Corrective Actions

1. The following is a listing of all corrective actions noted during recent ORSE from 08 Aug 2014.

2. The below are all the areas audited with the corrective actions listed below:

Discrepancy
Root Cause
Corrective Action
The MDR did not have a process in place to audit records, no way to prove that records were being audited upon completion of Radiation Medical Examinations. MDR did not utilize ref (e) to audit records upon completion of Radiation Medical Examination. MDR will utilize ref (e) upon completion of Radiation Medical Examination to properly audit health records. E5418 – Block 23 did not indicate the level of training for the physician (UMO, RAM, or RHI). MDR did not utilize ref (e) to audit records upon completion of Radiation Medical Examination. MDR will utilize ref (e) upon completion of Radiation Medical Examination to properly audit health records. P1135 – Incomplete information pertaining to the Examining Facility. MDR did not utilize ref (e) to audit records upon completion of Radiation Medical Examination. MDR will utilize ref (e) upon completion of Radiation Medical Examination to properly audit health records. W7909 and H3324 – Missing exposures, corrections made, but were made incorrectly on multiple occasions.

MDR did not utilize ref (e) to audit records of NAVMED 6470/10. MDR will utilize ref (e) upon completion of NAVMED 6470/10 to properly correct health records. P1135 – Corrections improperly made on multiple occasions. MDR did not utilize ref (e) to audit records of NAVMED 6470/10. MDR will utilize ref (e) upon completion of NAVMED 6470/10 to properly correct health records. Contrary to Ref (a), article 5-2(1) (C), MDR did not retain last two quarters of exposure information. MDR utilized one disc to save all quarters of exposure information. MDR has multiple discs to retain information of quarterly exposure. Contrary to reference (b) article 216.3.4.1, Electronic Pocket Dosimetry readings were not crossed out upon receipt of final exposure in block 18 of the Exposure Record Cards on multiple occasions. MDR improperly implemented changes to reference (b) article 216.3.4.1 to complete Exposure Record cards.

MDR aware of changes and will properly utilized reference (b) article 216.3.4.1 to complete Exposure Record cards. Contrary to reference (b), article 216.3.4.1, the Chemical and Radiological Controls Assistant (CRA) did not initial block 21 of one exposure record card. Due to a previous error, exposure record card was recreated with an oversight by CRA. CRA will complete exposure record cards IAW reference (b), article 216.3.4.1. Contrary to reference (b), article 216.3.4, block 6/7 on one occasion did not have the appropriate month, day; year dosimetry was issued and will expire. Due to a previous error, exposure record card was recreated with an oversight by CRA. CRA will complete exposure record cards IAW reference (b), article 216.3.4.1. Contrary to reference (b), article 216.3.4, dosimetry numbers were not annotated in block 8 on multiple occasions. Due to a previous error, exposure record card was recreated with an oversight by CRA. CRA will complete exposure record cards IAW reference (b), article 216.3.4.1.

Contrary to reference (e), article 2.7.c(6) (a), the XO did not on one occasion sign as verifying on the NAVMED 6470/3 when submitting the dosimeters for processing. Due to a previous error, exposure record card was recreated with an oversight by XO. XO will ensure all pages of the NAMED 6470/3 are signed prior to submission to dosimetry processor. Contrary to reference (e), article 2.7.c (6) (c), the XO did not initial each page of the NAVMED 6470/3 upon receipt of exposure. Due to a previous error, exposure record card was recreated with an oversight by XO. XO will ensure all pages of the NAMED 6470/3 are initialed prior to submission to dosimetry processor.

Contrary to reference (e), article 2.16.a (3), on one occasion the MDR did not include an exposure investigation/exposure estimate as part of the quarterly/monthly report. Exposure investigation/exposure estimate was routed at separate time of submission of quarterly/monthly report. Exposure investigation/exposure estimate will be included in all future quarterly/monthly reports. Contrary to reference (a), article 5-6, a second Unclassified copy was not prepared on two occasions. MDR did not make an unclassified copy of exposure investigation/exposure estimates. MDR will make an unclassified copy of all exposure investigation/exposure estimates. Contrary to reference (a) article 5-6, the estimate for Chaney did not contain all calculations or justify why the assigned dose was used. MDR improperly completed dose estimate/investigation.

MDR made corrections to dose estimate/investigation to reflect justification of assigned dose Contrary to reference (b) article 106.5, all non-nuclear trained personnel were trained as limited radiation workers. Non-nuclear trained personnel were over trained.

Non-nuclear trained personnel will be trained IAW reference (b) article 106.5. Contrary to reference (e), article 2.16.a (2), the CRA, did not evaluate the Command’s Local Control levels. CRA was not included in via line of Local Control level correspondence. CRA has been added to VIA line of Local Control levels correspondence. Contrary to reference (e) article 2.16.a (3), the MDR did not enclose any exposure results into quarterly/monthly reports to Commanding Officer MDR did not include quarterly/monthly reports in enclosures. Quarterly/monthly reports included in enclosures.

Contrary to reference (a), article 5-6, exposure estimate results were not annotated on the NAVMED 6470/1, Summary of Exposure to BUMED. MDR did not include Summary of Exposure to BUMED due to Technical overlook. Toggle was not chosen for dissemination of this information through the computer based program. Toggle was chosen for report on NAVMED 6470/1.

Summary of Exposure Report and all supplemental documents were not properly classified as “NOFORN.” MDR improperly headed documents.
Documents were properly headed.
Contrary to reference (b), article 201, the Annual Summary of Exposure NAVSEA was not sent to the cognizant TYCOM. MDR was unfamiliar with the reference (b), article 201 protocol. MDR has become familiar with reference (b), article 201 protocol and corrected NAVSEA report. Contrary to reference (a), article 5-12.3, Reports to personnel, on one occasion, the date and results of internal monitoring was not reported to the individual. MDR utilized a spread sheet in which member did not initial for internal monitoring. Member initial spread sheet as proof od receipt of Report to Personnel. Contrary to reference (a) article 5-12, Situational reports, on one occasion, the supplemental documents to report were not classified as “NOFORN.” MDR improperly headed documents.

Documents were properly headed.
Situational reports, on one occasion, comments for contamination incidents were not properly recorded in the member’s records. MDR did not include comments for contamination incidents due to Technical overlook. Toggle was not chosen for dissemination of this information through the computer based program. Toggle was chosen for report on NAVMED 6470/1.

Situational reports, on one occasion, an Exposure Estimate was not documented on the report. MDR did not include comments for Exposure Estimate due to Technical overlook. Toggle was not chosen for dissemination of this information through the computer based program. Toggle was chosen for report on NAVMED 6470/1.

Check-out Sheet, the check-out sheet did not have a note to Radiation workers to complete internal monitoring six months prior to transferring to a non-nuclear propulsion billet. MDR did not include a note to Radiation workers to complete internal monitoring six months prior to transferring to a non-nuclear propulsion billet. Note added to check-out sheet to Radiation workers to complete internal monitoring six months prior to transferring to a non-nuclear propulsion billet. The MDR did not provide an in-brief to the ORSE team prior to starting the exam, nor did he mention that it needed to be done. The MDR trained the ORSE team with article 208 training. MDR unknowledgeable of how to conduct ORSE in-brief.