Event Notification Report for January 16, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/15/2004 - 01/16/2004
EVENT NUMBERS
404614045240454404554045640464
General Information or Other
Event Number: 40461
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: INDUSTRIAL SERVICES OF AMERICA
Region: 1
City: LOUISVILLE State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GRESHAM
HQ OPS Officer: RICH LAURA
Licensee: INDUSTRIAL SERVICES OF AMERICA
Region: 1
City: LOUISVILLE State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GRESHAM
HQ OPS Officer: RICH LAURA
Notification Date: 01/21/2004
Notification Time: 16:28 [ET]
Event Date: 01/16/2004
Event Time: 00:00 [CST]
Last Update Date: 01/21/2004
Notification Time: 16:28 [ET]
Event Date: 01/16/2004
Event Time: 00:00 [CST]
Last Update Date: 01/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CLIFFORD ANDERSON (R1)
LAWRENCE KOKAJKO (NMSS)
CLIFFORD ANDERSON (R1)
LAWRENCE KOKAJKO (NMSS)
KENTUCKY AGREEMENT STATE REPORT ON LOSS OF RADIOACTIVE MATERIAL FOUND AT SCRAP YARD
On 1/16/04, the radiation detectors alarmed at the North American Stainless scrap yard, located in Ghent, Kentucky, when a truck entered the scrap yard. The scrap yard radiation detectors indicated 42 microrem per hour. The truck was not accepted and sent back to its origin. The scrap material in the truck came from Industrial Services of America. Investigation determined that a piece of a fixed gauge caused the radiation alarms to set off. Apparently, the gauge went through a shredder. On-contact radiation readings were 35 millirem/hour with the shutter closed and 58 millirem/hour with the shutter open. This was considered a loss of radioactive material and further review will be performed to try to determine the owner of the gauge.
On 1/16/04, the radiation detectors alarmed at the North American Stainless scrap yard, located in Ghent, Kentucky, when a truck entered the scrap yard. The scrap yard radiation detectors indicated 42 microrem per hour. The truck was not accepted and sent back to its origin. The scrap material in the truck came from Industrial Services of America. Investigation determined that a piece of a fixed gauge caused the radiation alarms to set off. Apparently, the gauge went through a shredder. On-contact radiation readings were 35 millirem/hour with the shutter closed and 58 millirem/hour with the shutter open. This was considered a loss of radioactive material and further review will be performed to try to determine the owner of the gauge.
Power Reactor
Event Number: 40452
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: JAMES BAPTIST
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: JAMES BAPTIST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/16/2004
Notification Time: 02:01 [ET]
Event Date: 01/16/2004
Event Time: 00:20 [CST]
Last Update Date: 01/16/2004
Notification Time: 02:01 [ET]
Event Date: 01/16/2004
Event Time: 00:20 [CST]
Last Update Date: 01/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)
JULIO LARA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO BOTH TRAINS OF SAFETY INJECTION DECLARED INOPERABLE
The following information was obtained from the licensee via facsimile:
"Inspections of the 'A' SI [Safety Injection] Pump lube oil cooler today per PMP [Plant Maintenance Procedure] 33-01 revealed silt and lake weed accumulation at tube pass inlets. Calculation C11423 Rev. 0, Addendum A was recently performed to determine service water flow and temperature requirements for the safety injection pump lube oil coolers. The calculation provides the required service water flow rate based on number of tubes blocked and SW [Service Water] temperature. At 1640 [hrs][CST], 1/15/04, it was reported that a visual inspection was performed on the 'A' SI Pump HX [Heat Exchanger] tube inlet and 17 of 20 tubes were found to be blocked. The flow for the 'A' HX was 3 - 3.8 gpm and after cleaning elevated to 5.95 - 6.05 gpm. This concern prompted an investigation into 'B' SI Pump HX and a flow test was performed at 1951 [hrs] on 1/15/04. The results from this test was no flow from 17 of the 20 tubes as seen from the outlet of the HX and a similar flow rate as seen in HX 'A'. The determination was made that this had potentially made both trains of SI Pump HX inoperable and that this needed to be reported under GNP 11.08.04 -'Reportability Determinations'. The Calculation (C11423) used data that was contradictory to current Surveillance Procedure acceptance criteria and used values that may not be indicative of post accident conditions. In a teleconference with Senior Plant Management, it was determined that future operability of the SI Pump lube oil HX cannot be verified and that both trains would be declared inoperable at time 0020 [hrs] [on] 1/16/04. This is in contradiction with the plant Technical Specification,3.3.b Emergency Core Cooling, and placed the plant in the standard shutdown sequence."
The plant shutdown will commence at 0120 hrs CST.
The NRC Resident Inspector has been notified by the licensee.
The following information was obtained from the licensee via facsimile:
"Inspections of the 'A' SI [Safety Injection] Pump lube oil cooler today per PMP [Plant Maintenance Procedure] 33-01 revealed silt and lake weed accumulation at tube pass inlets. Calculation C11423 Rev. 0, Addendum A was recently performed to determine service water flow and temperature requirements for the safety injection pump lube oil coolers. The calculation provides the required service water flow rate based on number of tubes blocked and SW [Service Water] temperature. At 1640 [hrs][CST], 1/15/04, it was reported that a visual inspection was performed on the 'A' SI Pump HX [Heat Exchanger] tube inlet and 17 of 20 tubes were found to be blocked. The flow for the 'A' HX was 3 - 3.8 gpm and after cleaning elevated to 5.95 - 6.05 gpm. This concern prompted an investigation into 'B' SI Pump HX and a flow test was performed at 1951 [hrs] on 1/15/04. The results from this test was no flow from 17 of the 20 tubes as seen from the outlet of the HX and a similar flow rate as seen in HX 'A'. The determination was made that this had potentially made both trains of SI Pump HX inoperable and that this needed to be reported under GNP 11.08.04 -'Reportability Determinations'. The Calculation (C11423) used data that was contradictory to current Surveillance Procedure acceptance criteria and used values that may not be indicative of post accident conditions. In a teleconference with Senior Plant Management, it was determined that future operability of the SI Pump lube oil HX cannot be verified and that both trains would be declared inoperable at time 0020 [hrs] [on] 1/16/04. This is in contradiction with the plant Technical Specification,3.3.b Emergency Core Cooling, and placed the plant in the standard shutdown sequence."
The plant shutdown will commence at 0120 hrs CST.
The NRC Resident Inspector has been notified by the licensee.
Power Reactor
Event Number: 40454
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SMITH
HQ OPS Officer: GERRY WAIG
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SMITH
HQ OPS Officer: GERRY WAIG
Notification Date: 01/16/2004
Notification Time: 13:48 [ET]
Event Date: 01/16/2004
Event Time: 11:37 [EST]
Last Update Date: 01/16/2004
Notification Time: 13:48 [ET]
Event Date: 01/16/2004
Event Time: 11:37 [EST]
Last Update Date: 01/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ROBERT HAAG (R2)
ROBERT HAAG (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP
"At 1137 hours EST on January 16, 2004, with Watts Bar Unit 1 in Mode 1 at 100 % power, a turbine trip and reactor trip occurred. This is reportable as a 4-hour notification under 10 CFR 50.72 (b)(2)(iv)(B) and an 8-hour notification under 10 CFR 50.72 (b)(3)(iv)(A). In addition, per design, there was auto start of the Auxiliary Feedwater system which is reportable as an 8-hour notification under 10 CFR 50.72 (b)(3)(iv)(A). Plant safety systems performed as designed and the reactor is currently stable in mode 3.
"At the time of the trip, plant personnel were performing scheduled Solid State Protection System (SSPS) surveillance testing on the B Train Reactor Trip Breaker. Plant personnel are currently investigating the cause of the event."
The licensee also reported that all control rods inserted on the reactor trip, no primary or secondary system relief valves operated, and that reactor temperature is being maintained using steam dump to the condenser. Steam generator water levels are being maintained using auxiliary feedwater. The station electrical system is available and in a normal configuration. All ECCS equipment is available. The reactor is currently stable at 2230 psig, 559 degrees Fahrenheit.
The licensee has notified the NRC Resident Inspector.
"At 1137 hours EST on January 16, 2004, with Watts Bar Unit 1 in Mode 1 at 100 % power, a turbine trip and reactor trip occurred. This is reportable as a 4-hour notification under 10 CFR 50.72 (b)(2)(iv)(B) and an 8-hour notification under 10 CFR 50.72 (b)(3)(iv)(A). In addition, per design, there was auto start of the Auxiliary Feedwater system which is reportable as an 8-hour notification under 10 CFR 50.72 (b)(3)(iv)(A). Plant safety systems performed as designed and the reactor is currently stable in mode 3.
"At the time of the trip, plant personnel were performing scheduled Solid State Protection System (SSPS) surveillance testing on the B Train Reactor Trip Breaker. Plant personnel are currently investigating the cause of the event."
The licensee also reported that all control rods inserted on the reactor trip, no primary or secondary system relief valves operated, and that reactor temperature is being maintained using steam dump to the condenser. Steam generator water levels are being maintained using auxiliary feedwater. The station electrical system is available and in a normal configuration. All ECCS equipment is available. The reactor is currently stable at 2230 psig, 559 degrees Fahrenheit.
The licensee has notified the NRC Resident Inspector.
Fuel Cycle Facility
Event Number: 40455
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: TOM E. WHITE
HQ OPS Officer: GERRY WAIG
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: TOM E. WHITE
HQ OPS Officer: GERRY WAIG
Notification Date: 01/16/2004
Notification Time: 21:42 [ET]
Event Date: 01/16/2004
Event Time: 15:27 [CST]
Last Update Date: 01/16/2004
Notification Time: 21:42 [ET]
Event Date: 01/16/2004
Event Time: 15:27 [CST]
Last Update Date: 01/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROBERT HAAG (R2)
THOMAS ESSIG (NMSS)
ROBERT HAAG (R2)
THOMAS ESSIG (NMSS)
24 HOUR NOTIFICATION FOR BULLETIN 91-01 LOSS OF CRITICALITY SAFETY CONTROLS INVOLVING WASTE DRUM
"At 1526 on 1-16-04, the Plant Shift Superintendent (PSS) was notified that a waste drum was not characterized and handled properly and handled as fissile waste. This is a continuation of PGDP Event Report No. PAD-2004-003, NRC Event Report 40447.
"During the investigation of ATRC-03-4095, container RFD# 215759-20, which had been characterized as NCS [nuclear criticality safety] spacing exempt based on the drum being heterogeneous material, it was identified that this waste drum contained spent alumina material violating NCSA (nuclear criticality spacing analysis] WM0-001. The purpose of this NCSA requirement is to determine if the waste drum requires two independent characterization results. Two independent characterization methods were not utilized for characterization of this drum.
"PGDP Assessment and Tracking Report No. ATR 04-0166; PGDP Event Report No. PAD-2004-004.
NRC Event Worksheet 40455
Responsible Division: Production Support
"SAFETY SIGNIFICANCE OF EVENTS: The control for performing two independent analysis for determining the U235 mass was violated but one drum monitor analysis determined that the drum did contain less than the safe mass for spacing exempt waste drums. Since the process condition was maintained, the safety significance is low but double contingency was not maintained.
"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIOS) OF HOW CRITICALITY COULD OCCUR: In order for a criticality to be possible, two or more waste drums would have to contain greater than 120 grams U235 and not have the proper spacing maintained between the waste drum.
"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC
The process condition relied upon for double contingency for this scenario is mass.
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS): The drum has been characterized to show that Uranium mass is less than 120g U235.
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency is based on the requirement that uranium waste material must be characterized to show that the U235 mass of the waste drum is less than 120 grams. This control was not violated and the process condition of mass was maintained.
"The second leg of double contingency is based on the requirement that high density uranium homogeneous waste material be characterized using an independent analysis. Since the waste drum material was mistakenly identified as heterogeneous material, only one analysis was performed. Therefore, this control was violated. One drum monitor analysis determining that the waste drum contained less than 120 grams U235. Although the control was violated, the process condition was maintained. Since this scenario relies on two controls on one parameter and this control was violated, double contingency was not maintained.
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
Access to the area has been flagged off and access controlled until drums retagged and properly stored.
"The NRC Senior Resident Inspector has been notified of this event."
"At 1526 on 1-16-04, the Plant Shift Superintendent (PSS) was notified that a waste drum was not characterized and handled properly and handled as fissile waste. This is a continuation of PGDP Event Report No. PAD-2004-003, NRC Event Report 40447.
"During the investigation of ATRC-03-4095, container RFD# 215759-20, which had been characterized as NCS [nuclear criticality safety] spacing exempt based on the drum being heterogeneous material, it was identified that this waste drum contained spent alumina material violating NCSA (nuclear criticality spacing analysis] WM0-001. The purpose of this NCSA requirement is to determine if the waste drum requires two independent characterization results. Two independent characterization methods were not utilized for characterization of this drum.
"PGDP Assessment and Tracking Report No. ATR 04-0166; PGDP Event Report No. PAD-2004-004.
NRC Event Worksheet 40455
Responsible Division: Production Support
"SAFETY SIGNIFICANCE OF EVENTS: The control for performing two independent analysis for determining the U235 mass was violated but one drum monitor analysis determined that the drum did contain less than the safe mass for spacing exempt waste drums. Since the process condition was maintained, the safety significance is low but double contingency was not maintained.
"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIOS) OF HOW CRITICALITY COULD OCCUR: In order for a criticality to be possible, two or more waste drums would have to contain greater than 120 grams U235 and not have the proper spacing maintained between the waste drum.
"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC
The process condition relied upon for double contingency for this scenario is mass.
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS): The drum has been characterized to show that Uranium mass is less than 120g U235.
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency is based on the requirement that uranium waste material must be characterized to show that the U235 mass of the waste drum is less than 120 grams. This control was not violated and the process condition of mass was maintained.
"The second leg of double contingency is based on the requirement that high density uranium homogeneous waste material be characterized using an independent analysis. Since the waste drum material was mistakenly identified as heterogeneous material, only one analysis was performed. Therefore, this control was violated. One drum monitor analysis determining that the waste drum contained less than 120 grams U235. Although the control was violated, the process condition was maintained. Since this scenario relies on two controls on one parameter and this control was violated, double contingency was not maintained.
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
Access to the area has been flagged off and access controlled until drums retagged and properly stored.
"The NRC Senior Resident Inspector has been notified of this event."
Power Reactor
Event Number: 40456
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: ROBERT BABEU
HQ OPS Officer: GERRY WAIG
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: ROBERT BABEU
HQ OPS Officer: GERRY WAIG
Notification Date: 01/16/2004
Notification Time: 23:29 [ET]
Event Date: 01/16/2004
Event Time: 23:16 [EST]
Last Update Date: 01/17/2004
Notification Time: 23:29 [ET]
Event Date: 01/16/2004
Event Time: 23:16 [EST]
Last Update Date: 01/17/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAMES NOGGLE (R1)
DAVID MATTHEWS (NRR)
HO NIEH (IRO)
EACHES (FEMA)
MARTIN HYMAN (DHS)
JAMES NOGGLE (R1)
DAVID MATTHEWS (NRR)
HO NIEH (IRO)
EACHES (FEMA)
MARTIN HYMAN (DHS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOUE DECLARED AT OYSTER CREEK DUE TO INTAKE LOW WATER LEVEL
The licensee declared a NOUE due to intake water level less than or equal to minus 2.0 feet on the staff. The Oyster Creek EAL table classification used to classify this event is 02. There is no radioactive release in progress. The intake low water level condition is worsened by wind conditions (301 degrees at 26.1 MPH) and low tide. The licensee expects that after low tide (~2330 EST) the intake water level condition will improve.
The licensee will notify the NRC Resident Inspector and the State of New Jersey.
* * * UPDATE ON 01/17/04 BY R. BABEU TO C GOULD * * *
The licensee has terminated the NOUE @ 0130 based on the level being less than -2ft (actual level is -1.5ft) The level is stable and the tide is incoming. The reactor is still at 100% power. The licensee has notified the state and will notify the NRC Resident Inspector.
The HOO notified FEMA(David Barton), DHS(Justin Abold), Reg1 RDO(James Noggle), EO(David Matthews) and DIRO Manager(Ho Nieh)
The licensee declared a NOUE due to intake water level less than or equal to minus 2.0 feet on the staff. The Oyster Creek EAL table classification used to classify this event is 02. There is no radioactive release in progress. The intake low water level condition is worsened by wind conditions (301 degrees at 26.1 MPH) and low tide. The licensee expects that after low tide (~2330 EST) the intake water level condition will improve.
The licensee will notify the NRC Resident Inspector and the State of New Jersey.
* * * UPDATE ON 01/17/04 BY R. BABEU TO C GOULD * * *
The licensee has terminated the NOUE @ 0130 based on the level being less than -2ft (actual level is -1.5ft) The level is stable and the tide is incoming. The reactor is still at 100% power. The licensee has notified the state and will notify the NRC Resident Inspector.
The HOO notified FEMA(David Barton), DHS(Justin Abold), Reg1 RDO(James Noggle), EO(David Matthews) and DIRO Manager(Ho Nieh)
General Information or Other
Event Number: 40464
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: HILLCREST HOSPITAL
Region: 3
City: MAYFIELD HEIGHTS State: OH
County:
License #: OH02120180042
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: STEVE SANDIN
Licensee: HILLCREST HOSPITAL
Region: 3
City: MAYFIELD HEIGHTS State: OH
County:
License #: OH02120180042
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/22/2004
Notification Time: 09:29 [ET]
Event Date: 01/16/2004
Event Time: 16:10 [EST]
Last Update Date: 01/22/2004
Notification Time: 09:29 [ET]
Event Date: 01/16/2004
Event Time: 16:10 [EST]
Last Update Date: 01/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROGER LANKSBURY (R3)
ROBERTO TORRES (NMSS)
ROGER LANKSBURY (R3)
ROBERTO TORRES (NMSS)
AGREEMENT STATE REPORT INVOLVING AN ABNORMAL OCCURRENCE (AO)
On 11/20/03 a 19 year old female patient received 140.1 millicuries I-131 for thyroid carcinoma as prescribed. At the time she was unaware and had completed the required forms indicating she was not pregnant. On 12/5, 12/8 and 12/11/03 quantitative tests confirmed that she was pregnant. The results were provided to her endocrinologist who recommended that a fetal dose calculation be performed. The hospital was notified and their consultant informed the endocrinologist that the fetus would have received 19.6 rads. The Endocrinologist sent the results to the Center for Human Genetics at University Hospital in Cleveland where as assessment was performed that the pregnancy could safely continue.
The Ohio Bureau of Radiation was informed on 1/16/04 and submitted the information to the NRC Region III office. NRC Region III (Lynch) recommended making a telephonic notification due to the incident meeting the criteria of an AO even though Ohio is not required to conform with the revised reporting requirements for a period of three years (October 2005) after the final rule is issued.
Hillcrest Hospital has implemented pregnancy testing for child bearing age female patients receiving radiation therapy.
On 11/20/03 a 19 year old female patient received 140.1 millicuries I-131 for thyroid carcinoma as prescribed. At the time she was unaware and had completed the required forms indicating she was not pregnant. On 12/5, 12/8 and 12/11/03 quantitative tests confirmed that she was pregnant. The results were provided to her endocrinologist who recommended that a fetal dose calculation be performed. The hospital was notified and their consultant informed the endocrinologist that the fetus would have received 19.6 rads. The Endocrinologist sent the results to the Center for Human Genetics at University Hospital in Cleveland where as assessment was performed that the pregnancy could safely continue.
The Ohio Bureau of Radiation was informed on 1/16/04 and submitted the information to the NRC Region III office. NRC Region III (Lynch) recommended making a telephonic notification due to the incident meeting the criteria of an AO even though Ohio is not required to conform with the revised reporting requirements for a period of three years (October 2005) after the final rule is issued.
Hillcrest Hospital has implemented pregnancy testing for child bearing age female patients receiving radiation therapy.