United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 27, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/24/2006 - 02/27/2006

** EVENT NUMBERS **


42354 42357 42358 42359 42360 42361 42362 42363 42364 42370 42374 42375

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General Information or Other Event Number: 42354
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/21/2006
Notification Time: 17:21 [ET]
Event Date: 02/21/2006
Event Time: [CST]
Last Update Date: 02/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE - LOSS OF IRIDIUM SEED STRAND FOLLOWING MEDICAL TREATMENT

The following is a summary of information provided by the State via email:

The licensee's Radiation Safety Officer indicated that a gynecological implant of seeds contained in a nylon ribbon were missing at the completion of a patient treatment. The "strand" contained 10 seeds of 0.675 milliCi, each, which was part of a treatment that included 9 total strands of both Cs-137 and Ir-192 sources. The lost strand contained 10 Ir-192 seeds.

A resident physician removed the strands at the end of the treatment on the evening of 2/18/06. The treatment had begun on 2/15/06. After returning the strands to the radiation oncology lab it was noted that only 8 strands were present, rather than the 9 which were initially implanted. The patient was thoroughly surveyed and eventually x-ray'd to confirm the missing strand did not remain in the patient. The operating room, the patient's room, the remaining linen and trash from the patient's room, the hallway between the patient's room and the radiation oncology source storage location, the entire nursing floor, the radiation oncology department, the hospital's linen holding facility, the biohazardous waste holding facility and loading docks were all monitored without any success of locating the strand. The patient had been essentially immobilized for the treatment and had received a Foley catheter for relieving her bladder. As such, use of the toilet facilities were not likely (although they too were monitored). Surveys were conducted with instruments that were likely to detect the radiation field associated with almost 7 mCi of Ir-192 (i.e., 4 to 5 milliRem/hr at 1 meter) by the staff.

Interviews were conducted with the nursing staff to determine additional details regarding handling of trash and linen from the patient's room. Although the licensee's surveys showed no elevated levels present at the time, the licensee indicated that waste and linen from the room would be held pending potential surveys by the Division.

The licensee has also monitored their contracted biohazardous waste treatment facility in Cicero, IL on 2/20/06 with negative results. They also planned to visit the linen laundering facility in Palwaukee, IL on the slim chance that the strand was carried off in soiled linens that might have been changed during the patient's stay.

The resident involved, the residency staff and the residency director received additional instruction regarding established procedures, in conjunction with this event, with regards to explanation of sources and accounting procedures. Similarly, the nursing staff was interviewed and refreshed on established procedures with regards to linen and waste processing from patients' rooms. The patient was scheduled to return for a follow up visit on 2/22/06 at which time she was going to be interviewed again to determine if there was any additional information she could provide to help locate the missing strand.

Illinois Report #IL060013

* * * UPDATE PROVIDED BY PERRERO TO JEFF ROTTON AT 1034 EST ON 02/23/06 * * *

The missing radioactive sources reported by the Illinois Emergency Management Agency (IEMA) on February 21, 2006 at 17:21 from Northwestern Memorial Hospital have been recovered by the facility's radiation safety officer. A radiation monitor alarm was reported to IEMA by the Prairie Hills Landfill staff in Morrison, IL on 2/21/2006. IEMA personnel investigated that alarm yesterday [02/22/06] and confirmed the presence of Ir-192 by gamma spectroscopy as part of a load of trash that was traced back to the hospital's laundry service provider. Arrangements were made to have the ribbon of 10 sources picked up by hospital staff this morning and returned to the hospital for proper disposal.

Notified R3DO (Hills) and NMSS EO (Morell)


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 42357
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONAM MMP
Region: 4
City: CARSON State: CA
County:
License #: CA4832-19
Agreement: Y
Docket:
NRC Notified By: CJ SALGADO
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 16:02 [ET]
Event Date: 02/22/2006
Event Time: 08:30 [PST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL EXTREMITY OVEREXPOSURE

At 0830 PST on 2/22/06 following a radiography shoot at the BP Refinery in Carson, CA, the Assistant Radiographer approached the camera without a survey meter and disconnected the guide tube. The Radiographer noticed that the pigtail was hanging out indicating that the source was not in the shielded volume. A preliminary estimate of the overexposure to the Assistant Radiographer is between 128 - 358 Rem to either hand based on a duration of 14 seconds from a 62.88 Ci Ir-192 source used in the INC-IR100 camera, S/N 6744. The Assistant Radiographer's pocket dosimeter (PD) showed off-scale high (100 mR) while the Radiographer's PD indicated 10 mR. Both employee's submitted their OSLs (Optically Stimulated Luminescent) whole body badges for readings. The Assistant Radiographer has no physical manifestations of a radiological overexposure at this time. The State of CA was notified at 1150 PST and has initiated an investigation into this incident.

CA Investigation # 022206.

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General Information or Other Event Number: 42358
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 04/17/2003
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A RADIOPHARMACEUTICAL MISADMINISTRATION

The following information was received via facsimile:

"NY-06-001

"Radiopharmaceutical Misadministration. (NYS DOH Internal Tracking No. 86)

"New York law prohibits the release of any identities in cases of medical, events. Therefore the facility name, etc., is not contained in this report.

"Date of occurrence 4/17/2003

"The patient was prescribed 300mCi of I-131 NaI for thyroid carcinoma but received only 233 mCi.

"Licensee received two vials from the radiopharmacy as ordered, one with 200 mCi and the other with 100 mCi. The vials were, as per Licensee's protocol, left in the outer plastic sleeve during assay, and the assays were within acceptable limits. Upon completion of administration to the patient, the vials were again assayed to access the residual activity in the vials. Nothing unusual was noted for the 100 mCi vial, however about 90 mCi remained in the 200 mCi vial. Water was added to that vial and the patient was administered that liquid portion. The vial was again assayed and about 70 mCi remained. The licensee asked the pharmacy for additional I-131 but was told that the additional dosage would not be available until the next day. Consequently the patient was released with only having received 233 of the 300 mCi prescribed. The patient and referring MD were notified.

"The RSO/licensee staff investigated. They noted that there was some liquid between the glass vial and its outer plastic sleeve. Upon close examination of the vial it appears that the seal between the vial and septum was flawed allowing material to 'leak' from the vial. Additional surveys of packaging and area were performed. The need for bioassays of those involved in the administration was addressed.

"We received copies of reports from both the medical licensee and radiopharmacy. It appears that the seal on the vial was compromised thus allowing material to move outside the vial but remain contained within the outer plastic vial. Thus it had appeared that the vial was okay for use. Bioassay and survey measurements were performed with negative results. Actions to prevent repeat of such an event were included in both reports.

"The licensee followed up in regard to the patient. The treating physician stated that the dose was within the therapeutic range by existing standards. The patient was subsequently retreated with 300 mCi of I-131 in August of 2004. This post-treatment scan was positive and he was advised to return again in 6 - 9 months for re-evaluation. He did not, citing difficulties relating to employment etc. However, some time later he agreed to come in for further follow-up."

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General Information or Other Event Number: 42359
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 12/14/2003
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION

The following information was received via facsimile:

"NY-06-002

"HDR Brachytherapy medical event (NYS DOH Internal Tracking; No. 13)

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"RSO reported a medical misadministration involving a female patient treated on 5/12-14/2003 with SYED(needles)/HDR (Varian unit). Apparently there was an error, with respect to the area treated (incorrect dwell positions), which was not discovered until a final chart review. The treatment plan and double check of the calculations were performed as required. A different physicist than the one who did the treatment plan and double checks discovered the error. The facility submitted a written report. According to the report, since the original catheters had been discarded, reconstructing the scenario to the best of their ability, they concluded that all catheters and connecting tubes had the same lengths as previous similar implants. The measurement of 4 catheters on the first implant day obtained a catheter length of 119.8 cm. It was not repeated for the other 7 catheters and not double-checked by measurement by another physicist. However, the number, 119.8 cm is different from what they usually get for this type of procedure. Therefore, they concluded that the error occurred at this stage of the planning: i.e., (1) the planner did not verify that numbers were similar to what they usually get. (2) physics double check prior to the procedure did not include a second measurement nor did it check if the numbers were reasonable. The measurement was incorrect. Their corrective actions, if followed strictly, should prevent this error from happening again.

"Target (Tumor) Intended 2000 cGy. Delivered 150 cGy.

"Normal Tissue Expected 150 cGy. Delivered 2000 cGy.

"The patient was seen by her gynecological oncologist. This physician and the radiation oncologist determined that the patient should not be adversely affected because the dose was within tolerance of tissue including those of the vagina, rectum and bladder. However they were concerned that the tumor bed did not receive an adequate radiotherapy dose. The patient received additional low dose brachytherapy treatment. The LDR was given on 6/27/03, 1200 cGy to 0.5 cm from the cylinder surface. This treatment was delivered as intended."

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General Information or Other Event Number: 42360
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 11/29/2005
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A BROKEN I-125 BRACHYTHERAPY SEED

The following information was received via facsimile:

"NY-06-003

"Broken I-125 brachytherapy seed. (NYS DOH Internal Tracking No. 421)

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"RSO reported a broken I-125 source from a prostate seed implant on 11/29/05. The cartridge/source jammed in the applicator and a source was ruptured. All fragments were recovered in the rinse of the applicator and the patient did not have any seed fragments implanted. The written report stated: 90 seeds were ordered, 74 were implanted, 16 unused seeds were recovered (15 intact, one ruptured). The Mick applicator is a model 200-TP. The seeds were GE Healthcare Medi-physics supplied by Oncura Inc. The apparent activity per seed was 0.47 mCi. The radiation oncologist who performed the procedure is experienced (500+ cases). He stated that during the procedure the applicator jammed several times and that he was required to remove seeds from the applicator. It was probably during that process that the seed was ruptured and the loose seeds fell to the table. The medical physicist, upon going to the operating room to retrieve the unused seeds identified two seeds had become loose, one of which was damaged (appeared shorter than the others). A radiological survey indicated that no contamination was present on instruments or the area used for the implant. The inner contents of the broken seed, a silver rod, were recovered. Measurements indicate that the activity remained with the rod rather than being spread around/causing contamination. Bioassay measurements, thyroid and urine, were performed on the patient, physicist and RSO, all with negative results. All unused seeds were placed into the decay in storage program.

"This event did not constitute a misadministration because the number of seeds implanted was as per the treatment plan, and there is no evidence that a leaking (ruptured) seed was implanted. New applicators were ordered and placed into service."

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General Information or Other Event Number: 42361
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: VASSAR COLLEGE
Region: 1
City: POUGHKEEPSIE State: NY
County:
License #: RML # 410
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 12/13/2004
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)
ILTAB (via email) ()

Event Text

AGREEMENT STATE REPORT INVOLVING A LOST/MISSING SOURCE

The following information was received via facsimile:

"NY-06-004

"Lost/missing Am-241, 250 nano-curie source, 12/13/2004 Vassar College, Poughkeepsie, NY 12604, RML # 410

"College staff called to report that they had lost a 250 nCi Am-241 source. The source is a button source, approximately 2 cm in diameter. The source was discovered missing about 3 months ago, but they failed to report to NYS DOH because they were trying to locate it. The source may have been moved from its storage space in the physics department to a location in the biology department in December 2003 when they were preparing a 10 mCi Am-241 source for shipment to NSSI for disposal at Los Alamos. They think they may have shipped this source along with the 10 mCi Am-241 source. The last time they actually saw the source was when it was leak tested in 2002. Los Alamos is preparing to go through shipments stored at NSSI for repackaging and disposal. Los Alamos will look for the missing source in the shipment. Vassar College will send a written report.

"An acknowledgement of their written report was sent and it asked them to keep us apprised of the results of the search at NSSI/LANL. A Notice of Violation was issued for missing quarterly inventories, late reporting of the missing source, no record of transfer/disposal of source."

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 42362
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANERSEAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 05/26/2004
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING AN INTRAVASCULAR BRACHYTHERAPY EVENT

The following information was received via facsimile:

"NY-06-005

"Intravascular Brachytherapy event. (NYS DOH Internal Tracking No. 223)

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"RSO of the hospital called to report that on May 26, 2004, during the introduction of Novoste Sr-90 (3.5 French catheter with the 40mm source train) it was noted, on fluoroscopy that the sources did not advance into the intended target tissue site in the right coronary artery. The licensee used a survey meter to confirm the source train was not in its intended position (rough check). The measurement served to confirm that the source train advanced partially and became stuck in the patient's abdomen. Emergency procedures were followed and all sources were removed within 30 seconds from the 63 [year old] female patient. The catheter assembly containing all sources was placed into a Lucite shield (bailout box). Confirmation of the stuck sources in the transfer case was obtained through fluoroscopy and indicated that the sources were trapped 13 cm from the distal end of the guide catheter. The patient was informed of the event and was subsequently treated with a stent.

"This is reportable under 10 NYCRR 16.25(a)(3)&7 (part of the body other than intended and total dose deviation greater than 10 %). The hospital will send the catheter back to Novoste for an evaluation and will submit a written report following Novoste written analysis.

"The incident reports from the facility, as well as from Novoste, were provided to DOH. Novoste provided guidance to avoid a recurrence."

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General Information or Other Event Number: 42363
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 09/29/2004
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING AN INTRAVASCULAR BRACHYTHERAPY EVENT

The following information was received via facsimile:

"NY-06-006

"Intravascular Brachytherapy event. (NYS DOH Internal Tracking No 278)

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"The RSO from the Hospital called on 9/30/04 to report a Novoste Beta Cath IVBT malfunction on 9/29/04. They were using 3.5 French catheter system. They had some difficulty accomplishing a 90-degree bend; at the end of the 3 min 14 seconds treatment time, their attempts to retract the source train failed and the cardiologist had to pull out the catheter manually along with the source train. They notified the FDA and NOVOSTE. They calculated that the patient's heart received a dose of 20 cGy, which the oncologist stated is within tolerance and he anticipates no adverse consequences for the patient. Since the intended dose was delivered to the treatment site, the oncologist believes this is not a medical event. An estimate of dose to the cardiologist's hand indicates an extremity exposure of no more than 3.85 rem which will be added to his annual exposure record."

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General Information or Other Event Number: 42364
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT DISCLOSED BY STATE LAW
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: R. DANSEREAU (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2006
Notification Time: 15:25 [ET]
Event Date: 11/05/2004
Event Time: [EST]
Last Update Date: 02/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING AN I-131 RADIOPHARMACEUTICAL MISADMINISTRATION

The following information was received via facsimile:

"NY-06-007

"Radiopharmaceutical therapy misadministration involving Iodine-131 (NYS DOH Internal Tracking Nos. 265 & 342)

"Date 11/5/2004

"New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report.

"A 150 mCi therapeutic dose (capsule) of lodine-131 was prescribed for a patient, however the patient received only one of two 75-mCi capsules. The capsule was eventually retrieved after a waste container tripped a radiation monitor at a waste transfer station. Patient has been notified and the hospital is conducting clinical follow-up. The following is a summary of the incident:

"The Bureau of Environmental Radiation Protection (BERP) received a request to issue a DOT exemption to allow BFI of Buffalo, NY to return a contaminated municipal solid waste in a compactor container from American Ref-Fuel to the Hospital. DOH staff went to the site to conduct a radiological survey of the trash compactor. The maximum reading at contact was 15 mR/hr (bkg = 0.02 mR/hr). Driver side reading was background. The DOT exemption was issued and the trash container was returned to the hospital. Upon return of the waste compactor it was isolated behind the utility building and the workers, plant engineering staff, were informed of the precautions - stay away.

"On 11/17/04 DOH participated in a conference call with hospital staff (Radiation Safety Officer, the treating MD and the Chief Nuclear Medicine Tech). The patient was prescribed a dosage of iodine 131, which was contained in 2 capsules supplied by a radiopharmacy. The treating MD stated that he saw the patient put each of the two capsules in the mouth, one at a time followed by water. Each capsule was in a separate cup. They claim that the patient stated that she took both.

"A post administration rad survey reading was taken, as per their routine procedure, and the results were within the range of what was expected, given the activity of the material. This reading apparently was measuring the exposure from the material administered as well as the capsule in the trash next to the patient. In this geometry, the measurement appeared to indicate that the patient had taken the full dose - both capsules. One of the capsules was either not taken or was spit out into the cup. This was then discarded in the normal trash.

"The capsule was isolated intact on 11/12/04 by a person who works for an asbestos firm. He did not have a personal rad monitoring device and the hospital was not aware of his level of radiation safety training. This unqualified person apparently sifted through the waste in the presence of the Chief CNMT - she had the survey meter. The capsule activity on the day of treatment was 75 mCi and about 40 mCi on the date of recovery. Hospital staff were aware that a capsule was lost and that a significant misadministration occurred but they did not immediately report either event to the Department as required by 10 NYCRR 16.15 and 16.25.

"On 11/22/04, DOH staff performed an onsite investigation. Hospital staff including the RSO; Performance Improvement Manager; Chief CNMT; radiation therapy physicist; Radiology Manager; and the authorized user that administered the I-131 were interviewed. The Director of Facilities was unavailable as he had an emergency surgery the day before this scheduled investigation. Hospital staff informed us that the Director of Facilities was primarily involved with this incident because he manages the hospital's waste. Hospital staff could not explain why the RSO or RSC were not more involved in this incident. They were informed of the immediate reporting requirements for lost sources and misadministrations. It was also strongly suggested that they evaluate why the RSO and RSC did not take a greater role in responding to this incident.

"A consultant provided conservative dose estimates as follows: Housekeeper who emptied the waste container - 35 mrem, in-house waste handler 63 [mrem] and the asbestos contractor 101 mrem. DOH staff interviewed housekeeping staff and reconstructed the handling times for this person, and determined the handling time assumptions used by the consultant were greatly overestimated so the dose estimates were likely lower. The contractor that entered the dumpster was not available to be interviewed.

"Due to the nature of the violations and manner in which the facility mishandled the event including allowing an unqualified person to retrieve the capsule and lack of RSO and RSC involvement/oversight, enforcement action was pursued and the facility was fined."

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Power Reactor Event Number: 42370
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEE KELLY
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/23/2006
Notification Time: 15:07 [ET]
Event Date: 02/23/2006
Event Time: 04:00 [PST]
Last Update Date: 02/24/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG PICK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned

Event Text

MINOR LEAKAGE OF WASTEWATER FROM TRANSPORT TRUCK

"On February 22, 2006, at 1000 PST, two tankers containing wastewater with trace levels of radioactivity departed San Onofre Nuclear Generating Station (SONGS) Unit 1 Industrial Site for Clive, Utah. Each truck contained about 4500 gallons of water. At about 0400 PST February 23, 2006, SCE was notified by the trucking company [Triad Transport Company] that minor leakage from a valve on top of one of the trucks had been observed. The leakage was observed while the truck was stopped in Parawan, Utah approximately 4 hours from its destination.

"The driver of the truck immediately notified his management who traveled to the site, identified the origin of the leak as spray from a valve on top of the truck, relieved the tank pressure from a vent valve, and stopped the leak. Dampness was observed on the ground beside the tanker. Unconfirmed measurements indicate radiation levels are near background.

"SCE has dispatched a team to the site to coordinate remediation efforts as necessary. The second tanker has arrived at the site in Clive, Utah and no leakage was observed during receipt inspection. The Director of the Utah's Division of Radiation Control and the NRC Resident Inspectors have been notified of this occurrence. At the time of this report, Unit 1 was undergoing decommissioning."

The activity from the radionuclides in the entire truck totaled 70.9 mCi, and primarily consisted of Cs-137 (41 mCi), Ni-63 (15 mCi), and Co-60 (5 mCi). The transport company notified the National Response Center. The truck traveled thru 4 States: CA, NV, AZ UT.

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Power Reactor Event Number: 42374
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARRI MARCHIONDA
HQ OPS Officer: JOE O'HARA
Notification Date: 02/24/2006
Notification Time: 10:20 [ET]
Event Date: 02/24/2006
Event Time: 08:54 [CST]
Last Update Date: 02/24/2006
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVID HILLS (R3)
THOMAS BLOUNT (IRD)
MEL LEACH (IRD)
JIM DYER (NRR)
IAN JUNG (NRR)
LIGGETT (FEMA)
CARLEDGE (DHS)
C. PETERSON (R3)
BILL KANE (DEDR)
GREG PICK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNUSUAL EVENT DUE TO FIRE IN THE PROTECTED AREA NOT EXTINGUISHED WITHIN 15 MINUTES

"At 0836 the control room received a Unit 1B CV/SI pump room fire alarm. An operator reported smoke in the 1B SI pump room at 0840. An unusual event was declared at 0854 due to HU6, fire in the protected area not extinguished within 15 minutes. Sounds of arcing can be heard but flames have not been located. It is suspected that an RWST heater has failed in a pipe tunnel above the 1B SI pump room. The breaker for the RWST heater has been deenergized. The RWST heater pump has been deenergized. Offsite fire department assistance has been requested."

The licensee is ventilating the area in order to perform a more thorough inspection of the area and determine the cause of the fire. Both Units1 and 2 remain at 100% reactor power.

The NRC Resident Inspector, State and local officials have been notified by the licensee.

The NRC has entered the Monitoring Mode at 1036.

The NRC Operations Center notified the following organizations: HHS/FDA (V. Howard-King), USDA (Brown), EPA/NRC (Rawls) and DOE (Silva).

* * * UPDATE FROM MARCHIONDA TO KNOKE AT 12:49 EST ON 02/24/06 * * *

"At 11:09 CST on 02/24/06, Byron terminated an Unusual Event that was declared at 08:54 CST today in accordance with HU6 due to a fire in the Protected Area not extinguished within 15 minutes. The RWST [Refueling Water Storage Tank] heater has been confirmed as the source of the smoke that caused the fire alarm. The heater has been deenergized and the area is being ventilated.

The NRC exited the Monitoring Response Mode at 12:52 EST.

The NRC Resident Inspector and State officials have been notified by the licensee. NRC made notifications to R3DO(Hills), IRD Managers (Leach, Blount, Wilson), NRR EO (Jung), NRR ET (Dyer), HQ PAO (Brenner), R4DO(Pick), DHS (Carledge), FEMA (Liggett), HHS/FDA( Miller), USDA (Byzustek), EPA/NRC (Rawls, Ribordy), and DOE (Silva).

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Power Reactor Event Number: 42375
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: JOE O'HARA
Notification Date: 02/26/2006
Notification Time: 04:32 [ET]
Event Date: 02/26/2006
Event Time: 02:50 [CST]
Last Update Date: 02/26/2006
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
Person (Organization):
LINDA SMITH (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 70 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO MSR HIGH LEVEL

"This report is being made pursuant to 10CFR50.72 (b) (2) (iv) (B) actuation of RPS when the reactor is critical (4 hour report) and 10CFR50.72 (b) (3) (iv) (A) actuation of PCIS group 2 (8 hour report).

"At 0250 on 2/26/06, Central Standard Time, Cooper Nuclear Station was manually scrammed due to main turbine reheat valve remaining closed following testing concurrent with a high level in the moisture separator. Alarm card procedure for this condition required removing the turbine from service. Subsequent to the scram, reactor vessel level lowered to minus 20 inches wide range indication. This corresponds to approximately 140 inches above the top of the fuel. A primary containment isolation system (PCIS) group 2 isolation occurred as expected due to level transient. All automatic actions occurred as expected.

"The NRC Senior Resident Inspector has been informed of the event."

The reactor scram was uncomplicated, all control rods fully inserted, and no relief or safety valves lifted. The electrical lineup is normal, and the decay heat path is to the main condenser through the turbine bypass valves.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012