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# Report to Congress on Abnormal Occurrences – Fiscal Year 2015 (NUREG-0090, Volume 38)

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## Publication Information

**Manuscript Completed:**May 2016**Date Published:**May 2016

Office of Nuclear Regulatory Research United States Nuclear Regulatory Commission Washington, DC 20555-0001

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## 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 two medical events involving NRC licensees that the NRC identified as AOs during the fiscal year (FY) 2015 based on the criteria in Appendix A, "Abnormal Occurrence Criteria and Guidelines for Other Events of Interest." One event involved radiation exposure to an embryo/fetus during treatment of the patient, and the other event was a medical event as defined in Part 35 of Title 10 of the *Code of Federal Regulations*, "Medical Use of Byproduct Material."

In addition, this report describes fifteen medical events involving Agreement State licensees that have been identified as AOs during FY 2015 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, as amended (AEA) (Public Law 83-703), to regulate certain quantities of AEA material at facilities located within their borders. Currently, there are 37 Agreement States.

It should be noted that the seventeen AOs represent a small fraction of the average number of nuclear medicine and radiation therapy procedures conducted annually. In the United States in 2006, the number of diagnostic nuclear medicine procedures performed was 5,048,231, as reported in the National Council on Radiation Protection Report 160 – Ionizing Radiation Exposure of the Population of the United States (2009). The number of radiation therapy treatment procedures performed in 2013 was 1,016,565, as reported by the IMV Benchmark Report for Radiation Therapy (2014).

Appendix A to this report provides the NRC's criteria for identifying AOs, as well as the guidelines for identifying "other events of interest" (OEI). During FY 2015, the NRC identified no events that met the guidelines for inclusion in Appendix B, "Updates of Previously Reported Abnormal Occurrences." During FY 2015, the NRC identified three events that met the guidelines for inclusion in Appendix C, "Other Events of Interest," because these events attracted significant public interest. These events were a release of hydrogen fluoride at the Honeywell Metropolis Works Facility, a conversion facility located in Metropolis, Illinois; an event involving human exposure at International Isotopes Incorporated, Idaho Falls, Idaho; and a dual state (Oklahoma-Texas) contamination event from a generator operated by Tracerco at the University of Tulsa, Oklahoma. Appendix D, "Glossary," presents definitions of terms used throughout this report. Appendix E, "Conversion Table," presents conversions commonly used when calculating doses.

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