Office of Nuclear 

Material Safety

and Safeguards

NMSS Licensee Newsletter

(September-October 2003)

Contents Page

1. Tracking of Radioactive Sources. . . . . . . . . . 1

2. Proposed Rule on Medical Training and 

Experience . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. Generic Communications Issued 

(May 1, 2003–September 9, 2003). . . . . . . 3

4. Significant Events. . . . . . . . . . . . . . . . . . . . 5

5. Significant Enforcement Actions . . . . . . . . 8

6. Selected Federal Register Notices

(June 1, 2003–September 30, 2003). . . . . . 10

NUREG/BR-0117

No. 03-3

Sep-Oct 2003

U.S. Nuclear 

Regulatory 

Commission

TRACKING OF RADIOACTIVE SOURCES

The events of September 11, 2001, heightened 

the nation’s concerns about the use of radioactive 

materials for a malevolent act. In June 2002, the 

Secretary of Energy and the Chairman of the U.S. 

Nuclear Regulatory Commission (NRC) met to 

address these concerns and discuss the nation’s 

ability to adequately protect inventories of nuclear 

materials that could be used in a radiological 

dispersal device (RDD). An attack involving an 

RDD has been of particular concern because of 

the widespread use of radioactive materials in the 

United States and abroad by industry, hospitals, 

and academic institutions. In May 2003, the report 

written by the U.S. Department of Energy (DOE)/

NRC Working Group (WG) convened to study these 

concerns was accepted by the Secretary of DOE and 

the NRC Chairman. The WG generated a list of 

radionuclides and thresholds for which the tracking 

of sources was recommended. A similar study 

undertaken by the International Atomic Energy 

Agency (IAEA) created a list of radionuclides and 

thresholds similar to the DOE/NRC list. NRC 

recently determined that it will use the IAEA list to 

support international cooperation on source tracking.

This direction parallels proposed legislation known 

as the “Dirty Bomb Prevention Act” currently 

under discussion in Congress (S-350 and HR-891, 

current progress available through the Thomas 

locator service website http://thomas.loc.gov/). 

The Monterey Institute, in a report issued by the 

Center for Nonproliferation Studies in January 

2003, recommends enhanced regulation of highrisk sources. Also, as noted in the Monterey 

Institute report, the Health Physics Society has 

recommended the development of a confidential 

national tracking system for licensed sources. A 

similar recommendation was made in the National 

Research Council report issued in late 2002 

(recommendation 2.11).

Comments, and suggestions you may have for 

information not currently included, that might be 

helpful to licensees, should be sent to:

E. Kraus

NMSS Licensee Newsletter Editor

Office of Nuclear Material Safety and Safeguards

Two White Flint North, Mail Stop 8-A-23

U.S. Nuclear Regulatory Commission

Washington, D.C. 20555-0001

NMSS Licensee Newsletter
2 

NRC has started work on a new national system 

to track radioactive sources of greatest concern, 

as designated on the IAEA list. However, since 

current regulations do not require reporting source 

inventories, NRC and the Agreement States (AS’) 

only know the quantities a given licensee has been 

authorized to use, not what a licensee has at a given 

moment. Thus, the first step, as directed by the 

Commission, is the creation of an interim inventory 

—a ‘snapshot’ of the existing sources. The interim 

inventory is necessary to provide NRC and the AS’ 

with greater detail on the source population, to plan 

the development of the source tracking system. The 

process for the collection of the interim inventory 

data is being worked out at this time. Generally, the 

process will consist of the AS’ or NRC contacting 

all licensees authorized to possess quantities of 

radionuclides on the IAEA list, and in excess of the 

respective threshold, and asking for the details of 

the sources. Additional data such as the number of 

physical locations of sources under the license, nearterm disposition plans, and import/export aspects, 

will be requested. DOE is performing a similar 

inventory at its facilities.

As the interim inventory data are gathered, NRC 

will be convening a working group with DOE 

and the AS’ to designate the requirements of the 

national source tracking system. It is expected that 

regulatory changes will also need to be made to 

incorporate the tracking system into the regulations. 

The working group will determine the necessary 

changes and initiate the rule-making necessary 

to accomplish the changes. The working group 

will also work with other Federal agencies, such 

as the Departments of Transportation; Commerce; 

Homeland Security; Defense; and State; U.S. 

Customs and Border Patrol; Food and Drug 

Administration; and Environmental Protection 

Agency, to ensure that the system meets all domestic 

needs and international commitments while 

minimizing the impact on the industries involved 

and the burden on individual licensees.

A national source tracking system will offer the 

following safety and security benefits:

• Better accountability for the movement and 

possession of materials, which could help deter 

and detect source loss or theft. For example, 

the system could provide an automatic alert 

for a source that is shipped but not recorded as 

received at its destination. This information 

would allow prompt follow-up action to ensure 

that the source is secure.

• Use of the information as a planning tool for 

source pickup and disposal. 

• The ability of U.S. Customs Service and other 

officials to verify that radioactive materials 

entering the country are bound for an intended, 

legitimate recipient.

• Better information for decision-makers about 

actual movement, storage, use, and final 

disposition of radioactive materials in the United 

States. This information would be useful for, 

among other reasons, refining the assessment of 

the hazards posed by these materials in various 

situations. 

• Eventual elimination of multiple, existing 

source-tracking systems at DOE, and integration 

with a planned Internet-based licensing system 

at NRC. Thus, some costs of implementing the 

system would be recouped by the elimination of 

existing systems and by resource sharing.

• An easy-to-use, standard software tool for 

commercial licensees and DOE facilities to 

use in managing shipments and inventories 

of radioactive sources, as well as in fulfilling 

reporting requirements to regulatory agencies.

NRC is giving attention to unwanted sources and 

has provided funds to the Conference of Radiation 

Control Program Directors. It has also worked with 

DOE on the prioritization of sources and a schedule 

for pickup. 

The interim inventory will begin by mid-November 

2003. NRC expects to have an inventory of highrisk sources by April 2004. The overall goal is to 

create a working tracking system by about the end of 

2005 or early 2006.

(Contacts: Merri Horn, 301-415-8126, e-mail: 

mlh1@nrc.gov; William Ward, 301-415-7038, 

e-mail: wrw1@nrc.gov)
3

PROPOSED RULE ON MEDICAL 

TRAINING AND EXPERIENCE

A proposed rule to amend 10 CFR Part 35 was 

approved by the Executive Director for Operations 

and sent to the Commission on August 21, 2003. 

The proposed amendments would amend Part 35, 

“Medical Use of Byproduct Material,” to modify 

training and experience requirements related to 

recognition of specialty board certifications, as 

described in SECY–02–0194 (October 30, 2002) and 

approved by the Commission in Staff Requirements 

Memorandum (SRM)–02–0194 (February 12, 2003). 

The U.S. Nuclear Regulatory Commission (NRC) 

staff anticipates Commission action in the early 

Fall of 2003 and publication of the proposed rule 

in the Federal Register shortly thereafter, to solicit 

public comment over a 75-day period. Background 

on the proposed rule is available at NRC’s website: 

SECY–02–0194 is at: www.nrc.gov/reading-rm/

doc-collections/commission/secys/2002/; and 

SRM–02–0194 is at: www.nrc.gov/reading-rm/

doc-collections/commission/srm/2002/.

(Contact: Roger Broseus, NMSS, 301-415-7608, 

e-mail: rwb@nrc.gov)

GENERIC COMMUNICATIONS ISSUED

(May 1, 2003–September 9, 2003)

The following are summaries of U.S. Nuclear 

Regulatory Commission (NRC) generic 

communications. If one of these documents appears 

relevant to your needs and you have not received it, 

please call one of the technical contacts listed below. 

The Internet address for the NRC library of generic 

communications is: http://www.nrc.gov/reading-rm/

doc-collections/gen-comm/index.html. Please 

note that this address is case-sensitive and must be 

entered exactly as shown.

Bulletin

NRC Bulletin 2003-03, “Potentially Defective 1-Inch 

Valves for Uranium Hexafluoride Cylinders,” was 

issued on August 29, 2003. This bulletin was sent to 

the following recipients:

For Action:

(1) NRC licensees and certificate holders authorized 

to possess and use source material and/or special 

nuclear material for the heating, emptying, and 

filling of uranium hexafluoride (UF6) in 30- and 

48-inch cylinders, and

(2) Registered users of Certificates of Compliance 

for enriched (fissile) UF6 packages, under 

10 CFR Part 71.

For Information:

(1) Holders of Certificates of Compliance for 

enriched (fissile) UF6 packages under Part 71,

(2) U.S. Department of Transportation (DOT), and

(3) U.S. Department of Energy.

This bulletin was issued to advise addressees of the 

performance and safety concerns with 1-inch valves 

for UF6 cylinders manufactured by the Hunt Valve 

Company (hereafter, Hunt) of Salem, Ohio. NRC 

requests Action Addressees to take specified actions 

intended to identify potentially defective Hunt 

valves under their control; ensure that cylinders with 

Hunt valves already installed are safely used and 

transported during a transition period, not to exceed 

12 months; and ensure that only valves verified to be 

compliant with NRC regulations, NRC licenses and 

certificates, and DOT regulations are in use by the 

end of the transition period. All Action Addressees 

are required to provide NRC with a written response 

to this bulletin.

(Contacts: Lance J. Lessler, NMSS, 301-415-8144, 

e-mail: ljl@nrc.gov; Adelaide Giantelli, SFPO, 

301-415-3521, e-mail: asg2@nrc.gov)

Information Notices (INs)

IN 2002-31, Supplement 1, “Potentially Defective 

UF6 Cylinder Valves (1-Inch),” was issued on 

March 24, 2003. This notice was issued to all NRC 

licensees authorized to possess and use source 

material and/or special nuclear material for heating, 

emptying, filling, or shipping (30- and 48-inch) 

cylinders of uranium hexafluoride (UF6). NRC 

previously issued IN–/UF6 2002–31, to inform 

addressees about two safety concerns related to 

1-inch UF6 cylinder valves manufactured by the 

Hunt Valve Company, Inc., of Salem, Ohio. The 

safety concerns were: (1) cracked packing nuts; and 
4 

(2) the loss of material traceability and failure to 

conduct hardness testing of the valve stems. Since 

then, the United States Enrichment Corporation has 

conducted a series of tests to verify that the valves 

would perform their intended safety function.

NRC is issuing this supplement to inform 

addressees that, as a result of those tests, a 

number of valves failed to meet the seal leakage 

performance requirements.

(Contact: William Troskoski, NMSS 301-415-8076, 

e-mail: wmt@nrc.gov)

IN 2003-09, “Source Positioning Errors and System 

Malfunctions During Administration of Intravascular 

Brachytherapy,” was issued on July 16, 2003. This 

notice was issued to all medical licensees to inform 

them of four recently reported medical events, with 

two separate device types, that have occurred during 

the conduct of intravascular brachytherapy (IVB) 

procedures. These medical events involved errors in 

positioning the IVB sources or system malfunctions, 

resulting in administration of the dose to the wrong 

treatment site. Two events involved inadequate 

understanding of source positioning details for 

the most recent device being employed. The third 

event involved catheter malfunction and inadequate 

visualization of the active source, and the fourth 

event involved system malfunction.

(Technical Contacts: Penny Lanzisera, Region I, 

610-337-5169, e-mail: pan@nrc.gov; 

Thomas K. Thompson, Region I, 610-337-5303, 

e-mail: tkt@nrc.gov)

IN 2003-10, “Criticality Monitoring System 

Degradation at BWX Technologies, Inc., Nuclear 

Products Division, Lynchburg, VA,” was issued on 

August 4, 2003. This notice was sent to all NRC 

licensees authorized to possess a critical mass of 

special nuclear material, to inform them of a safety 

concern in EC1-X and EC2-X Thermo Electron 

(formerly Eberline) analog monitors. The safety 

concern arises when these systems, used as either inline monitors or criticality monitors, are exposed to 

power surges, such as in a lightning storm, causing 

a failure of the alarm function of the EC1-X and 

EC2-X monitors, without indication.

(Technical Contact: Billy Gleaves, NMSS, 

301-415-5848, e-mail: bcg@nrc.gov)

IN 2003-12, “Problems Involved in Monitoring 

Dose to the Hands Resulting from the Handling of 

Radiophamaceuticals,” was issued on August 22, 

2003. This notice was sent to all holders of 10 CFR 

Parts 32, 33, and 35 licenses, to alert them to 

potential difficulties that may be encountered when 

monitoring doses to the hands of workers involved 

in handling radiopharmaceuticals. This IN describes 

some of these difficulties, the work that is being 

conducted to resolve them, and interim guidance that 

NRC will adopt pending completion of this work.

(Contacts: Sami Sherbini, NMSS, 301-415-7853, 

e-mail: sxs2@nrc.gov; Anita Turner, Ph.D., 

NMSS, 301-415-5508, e-mail: alt@nrc.gov; 

Joseph DeCicco, NMSS, 301-415-7833, e-mail: 

jxd1@nrc.gov)

Regulatory Issue Summaries (RIS’)

RIS 2003-11,” Reporting Requirements for 

Distributors of Devices Subject to the General 

License Requirements of 10 CFR 31.5,” was 

issued on July 16, 2003. This summary was sent 

to all licensees authorized to distribute devices 

containing byproduct material under 10 CFR 32.51, 

or equivalent Agreement State regulation, to remind 

them of the requirement to make accurate and 

timely transfer reports to NRC, pursuant to 10 CFR 

32.52, or equivalent Agreement State regulations/

license conditions.

(Contact: William R. Ward, NMSS, 301-415-7038, 

e-mail: wrw1@nrc.gov)

RIS 2003-15, “Consolidation of the Region I 

and Region II Materials Program,” was issued 

on September 05, 2003. This summary was 

sent to all materials licensees to inform them of 

the consolidation of the Region I and Region II 

materials program.

(Contact: George C. Pangburn, Region I, 

610-337-5281, e-mail: gcp@nrc.gov)

(General Contact: Ivelisse M. Cabrera, NMSS, 

301-415-8152, e-mail: imc1@nrc.gov)
5

SIGNIFICANT EVENTS

The U.S. Nuclear Regulatory Commission (NRC) 

is providing summaries of these events to inform 

licensees of conditions they may encounter and of 

actions that may be taken to deal with them.

Event 1: Patient receives underdose during an 

intravascular brachytherapy treatment.

Date and Place: October 9, 2002; The Queen’s 

Medical Center, Honolulu, Hawaii.

Nature and Probable Causes: A patient undergoing 

intravascular brachytherapy treatment with a 

Novoste BetaCath system (model A1733) was 

prescribed treatment of 1840 centiGray (cGy) (rad) 

to the left anterior descending artery (LAD) to 

prevent scar tissue blockage. The treatment team 

introduced a catheter containing a radioactive source 

train into the patient, and, because the radiation 

oncologist and cardiologist believed that they could 

see the proximal and distal markers of the source 

train on the fluoroscopy monitor, the physicist did 

not perform a survey to ensure that the source train 

was in the patient’s chest. 

After treatment, the radiation oncologist was 

unable to return all of the radioactive sources to 

the device. Consequently, the cardiologist pulled 

the entire catheter out of the patient and placed 

it in the bail-out box. On closer inspection, the 

oncologist discovered a kink in the catheter where 

the distal seed and marker were stuck. The kink 

was attributed to the patient’s anatomy. A review of 

the cinematography images revealed that only one 

active seed reached the proper location, whereas 

five seeds were positioned in the beginning LAD, 

and 10 seeds were outside the cinematography field 

of view. Instead of the correct site receiving the 

intended 1840 cGy (rad), it received approximately 

125 cGy (rad). The remaining dose, which is not 

expected to cause an adverse effect, was delivered 

to an unintended section of the LAD and aorta. The 

cause of the event was human error because the 

licensee did not perform a survey to verify that the 

radioactive sources were in the proper location. The 

patient’s anatomy was a contributing factor.

Actions Taken to Prevent Recurrence

Licensee: Based on the cause and contributing 

factors of the medical event, the licensee modified 

its procedures to require additional documented 

verification of the position of the markers by the 

radiological technologist and medical physicist.

Event 2: Minor patient receives overdose of 

radioiodine.

Date and Place: March 28, 2003; Deaconess 

Hospital, Evansville, Indiana

Nature and Probable Causes: During therapy 

for a thyroid condition, a 9-year-old patient 

received a dose of 15.6 megabecquerels (MBq) 

(421 microcuries) of liquid iodine-131 instead of 

the prescribed dose of 0.15 MBq (4 microcuries). 

According to the licensee’s procedures, either 

liquid I-131 or I-123 in capsule form may be used 

for the thyroid therapy. However, the appropriate 

dose for the liquid I-131 therapy is 0.15 MBq (4 

microcuries), whereas the appropriate dose for the I123 capsule therapy is 14.8 MBq (400 microcuries). 

Because the patient was unable to swallow the 

capsule, the technologist placed a telephone request 

to a local commercial radiopharmacy for liquid 

I-131. While doing so, the technologist erroneously 

ordered 14.8 MBq (400 microcuries). The licensee 

identified the error while reviewing related 

paperwork on April 2, 2003. 

The intended thyroid dose was approximately 13 

centisieverts (cSv) (rem), but NRC’s contracted 

medical consultant estimated that the patient 

received a thyroid dose of 1370 cSv (rem) and 

an effective dose equivalent of 42 cSv (rem). 

However, no acute radiation effects are expected. 

This medical event was caused by human error.

Actions Taken to Prevent Recurrence

The licensee developed a standardized order form, 

modified the computer to disallow an inappropriate 

dose entry, created two separate written policies for 

capsule and liquid thyroid uptake procedures, and 

provided in-service training on this event to nuclear 

medicine technologists.
6 

Event 3: Patient receives brachytherapy treatment to 

unintended site.

Date and Place: May 6, 2003, Washington Hospital 

Center, Washington, District of Columbia

Nature and Probable Consequences: A patient 

received a brachytherapy treatment to an unintended 

site. The event took place, during treatment for 

coronary restenosis, using a Novoste 3.5 French 

intravascular brachytherapy device (model A1767). 

The licensee stated that the 1.95-gigabecquerel 

(52.7-millicurie) AEA Technology strontium-90 

source train (model SICW.2) did not travel all the 

way to the treatment position within the delivery 

catheter, but instead traveled to a point more than 

40 millimeters (mm) proximal to the treatment 

site. A small kink in the delivery catheter at that 

point kept the source train from traveling to the 

treatment position, but the flow of the sterile water 

used to send and retrieve the source train was not 

affected. The event was not identified until May 7, 

2003, when a medical physicist performed a quality 

assurance review of the treatment. The licensee 

stated that the treatment site was in a particularly 

difficult location and the radiopaque markers were 

difficult to see, but it appeared during the treatment 

that the source train had traveled to the intended 

treatment site. The licensee added that, in retrospect, 

the distal end of the seed train was mistaken for the 

proximal end of the seed train. The 40-mm source 

train delivered the entire prescribed dose of 2300 

cGy (rad) to vasculature located at least 40 mm 

proximal to the intended treatment site. The licensee 

will evaluate the patient to determine if additional 

treatment is necessary. This medical event was 

caused by human error, in that the licensee failed to 

verify the treatment site. NRC contracted a medical 

consultant to review this event. He determined that 

no deterministic effects other than fibrosis of the 

vessel wall are expected. 

Actions Taken to Prevent Recurrence

The licensee emphasized to applicable personnel the 

importance of carefully observing the source train 

during positioning. The licensee also recommended 

to the manufacturer that the distal marker of the seed 

train be lengthened so that the distal and proximal 

markers can be easily differentiated. 

Event 4: Patient receives brachytherapy treatment to 

unintended part of the body because of equipment 

malfunction.

Date and Place: May 22, 2003, Union Memorial 

Hospital, Baltimore, Maryland.

Nature and Probable Consequences: During a 

cardiac brachytherapy procedure conducted at 

the licensee’s facility, a malfunction of the drive 

mechanism occurred with a Guidant intravascular 

brachytherapy device (model Galileo III, serial 

#27958595) containing a P-32 source with an 

activity of 3.48 gigabecquerels (94.9 millicuries). 

The malfunction occurred during the treatment of 

the third of three patients. The first two treatments 

were completed without incident. The treatment 

of the third patient was initiated with the dummy 

source successfully reaching the proper dwell 

position (confirmed visually via fluoroscopy) 

and returning to the cartridge. The active source 

was then advanced into the catheter, but when the 

licensee determined that the source movement light 

continued to blink well after the anticipated transit 

time, the licensee initiated a fluoroscopic view of 

the treatment site. The source was not observed 

in the fluoroscopic field of view, so the licensee 

assumed a machine malfunction had occurred and 

initiated emergency procedures. Radiation surveys 

were performed, which confirmed that the source 

had stopped inside the patient. The indicator light 

on the console continued to indicate that the source 

was in transit even after the licensee confirmed the 

source was in the patient and not at the treatment 

site. The licensee was unable to retract the source 

to its shielded position using the machine interrupt, 

the system stop button, or the manual hand-wheel. 

At that point, the attending physician removed the 

catheter and source from the patient and dropped 

them on the operating room floor. After the power 

cord was removed from the wall receptacle, the 

source retracted into its shielded position. The 

licensee stated that it took approximately 45 to 

60 seconds to remove the source from the patient. 

The manufacturer representative present during the 

treatment indicated that this period was 60 to 90 

seconds. The licensee estimated a worst-case dose 

to the wall of the patient’s artery as approximately 

1038 centigray (rad) based on a 60-second 

exposure time. 
7

The source delivery unit was taken to the licensee’s 

“hot” laboratory after the event, and the daily 

quality assurance (QA) checks were performed in 

the physics and clinical modes. The unit passed 

both QA checks. The manufacturer representative 

present during the procedure immediately notified 

the manufacturer’s technical center. The device 

was returned to the manufacturer for evaluation, 

and a new device was provided to the licensee. 

This medical event was caused by equipment 

malfunction. The manufacturer was able to 

simulate a similar type of failure on two occasions 

and identified a defective U14 timer chip (also 

called the 8254 chip), a component of the central 

processing unit’s motor control board logic chip, as 

the cause of the malfunction. The defective timer 

chip was replaced. The State of Maryland ruled out 

human error as the cause of the drive mechanism 

malfunction.

Actions Taken to Prevent Recurrence

As a result of this incident, the State of Maryland is 

considering implementing a requirement for all of its 

licensees with intravascular brachytherapy devices 

to conduct annual emergency exercises. 

Event 5: Patient receives dose to incorrect area 

during high-dose-rate remote-afterloader treatment

Date and Place: June 6, 2003, Saint Joseph’s 

Hospital, Houston, Texas

Nature and Probable Consequences: The licensee 

(aka Sisters of Charity of the Incarnate World) 

reported that a patient received a dose to an 

incorrect area during a breast cancer treatment 

involving an MDS Nordion high-dose-rate remoteafterloader (HDR) unit, model GammaMed 

Plus. At the beginning of the sixth treatment, the 

physicist discovered a geographic location error 

on the placement of a 111-gigabecquerel (3-curie) 

iridium-192 source (MDS Nordion model 232, 

serial #D24A-485). The licensee further discovered 

an input error on the five previous treatments. 

Measurements should have been entered into the 

HDR unit in millimeters, but were mistakenly 

entered in centimeters. Therefore, the source never 

entered the patient’s body. The physicist estimated 

a 7000 centigray (cGy) (rad) superficial dose to 

the skin at a depth of up to 1 cm. Deep dose was 

estimated at 3400 cGy (rad) at 1 cm; 1500 cGy 

(rad) at 2 cm; and 1000 cGy (rad) at 3 cm. The 

patient developed a small red spot, which is being 

monitored by the licensee for potential blistering. 

The cause of this event was human error.

Actions Taken to Prevent Recurrence

To prevent recurrence, the licensee will compare 

the console instructions to the approved quality 

assurance record before each treatment fraction.

Event 6: Patient receives wrong dose of 

radiopharmaceutical.

Date and Place: June 11, 2003; Christus Santa Rosa, 

San Antonio, Texas

Nature and Probable Consequences: The licensee 

reported that a patient received 85.1 megabecquerels 

(MBq) [2.3 millicuries (mCi)] of iodine-131 (I-131) 

instead of the prescribed dosage of 11.1 MBq (300 

microcuries). The licensee discovered the error when 

the patient returned after 48 hours for a scan. The 

doctor asked the technologist for the prescription 

that was issued, and discovered that the technologist 

had ordered the wrong dose for the prescribed 

procedure. The cause of this event was human error. 

Actions Taken to Prevent Recurrence

I-131 doses will require concurrence by the 

physician before the dose is ordered.

Event 7: Overexposures to members of the public.

Date and Place: June 29, 2003, Monsanto Chemical 

Plant, Luling, Louisiana

Nature and Probable Consequences: The licensee 

reported that members of the public received 

radiation exposures because of a loss of control of 

a 37-gigabecquerel (1-curie) cesium-137 (Cs-137) 

source that came out of a damaged Berthold level 

gauge (model LB 7442). The gauge was damaged 

on June 29, 2003, causing the source to come out 

of its shield. The licensee stated that it appears that 

vibration of the centrifuge unit on which the gauge 

was mounted may have caused a failure that allowed 

the source holder with attached source to fall 

from the gauge. Surveys of the relevant areas and 
8 

smears taken on the source indicate that no source 

leakage occurred. 

The event occurred when an employee noticed that 

the gauge’s handle mechanism had broken off and 

fallen to the floor beneath the gauge. The worker 

picked up the broken pieces, which included the 

Cs-137 source, carried them to the planner’s office, 

and placed them on the planner’s desk. The source 

remained on the planner’s desk until discovery on 

July 10, 2003. It was determined that the planner 

occupied the desk for approximately 50 to 60 hours 

and received a whole-body dose in the range of 35 to 

74 centisieverts (cSv) (rem). This determination was 

based on an analysis of the planner’s schedule and 

work habits and on the exposure level of the source. 

The person that carried the source to the planner’s 

desk received an extremity dose of between 24 and 

314 cSv (rem) to the hand. Others may have also 

been exposed. Blood tests were performed for seven 

individuals. No cellular effects were observed, and 

no one has shown signs of sickness or erythema. 

Actions Taken to Prevent Recurrence

A factor that contributed to the event was the level 

of training given to the planner, and the person 

who found the source. The planner and the person 

who found the source were trained to recognize the 

radiation symbol and to be aware of radioactive 

gauges, but not to recognize the source capsule 

itself. Training will now include pictures of the 

source itself. 

(Contact: Angela R. Williamson, NMSS, 301-415-

5030, e-mail: arw@nrc.gov)

SIGNIFICANT ENFORCEMENT 

ACTIONS

The U.S. Nuclear Regulatory Commission’s 

(NRC’s) enforcement program can be accessed 

via NRC’s homepage [http://www.nrc.gov/] under 

“What We Do.” Documents related to cases can 

be accessed at [http://www.nrc.gov/], “Electronic 

Reading Room,” “Documents in ADAMS.” 

ADAMS is the Agencywide Document Access and 

Management System. Help in using ADAMS is 

available from the NRC Public Document Room, 

telephone: 301-415-4737 or 1-800-397-4209. 

Gauges

Tamfelt, Inc. (EA-03-121)

On August 28, 2003, a Notice of Violation was 

issued for a Severity level III problem involving the 

possession and/or use of licensed material in areas 

of NRC jurisdiction without a specific or general 

NRC license and the failure to file NRC Form 241, 

“Report of Proposed Activities in Non-Agreement 

States, Areas of Exclusive Federal Jurisdiction, or 

Offshore Waters,” with NRC before conducting 

licensed activities in NRC jurisdiction.

Daniel Kaidel (EA-03-120)

On July 10, 2003, a Notice of Violation was issued 

for a Severity Level III violation involving the 

licensee’s inappropriate transfer of licensed material 

[approximately 5.6 gigabecquerels (150 millicuries) 

of americium-241 in a portable gauge] to a person 

who was not authorized to receive such byproduct 

material, and the licensee’s failure to verify, before 

transfer, that the person had a license to receive 

byproduct material. 

Roofing Consultants, Ltd. (EA-03-094)

On July 8, 2003, a Notice of Violation was issued 

for a Severity Level III problem involving the 

failure to secure from unauthorized removal, or limit 

access to, licensed material [1.9 gigabecquerels (50 

millicuries) of americium/beryllium in a moisture 

density gauge] in an unrestricted area; failure 

to control and maintain constant surveillance of 

this licensed material; and failure to provide the 

manufacturer’s training to an individual who used 

licensed material. 

Structural Testing and Inspection (EA-03-006)

On July 1, 2003, a Notice of Violation was issued 

for a Severity level II violation involving the willful 

failure to obtain a specific license from NRC or 

an Agreement State before acquiring and using 

two Troxler Model 3411 gauging devices, each 

containing about 370 megabecquerels [10 millicuries 

(mCi)] of cesium-137 and about 1.9 gigabecquerels 

(50 mCi) of americium-241. Although a civil 

penalty would normally be considered for this type 
9

of case, NRC exercised discretion in accordance 

with Section VII.B.6 of the Enforcement Policy and 

refrained from assessing a civil penalty based on the 

fact that the gauges were returned to an authorized 

NRC licensee and the company withdrew its 

application for an NRC license. 

Medical

Deaconess Hospital (EA-03-092)

On August 29, 2003, a Notice of Violation was 

issued for a Severity Level III violation involving 

the failure to have a written directive and follow 

the direction of an authorized user and the failure 

to administer iodine-131 sodium iodide within the 

prescribed dosage range. 

Lankenau Hospital (EA-03-147)

On August 21, 2003, a Notice of Violation was 

issued for a Severity Level III violation involving 

the licensee’s failure to secure from unauthorized 

removal, limit access to, and control and maintain 

constant surveillance of, licensed material [28 

gigabecquerels (763 millicuries) of iridium-192] 

that was located in an unrestricted area.

Northern Michigan (EA-03-122)

On August 11, 2003, a Notice of Violation was 

issued for a Severity Level III violation involving 

the failure to secure from unauthorized removal, 

limit access to, and control and maintain constant 

surveillance of, licensed material [a molybdenumtechnetium generator (Mo-99/Tc-99m) containing 

44.8 gigabecquerels (1210 millicuries); 13 

gigabecquerels (351 millicuries) of technetium99m in unit dose form; 15 megabecquerels (400 

microcuries) of iodine-131; and several check 

sources in the microcurie range] that was stored in a 

controlled area.

Columbia Hospital (EA-03-112)

On July 30, 2003, a Notice of Violation and 

Proposed Imposition of Civil Penalty in the amount 

of $3000 was issued for a Severity Level III 

violation involving the willful failure to secure from 

unauthorized removal, limit access to, and control 

and maintain constant surveillance of, licensed 

material [148 megabecquerels (4 millicuries) of 

iodine-131; 8 gigabecquerels (219 millicuries) 

of technetium-99m; and 7 megabecquerels (189 

microcuries) of cesium-137) that was stored in a 

controlled area. 

Howard University Hospital (EA-03-088)

On June 27, 2003, a Notice of Violation and 

Proposed Imposition of Civil Penalty in the amount 

of $3000 was issued for a Severity Level III 

violation involving the failure to perform adequate 

area surveys, within the licensee’s facility, which 

resulted in a substantial potential for exposures in 

excess of the regulatory limits.

Doylestown Hospital (EA-03-125)

On June 26, 2003, a Notice of Violation was 

issued for a Severity Level III violation involving 

the licensee’s failure to complete required 

manufacturer’s training before using an intravascular 

brachytherapy system.

Radiography

Longview Inspection, Inc. (EA-03-101)

On August 18, 2003, a Notice of Violation and 

Proposed Imposition of Civil Penalty in the 

amount of $6000 was issued for a Severity Level 

III problem involving the failure to control and 

maintain constant surveillance of licensed material 

[4.5 terabecquerels (121 curies) of iridium-192 

contained in a radiographic exposure device] that 

was in an unrestricted area and the failure to lock 

the radiographic exposure device while it was not 

under the direct surveillance of a radiographer or a 

radiographer’s assistant.

Mid American Inspection Services, Inc. 

(EA-03-100)

On August 12, 2003, a Notice of Violation and 

Proposed Imposition of Civil Penalty in the 

amount of $6000 was issued to Mid American 

Inspection Services for a Severity Level III problem 

involving two violations—the failure to secure 

from unauthorized removal or maintain constant 

surveillance of licensed material, and the failure to 

ensure that shipping papers are in a vehicle while 
10 

transporting radioactive material. On April 10, 2003, 

an NRC inspection identified that a radiography 

camera was stored in a vehicle being repaired at 

an automobile dealership for 7 days. In addition, 

the radiographer had removed the shipping papers 

from the vehicle when it was left for repairs and 

the dealership personnel test drove the vehicle on 

public roads.

Testmaster Inspection Company, Inc. 

(EA-03-081)

On July 2, 2003, a Notice of Violation and Proposed 

Imposition of Civil Penalty in the amount of 

$5500 was issued for a Severity Level III violation 

involving the deliberate failure to use a radiation 

survey instrument during radiographic operations. 

Nondestructive and Visual Inspection, Inc. 

(EA-03-031)

On June 16, 2003, a Notice of Violation and 

Proposed Imposition of Civil Penalty in the 

amount of $6000 was issued for a Severity Level 

III violation involving the failure to secure from 

unauthorized removal, or limit access to, licensed 

material [about 1.9 terabecquerels (52 curies) of 

iridium-192 in an industrial radiographic exposure 

device] located on a platform in Federal waters in 

the Gulf of Mexico, which is an unrestricted area, 

and the failure to control and maintain constant 

surveillance of this licensed material. 

Other

BWX Technologies, Inc. (EA-03-119)

On August 11, 2003, a Notice of Violation and 

Exercise of Enforcement Discretion was issued for a 

Severity Level III problem involving two interrelated 

violations. The violations involved the failure to 

maintain a criticality monitoring system (CMS) 

capable of energizing a clearly audible signal if an 

accidental criticality were to occur as required by 

Safety Condition S-1 of the license and the failure to 

conduct a functional test of the CMS as required by 

procedures. Given the circumstances of a previous 

enforcement action, NRC considered it appropriate 

to exercise enforcement discretion in accordance 

with Section VII.B.6 of the Enforcement Policy and 

forego consideration of the factor of “Identification” 

in its civil penalty assessment process. On the basis 

of this determination, the safety significance of the 

violations that are the subject of this Notice, and 

the prompt and comprehensive corrective actions 

taken by the licensee, a civil penalty in this case was 

not warranted.

Individual Actions 

Lowell S. Trujillo (IA-03-002)

On June 26, 2003, an Immediately Effective Order 

Prohibiting Involvement in NRC-Licensed Activities 

(for 3 years) was issued to the individual because he 

deliberately purchased, possessed, and used nuclear 

material [about 370 megabecquerels (10 millicuries) 

(mCi) of cesium-137 and about 1.9 gigabecquerels 

(50 mCi) of americium-241 in two gauging devices], 

in violation of NRC requirements. 

(Contact: Sally Merchant, 301-415-7842; e-mail: 

slm@nrc.gov)

SELECTED FEDERAL REGISTER

NOTICES

(June 1, 2003–September 30, 2003)

NOTE: U.S. Nuclear Regulatory Commission 

(NRC) contacts may be reached by mail at the U.S. 

Nuclear Regulatory Commission, Washington, DC 

20555-0001.

FINAL RULES 

“Parts 72 and 73 Event Notification Requirements,” 

68 FR 33611, June 5, 2003. (Contact: Mark 

Haisfield, NMSS, 301-415-6196, e-mail: 

mfh@nrc.gov)

“Medical Use of Byproduct Material; Clarifying 

and Minor Amendments; Confirmation of Effective 

Date,” 68 FR 35534, June 16, 2003. (Contact: 

Dr. Anthony N. Tse, NMSS, 301-415-6233, e-mail: 

ant@nrc.gov)

“Revision of Fee Schedules; Fee Recovery for FY 

2003,” 68 FR 36714, June 18, 2003. (Contacts: 

Ann Norris, OCFO, 301-415-7807; Tammy Croote, 

OCFO, 301-415-604)
11

“List of Approved Spent Fuel Storage Casks: NACMPC Revision (Direct final rule),” 68 FR 42570, 

July 18, 2003. (Contact: Jayne M. McCausland, 

NMSS, 301-415-6219, e-mail: jmm2@nrc.gov)

“List of Approved Spent Fuel Storage Casks: 

Standardized NUHOMS-24P, -52B, and -61BT, 

Revision 5 (Direct final rule),” 68 FR 49683, 

August 19, 2003. (Contact: Jayne M. McCausland, 

NMSS, 301-415-6219, e-mail: jmm2@nrc.gov)

“Geological and Seismological Characteristics for 

Siting and Design of Dry Cask Independent Spent 

Fuel Storage Installations and Monitored Retrievable 

Storage Installations,” 68 FR 54143, September 16, 

2003. (Contact: Keith K. McDaniel, 301-415-5252, 

e-mail: kkm@nrc.gov)

“List of Approved Spent Fuel Storage Casks: NACMPC Revision, Confirmation of Effective Date,” 

68 FR 55304, September 25, 2003. (Contact: Jayne 

M. McCausland, NMSS, 301-415-6219, e-mail: 

jmm2@nrc.gov)

PROPOSED RULES

“List of Approved Spent Fuel Storage Casks: 

NAC-MPC Revision (Companion proposed rule),” 

68 FR 42646, July 18, 2003. (Contact: Jayne M. 

McCausland, NMSS, 301-415-6219, e-mail: 

jmm2@nrc.gov)

“Security Requirements for Portable Gauges 

Containing Byproduct Material,” 68 FR 45172, 

August 1, 2003. (Contact: Lydia Chang, NMSS, 

301-415-6319, e-mail: lwc1@nrc.gov)

“List of Approved Spent Fuel Storage Casks: 

Standardized NUHOMS-24P, -52B, and -61BT 

Revision 5 (Companion proposed rule),” 68 FR 

49726, August 19, 2003. (Contact: Jayne M. 

McCausland, NMSS, 301-415-6219, e-mail: 

jmm2@nrc.gov)

OTHER NOTICES

“Governors’ Designees Receiving Advance 

Notification of Transportation of Nuclear 

Waste,” 68 FR 38727, June 30, 2003. (Contact: 

Rosetta O. Virgilio, OSTP, 301-415-2367, e-mail: 

rov@nrc.gov)

“Update to Governors’ Designees Receiving 

Advance Notification of Transportation of Nuclear 

Waste,” 68 FR 40704, July 8, 2003. (Contact: 

Rosetta O. Virgilio, OSTP, 301-415-2367, e-mail: 

rov@nrc.gov)

“Amersham Corporation (Now Known as AEA 

Technology QSA, Inc.): Denial of Petition for 

Rulemaking (PRM-34-5),” 68 FR 41757, July 15, 

2003. (Contact: Thomas Young, 301-415-5795, 

e-mail: tfy@nrc.gov)

“State of Wisconsin, Discontinuance of Certain 

Commission Regulatory Authority Within the State,” 

68 FR 44820, July 30, 2003. (Contact: Lloyd A. 

Bolling, OSTP, 301-415-2327, e-mail: lab@nrc.gov)

“Radiological Emergency Preparedness; Planning 

and Preparing for a Fast-Breaking Event (FEMA/

Dept of Homeland Security), Notice with request 

for comments,” 68 FR 49783, August 19, 2003.

(Contact: Vanessa E. Quinn, FEMA, 202-646-3664, 

e-mail: vanessa.quinn@dhs.gov)

“Notice of Availability of a Standard Review Plan 

(NUREG-1569) for Staff Reviews for in Situ Leach 

Uranium Extraction License Applications,” 68 FR 

51034, August 25, 2003. (Contact: John Lusher, 

301-415-7694, e-mail: jhl@nrc.gov)

“Notice of Availability of a Standard Review Plan 

(NUREG-1620), Revision 1 for Staff Reviews of 

Reclamation Plans for Mill Tailings Sites Under Title 

II of the Uranium Mill Tailings Radiation Control 

Act,” 68 FR 51040, August 25, 2003. (Contact: 

John Lusher, 301-415-7694, e-mail: jhl@nrc.gov)

“State of Utah; NRC Staff Assessment of Utah’s 

Proposed Alternative Standard to Use Utah’s 

Existing Groundwater Regulations in Lieu of the 

Nuclear Regulatory Commission’s Regulations,” 

68 FR 51516, August 27, 2003. (Contact: 

Dennis M. Sollenberger, 301-415-2819, e-mail: 

dms4@nrc.gov)

“Radiological Emergency Preparedness: Review 

of Exercise Evaluation Criteria and Methodology 

(FEMA),” 68 FR 52219, September 2, 2003. 

(Contact: Vanessa E. Quinn, FEMA, 202-646-3664, 

e-mail: vanessa.quinn@dhs.gov)
12

“Notice of Availability: Environmental Review 

Guidance for Licensing Actions Associated with 

NMSS Programs (NUREG-1748, Final Report),” 68 

FR 53205, September 9, 2003. (Contact: Matthew 

Blevins, 301-415-7684, e-mail: mxb6@nrc.gov) 

“Notice of Availability: Office of Nuclear 

Material Safety and Safeguards Consolidated 

Decommissioning Guidance; NUREG-1757 

(Revision 1 of Volume 1; final Volumes 2 and 3),” 

68 FR 54503, September 17, 2003. (Contact: Duane 

W. Schmidt, 301-415-6919, e-mail: dws2@nrc.gov)

(General Contact: Paul Goldberg, NMSS, 

301-415-7842, e-mail: pfg@nrc.gov)