| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
11/03/2004 - 11/04/2004 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 41159 | Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: BARD BRACHYTHERAPY
Region: 3
City: CAROL STREAM State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL GOTT | Notification Date: 10/29/2004
Notification Time: 15:10 [ET]
Event Date: 10/29/2004
Event Time: [CDT]
Last Update Date: 11/02/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RONALD GARDNER (R3)
SANDRA WASTLER (NMSS)
| Event Text AGREEMENT STATE REPORT
"On October 29, the radiation safety officer (RSO) for Bard Brachytherapy, Mr. Ed Zduenk called the Division to report an excessive radiation level from a package that they had received. Federal Express had delivered a container that was shipped by Northwest Hospital, Randallstown, Maryland on October 26, 2004. The maximum measured radiation level on the surface of the package was 500 milliRem/h. At a distance of 3 feet, the measured radiation level was indistinguishable from background.
"After verifying that the package was intact and undamaged, the RSO proceeded to take measurements in the delivery vehicle. No elevated radiation levels were noted. With the package repositioned in the vehicle as described by the driver, additional measurements were made. There were no elevated readings detected on the exterior of the truck nor at the driver's position. As such, the RSO estimated the driver's exposure to be minimal from handling the package and briefly working at the rear of the delivery vehicle. The carrier was subsequently contacted with this information as well.
"After the package was accepted and moved to a safe location at the facility, additional measurements were taken. The maximum dose rate measured at 1 foot was 10 milliRem/h and at 2 feet was 2 milliRem/h. The container was expected to have 112 sealed sources of I-125 with an actual activity of 0.476 milliCurie each for a total of 53.3 milliCurie. After the package was opened and its contents inventoried, it was determined that all of the sources were accounted for. When the package was opened, the RSO observed that the lid of the interior primary shielded container was not in its expected position. Although some of the sources remained in the shielded container, the other sources were only in their shielded applicator. No sources were 'loose' in the box.
"Considering the shipper, the state of Maryland was notified of this event. This item is still open pending investigation to determine the cause of the event."
IL report number IL040068 |
| General Information or Other | Event Number: 41161 | Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County: FAYETTE
License #: 20126696
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: BILL GOTT | Notification Date: 10/29/2004
Notification Time: 16:52 [ET]
Event Date: 10/22/2004
Event Time: 14:00 [CDT]
Last Update Date: 10/29/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHRISTOPHER CAHILL (R1)
PATRICIA HOLAHAN (NMSS)
| Event Text AGREEMENT STATE REPORT
During the interlock check of a JL Shephard Model 1 Number 68-10 Irradiator, the source rod was lifted with the machine in the off position, indicating a failure of the interlock. Exposure determinations of the technicians present indicated an exposure less than reportable limits. An investigation is in progress. |
| General Information or Other | Event Number: 41162 | Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: LDS HOSPITAL
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800102
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT | Notification Date: 10/29/2004
Notification Time: 18:25 [ET]
Event Date: 10/26/2004
Event Time: 11:30 [MDT]
Last Update Date: 10/29/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GARY SANBORN (R4)
PATRICIA HOLAHAN (NMSS)
| Event Text AGREEMENT STATE REPORT - MEDICAL EVENT
"This event involved an HDR brachytherapy unit [Varian Medical Systems, Inc. Model GammaMed plus, serial number E159; with sealed source Model GammaMed 232, serial number 24-07-4445-004-082504-11622-71 (connector serial number D24E445)]. The female patients larynx cancer treatment plan called for four HDR brachytherapy treatments. On October 26, 2004, two HDR brachytherapy treatments were given. Before the third treatment was to be given, on October 27, 2004, an error was discovered. The prescribing physician stopped the treatment until dosimetry information was completed. The third treatment was not given. The error was caused because a circular tool was used to mark the treatment site. The diameter of the circle was used when the radius should have been applied. As a result, the area treated was 2 cm away from the defined locus instead of 1 cm. The total source length treated was 11 cm, (approximately 1 cm diameter cylinder surrounding the brachytherapy source placed inside a tracheotomy tube). The prescribed dose was 500 cGy (centiGray) to the entire 11 cm length. The worse case patient dose scenario was that the patient received 2,756 cGy at one dwell position out of 23 dwell positions along the 11 cm treatment length. The dose delivered would have been 551% greater than the prescribed dose at the position respective to the worst-case scenario. The licensee does not anticipate any adverse health affects to the patient. The Utah Division of Radiation Control is currently investigating this event." |
| Power Reactor | Event Number: 41169 | Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUANE GARTNER
HQ OPS Officer: STEVE SANDIN | Notification Date: 11/03/2004
Notification Time: 05:15 [ET]
Event Date: 11/03/2004
Event Time: 03:10 [EST]
Last Update Date: 11/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
| Person (Organization):
DAVID SILK (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Refueling | 0 | Refueling | Event Text OFFSITE MEDICAL TREATMENT FOR INJURED CONTAMINATED WORKER
"On 11/03/04 at approximately 0256 hrs, a refueling bridge operator was injured when his gloved right hand became entangled in the refuel bridge mast during the performance of core alterations. The moving mast sections crushed two of the operator's fingers, and the bridge was immediately shutdown by the spotter. An irradiated fuel bundle had just been removed from the reactor core at the time of the incident, and was being raised to the full up position for transport to the spent fuel pool. The refueling SRO directed the bridge power be turned on to lower the mast slightly and release the operator's hand. The bridge operator was escorted off of the refuel floor by radiation protection and site medical personnel. A bridge relief crew completed the movement of the irradiated fuel bundle to its target location in the spent fuel pool, and core alterations were stopped pending completion of an accident investigation.
"The injured bridge operator was contaminated with approximately 5000 counts per minute on the injured hand, and was transported offsite by radiation protection and site medical personnel at approximately 0310 hrs. The operator was subsequently de-contaminated inside of the ambulance under the care of the emergency room physician, and the contaminated material was returned to site inside the ambulance. Once decontaminated, the operator was admitted to the Salem Memorial Hospital emergency room in Salem, New Jersey."
The licensee informed the Lower Alloways Creek Township and the NRC Resident Inspector and does not plan a press release. |
| Other Nuclear Material | Event Number: 41170 | Rep Org: OXFORD INSTRUMENTS
Licensee: ABBEY METAL CORPORATION
Region: 1
City: MOONACHIE State: NJ
County:
License #:
Agreement: N
Docket:
NRC Notified By: LAURA ZIEGLER
HQ OPS Officer: JEFF ROTTON | Notification Date: 11/03/2004
Notification Time: 11:21 [ET]
Event Date: 06/16/2004
Event Time: [EST]
Last Update Date: 11/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
DAVID SILK (R1)
JOHN HICKEY (NMSS)
| Event Text GENERAL LICENSED RADIOACTIVE MATERIAL LOST DURING BUILDING FIRE
During a fire in the licensee building on 06/16/04, a XMET model 2000 instrument, serial # 500577 was destroyed completely. The instrument probe (serial # 501888) contained two sealed sources, 20 millicuries Cd-109 and 30 millicuries Am-241. The local fire department and Hazmat team responded to the scene. The licensee RSO conducted a survey and found no contamination or radiation. NRC Region 1 office was notified on 6/30/04. |
| Fuel Cycle Facility | Event Number: 41171 | Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PIKETON State: OH
County: PIKE
License #: GDP-2
Agreement: Y
Docket: 0707002
NRC Notified By: JAMES McCLEERY
HQ OPS Officer: ARLON COSTA | Notification Date: 11/03/2004
Notification Time: 13:11 [ET]
Event Date: 11/02/2004
Event Time: 17:35 [EST]
Last Update Date: 11/03/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
| Person (Organization):
STEPHEN CAHILL (R2)
JOHN HICKEY (NMSS)
| Event Text 24 HOUR BULLETIN 91-01 REPORT INVOLVING TANKER TRUCK ASSAY RESULTS EXCEEDING VALUES
"DESCRIPTION:
11/2/04 at 1735 the Plant Shift Superintendent (PSS) office was notified of a tanker truck located outside the east corner of the X-700 has uranium results at 322.0 +/- 64.4 PPM and 4.87 +/- 0.49 U-235 assay. No NCSA applies to this operation. This is reportable per NRCB 91-01 as a 24 hour event.
"SAFETY SIGNIFICANCE:
Very Low Safety Significance. The amount and concentration of uranium involved cannot possibly achieve a critical configuration.
"POTENTIAL CRITICALITY:
There are no criticality pathways involved due to the limited mass and concentration of material.
"CONTROLLED PARAMETERS:
No NCSA was established for this operation, so there are no control parameters. However, the limited mass and concentration of the solution does not warrant double contingency control because a criticality is not credible.
"NUCLEAR CRITICALITY SAFETY CONTROLS:
No NCSA controls were established for this operation.
"CORRECTIVE ACTIONS:
Upon discovery the PSS office directed entering an anomalous condition. Additional samples are being taken to confirm results. Contents of tanker are to be removed. | |