Report to Congress on Abnormal Occurrences - Fiscal Year 2005 (NUREG-0090, Volume 28)
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Date Published: April 2006
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) 2005.
The report describes three events at NRC-licensed facilities that meet the criteria to be classified as AOs, as defined in Appendix A to the report. All three events occurred at medical institutions. The first event involved a patient who received the incorrect dose distribution while undergoing therapeutic brachytherapy1 treatment. The second event involved an infant who was administered the incorrect diagnostic dosage of technetium-99m. The third event involved three patients who received unintended radiation doses to the skin of their thighs while undergoing therapeutic treatment.
Reports from Agreement States are also included. 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 34 Agreement States (Minnesota became the 34th Agreement State on March 31, 2006). During Fiscal Year 2005, Agreement States reported six events that occurred at Agreement State-licensed facilities, including five therapeutic medical events and one diagnostic medical event. All six events met the criteria for AO categorization.
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, “Updates of Previously Reported Abnormal Occurrences,” does not contain any updated information on AO events reported in the FY 2004 Report to Congress on Abnormal Occurrences because no new significant information became available. Appendix C, “Other Events of Interest,” contains one new event of interest on safe-shutdown safety-related systems at the Kewaunee Power Station and updated information on a spent fuel record accountability discrepancy at the Humboldt Bay Power Plant.