Report to Congress on Abnormal Occurrences - Fiscal Year 2004 (NUREG-0090, Volume 27)
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Date Published: April 2005
U.S. Nuclear Regulatory Commission
Office of Nuclear Regulatory Research
Washington, DC 20555-0001
Section 208 of the Energy Reorganization Act of 1974 (Public Law 93-438) defines an "abnormal occurrence" (AO) as an unscheduled incident or event that the U.S. Nuclear Regulatory Commission (NRC) determines to be significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (Public Law 104-66) requires that the NRC must report AOs to Congress annually. This report describes those events that the NRC or an Agreement State identified as AOs during fiscal year (FY) 2004.
The report describes four events at NRC-licensed facilities that meet the criteria to be classified as AOs. One event involved a uranium hexafluoride (UF6) release at a fuel cycle facility. Another event, also at a fuel cycle facility, revealed excessive uranium concentrations found in ash deposits in various locations in an incinerator. A third event involved a patient undergoing therapeutic brachytherapy treatment. The fourth event involved an unintentional excessive dose of sodium iodide (1-131) administered to a patient. The report also addresses 13 AOs at facilities licensed by Agreement States. Agreement States are those States that have entered into formal agreements with the NRC pursuant to Section 274 of the Atomic Energy Act (AEA) to regulate certain quantities of AEA material at facilities located within their borders. Currently, there are 33 Agreement States. During FY 2004, the NRC received notification of 13 events that occurred at Agreement State-licensed facilities, including 8 therapeutic medical events, 3 diagnostic medical events, 1 event involving an unintentional therapeutic dose of 1-131 to an embryo/fetus, and 1 event invoing an extremity overexposure to a radiopharmacy trainee.
Appendix A to this report presents the NRC's criteria for selecting AOs, as well as the guidelines for selecting "Other Events of Interest." Appendix B, "Update of Previously Reported Abnormal Occurrences," provides an update concerning one event that the NRC initially reported in the annual report to Congress for FY 2003. Specifically, that update addresses inspection and enforcement actions that the NRC undertook following an unplanned radiological overexposure to a radiographer. Appendix C, "Other Events of Interest," describes licensee record accountability discrepancies at two nuclear power plants, loss of offsite power at another nuclear power plant, and a stuck source in an exposed position at an irradiator facility.