EA-01-180 - Glendive Medical Center

November 1, 2001

EA-01-180

Mr. Grant Asay
Chief Executive Officer
Glendive Medical Center
202 Prospect Drive
Glendive, Montana 59330-1999

SUBJECT:

NOTICE OF VIOLATION & EXERCISE OF ENFORCEMENT DISCRETION (NRC INSPECTION REPORT 030-12470/01-01)

Dear Mr. Asay:

This refers to the inspection conducted at Glendive Medical Center on May 21, 2001. A final, telephonic exit briefing was conducted on August 3, 2001, to inform you that the NRC had identified an apparent violation of NRC requirements for which the NRC was considering escalated enforcement action. NRC Inspection Report 030-12470/01-01, issued on August 29, 2001, described this apparent violation.

In the letter transmitting the inspection report, we provided you the opportunity to address the apparent violation identified in the report by either attending a predecisional enforcement conference or by providing a written response before we made a final enforcement decision. In a letter dated September 11, 2001, Mr. Thomas Christensen, your radiology manager, provided a written response to the apparent violation.

Based on the information developed during the inspection, and the information that you provided in your September 11 letter, the NRC has determined that a violation of NRC requirements occurred. This violation is cited in the enclosed Notice of Violation (Notice). The circumstances surrounding it were described in detail in the subject inspection report.

The violation involved a failure to control and maintain constant surveillance of licensed material. Specifically, on May 20, 2001, a courier delivered a one-curie molybdenum-99/technetium-99m generator to the nuclear medicine imaging room and failed to lock the imaging room door prior to leaving. The generator remained in the unlocked imaging room and was not maintained under constant surveillance for approximately four hours.

Although this violation resulted in no actual safety consequences, maintaining licensed material under constant surveillance is an important deterrent in preventing theft or unauthorized removal and possible radiological hazards to members of the public. Therefore, this violation has been categorized in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600 at Severity Level III.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $3,000 is considered for a Severity Level III violation. Because your facility has been the subject of escalated enforcement action within the last 2 years,⁽¹⁾ the NRC considered whether credit was warranted for Identification and Corrective Action in accordance with the civil penalty assessment process in Section VI.C.2 of the Enforcement Policy. The violation was identified by the NRC during an inspection on May 21, 2001. Thus, credit for identification is not warranted. In your September 11 letter, you described several corrective actions taken immediately following the inspection. These included: 1) requiring that generators be placed in the hot lab; 2) installing an automatic door closer on the hot lab door, guaranteeing door closure; 3) modifying the door lock to confirm locking of the door upon closure; and 4) requiring department personnel to check the door after deliveries to confirm the status of the door. You also stated that you would conduct a Department Performance Improvement Study to assure that the door is shut and locked after a generator is delivered. Thus, credit for corrective action is warranted.

Consideration of the identification and corrective action factors, as discussed above, would result in the assessment of a civil penalty at the base value of $3,000. However, the NRC has considered the circumstances surrounding this violation, and has concluded that the incident that occurred on May 20, 2001 was an isolated occurrence caused by personnel error. Your corrective actions for the previous NRC enforcement action (EA-00-076) appear to have been otherwise effective in assuring the appropriate level of security for licensed material. Therefore, the NRC has decided to exercise discretion, as provided for in section VII.B.6 of the Enforcement Policy, and will not assess a civil penalty for this violation.

The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence, and the date when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 030-12470/01-01, issued August 29, 2001, and letters from Mr. Christensen dated May 25, 2001 and September 11, 2001. Therefore, you are not required to respond to this letter unless the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at the Public NRC Library.

		Sincerely,
		/RA/
		Ellis W. Merschoff Regional Administrator

Docket No. 030-12470
License No. 25-17265-01

Enclosure:  Notice of Violation

cc w/Enclosure:
State of Montana

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NOTICE OF VIOLATION

Glendive Medical Center Glendive, Montana

Docket No. 030-12470 License No. 25-17265-01 EA-01-180

During an NRC inspection conducted on May 20, 2001, a violation of NRC requirements was identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violation is listed below:

10 CFR 20.1801 requires, in part, that the licensee secure from unauthorized removal licensed material that is stored in a controlled area. 10 CFR 20.1802 requires, in part, that the licensee control and maintain constant surveillance of licensed material that is in a controlled area and that is not in storage. As defined in 10 CFR 20.1003, controlled area means an area, outside of a restricted area but inside the site boundary, access to which can be limited by the licensee for any reason.

Contrary to the above, on May 20, 2001, the licensee did not secure from unauthorized removal licensed material located in the nuclear medicine imaging room, which is a controlled area, and the licensee did not control and maintain constant surveillance of this licensed material. The licensed material was a one-curie molybdenum-99/technetium-99m generator.

This is a Severity Level III violation (Supplement IV).

The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence and the date when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 030-12470/01-01, issued August 29, 2001, and letters from the Licensee dated May 25, 2001 and September 11, 2001. However, you are required to submit a written statement or explanation pursuant to 10 CFR 2.201 if the description in the referenced documents does not accurately reflect your corrective actions or your position. In that case, or if you choose to respond, clearly mark your response as a "Reply to a Notice of Violation," and send it to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region IV, within 30 days of the date of the letter transmitting this Notice of Violation (Notice).

If you contest this enforcement action, you should also provide a copy of your response, with the basis for your denial, to the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001.

Under the authority of Section 182 of the Act, 42 U.S.C. 2232, any response that you choose to submit shall be submitted under oath or affirmation.

If you choose to respond, your response will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at the Public NRC Library. Therefore, to the extent possible, the response should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the Public without redaction.

Dated this 1st day of November 2001

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¹ A Notice of Violation and $2,750 civil penalty (EA-00-076) was issued to Glendive Medical Center on June 29, 2000, for a similar violation involving a failure to secure licensed material.