EA-01-312 - Veterans Health Administration

December 28, 2001

EA-01-312

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

SUBJECT:

NOTICE OF VIOLATION NRC INSPECTION REPORT 03002267/2001-003(DNMS) – V. A. MEDICAL CENTER, ST LOUIS, MISSOURI

Dear Mr. McGuire:

This refers to the inspection conducted on November 27, 2001, at the V. A. Medical Center in St. Louis, Missouri. The purpose of the inspection was to determine whether activities authorized by the license were conducted safely and in accordance with NRC requirements. As a result of the inspection, two apparent violations of NRC requirements were identified. The violations involve the failures to secure licensed material from unauthorized access and to dispose of licensed material in an authorized manner. At the conclusion of the inspection, the findings were discussed with Linda Kurz, the Medical Center Director, and Larry Chandler, the Facility Radiation Safety Officer.

In a telephone conversation on December 14, 2001, Marc Dapas of my staff informed Ms. Kurz that the NRC was considering escalated enforcement for the apparent violation involving the failure to secure from unauthorized access or maintain constant surveillance over licensed material in an unrestricted area. Mr. Dapas also informed Ms. Kurz that we had sufficient information regarding the apparent violations and V. A. Medical Center's corrective actions to make an enforcement decision without the need for a predecisional enforcement conference or a written response. Ms. Kurz indicated that V. A. Medical Center did not believe that a predecisional enforcement conference was needed; however, a written response would be provided.

Based on the information developed during the inspection and the information provided in the V. A. Medical Center's December 18, 2001 response, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation (Notice) and the circumstances surrounding them are described in detail in the subject inspection report.

Violation A of the Notice involves the failure to secure from unauthorized access or maintain constant surveillance over licensed material in an unrestricted area. Specifically, on November 27, 2001, a radioactive material package was left unattended at the nuclear medicine reception desk, when the receptionist became involved with scheduling tasks.

The failure to adequately secure and limit access to licensed material in an unrestricted area is a significant safety concern. Implementing adequate security requirements for licensed material is intended to prevent members of the public from being unknowingly and unnecessarily exposed to radiation, and prevent the loss or theft of licensed material. 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 your facility has not been the subject of escalated enforcement actions 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 was warranted for corrective actions that included: (1) securing the package immediately after the violation was identified; (2) revising the package receipt procedure to include specific requirements to maintain constant surveillance of packages and lock them within a secured room as soon as possible after receipt; (3) training applicable staff regarding the revised package receipt procedure; and (4) planning to revise the refresher training to include discussion of the revised package receipt procedure.

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 escalated enforcement action that may subject you to increased inspection effort.

Violation B of the Notice involves the failure to properly dispose of radioactive material in accordance with the requirements of 10 CFR 20.2001. This violation is categorized in accordance with the Enforcement Policy at Severity Level IV.

The NRC has concluded that information regarding the reason for the violations, the corrective actions taken and planned to correct the violations and prevent recurrence, and the date when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 03002267/2001-003(DNMS), and the V. A. Medical Center's letter, dated December 18, 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 enclosures, and your response, if any, 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/
	J. E. Dyer Regional Administrator

Docket No. 030-02267
License No. 24-00144-05

Enclosure: Notice of Violation

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NOTICE OF VIOLATION

V. A. Medical Center St. Louis, Missouri

Docket No. 030-02267 License No. 24-00144-05 EA-01-312

During an NRC inspection conducted on November 27, 2001, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violations are listed below:

A.	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 November 27, 2001, the licensee did not secure from unauthorized removal or limit access to a package containing 7,052 microcuries of iodine-131, located on the Nuclear Medicine Department reception desk, which is an unrestricted area, nor did the licensee control and maintain constant surveillance of this licensed material.
This is a Severity Level III violation (Supplement IV).
B.	10 CFR 20.2001(a) requires, in part, that the licensee dispose of licensed material only by transfer to an authorized recipient, or by decay in storage, or by release in effluents within the limits in Part 20, or by an approved method not otherwise authorized in the regulations in this chapter. Contrary to the above, on May 4, 2001, the licensee disposed of 200 microcuries of sulfur-35, a licensed material, by release to the non-radioactive trash, a method not authorized by 10 CFR 20.2001.
This is a Severity Level IV violation (Supplement IV).

The NRC has concluded that information regarding the reason for the violations, the corrective actions taken and planned to correct the violations and prevent recurrence and the dates when full compliance was achieved is already adequately addressed on the docket in Inspection Report No. 03002267/2001-003(DNMS), and the V. A. Medical Center's letter, dated December 18, 2001. 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. 20555-0001 with a copy to the Regional Administrator, Region III, 801 Warrenville Road, 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, U.S. Nuclear Regulatory Commission, Washington, D.C. 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 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, it should not include any personal, privacy, proprietary, or safeguards information so that it can be placed in the PARS without redaction.

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

Dated this 28^th day of December 2001.