Event Notification Report for April 6, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/05/1999 - 04/06/1999
** EVENT NUMBERS **
35544 35545 35546
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|Hospital |Event Number: 35544 |
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| REP ORG: BRICK HOSPITAL |NOTIFICATION DATE: 04/05/1999|
|LICENSEE: BRICK HOSPITAL |NOTIFICATION TIME: 06:46[EDT]|
| CITY: BRICK REGION: 1 |EVENT DATE: 04/05/1999|
| COUNTY: OCEAN STATE: NJ |EVENT TIME: 06:30[EDT]|
|LICENSE#: 29-20690-01 AGREEMENT: N |LAST UPDATE DATE: 04/05/1999|
| DOCKET: 03020725 |+----------------------------+
| |PERSON ORGANIZATION |
| |KATHLEEN MODES R1 |
| |DON COOL NMSS |
+------------------------------------------------+JOSEPH GIITTER IRO |
| NRC NOTIFIED BY: MICHAEL CAPRIO | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAAA 20.1906(d) SURFACE CONT/ EXT RAD | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| RECEIPT OF A PACKAGE CONTAINING RADIOPHARMACEUTICALS WITH SURFACE |
| CONTAMINATION (EXTERNAL RADIATION LEVELS GREATER THAN TRANSPORTATION |
| LIMITS) |
| |
| At approximately 0630 on 04/05/99, Brick Hospital (located in Brick, NJ) |
| received its daily shipment of radiopharmaceuticals from Nycomed Amersham |
| (located in Livingston, NJ); and the area radiation monitor alarm |
| annunciated when the delivery agent walked in with the package. The |
| shipment/package in question was a Yellow-II container, and it contained 400 |
| mCi of Technetium-99m and 0.1 mCi of Iodine-123. |
| |
| The licensee surveyed the package and performed wipe tests with the |
| following results (as measured using a Victoreen #450 ionization chamber): |
| 960 mR/hour at the surface and 18.5 mR/hour at a distance of 3 feet. The |
| contamination level on the outer surface of the shipping package was 26,912 |
| disintegrations per minute. (NOTE: External radiation standards require |
| that each package of radioactive materials offered for transportation must |
| be designed and prepared for shipment so that, under conditions normally |
| incident to transportation, the radiation levels do not exceed 200 mR/hour |
| at any point on the external surface of the package.) |
| |
| The licensee notified Nycomed Amersham; and at the request of Nycomed |
| Amersham, Brick Hospital representatives opened the contaminated package to |
| inspect the contents for breakage. Although the internal containers |
| appeared to be sealed in plastic and intact, a wipe test of the outside |
| surfaces of the lead pigs revealed contamination levels that were too hot to |
| count. The contaminated package was placed in a shielded leak storage |
| container (a shielded radioactive waste module). |
| |
| The licensee reported that there was no spread of contamination at Brick |
| Hospital. The status of the delivery agent was unknown. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
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|Hospital |Event Number: 35545 |
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| REP ORG: HINES VA HOSPITAL |NOTIFICATION DATE: 04/05/1999|
|LICENSEE: HINES VA HOSPITAL |NOTIFICATION TIME: 16:09[EDT]|
| CITY: CHICAGO REGION: 3 |EVENT DATE: 04/05/1999|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: 12-01087-09 AGREEMENT: Y |LAST UPDATE DATE: 04/05/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE BURGESS R3 |
| |FRED COMBS NMSS |
+------------------------------------------------+JOSEPH GIITTER IRO |
| NRC NOTIFIED BY: LAWRENCE CASE | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION INVOLVING WRONG PATIENT |
| |
| AN ELDERLY FEMALE PATIENT SCHEDULED FOR AN ORBITAL DOSE ON 04/02/99 USING A |
| LINEAR ACCELERATOR RECEIVED 200 cGy SINGLE FRACTION TO AN AREA NEAR THE |
| INTENDED TREATMENT SITE FROM A THERATRON Co-60 UNIT. THE REFERRING |
| PHYSICIAN WAS INFORMED AND NOTIFIED THE PATIENT WHO WAS RELEASED AND SENT |
| HOME. THE LICENSEE SUSPECTS THE ERROR WAS DUE TO THE SIMILARITY IN NAMES |
| BETWEEN BOTH ELDERLY FEMALE PATIENTS; ONE SCHEDULED FOR TELETHERAPY AND THE |
| OTHER FOR LINEAR ACCELERATOR TREATMENT. THE PRESCRIBED DOSE AND CONDITION |
| WAS NOT AVAILABLE AT THE TIME OF THE REPORT. THE THERATRON SOURCE WAS |
| 13,000 CURIES AS OF MARCH 1999. |
| |
| THE LICENSEE NOTIFIED NRC REGION 3. |
| |
| (CALL THE NRC OPERATIONS OFFICER FOR LICENSEE CONTACT INFORMATION.) |
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|Power Reactor |Event Number: 35546 |
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| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 04/05/1999|
| UNIT: [] [2] [] STATE: NJ |NOTIFICATION TIME: 16:37[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/05/1999|
+------------------------------------------------+EVENT TIME: 15:00[EDT]|
| NRC NOTIFIED BY: MIKE HOSKINS |LAST UPDATE DATE: 04/05/1999|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |FRANK COSTELLO R1 |
|10 CFR SECTION: | |
|ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
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EVENT TEXT
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| CONTAINMENT ISOLATION VALVES FAILED LOCAL LEAKRATE TESTING (LLRT). |
| |
| THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE: |
| |
| "DURING TYPE 'C' LOCAL LEAKRATE TESTING OF A STATION AIR PENETRATION TO |
| CONTAINMENT, THE AS-FOUND CONDITION OF THE ASSOCIATED VALVES (2SA119-INBOARD |
| CHECK VALVE, 2SA118-OUTBOARD MANUAL VALVE) ALLOWED LEAKAGE BEYOND |
| MEASUREMENT CAPACITY OF THE TEST EQUIPMENT. THE ASSOCIATED LEAKAGE WOULD |
| HAVE BEEN IN EXCESS OF THE TECH SPEC ALLOWABLE LIMIT FOR BOTH TYPE 'B' AND |
| 'C' (REFERENCE TS 3.6.1.2). CURRENTLY, THE PLANT IS IN A MODE (MODE 5) IN |
| WHICH THE LEAKAGE REQUIREMENTS ARE NOT APPLICABLE (TS 3.6.1.2 APPLICABLE |
| MODES 1 THROUGH 4). THIS CONDITION HAS BEEN ENTERED INTO THE PLANT'S |
| CORRECTIVE ACTION PROGRAM, AND CORRECTIVE MAINTENANCE WORK ORDERS ARE BEING |
| GENERATED. AT THE TIME OF THE DISCOVERY, THIS CONDITION HAD NO IMPACT ON |
| PLANT OPERATION." |
| |
| THE LICENSEE PLANS TO INFORM STATE AND LOCAL AGENCIES AND THE NRC RESIDENT |
| INSPECTOR. |
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