EA-04-019 - V.A. Department of, AR

April 7, 2004

EA-04-019

E. Lynn McGuire, Director
National Health Physics Program (115HP/NLR)
Department of Veterans Affairs
Veterans Health Administration
2200 Fort Roots Drive
Little Rock, AR 72114

SUBJECT:

NOTICE OF VIOLATION EDWARD HINES, JR., VETERANS AFFAIRS HOSPITAL (NRC ROUTINE INSPECTION REPORT NO. 030-34325/2003-024 (DNMS))

Dear Mr. McGuire:

This refers to the inspection conducted from January 7 through 9, 2004, at the Edward Hines, Jr., Veterans Affairs Hospital, Hines, Illinois, a permittee under the Department of Veterans Affairs Master Materials License. The purpose of the inspection was to evaluate whether licensed activities were conducted safely and in accordance with the Department of Veterans Affairs' license and the NRC's rules and regulations. The inspection report was transmitted to you on February 6, 2004, and documented one apparent violation of NRC requirements involving the failure to secure licensed materials from unauthorized access or maintain constant surveillance of these materials.

In the letter transmitting the inspection report, we provided you with 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 our final enforcement decision. In a letter, dated March 4, 2004, you provided a written response to the apparent violation.

Based on the information developed during the inspection and the information that you provided in your March 4, 2004, letter, the NRC has determined that a violation of NRC requirements occurred. The violation is cited in the enclosed Notice of Violation (Notice) and the circumstances surrounding it are described in detail in the subject inspection report. During the inspection, the NRC identified that licensed materials were left in the unlocked waste compaction room within the unlocked radiation safety office, and radiation safety staff did not provide constant surveillance of these materials.

Although there were no actual radiation safety consequences associated with the violation, the failure to secure from unauthorized access or maintain constant surveillance over licensed materials is a significant safety issue. Implementation of adequate security measures is intended to prevent the loss or theft of licensed materials and to prevent members of the public from being unknowingly and unnecessarily exposed to radiation. 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 $3000 is considered for a Severity Level III violation. Because the permittee has not been the subject of escalated enforcement action within the last two inspections, the NRC considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section VI.C.2 of the Enforcement Policy. Credit is warranted for corrective actions that include: (1) immediately securing the licensed materials; (2) modifying the waste compaction room door locks to ensure controlled access to the room; (3) securing the source storage cabinet doors in the waste compaction room; (4) adjusting the radiation safety office door automatic closure device; and (5) initiating an internal security assessment of areas in the hospital where licensed materials are stored.

Therefore, to encourage prompt and comprehensive correction of violations, and in recognition of the absence of previous escalated enforcement action, I have been authorized, after consultation with the Director, Office of Enforcement, not to propose a civil penalty in this case. However, significant violations in the future could result in a civil penalty. In addition, issuance of this Severity Level III violation constitutes an escalated enforcement action that may subject you to increased inspection effort.

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. 030-34325/2003-024 (DNMS) and your March 4, 2004, letter. Therefore, you are not required to respond to this letter unless the descriptions in our report and your letter do 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 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response, if any, will be made available electronically for public inspection in the NRC Public Document Room or from the NRC's document system (ADAMS), which is accessible from the NRC Web site at the Public NRC Library. To the extent possible, your response should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the Public without redaction. The NRC also includes Issued Significant Enforcement Actions on its Web site.

		Sincerely,
		/RA/ Geoffrey E. Grant
		James L. Caldwell Regional Administrator

Docket No. 030-34325
License No. 03-23853-01VA

Enclosure: Notice of Violation

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NOTICE OF VIOLATION

Department of Veterans Affairs Little Rock, Arkansas

Docket No. 030-34325 License No. 03-23853-01VA EA-04-019

During an NRC inspection conducted from January 7 through 9, 2004, 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 that the licensee secure from unauthorized removal or access licensed materials that are stored in controlled or unrestricted areas. 10 CFR 20.1802 requires that the licensee control and maintain constant surveillance of licensed material that is in a controlled or unrestricted 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; and unrestricted area means an area, access to which is neither limited nor controlled by the licensee.

Contrary to the above, on January 7, 2004, the licensee did not secure from unauthorized removal or limit access to licensed materials located in the radiation safety office, which is a controlled area, nor did the licensee control and maintain constant surveillance of these licensed materials. Specifically, the radiation safety office was unlocked allowing unchallenged access to four molybdenum-99/technetium-99m generators containing a total of approximately 150 millicuries of molybdenum-99; four cesium-137 sealed sources containing a total of 112 millicuries; two strontium-90 sealed sources containing a total of 117 millicuries; and several other low millicurie or microcurie activity sealed sources.

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. 030-34325/2003-024 (DNMS) and the licensee's March 4, 2004, letter. However, you are required to submit a written statement or explanation pursuant to 10 CFR 2.201 if the descriptions in the inspection report or your letter do 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; EA-04-019" and send it to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001 with a copy to the Regional Administrator, Region III, 2443 Warrenville Road, Suite 210, Lisle, IL 60532-4351, 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.

If you choose to respond, your response will be made available electronically for public inspection in the NRC Public Document Room or from the NRC's document system (ADAMS), which 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.

In accordance with 10 CFR 19.11, you may be required to post this Notice within two working days.

Dated this 7^th day of April 2004.