Canada. ... Canadian Nuclear Commission canadienne. Violation. Relevant Facts I Faits pertinents

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1 I... ""I"'. ADMINISTRATIVE MONETARY PENALTY (AMP) NOTICE OF VIOLATION {Corporation) AVIS DE VIOLATION {Societe) Date of Notice I Date de l'avis: January 28, 2015 AMP Number I Numero de SAP: 2015-AMP- 04 Violation committed by I Violation commise par: AMOUNT OF PENAL TY I Alberta Health Services MONTANT DE LA SANCTION: Cross Cancer Institute $7,630 Due Date/Date d'echeance du paiement: February 27, 2015 Violation Knowingly making a false or misleading statement to the Commission. In violation of paragraph 48(d) of the Safety and Control Act Relevant Facts I Faits pertinents I, Andre Regimbald, Director General of the Directorate of Substance Regulation and Designated Officer authorized by the (CNSC) to issue notices of violation, believe on reasonable grounds that Alberta Health Services committed the above violation. The relevant facts pertaining to the violation are: The Alberta Health Services holds 38 licences issued by the CNSC for the possession and use of nuclear substances and prescribed equipment, and operation of Class II nuclear facilities throughout the province of Alberta. On April 2, 2014, the Alberta Health Services notified the CNSC, in accordance with sub-section 29(1) of the General Safety and Control Regulations that they had found two Cesium-137 sealed sources (1.45 GBq and 2.01 GBq) at their Cross Cancer Institute in Edmonton, Alberta (CNSC licence ). The sources, which presented a medium risk to the health and safety of people, had been found at the Cross Cancer Institute but not before one nuclear energy worker received an estimated radiation exposure of 12 msv. Alberta Health Services submitted an event report to the CNSC on April 23, 2014, as required under sub-section 29(2) of the General Safety and Control Regulations. E-Docs# Page 1 of/de 6

Violation committed by I Violation commise par: AMOUNT OF PENAL TY I Alberta Health Services MONTANT DE LA SANCTION: Cross Cancer Institute $7,630 Due Date/Date d'echeance du paiement: February 27,

2 ADMINISTRATIVE MONETARY PENALTY (AMP) SANCTION ADMINrSTRATIVE PECUNIAIRE (SAP) Between May 2 and May 20, 2014, the Alberta Health Services conducted a second internal investigation into the event and found out that the information submitted to the CNSC in the April 23 report was false and misleading. Differences between the original report and the internal investigation included pertinent details of how the found sources were handled, the personnel involved and the method for securing the found sources. These details were material differences that would have altered the response of the CNSC to the original report to ensure the safety of the public and workers. Alberta Health Services never communicated the results of their second internal investigation to the CNSC and never notified the CNSC that the information submitted in their April 23 report was false and misleading. Alberta Health Services appeared at the public Commission Meeting on August 21, 2014 in relation to the event involving the two found sources and never disclosed the results of their second internal investigation or that the information in their April 23 report was false and misleading. The CNSC discovered the results of the second investigation during an unannounced inspection at the Alberta Health Services Cross Cancer Institute in Edmonton on December 8-10, As a result of the CNSC inspection, the licensee voluntarily removed two Radiation Safety Officers from duty. Based on my review of this matter and a consideration of the 7 factors in section 5 of the CNSC Administrative Monetary Penalties Regulations, the amount of the penalty was determined by having regard to the following relevant facts: 1. Compliance History: The licensee has not been issued any Administrative Monetary Penalties or CNSC orders related to the licensed activities at the Cross Cancer Institute in the past five years. 2. Intention or negligence: The licensee demonstrated both intention and negligence by not disclosing to the CNSC the significant shortcomings and inaccuracies in the licensee's report filed with the CNSC on April 23, 2014 in relation to the event involving the two found Cs-137 sealed sources. 3. Actual or potential harm: At least three workers received a radiation dose from these sources with the highest dose estimated to be 12 msv. 4. Competitive or economic benefit: Alberta Health Services is a public institution and sole licensee providing cancer treatment services in Edmonton. There was no competitive or economic benefit as a result of this violation. E-Docs# Page 2 of/de 6

Differences between the original report and the internal investigation included pertinent details of how the found sources were handled, the personnel involved and the method for securing the found

3 l+i ADMINISTRATIVE MONETARY PENALTY (AMP) 5. Efforts to mitigate or reverse effects: The licensee did internally recognize the importance of the findings in the second investigation report. The licensee appears to have taken steps to address some of the contributing causes. 6. Assistance to Commission: The licensee did not obstruct the Commission and did produce requested documents and made staff available for interviews when requested to do so. 7. Attention of Commission: The licensee immediately reported the event to the Commission on April 2, 2014 and submitted an event report within 21 days as required by sub-section 29(2) of the General Safety and Control Regulations, however the licensee failed to inform the Commission of the false and misleading statements when discovered in May of E-Docs# Page 3 of/de 6 Gmada

Assistance to Commission: The licensee did not obstruct the Commission and did produce requested documents and made staff available for interviews when requested to do so. 7.

4 Penalty Calculation I Calcul de la sanction: (a) (b) ADMINISTRATIVE MONETARY PENAL TY (AMP) (See Administrative Monetary Penalties Regulations of the SOR/ ) (Veuillez consulter le Reglement sur!es sanctions administratives pecuniaires de la Commission canadienne de sfuete nucleaire, DORS/ ) Category of Violation I Categorie de violation Category A/Categorie A D Category B/Categorie B x Category C/Categorie C D Penalty Range I Bareme de sanction Category Minimum Maximum Maximum - Minimum Categorie A $1 000 $ $ B $1 000 $ $ (c) Determining Factors I Facteurs determinants c $1 000 $ $ F actors/f acteu rs Scale of regulatory significance/ Assessed Echelle de!'importance sur le plan Score/Ponderation reqlementaire evaluee 1. Compliance history I 0, +1, +2, +3, +4, +5 0 Antecedents en matiere de conformite 2. Intention or negligence I 0, +1, +2, +3, +4, Intention OU neqliqence 3. Actual or potential harm I 0, +1, +2, +3, +4, Dommages reels ou potentiels 4. Competitive or economic benefit I 0, +1, +2, +3, +4, +5 0 Avantage economique ou concurrentiel 5. Efforts to mitigate or reverse effects/ -2, -1, 0, +1, +2, +3 0 Efforts pour attenuer ou neutraliser les effets 6. Assistance to Commission I -2,-1, 0,+1, +2, +3 0 Aide apportee a la Commission 7. Attention of Commission I -2, -1,0, +1, +2, Violation declaree a la Commission Total (l ) [rounded to 2 decimal points/arrondi a 2 decimales pres]= 0.17 [difference between category maximum and minimum/ ecart entre le montant minimal et le montant maximal] = x $ 1000 [minimum for the category/montant minimal pour la categorie] = $7, being the maximum value of regulatory significance i etant la valeur max1male de I' importance sur the plan reglementa1re E-Docs# Page 4 of/de 6

B/Categorie B x Category C/Categorie C D Penalty Range I Bareme de sanction Category Minimum Maximum Maximum - Minimum Categorie A $1 000 $12 000 $11 000 B $1 000 $40 000 $39 000 (c) Determining

5 ADMINISTRATIVE MONETARY PENALTY (AMP) To Request a Review I Pour presenter une demande de revision As a person subject to an Administrative Monetary Penalty, you have the right to request a review of the amount of the penalty or the facts of the violation, or both. Your request must be made in writing indicating the reasons why you are requesting a review and providing supporting information. If you choose to request a review you must do so within 30 days of the date of the notice in writing by contacting: Marc Leblanc Commission Secretary 280 Slater Street Ottawa ON KlP 5S9 Facsimile: (613) Telephone: (613) interventions@cnsc-ccsn.gc.ca En tant que personne faisant l'objet d' une sanction administrative pecuniaires, vous avez le droit de demander une revision du montant de la penalite ou des faits quanta la violation, OU des deux. Vous devez presenter votre demande par ecrit, y indiquer pourquoi YOUS demandez une revision et inclure toute information a l'appui de votre demande. Si YOUS demandez une revision, YOUS devez le faire dans!es 30 jours suivant la date de l'avis, par ecrit en communiquant avec : Marc Leblanc Secretaire de la Commission de surete nucleaire 280, rue Slater Ottawa (Ontario) KlP 5S9 Telecopieur: Telephone: (613) Courriel: interventions@cnsc-ccsn.gc.ca Payment I Paiement The manner in which this administrative monetary penalty may be paid is by sending a cheque to: Receiver General for c/o Finance Division P.O. Box 1046, Station "B" Ottawa, Ontario KlP 5S9 For other payment methods and further instructions, please refer to the attached "Notice of Payment Due" Should you not pay the penalty nor exercise your right to a review, you will be considered to have committed the violation and will be liable to the penalty set out herein. E-Docs# Cette sanction administrative pecuniaires peut etre payees par cheque libelle au nom du : Receveur general du a/s de surete nucleaire Division des Finances C.P. 1046, Succursale B Ottawa (Ontario) KlP 5S9. D'autres methodes de paiement sont disponibles, comme un virement, un depot direct et un paiement par carte de credit. Pout de!' information sur ces autres methodes de paiement, veuillez consulter le document Avis de paiement du ci-joint. Si vous ne payez pas la sanction et n'exercez pas votre droit de revision, on considerera que vous avez commis la violation et vous serez passible de la sanction mentionnee aux presentes. Page 5 of/de 6 Can d.... a a

If you choose to request a review you must do so within 30 days of the date of the notice in writing by contacting: Marc Leblanc Commission Secretary 280 Slater Street Ottawa ON KlP 5S9 Facsimile:

6 Commission canadieme ADMINISTRATIVE MONETARY PENALTY {AMP) SANCTION ADMINISTRATIVE PECUNIAIRE {SAP) Issued by/delivre par 2015 I 0 1 I 2 8 Andre Regimbald Designated Officer/Fonctionnaire designe Date Telephone/Telephone: /Courriel: Andre.Regimbald@cnsc-ccsn.gc.ca E-Docs# Page 6 of/de 6

Regimbald Designated Officer/Fonctionnaire designe Date Telephone/Telephone:

~~ SANCTION ADMINISTRATIVE PECUNIAIRE (SAP)

~~ SANCTION ADMINISTRATIVE PECUNIAIRE (SAP) de Commission 80ret6 nucf6alre canadienne ADMINISTRATIVE MONETARY PENAL TY (AMP) ~~ NOTICE OF VIOLATION (Corporation) AVIS DE VIOLATION (Societe) Date of Notice /Date de l'avis: January 15, 2015 AMP Number