Re: MIT Prelim Unusual Occurrence

[lambert@HAL.HAHNEMANN.EDU]

Sandy:

NRC notification is required when an event "involving the loss of control 
of licensed material ... that may have caused or threatens to cause ... an 
individual to receive in a period of 24 hours a TEDE of 5 rems."  NRC 
reporting is required for an occurrence in which "doses in excess of the 
... occupational dose limits for adults."  

The point of my comment is that if the NRC wants licensees to report 
incidents voluntarily (i.e., even though they are not required to by 
regulation), then the NRC should not take these events into the public arena 
until they have investigated the incident.  Why would a licensee 
voluntarily report events if the NRC is going to report the incident to 
the public and to Congress, before it has conducted a thorough 
investigation?  
 
I disagree your statement that the fact that it was reported makes it an 
unusual occurrence.  I once reported an exposure on a film badge which, 
after investigation could only have come from the badge being deliberately 
sabotaged (placed in an irradiator).  The individual was not exposed.  
(If she had received the exposure she would have been dead.)  The fact 
that I reported it does not make the incident an unusual occurrence.

Would you agree that it would not be reportable and would not be an unusual
event if this was a case of a 1 uCi uptake due to mouth pipetting?  
Clearly it would be a violation of procedures.  I suggest that if it were 
only 1 uCi, then the NRC would have found it on a routine inspection, would 
have cited the institution, and mitigated the violation due to self 
discovery and prompt, comprehensive corrective actions.  Then the 
question becomes at what level does the event become an unusual occurrence?  I
believe that it should be at the reporting level - a TEDE of 5 rems.  

This event very well may warrant classification as a unusual 
occurrence, but more facts are needed.  (Remember, the NRC said that 
the initial report was all the information that they had.)

Sandy Perle wrote:
>      Ken. I would suggest that even though the exposure "may" turn out to 
>      be less than allowed by regulations, the event was "unplanned" and as 
>      such has most likely violated procedures within the facility. In that 
>      event, the NRC still likes to use the terms "had the potential to 
>      exceed regulatory limits" and the only reason the incident "might be" 
>      less than regulatory limits, it was only by chance and without any 
>      interaction/intervention by the licensed facility. In the nuclear 
>      power industry we have seen many facilities cited for this very 
>      problem, the potential to exceed while not, after a thorough 
>      evaluation of the actual dose to be assigned, or shall I say, the 
>      "engineered" dose reconstruction, which miraculously seems to be just 
>      under the regulatory limits.
>      
>      The fact that the incident was reported makes it an unusual event in 
>      itself. After a review of the facility I surmise that they will at a 
>      minimum be cited for violating their procedures, not having the proper 
>      precautions in place to preclude this incident from happening, and 
>      probably a citation of inadequate training.
>      
>      In any event, the incident was unfortunate and should not have 
>      happened in the first place. Remember, the regulatory limits don't 
>      imply good health physics practices. Those below being good and those 
>      above meaning bad. Even with a small unexpected uptake or a small 
>      external exposure is an indicator that the process is in trouble and 
>      needs some serious evaluation. Countermeasures are necessary with a 
>      follow-up program to ensure that the system functions as necessary.