Information Notice 2000-15, 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.
IN2000-15Page3of Discussion
- Someofthecontributingcausesoftheseexposureeventscanbesummarizedasfollows:
ÿLicenseefailedtomonitorpocketdosimetryresults;
ÿDosimetrybadgesnotmailedtotheprocessorinatimelymannerbythelicensee;
ÿDosimetrybadgesandcontrolswerenotmailedtogethertotheprocessor;
ÿDosedeterminedsolelyontheresultsofquarterlydosimeterrecords;
ÿRadiographerswereassignedjobsbeforeknowingtheircurrentcumulativedoses;
ÿImpactoftheworkloadwasnotassessedregardingitsimpactonexposures.Alllicenseesusingradiographydevicesareremindedoftheimportanceof:
ÿTrackingdosesonatimelybasis,toensurethatanindividualisnotapproachingadoselimit;
ÿTimelyreturnofbadgesandcontrols,together,tothedosimetryprocessor;
ÿObtainingreportsfromdosimetryprocessorsinatimelymanner;
ÿTrainingemployeesontheimportanceofnotsharingpocketdosimetersandbadges;
ÿAssessingincreasedworkloadanditsimpactonemployeeexposures;
ÿNotallowingworkpressuresandworkloadstointerferewithappropriateradiationsafetypracticesandtheradiationsafetyprogram;and
ÿALARAprogramsreflectingappropriateandtimelyactions.Licenseesareultimatelyresponsibleforensuringthattheirworkersdonotexceedtheannualdoselimitsin10CFRPart20.Licenseesmaywishtoconsideractionstoimprovethetracking
andcontrolofworkerdoses.Thisinformationnoticerequiresnospecificactionnorwrittenresponse.Ifyouhaveanyquestionsabouttheinformationinthisnotice,pleasecontactthetechnicalcontactlistedbelow
ortheappropriateregionaloffice./RA/DonaldA.Cool,DirectorDivisionofIndustrialandMedicalNuclearSafetyOfficeofNuclearMaterialSafetyandSafeguardsTechnicalContact:LindaM.Psyk,NMSS(301)415-0215 E-mail:lmp1@nrc.gov
Attachments:1.ListofRecentlyIssuedNMSSInformationNotices
2.ListofRecentlyIssuedNRCInformationNotices
IN2000-15Page3of3 Discussion:Someofthecontributingcausesoftheseexposureeventscanbesummarizedasfollows:
ÿLicenseefailedtomonitorpocketdosimetryresults;
ÿDosimetrybadgesnotmailedtotheprocessorinatimelymannerbythelicensee;
ÿDosimetrybadgesandcontrolswerenotmailedtogethertotheprocessor;
ÿDosedeterminedsolelyontheresultsofquarterlydosimeterrecords;
ÿRadiographerswereassignedjobsbeforeknowingtheircurrentcumulativedoses;
ÿImpactoftheworkloadwasnotassessedregardingitsimpactonexposures.Alllicenseesusingradiographydevicesareremindedoftheimportanceof:
ÿTrackingdosesonatimelybasis,toensurethatanindividualisnotapproachingadoselimit;
ÿTimelyreturnofbadgesandcontrols,together,tothedosimetryprocessor;
ÿObtainingreportsfromdosimetryprocessorsinatimelymanner;
ÿTrainingemployeesontheimportanceofnotsharingpocketdosimetersandbadges;
ÿAssessingincreasedworkloadanditsimpactonemployeeexposures;
ÿNotallowingworkpressuresandworkloadstointerferewithappropriateradiationsafetypracticesandtheradiationsafetyprogram;and
ÿALARAprogramsreflectingappropriateandtimelyactions.Licenseesareultimatelyresponsibleforensuringthattheirworkersdonotexceedtheannualdoselimitsin10CFRPart20.Licenseesmaywishtoconsideractionstoimprovethetracking
andcontrolofworkerdoses.Thisinformationnoticerequiresnospecificactionnorwrittenresponse.Ifyouhaveanyquestionsabouttheinformationinthisnotice,pleasecontactthetechnicalcontactlistedbelow
ortheappropriateregionaloffice./RA/DonaldA.Cool,DirectorDivisionofIndustrialandMedicalNuclearSafetyOfficeofNuclearMaterialSafetyandSafeguardsTechnicalContact:LindaM.Psyk,NMSS(301)415-0215 E-mail:lmp1@nrc.gov
Attachments:1.ListofRecentlyIssuedNMSSInformationNotices
2.ListofRecentlyIssuedNRCInformationNoticesACCESSIONNUMBER:ML003753235C:\Ticket7886INRadiographer~.wpdOFCMSIBEMSIBTECHEDIMNSNAMELPsykJHickeyEKrausDCoolDATE8/2/009/20/008/3/009/25/00OFFICIALRECORDCOPY
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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(UO
2)Powder Accumulation2/22/2000AllNRClicensedfuel-cycledconversion,enrichment,and
fabricationfacilities
____________________________________________________________________________________OL=OperatingLicense
CP=ConstructionPermitAttachmentIN2000-15
Page1of1LISTOFRECENTLYISSUEDNRCINFORMATIONNOTICES
_____________________________________________________________________________________InformationDateof
NoticeNo.SubjectIssuanceIssuedto
________________________________________________________________________________2000-14Non-VitalBusFaultLeadstoFireandLossofOffsitePower9/27/2000Allholdersoflicensesfornuclearpowerreactors2000-13ReviewofRefuelingOutage
Risk9/27/2000AllholdersofOLfornuclearpowerreactors2000-12PotentialDegradationofFirefighterPrimaryProtective
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