| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/21/2003 - 08/22/2003 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 40085 | Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: FRED HUTCHINSON CANCER RESEARCH CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-L042-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOHN MacKINNON | Notification Date: 08/18/2003
Notification Time: 18:10 [EST]
Event Date: 06/19/2000
Event Time: 12:00 [PDT]
Last Update Date: 08/18/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAIR SPITZBERG (R4)
JOHN HICKEY (NMSS)
| Event Text OVEREXPOSURE
"Exposure (intended/actual): consequences: Actual exposure received was Licensee: Fred Hutchinson Cancer "Research Center
"City and state: Seattle, Washington
"License number: WN-L042-1
"Type of license: Medium Broad License
"Date of event: Reported by licensee on 19 June 2000, (indicated overexposure for the wear period between 5 April to 4 "May 2000).
"Location of Event: Seattle, Washington
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) On 19 June 2000, the licensed RSO reported that their dosimetry badge provider (Landauer Inc.) had notified them that one of the Fred Hutchinson employees had apparently received an exposure of 317,791 millirem of high energy gamma radiation. This employee performs animal studies involving irradiations using both a Linac and a Cobalt 60 irradiator (a J.L. Shepherd Model 285, Serial Numbers 625 & 626).
"The RSO immediately started an investigation of the reported overexposure. The RSO discovered that the individual's dosimetry badge had been lost during the second week of April 2000 for a period of about one week. An unknown person, via the inter-office mail system, returned it to the individual the next week. The employee was unable to recall any situation that would have lead to an exposure of any amount greater then the usual for the work performed over that time period.
"Several circumstantial events as well as actual occurrences seem to indicate that the exposure was probably only received by the dosimetry badge. These were: first, the employee indicated that the dosimetry badge had been lost during the second week of April 2000, for a period of about one week. Second, only the Cobalt 60 irradiator was in operation during that period; the Linac was out of service then. Third, since several groups share use of the irradiator, the badge conceivably was found, in the irradiator room, by one of those people and returned in the inter-office mail system. Lastly, the employee never experienced any radiation related illnesses. The reported exposure of 317,791 millirem was removed from the employee's exposure history and replaced with a 20 millirem exposure (average monthly exposure for previous 12 months).
"No DOH on-site investigation was made or media attention was noted.
"What is the notification or reporting criteria involved? 10 CFR 20.2202 (a)(1) significant . After reviewing our incident files and the Handbook on Nuclear Material Event Reporting in the Agreement States , we determined that an immediate notification should have been sent to NRC. This did not occur; consequently we are now submitting this completed report, although late.
"Activity and Isotope(s) involved: 518 terabecquerels (1400 curies), cobalt 60.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) The initial notification indicated that one worker (employee) had been overexposed. The event did not involve a member of the public. The Landauer report indicated that an employee had received a whole-body exposure of 317,719 millirem of high-energy gamma radiation. No consequences will be realized since the exposure was later determined to only involve the dosimetry badge. The employee's exposure history was revised to indicate a 20 millirem exposure for that period of wear.
"Lost, Stolen or Damaged? (mfg., model, serial number) The employee's dosimetry badge was lost for a period of about one week.
"Disposition/recovery: Badges were to be used by placing them into a pouch for individuals using the irradiator devices.
"Leak test? N/A
"Vehicle: N/A
"Release of activity? None
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: J.L. Shepherd Model 285 irradiator.
"Exposure (intended/actual): consequences: Actual exposure received was estimated to be the usual, average amount of 20 millirem for that wear period.
"Was patient or responsible relative notified? N/A
"Was written report provided? Yes, from licensed RSO dated 21 July 2000.
"Was referring physician notified? N/A
"Consultant used? No"
Washington State Event Report # WA-00-023. |
| General Information or Other | Event Number: 40087 | Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOURCE PRODUCTION AND EQUIPMENT CO.
Region: 4
City: SAINT ROSE State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: JOHN MacKINNON | Notification Date: 08/19/2003
Notification Time: 14:23 [EST]
Event Date: 08/05/2003
Event Time: 12:00 [CDT]
Last Update Date: 08/19/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAIR SPITZBERG (R4)
JOHN HICKEY (NMSS)
| Event Text OVEREXPOSURE
Louisiana Radiation Protection Division received the following information on August 6, 2003 from Source Production and Equipment Co., located in Saint Rose.
On August 5, 2003 a Hot Cell operator discovered material on the floor that was reading a high radiation level. He believed the source was a form of contamination which he attempted to clean up with his hand and a swipe. It was later discovered the same day that the source was a iridium-192 wafer that had inadvertently been released from the Hot Cell (the caller said that it took them fours hours to find out how the wafer got out of the Hot Cell). The persons radiation badge was sent in for a reading on August 6, 2003. Whole Body dose to the person from the badge was 157 millirems. Hand exposure calculation is still being investigated but the exposure to his hand ranges from 20 Rem to 700 Rems. Two weeks after the incident the person hand does not show any clinical indication to exposure to a high dose of radiation (no reddening). This event is under investigation.
The size of the iridium-192 wafer is approx. 0.1 inches in diameter, 0.01 inches in thickness with a total activity of 7.6 curies.
NRC Region 4 was notified of this event by Louisiana Radiation Protection Division.
Called did not have the licensee's license number or the State of Louisiana event number. |
| General Information or Other | Event Number: 40088 | Rep Org: ILLINOIS DEPT OF NUCLEAR SAFETY
Licensee: RUSH NORTH MEDICAL CENTER
Region: 3
City: SKOKIE State: IL
County:
License #: IL-01578-01
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: JOHN MacKINNON | Notification Date: 08/19/2003
Notification Time: 18:44 [EST]
Event Date: 08/18/2003
Event Time: 11:00 [CDT]
Last Update Date: 08/19/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
THOMAS KOZAK (R3)
E. WILLIAM BRACH (NMSS)
| Event Text PATIENT EXCEEDED PRESCRIBED DOSE.
A patient was undergoing an intravascular brachytherapy procedure using a Novoste 40 mm. Sr-90 system with a prescribed dose of 23 gray. Due to difficulties retracting the source train to its shielded position, the exposure time was 5.09 minutes (one minute longer than the planned 4.09 minutes). Preliminary estimates indicate that the delivered dose exceeded the prescribed dose by approximately 25 percent. Novoste was notified and a Novoste representative went to the medical facility to investigate. The Novoste system will be sent to Novoste in Georgia for analysis. The licensee continues to investigate and refine the dose calculations and will submit the required written report as soon as possible.
Illinois assigned event number: IL030064. |
| Other Nuclear Material | Event Number: 40094 | Rep Org: RADIATION SAFETY ACCOCIATES, INC.
Licensee: P&G - CLAIROL, INC.
Region: 1
City: Stamford State: CT
County:
License #: 0611703-02
Agreement: N
Docket:
NRC Notified By: K. PAUL STEINMEYER
HQ OPS Officer: MIKE RIPLEY | Notification Date: 08/21/2003
Notification Time: 13:06 [EST]
Event Date: 07/31/2003
Event Time: [EDT]
Last Update Date: 08/21/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
| Person (Organization):
JOHN KINNEMAN (R1)
WILLIAM BRACH ()
| Event Text TWO NICKEL-63 SOURCES LOST
Radiation Safety Associates, a consultant for the licensee, reported that two detector cells for gas chromatography units containing 15 millicuries of nickel-63 were determined to be missing. The two sources are a Perkin Elmer Model # 6000204 (Serial # 1140) and an HP/Agilant Technologies Model # G2379A (Serial U0169). Radiation Safety Associates, Inc. was performing decommissioning activities for the licensee at its Stamford, CT, facilities. In performing an inventory of material in one area of the facility, they were unable to locate a cardboard box which supposedly contained the sources. The box had been set aside and marked "save" for disposal as radioactive waste. The consultant believes that the box was inadvertently disposed of as normal trash. Trash is picked up by Waste Management, Inc. at P&G-Clairol on a daily basis. Trash is then taken to the Bridgeport, CT incinerator where it is incinerated daily. |
| Power Reactor | Event Number: 40095 | Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: RICH LAURA | Notification Date: 08/22/2003
Notification Time: 04:05 [EST]
Event Date: 08/22/2003
Event Time: 02:59 [EDT]
Last Update Date: 08/22/2003 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
| Person (Organization):
JOHN KINNEMAN (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown | Event Text TURBINE TRIP CAUSES AUTOMATIC REACTOR SCRAM AT OYSTER CREEK
The licensee reported that an automatic reactor scram occurred at 0259 due to a turbine generator trip from a hi-hi moisture separator water level. One control rod indicated position 02; however, the remainder of the control rods indicated full in. All other systems and components functioned as designed. The licensee is cooling the plant down to cold shutdown.
The licensee notified the NRC Resident Inspector. | |