin 

in the perineum and into the prostate using continuous ultrasound guidance. Once accurate 

needle placement is confirmed, the seeds in that needle are released. This process is 

continued until all of the radioactive seeds have been implanted. 

Brachytherapy Source—as defined in 10 CFR 35.2, a radioactive source or a 

manufacturer-assembled source train or a combination of these sources that is designed to 

deliver a therapeutic dose within a distance of a few centimeters. 

Catheter 1—a tubular medical device for insertion into canals, vessels, passageways, or body 

cavities for diagnostic or therapeutic purposes to permit injection or withdrawal of fluids or to 

keep a passage open. 

 

1 These terms are not defined in 10 CFR, a management directive, an inspection procedure, or an NRC policy 

statement. Rather, they are defined based on definitions in Merriam-Webster’s “MedlinePlus Online Medical 

Dictionary.” MedlinePlus is a service of the U.S. National Library of Medicine and the National Institutes of 

Health (see http://www.nlm.nih.gov/medlineplus/mplusdictionary.html). 
D-2 

Cervical Cancer1

—cancer of the cervix, the narrow neck at the lower part of a woman's uterus, 

just above the vagina. 

Dose Equivalent (HT)—as defined in 10 CFR 20.1003, “Definitions,” the product of the 

absorbed dose in tissue, quality factor, and all other necessary modifying factors at the location 

of interest; the units of dose equivalent are the roentgen equivalent man (rem) and sievert (Sv). 

Effective Dose Equivalent (HE)—as defined in 10 CFR 20.1003, the sum of the products of the 

dose equivalent to the organ or tissue (HT) and the weighting factors (wT) applicable to each of 

the body organs or tissues that are irradiated. 

Exposure—as defined in 10 CFR 20.1003, being exposed to ionizing radiation or to radioactive 

material. 

External Dose—as defined in 10 CFR 20.1003, that portion of the dose equivalent received 

from radiation sources outside the body. 

Foley Catheter2

—a flexible plastic tube (a catheter) inserted into the bladder to provide 

continuous urinary drainage. 

Glans (Bulb of Penis)2

—the rounded head of the penis. 

Gray (Gy)—as defined in 10 CFR 20.1004, “Units of Radiation Dose,” the international system’s 

unit of absorbed dose; 1 gray is equal to an absorbed dose of 1 joule/kilogram (100 rad). 

Interstitial1

—situated within but not restricted to or characteristic of a particular organ or tissue, 

used especially of fibrous tissue. 

Manual Brachytherapy—as defined in 10 CFR 35.2, a type of brachytherapy in which the 

brachytherapy sources (e.g., seeds, ribbons) are manually placed topically on or inserted either 

into the body cavities that are close to a treatment site or directly into the tissue volume. 

Medical Event—as defined in 10 CFR 35.2, an event that meets the criteria in 

10 CFR 35.3045(a) or (b). Regulations in 10 CFR 35.3045(a) state that a licensee shall report 

any event, except for an event that results from patient intervention, in which the administration 

of byproduct material or radiation from byproduct material results in: 

(1) a dose that differs from the prescribed dose or dose that would have resulted from the 

prescribed dosage by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv 

(50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin 

and: (i) the total dose delivered differs from the prescribed dose by 20 percent or more; 

(ii) the total dosage delivered differs from the prescribed dosage by 20 percent or more 

or falls outside the prescribed dosage range; or (iii) the fractionated dose delivered 

differs from the prescribed dose, for a single fraction, by 50 percent or more; 

 2 These terms are not defined in 10 CFR, a management directive, an inspection procedure, or an NRC policy 

statement. Rather, they are defined based on definitions in MedicineNet’s “Online MedTerms Medical 

Dictionary.” MedicineNet is an online service part of WebMD (see http://www.medterms.com).
D-3 

(2) a dose that exceeds 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an 

organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin from any of the 

following: (i) an administration of a wrong radioactive drug containing byproduct material; 

(ii) an administration of a radioactive drug containing byproduct material by the wrong 

route of administration; (iii) an administration of a dose or dosage to the wrong individual 

or human research subject; (iv) an administration of a dose or dosage delivered by the 

wrong mode of treatment; or (v) a leaking sealed source; 

(3) a dose to the skin or an organ or tissue other than the treatment site that exceeds by 

0.5 Sv (50 rem) to an organ or tissue and 50 percent or more of the dose expected from 

the administration defined in the written directive (excluding, for permanent implants, 

seeds that were implanted in the correct site but migrated outside the treatment site). 

Regulations in 10 CFR 35.3045(b) state that a licensee shall report any event resulting from 

intervention of a patient or human research subject in which the administration of byproduct 

material or radiation from byproduct material results or will result in unintended permanent 

functional damage to an organ or a physiological system, as determined by a physician. 

Prescribed Dosage—as defined in 10 CFR 35.2, the specified activity or range of activity of 

unsealed byproduct material as documented (1) in a written directive or (2) in accordance with 

the directions of the authorized user for procedures performed pursuant to 10 CFR 35.100, “Use 

of Unsealed Byproduct Material for Uptake, Dilution, and Excretion Studies for Which a Written 

Directive Is Not Required,” and 10 CFR 35.200, “Use of Unsealed Byproduct Material for 

Imaging and Localization Studies for Which a Written Directive Is Not Required.” 

Prescribed Dose—as defined in 10 CFR 35.2; (1) for gamma stereotactic radiosurgery, the 

total dose as documented in the written directive; (2) for teletherapy, the total dose and dose per 

fraction as documented in the written directive; (3) for manual brachytherapy, either the total 

source strength and exposure time or the total dose, as documented in the written directive; or 

(4) for remote brachytherapy afterloaders, the total dose and dose per fraction as documented 

in the written directive. 

Rad—as defined in 10 CFR 20.1004, the special unit of absorbed dose; 1 rad is equal to an 

absorbed dose of 100 ergs/gram or 0.01 joule/kilogram (0.01 gray). 

Radiation (Ionizing Radiation)—as defined in 10 CFR 20.1003, alpha particles, beta particles, 

gamma rays, x-rays, neutrons, high-speed electrons, high-speed protons, and other particles 

capable of producing ions; radiation, as used in 10 CFR Part 20, “Standards for Protection 

against Radiation,” does not include non-ionizing radiation, such as radiowaves or microwaves, 

or visible, infrared, or ultraviolet light. 

Radiation Oncologist2

—a specialist in the use of radiation therapy as a treatment for cancer. 

Radiation pneumonitis2

—Inflammation of the lungs as a result of radiation. 

Radiation Therapy (Radiotherapy)2

—treatment in which high-energy rays are used to damage 

cancer cells and stop them from growing and dividing. A specialist in radiation therapy is called 

a “radiation oncologist.” 
D-4 

Reactive Inspection—as defined in NRC Inspection Procedure 43003, “Reactive Inspections of 

Nuclear Vendors,” an inspection performed for the purpose of obtaining additional information 

and/or verifying adequate corrective actions on reported problems or deficiencies. 

Rem—as defined in 10 CFR 20.1004, the special unit of any of the quantities expressed as 

dose equivalent; the dose equivalent in rem is equal to the absorbed dose in rad multiplied by 

the quality factor (1 rem = 0.01 sievert). 

Shallow Dose Equivalent (HS)—as defined in 10 CFR 20.1003, which applies to the external 

exposure of the skin of the whole body or the skin of an extremity, the dose equivalent at a 

tissue depth of 0.007 centimeter (7 milligrams/square centimeter). 

Sievert (Sv)—as defined in 10 CFR 20.1004, the international system’s unit of any of the 

quantities expressed as dose equivalent; the dose equivalent in sieverts is equal to the 

absorbed dose in gray multiplied by the quality factor (1 Sv = 100 rem). 

Source Material—as defined in 10 CFR 40.4; (1) uranium or thorium, or any combination 

thereof, in any physical or chemical form; or (2) ores that contain by weight one-twentieth of one 

percent (0.05 percent) or more of: (i) uranium; (ii) thorium; or (iii) any combination thereof. 

Source material does not include special nuclear material. 

Special Nuclear Material—as defined in 10 CFR 70.4, “Definitions”: (1) plutonium, 

uranium-233, uranium enriched in the isotope 233 or in the isotope 235, and any other material 

that the Commission, pursuant to the provisions of Section 51, “Special Nuclear Material,” of the 

Atomic Energy Act, determines to be special nuclear material, but not including source material; 

or (2) any material artificially enriched by any of the foregoing but not including source material. 

Therapeutic Dose—as defined in 10 CFR 35.2, a radiation dose delivered from a source 

containing byproduct material to a patient or human research subject for palliative or curative 

treatment. 

Trigeminal Neuralgia2

—Inflammation of the trigeminal nerve (the fifth cranial nerve) that most 

commonly causes paroxysms of very intense lightning pain in the areas of the face the nerve 

supplies -- the lips, eye, nose, scalp, forehead, gums, cheek, and chin -- on the involved side of 

the face. A less common "atypical" form of the disease causes a more constant, dull, burning, or 

aching pain.

Treatment Site—as defined in 10 CFR 35.2, the anatomical description of the tissue intended 

to receive a radiation dose, as described in a written directive. 

Urethra2

—the transport tube leading from the bladder to discharge urine outside the body. 

Written Directive—as defined in 10 CFR 35.2, an authorized user’s written order for the 

administration of byproduct material or radiation from byproduct material to a specific patient or 

human research subject, as specified in 10 CFR 35.40, “Written Directives.” 
E-1 

APPENDIX E 

CONVERSION TABLE 

Radioactivity and Ionizing Radiation 

QUANTITY FROM METRIC UNITS TO NON-SI UNITS DIVIDE BY 

 

(Radionuclide) Activity megabecquerel (MBq) curie (Ci) 37,000 

 terabecquerel (TBq) Ci 0.037 

 gigabecquerel (GBq) Ci 37 

Absorbed dose gray (Gy) rad 0.01 

 centigray (cGy) rad 1.0 

Dose equivalent sievert (Sv) roentgen equivalent 

man (rem) 

0.01 

 centisievert (cSv) rem 1.0 

 millisievert (mSv) rem 10 

 mSv millirem (mrem) 0.01 

 microsievert (μSv) mrem 10