Event Notification Report for January 28, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/27/2002 - 01/28/2002
General Information or Other
Event Number: 38727
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County: PROVIDENCE
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: GERRY WAIG
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County: PROVIDENCE
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: GERRY WAIG
Notification Date: 02/27/2002
Notification Time: 09:47 [ET]
Event Date: 01/28/2002
Event Time: 15:00 [EST]
Last Update Date: 02/27/2002
Notification Time: 09:47 [ET]
Event Date: 01/28/2002
Event Time: 15:00 [EST]
Last Update Date: 02/27/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES LINVILLE (R1)
JOHN HICKEY (NMSS)
JAMES LINVILLE (R1)
JOHN HICKEY (NMSS)
AGREEMENT STATE REPORT INVOLVING POSSIBLE MISADMINISTRATION
"Event description: Cordis Checkmate IVBT system was used to treat a coronary artery on 1/28/02. On 1/31/02 dosimetry and physicist records were being reviewed by licensee physics staff and it was discovered that the 'diameter' of the vessel was used in the calculation instead of the 'radius'. Agency was contacted by phone on 14 February 2002 to inform Agency of possible misadministration. At this time the actual increase in dose had not been determined. On 14 February 2002 the Agency was notified by FAX that, in fact, a misadministration had occurred. Estimated dose received by the outer portion of the coronary artery was 14.6 Gy rather than the intended 8 Gy. Patient and physician were notified."
"Event description: Cordis Checkmate IVBT system was used to treat a coronary artery on 1/28/02. On 1/31/02 dosimetry and physicist records were being reviewed by licensee physics staff and it was discovered that the 'diameter' of the vessel was used in the calculation instead of the 'radius'. Agency was contacted by phone on 14 February 2002 to inform Agency of possible misadministration. At this time the actual increase in dose had not been determined. On 14 February 2002 the Agency was notified by FAX that, in fact, a misadministration had occurred. Estimated dose received by the outer portion of the coronary artery was 14.6 Gy rather than the intended 8 Gy. Patient and physician were notified."
Power Reactor
Event Number: 38657
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: HOUFF
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: HOUFF
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 01/28/2002
Notification Time: 17:39 [ET]
Event Date: 01/28/2002
Event Time: 16:00 [EST]
Last Update Date: 01/28/2002
Notification Time: 17:39 [ET]
Event Date: 01/28/2002
Event Time: 16:00 [EST]
Last Update Date: 01/28/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CURTIS COWGILL (R1)
CURTIS COWGILL (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Decommissioned | 0 | Decommissioned |
OFFSITE NOTIFICATION OF AN OIL SPILL
A spill of approximately 40 gallons of turbine lube oil in the turbine hall occurred with no release to the environment. This amount was in excess of the reportable quantity of 10 gallons, so notification was made to the Connecticut Department of Environmental Protection of the spill. This incident occurred during a decommissioning activities in the turbine hall.
The NRC Resident Inspector was notified.
A spill of approximately 40 gallons of turbine lube oil in the turbine hall occurred with no release to the environment. This amount was in excess of the reportable quantity of 10 gallons, so notification was made to the Connecticut Department of Environmental Protection of the spill. This incident occurred during a decommissioning activities in the turbine hall.
The NRC Resident Inspector was notified.
Other Nuclear Material
Event Number: 38731
Rep Org: CANBERRA INDUSTRIES, INC.
Licensee: CANBERRA INDUSTRIES, INC.
Region: 1
City: WARRINGTON State: PA
County:
License #: 37-02401-01
Agreement: N
Docket:
NRC Notified By: TERRY SCHWAGER
HQ OPS Officer: MIKE NORRIS
Licensee: CANBERRA INDUSTRIES, INC.
Region: 1
City: WARRINGTON State: PA
County:
License #: 37-02401-01
Agreement: N
Docket:
NRC Notified By: TERRY SCHWAGER
HQ OPS Officer: MIKE NORRIS
Notification Date: 02/27/2002
Notification Time: 15:13 [ET]
Event Date: 01/28/2002
Event Time: 13:00 [EST]
Last Update Date: 02/27/2002
Notification Time: 15:13 [ET]
Event Date: 01/28/2002
Event Time: 13:00 [EST]
Last Update Date: 02/27/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES LINVILLE (R1)
DON COOL (NMSS)
JAMES LINVILLE (R1)
DON COOL (NMSS)
LOSS OF LICENSED NUCLEAR MATERIAL
On 1/28/02 at 1300, it was discovered that 13 Cl-36 sources were missing. The sources were 10 microcuries each and were manufactured on Nov 1995. The sources were 1 inch diameter, flat disc with mylar window, and assembled with an ion chamber instrument. Each source was individually packaged in a 2ft x 1ft x 1ft cardboard box. The assemblies were packaged for shipment on 1/28/02 and stored on a shelf prior to shipment. A clean up had been performed recently and it is believed by the Licensee, that these materials had been thrown into a waste dumpster for disposal.
There was no detectable radiation levels on the shipping container, and it is believed by the Licensee that there is no threat to the general population.
On 1/28/02 at 1300, it was discovered that 13 Cl-36 sources were missing. The sources were 10 microcuries each and were manufactured on Nov 1995. The sources were 1 inch diameter, flat disc with mylar window, and assembled with an ion chamber instrument. Each source was individually packaged in a 2ft x 1ft x 1ft cardboard box. The assemblies were packaged for shipment on 1/28/02 and stored on a shelf prior to shipment. A clean up had been performed recently and it is believed by the Licensee, that these materials had been thrown into a waste dumpster for disposal.
There was no detectable radiation levels on the shipping container, and it is believed by the Licensee that there is no threat to the general population.