EA-96-523 - Kapi'olani Health Care System

March 5, 1997

EA 96-523

Mr. John Jeffries, Sr. Vice President
Kapi'olani Health Care System
1319 Punahou Street
Honolulu, Hawaii 96826

SUBJECT:

NOTICE OF VIOLATION (NRC Inspection Report No. 030-31200/96-01)

Dear Mr. Jeffries:

This refers to the January 23, 1997, letter Kapi'olani Health Care System (Kapi'olani) submitted in response to the apparent violation identified in NRC Inspection Report 030-31200/96-01, issued on January 13, 1997. We note that your letter, which was addressed to Ms. Linda Howell, was received in our office on February 18, 1997.

The NRC inspection was completed on December 9, 1996. As indicated in the NRC letter transmitting the inspection report, one apparent violation was identified involving the security of licensed radioactive material, i.e., laboratories containing radioactive materials were not locked. Kapi'olani was given a choice of requesting a predecisional enforcement conference or submitting a written response to the apparent violation. Kapi'olani chose to submit a written response.

In its written response, Kapi'olani did not dispute the apparent violation and described specific actions taken to correct the violation. These actions included emphasis on the "locked when not occupied" policy for the involved laboratories, instruction to all laboratory personnel, unannounced checks of the areas, additional locks, a license amendment to clarify the areas requiring such security, and bimonthly audits in the future.

Based on the information developed during the inspection, and the information that you provided in your response to the inspection report, the NRC has determined that a violation of NRC requirements occurred. The violation is cited in the enclosed Notice of Violation (Notice) and involved a failure in November 1996 to follow requirements that the RIA and DNA laboratories be locked when not occupied.

Although the violation did not result in the theft or loss of radioactive material, the purpose of securing these areas is to prevent the unauthorized removal of materials that could pose a health and safety hazard. The NRC considers such violations a matter of significant regulatory concern; thus, this violation has been classified at Severity Level III in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $2,750 is considered for a Severity Level III violation. Because your facility has not been the subject of escalated enforcement action within the last 2 inspections, the NRC considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Given that the corrective actions described above were both prompt and comprehensive, credit is due for your corrective actions, resulting in no civil penalty being assessed in this case.

Accordingly, to encourage prompt and comprehensive correction of violations, and in recognition of the absence of previous escalated enforcement action, I have been authorized not to propose a civil penalty in this case. However, significant violations in the future, particularly violations of a similar nature, could result in a civil penalty. In addition, issuance of this Severity Level III violation constitutes escalated enforcement action which may subject you to more frequent inspection by NRC.

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. 30-31200/96-01 and a letter from the Kapi'olani Health Care System to the NRC dated January 23, 1997. 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 if you choose to submit one, will be placed in the NRC Public Document Room (PDR).

Should you have any questions concerning this letter, please contact Linda Howell at (817) 860-8213.

Sincerely,

org signed by Thomas Gwynn for J. E. Dyer Acting Regional Administrator

Docket No. 030-31200
License No. 53-23297-01

Enclosure: Notice of Violation

cc w/Enclosure:
State of Hawaii
Mr. Clinton Churchill
Chairman, Board of Trustees
Kapi'olani Health Care System
55 Merchant Street, 27th Floor
Honolulu, Hawaii 96813

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NOTICE OF VIOLATION

Kapi'olani Health Care System Honolulu, Hawaii

Docket No. 30-31200 License No. 53-23297-01 EA 96-523

During an NRC inspection conducted November 18 through December 9, 1996, 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:

Condition 20 of NRC License 53-23297-01 requires, in part, that the licensee conduct its program in accordance with the statements, representations, and procedures contained in an application and letter dated August 29, 1996, including any enclosures.

Paragraph 2 of Attachment 9.1 of the August 29, 1996, letter states, in part, "the DNA laboratory will be locked when not occupied." In addition, Attachment 10.6, at the section titled "DNA Laboratory Operation Procedures," states "the room shall be kept locked when not occupied." Paragraph 2 of the section on the RIA laboratory in the licensee's August 29, 1996, letter states, in part, "the RIA laboratory will be locked when not occupied."

Contrary to the above, on November 18, and 20, 1996, laboratories in which microcurie quantities of iodine-125 or phosphorus-32 were stored were not locked when not occupied. Specifically, on November 18, 1996, the RIA laboratory was not locked when not occupied by licensee personnel, and on November 20, 1996, the DNA laboratory was not locked when not occupied. (01013)

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. 030-31200/96-01 and a letter from the Kapi'olani Health Care System to the NRC dated January 23, 1997. Therefore, no response to this Notice is required. However, you are required to submit a written statement or explanation pursuant to 10 CFR 2.201 if the description therein 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, D.C. 20555 with a copy to the Regional Administrator, Region IV, 611 Ryan Plaza Drive, Suite 400, Arlington, Texas 76011.

Dated at Arlington, Texas
this 5th day of March 1997