NRC Press Release on NIH Contamination Incident

[Mike Grissom <mikeg@SLAC.Stanford.EDU>]

Radsafers following the events associated with the
P-32 incident at NIH may be interested in the following
news release from the US NRC.

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Nuclear Regulatory Commission
Office of Public Affairs
Washington DC 20555
Telephone: 301/415-8200 -- E-mail: opa@nrc.gov

No. 97-140
September 19, 1997

  NRC RESPONDS TO REQUESTS FOR ENFORCEMENT ACTION
        AGAINST NIH FOR CONTAMINATION EVENT

                Links to documents

The Nuclear Regulatory Commission staff has denied a
petition from Dr. Maryann Wenli Ma and her husband, Dr.
Bill Wenling Zheng, to revoke or suspend the nuclear
materials license of the National Institutes of Health
following a 1995 contamination event there involving
radioactive phosphorous-32 (P-32), but granted the
petitioner's request for other actions.

During the incident, Dr. Ma, then a pregnant NIH
researcher, was exposed to radiation in excess of NRC
occupational limits. Dr. Zheng, who also worked at
that time at NIH, and 25 others, were exposed to
radiation from a contaminated water cooler. One of the
25 individuals, classified as a non-radiation worker,
received an exposure in excess of NRC limits for
members of the public.

The P-32 contamination was the subject of an NRC
augmented inspection team (AIT) inspection and two
special NRC team inspections, as well as investigations
performed by the NRC Office of Investigations (OI), in
cooperation with the Federal Bureau of Investigation,
the Health and Human Services Office of the Inspector
General and the NIH Police Department.  A redacted
report and its associated exhibits from the NRC's AIT
was issued on January 29, 1996, and a full report on
January 13 of this year. The report from the NRC's OI
investigation, "National Institutes of Health:
Wrongful Administration of P-32, Case No. 1-96-033,"
was released on September 17, 1997.

NRC investigators concluded that the contamination was
deliberate but could not definitively identify who
caused the contamination with P-32. Also, the NRC did
not definitively identify the means of administering
the phosphorous-32 to Dr. Ma.

Normally, radiation overexposures of this sort would
be subject to significant enforcement action by NRC.
However, in this case, the Commission decided to
exercise enforcement discretion because there is no
evidence that NIH contributed directly or indirectly
to the deliberate misuse of licensed material; because
NIH could not reasonably have foreseen that an
employee would maliciously misuse licensed material as
appears to have been done in this case; and because
NIH cooperated fully in the investigation.

Although the NRC denied the petition to suspend or
revoke NIH's license, it has granted the petitioners'
request that NRC take other appropriate actions. NRC
granted the petitioners' request for enforcement
action against NIH for violations of NRC security and
control requirements and for violation of NRC
requirements related to radiation safety training,
ordering radioactive materials, inventory control of
radioactive materials, monitoring, and the issuance,
use, and collection of dosimetry. In addition, the
NRC's Region I office in King of Prussia,
Pennsylvania, issued a notice of violation (without
a civil penalty) to NIH on September 17, for failure
to submit a written report to NRC within 30 days after
learning that Dr. Ma received an occupational
radiation dose in excess of NRC limits.

Other NRC actions included a series of Confirmatory
Action Letters between July 1995 and June 1996. They
confirmed that NIH had agreed to take various
corrective measures, such as  (1) reduction of the
possibility of further ingestion of radioactive material
by NIH employees, (2) determination of the full scope of
the personnel contaminations at NIH, (3) further
enhancement and training of NIH staff regarding security
of radioactive material, (4) documentation of corrective
actions with respect to enforcement of a new NIH
security policy, and (5) modifications to the
surveillance plan for NIH laboratories.

The NRC has determined that NIH has made significant
efforts to improve its control of radioactive material.
This has included NIH staff meetings, training and
audits. NIH also completed a comprehensive physical
inventory of radioactive materials that now serves as
the baseline for on-line, real-time tracking of all
radioactive materials. NRC concluded that additional
enforcement action for security and control violations
was not warranted.

Copies of the OI report and exhibits, the letter to
NIH, and the director's decision will be available for
public inspection and copying at the NRC Public
Document Room, 2120 L Street, NW, Washington, DC 20555;
telephone: 202/634-3273.

All but the OI report and exhibits have been placed on
the NRC Internet homepage for viewing and downloading at

  http://www.nrc.gov/OPA/reports .

To view the docucuments:

     Letter to National Insititutes of Health
     Director's Decision of the Petition

[refer to the web address shown above.]