Information Notice 2000-15, Recent Events Resulting in Whole Body Exposures Exceeding Regulatory Limits

Recent Events Resulting in Whole Body Exposures Exceeding Regulatory Limits

ML003753235
Person / Time
Issue date:	09/29/2000
From:	Cool D A NRC/NMSS/IMNS
To:
Psyk L
References
IN-00-015
Download: ML003753235 (6)

ML003753235UNITEDSTATESNUCLEARREGULATORYCOMMISSIONOFFICEOFNUCLEARMATERIALSAFETYANDSAFEGUARDSWASHINGTON,D.C.20555September29,2000NRCINFORMATIONNOTICE2000-15:RECENTEVENTSRESULTINGINWHOLEBODYEXPOSURESEXCEEDINGREGULATORYLIMITS

Addressees

Allradiographylicensees.

Purpose

TheU.S.NuclearRegulatoryCommission(NRC)isissuingthisinformationnotice(IN)toalertaddresseestorecenteventsthatresultedinradiographersreceivingoccupationalwholebody

dosesinexcessofthe0.05sievert(5rem)totaleffectivedoseequivalentlimitspecifiedin10

CFR20.1201(a)(1).Itisexpectedthatrecipientswillreviewthisinformationforapplicabilityto

theirfacilitiesandconsideractions,asappropriate,toavoidsimilarproblems.However, suggestionscontainedinthisinformationnoticearenotnewNRCrequirements;therefore,no

specificactionnorwrittenresponseisrequired.DescriptionofCircumstances:InMarchofthisyear,theNRCwasnotifiedthatseveralradiographershadexceededtheannualwholebodydoselimitof0.05sievert(5rem)forcalenderyear1999.Thefollowing

describesthetwocases:Case1:Alicenseereportedthatfourradiographersreceivedtotaleffectivedoseequivalentsof7.224,6.534,6.104,and5.112cSv(rem)for1999.Thelicenseestatedthattheexposuresarosefrom

anunprecedentedworkloadduring1999.Radiographerswereusingdailypocketdosimeters, althoughreadingsdidnotreflecttheexposuresexpectedforalargerworkload.Thereasonfor

thisdiscrepancywasnotdetermined,althoughimproperuseofthedailypocketdosimetersmay

havebeenthecause.Dosimetryrecordsforthefourthquarterof1999werenotreceiveduntil

lateFebruary2000.Thus,thelicenseedidnotrealizethatitsemployeeshadexceeded

exposurelimitsuntilthedosimetryreportsarrived.Thedosimetryprocessorstatedthatthe

delayindosimetryrecordreturnswascausedbycomputerdifficulties,whichitencountered

whenupgradingitssystemforyear2000compliance.Thelicenseetookseveralcorrectiveactions.Itnowhasadatabaseprogram,allowingittodeterminethetotalpersonalpocketdosimeterreadingsatanygiventime.Onamonthlybasis, IN2000-15Page2of3thelicenseewillreviewthepocketdosimeterreadingstoensurethatradiographersarenotapproachingadoselimit.Ifanindividualreceivesapersonaldosimetryreadingofgreaterthan

0.4cSv(rem)inanymonth,theindividualwillbenotifiedandaplanwillbedevelopedfor

keepingthedosewithinlimits.Case2:Alicenseereportedthattworadiographersreceivedannualdosesthatexceededtheyearlylimitsfor1999.Oneindividualreceived2.14cSv(rem)duringthelastquarterof1999,which

puthistotaldoseat5.23cSv(rem)fortheyear.Anotherindividualreceived0.93cSv(rem)for

thelastquarterof1999,whichmadehistotalyeardose5.16cSv(rem).Thelicenseewasslowtoreturnthebadgestobeprocessed,sometimesdelayingreturningbadgesupto6weeksafterreceivingthemfromthefield.Thecontrolbadgeswerenotbeing

returnedwiththeemployeebadges,furtherdelayingtheprocesstime.Also,thedosimetry

processorhadcomputerproblemsthatdelayedthegenerationofdosereports.Thelicensee

didnotreceiveoneradiographer's1999fourth-quarterbadgeresultsuntillateFebruary2000,

andthesecondradiographer'squarterlybadgeresultsuntilMarch2000.Theprovisionsin10

CFR34.47(a)(4)requirethat,afterreplacement,eachfilmbadgeorTLDmustbeprocessedas

soonaspossible.Thedosimetryprocessornotifiedthelicenseethatanemployeehadexceededhis/herALARAlevelforthesecondquarterof1999.Thelicenseedidnotdocumentorfollowupthis

notification.Thelicenseealsostatedthattherewerediscrepanciesbetweentheweeklydosimeterrecordsandthequarterlyfilmbadgeresultsfromtheprocessor.Pocketdosimeterswerebeingused

andrecordedweekly,althoughthelicenseedidnotreviewtherecords.Thelicensee'sweekly

recordsindicatedthatoneradiographerhadexceededtheyearlylimitof0.05sievert(5rem)in

August1999,butnoactionwastakentoremovetheindividualfromdutiesinvolvingexposure

toradiation.Atyearend,theweeklypocketdosimeterrecordsindicated6.905cSv(rem)for

oneindividualand1.678cSv(rem)fortheotherindividual,whichdifferssignificantlyfromthe

filmbadgeresultsof5.156cSv(rem)and5.233cSv(rem).Althoughdosimetersharingwasa

possibility,thiscouldnotbedetermined.Theprovisionsin10CFR34.47(a)(2)requirethateach

filmbadgeandTLDmustbeassignedto,andwornby,onlyoneindividual.Threemajorcausescontributedtotheseoverexposures:1)thelicenseedidnotreturnemployeebadgesandcontrolbadgestogethertotheprocessor;2)thelicenseedidnotreturn

thebadgestotheprocessorinatimelymanner;and3)thelicenseedidnotreviewpocket

dosimeterresults.Thelicensee'scorrectiveactionsincluded:1)shippingthebadgestotheprocessorusinganexpressmailcarrier;2)documentingtelephonenotificationsfromthedosimetryprocessorthat

quarterlyALARAdoselevelsareexceeded;3)reviewingtheweeklypocketdosimetryreports;

and4)retrainingpersonnelandemphasizingthatthesharingofdosimetersisanunacceptable

practice.

IN2000-15Page3ofDiscussion:Someofthecontributingcausesoftheseexposureeventscanbesummarizedasfollows:

ÿLicenseefailedtomonitorpocketdosimetryresults;ÿDosimetrybadgesnotmailedtotheprocessorinatimelymannerbythelicensee;ÿDosimetrybadgesandcontrolswerenotmailedtogethertotheprocessor;ÿDosedeterminedsolelyontheresultsofquarterlydosimeterrecords;ÿRadiographerswereassignedjobsbeforeknowingtheircurrentcumulativedoses;ÿImpactoftheworkloadwasnotassessedregardingitsimpactonexposures.Alllicenseesusingradiographydevicesareremindedoftheimportanceof:ÿTrackingdosesonatimelybasis,toensurethatanindividualisnotapproachingadoselimit;ÿTimelyreturnofbadgesandcontrols,together,tothedosimetryprocessor;ÿObtainingreportsfromdosimetryprocessorsinatimelymanner;ÿTrainingemployeesontheimportanceofnotsharingpocketdosimetersandbadges;ÿAssessingincreasedworkloadanditsimpactonemployeeexposures;ÿNotallowingworkpressuresandworkloadstointerferewithappropriateradiationsafetypracticesandtheradiationsafetyprogram;andÿALARAprogramsreflectingappropriateandtimelyactions.Licenseesareultimatelyresponsibleforensuringthattheirworkersdonotexceedtheannualdoselimitsin10CFRPart20.Licenseesmaywishtoconsideractionstoimprovethetracking

andcontrolofworkerdoses.Thisinformationnoticerequiresnospecificactionnorwrittenresponse.Ifyouhaveanyquestionsabouttheinformationinthisnotice,pleasecontactthetechnicalcontactlistedbelow

ortheappropriateregionaloffice./RA/DonaldA.Cool,DirectorDivisionofIndustrialandMedicalNuclearSafetyOfficeofNuclearMaterialSafetyandSafeguardsTechnicalContact:LindaM.Psyk,NMSS(301)415-0215 E-mail:lmp1@nrc.govAttachments:1.ListofRecentlyIssuedNMSSInformationNotices

2.ListofRecentlyIssuedNRCInformationNotices

IN2000-15Page3of3Discussion:Someofthecontributingcausesoftheseexposureeventscanbesummarizedasfollows:ÿLicenseefailedtomonitorpocketdosimetryresults;ÿDosimetrybadgesnotmailedtotheprocessorinatimelymannerbythelicensee;ÿDosimetrybadgesandcontrolswerenotmailedtogethertotheprocessor;ÿDosedeterminedsolelyontheresultsofquarterlydosimeterrecords;ÿRadiographerswereassignedjobsbeforeknowingtheircurrentcumulativedoses;ÿImpactoftheworkloadwasnotassessedregardingitsimpactonexposures.Alllicenseesusingradiographydevicesareremindedoftheimportanceof:ÿTrackingdosesonatimelybasis,toensurethatanindividualisnotapproachingadoselimit;ÿTimelyreturnofbadgesandcontrols,together,tothedosimetryprocessor;ÿObtainingreportsfromdosimetryprocessorsinatimelymanner;ÿTrainingemployeesontheimportanceofnotsharingpocketdosimetersandbadges;ÿAssessingincreasedworkloadanditsimpactonemployeeexposures;ÿNotallowingworkpressuresandworkloadstointerferewithappropriateradiationsafetypracticesandtheradiationsafetyprogram;andÿALARAprogramsreflectingappropriateandtimelyactions.Licenseesareultimatelyresponsibleforensuringthattheirworkersdonotexceedtheannualdoselimitsin10CFRPart20.Licenseesmaywishtoconsideractionstoimprovethetracking

andcontrolofworkerdoses.Thisinformationnoticerequiresnospecificactionnorwrittenresponse.Ifyouhaveanyquestionsabouttheinformationinthisnotice,pleasecontactthetechnicalcontactlistedbelow

ortheappropriateregionaloffice./RA/DonaldA.Cool,DirectorDivisionofIndustrialandMedicalNuclearSafetyOfficeofNuclearMaterialSafetyandSafeguardsTechnicalContact:LindaM.Psyk,NMSS(301)415-0215 E-mail:lmp1@nrc.govAttachments:1.ListofRecentlyIssuedNMSSInformationNotices

2.ListofRecentlyIssuedNRCInformationNoticesACCESSIONNUMBER:ML003753235C:\Ticket7886INRadiographer~.wpdOFCMSIBEMSIBTECHEDIMNSNAMELPsykJHickeyEKrausDCoolDATE8/2/009/20/008/3/009/25/00OFFICIALRECORDCOPY-

Attachment1IN2000-15 Page1of1LISTOFRECENTLYISSUEDNMSSINFORMATIONNOTICES_____________________________________________________________________________________InformationDateof

NoticeNo.SubjectIssuanceIssuedto_____________________________________________________________________________________2000-12PotentialDegradationofFirefighterPrimaryProtective

Garments9/21/2000Allholdersoflicensesfornuclearpower,research,andtest

reactorsandfuelcyclefacilities2000-11LicenseeResponsibilityforQualityAssuranceOversightof

ContractorActivitiesRegarding

FabricationandUseofSpent

FuelStorageCaskSystems8/7/2000AllU.S.NRC10CFRPart50andPart72licensees,andPart72 CertificateofComplianceholders2000-10RecentEventsResultinginExtremityExposures

ExceedingRegulatoryLimits7/18/2000Allmateriallicenseeswhoprepareoruseunsealed

radioactivematerials,radio- pharmaceuticals,orsealed

sourcesformedicaluseorfor

researchanddevelopment2000-07NationalInstituteforOccupationalSafetyand

HealthRespiratorUserNotice:

SpecialPrecautionsforUsing

CertainSelf-Contained

BreathingApparatusAir

Cylinders4/10/2000Allholdersofoperatinglicensesfornuclearpowerreactors,non- powerreactors,andallfuelcycle

andmateriallicenseesrequiredto

haveanNRCapproved

emergencyplan2000-05RecentMedicalMisadministrationsResulting

fromInattentiontoDetail3/06/2000Allmedicallicensees2000-041999EnforcementSanctionsforDeliberateViolationsof

NRCEmployeeProtection

Requirements2/25/2000AllU.S.NuclearRegulatoryCommissionlicensees2000-03High-EfficiencyParticulateAirFilterExceedsMassLimit

BeforeReachingExpected

DifferentialPressure2/22/2000AllNRClicensedfuel-cycledconversion,enrichment,and

fabricationfacilities2000-02FailureofCriticalitySafetyControltoPreventUranium

Dioxide(UO2)PowderAccumulation2/22/2000AllNRClicensedfuel-cycledconversion,enrichment,and

fabricationfacilities

____________________________________________________________________________________OL=OperatingLicense

CP=ConstructionPermitAttachmentIN2000-15 Page1of1LISTOFRECENTLYISSUEDNRCINFORMATIONNOTICES_____________________________________________________________________________________InformationDateof

NoticeNo.SubjectIssuanceIssuedto________________________________________________________________________________2000-14Non-VitalBusFaultLeadstoFireandLossofOffsitePower9/27/2000Allholdersoflicensesfornuclearpowerreactors2000-13ReviewofRefuelingOutageRisk9/27/2000AllholdersofOLfornuclearpowerreactors2000-12PotentialDegradationofFirefighterPrimaryProtective

Garments9/21/2000Allholdersoflicensesfornuclearpower,research,andtest

reactorsandfuelcyclefacilities2000-11LicenseeResponsibilityforQualityAssuranceOversightof

ContractorActivitiesRegarding

FabricationandUseofSpent

FuelStorageCaskSystems8/7/2000AllU.S.NRC10CFRPart50andPart72licensees,andPart72 CertificateofComplianceholders2000-10RecentEventsResultinginExtremityExposures

ExceedingRegulatoryLimits7/18/2000Allmateriallicenseeswhoprepareoruseunsealed

radioactivematerials,radio- pharmaceuticals,orsealed

sourcesformedicaluseorfor

researchanddevelopment95-03,Supp2LossofReactorCoolantInventoryandPotentialLossof

EmergencyMitigation

FunctionsWhileinaShutdown

Condition7/03/2000AllholdersofOLfornuclearpowerreactorsexceptthosewho

haveceasedoperationsandhave

certifiedthatfuelhasbeen

permanentlyremovedfromthe

reactorvessel2000-09SteamGeneratorTubeFailureatIndianPointUnit26/28/2000AllholdersofOLfornuclearpowerreactors,exceptthosewho

havepermanentlyceased

operationsandhavecertifiedthat

fuelhasbeenpermanently

removedfromthereactorvessel2000-08InadequateAssessmentoftheEffectofDifferential

TemperaturesonSafety- RelatedPumps5/15/2000Allholdersofoperatinglicenseesfornuclearpowerreactors

____________________________________________________________________________________OL=OperatingLicense

CP=ConstructionPermit