Event Notification Report for April 16, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/15/2002 - 04/16/2002
Other Nuclear Material
Event Number: 38857
Rep Org: NORTHERN ENGRAVING
Licensee: NORTHERN ENGRAVING
Region: 3
City: GALEVILLE State: WI
County:
License #:
Agreement: N
Docket:
NRC Notified By: RANDY NEDRELO
HQ OPS Officer: LEIGH TROCINE
Licensee: NORTHERN ENGRAVING
Region: 3
City: GALEVILLE State: WI
County:
License #:
Agreement: N
Docket:
NRC Notified By: RANDY NEDRELO
HQ OPS Officer: LEIGH TROCINE
Notification Date: 04/16/2002
Notification Time: 16:33 [ET]
Event Date: 04/16/2002
Event Time: 15:00 [CDT]
Last Update Date: 04/16/2002
Notification Time: 16:33 [ET]
Event Date: 04/16/2002
Event Time: 15:00 [CDT]
Last Update Date: 04/16/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN MADERA (R3)
DON COOL (NMSS)
JOHN MADERA (R3)
DON COOL (NMSS)
DISCOVERY THAT AN AMERICIUM-241 SOURCE WAS MISSING FROM NORTHERN ENGINEERING IN GALEVILLE, WISCONSIN
At approximately 1500 CDT, the licensee discovered that an americium-241 source with an activity of about 11 millicuries was missing from the Galeville facility. It had previously been used as a static eliminator. Apparently, the licensee discontinued use of these static eliminators some time ago. Two had been returned to the supplier (NRD), one was found in an unusual location, and one was unaccounted.
The licensee stated that the corporate office was located in Sparta, Wisconsin.
The licensee notified the NRC Region 3 office (Mike Lafranzo).
(Call the NRC operations officer for a licensee contact telephone number.)
At approximately 1500 CDT, the licensee discovered that an americium-241 source with an activity of about 11 millicuries was missing from the Galeville facility. It had previously been used as a static eliminator. Apparently, the licensee discontinued use of these static eliminators some time ago. Two had been returned to the supplier (NRD), one was found in an unusual location, and one was unaccounted.
The licensee stated that the corporate office was located in Sparta, Wisconsin.
The licensee notified the NRC Region 3 office (Mike Lafranzo).
(Call the NRC operations officer for a licensee contact telephone number.)
Fuel Cycle Facility
Event Number: 38858
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: LEIGH TROCINE
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: LEIGH TROCINE
Notification Date: 04/16/2002
Notification Time: 22:10 [ET]
Event Date: 04/16/2002
Event Time: 13:55 [EDT]
Last Update Date: 04/16/2002
Notification Time: 22:10 [ET]
Event Date: 04/16/2002
Event Time: 13:55 [EDT]
Last Update Date: 04/16/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN MADERA (R3)
M. WAYNE HODGES (NMSS)
JOHN MADERA (R3)
M. WAYNE HODGES (NMSS)
NRC BULLETIN 91-01 RESPONSE - CRITICALITY CONTROL 24-HOUR REPORT
The following text is a portion of a facsimile received from the Portsmouth personnel:
"On 04/16/02, [a Recirculating Cooling Water (RCW)]/FREON status walkdown was performed to ensure compliance with the Nuclear Criticality Safety (NCS) controls of NCSA-0333_015A06. During the walkdown, it was found that the R-114 level on cell 33-6-9 Even and the East 'A' Booster could not be seen on the [sight] glass. The RCW supply block valves were found to be open."
"NCSA-0333_015.A06 requires that: 'The liquid R-114 level on shutdown cells shall be monitored weekly unless the R-114 is drained. If the R-114 level is not visible on the level indicator for the coolant system, the RCW supply block valve shall be closed.' "
"Since the R-114 was not visible on the [sight] glasses and the RCW supply block valves were open, the NCSA control was violated."
"SAFETY SIGNIFICANCE OF EVENTS: The safety significant of this event is low. The equipment involved contains less than a safe mass of material, and for water to get to material contained in the process side of the equipment, the condenser tubes must leak (filling the coolant system with water up to the level of the cooler tubes), and the cooler tubes must leak allowing the water to enter the process side of the equipment. The pressure of the coolant system for Cell 33-6-9 Even is approximately 8 psig, and the pressure of the East 'A' Booster coolant is greater than 30 psig. Therefore, neither the condenser nor the cooler tubes appear to be leaking."
"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR): For a criticality to occur, water must leak across the coolant system (i.e., both the condenser and cooler heat exchange tubes must be breached) and into the process side of the equipment. Once on the process side of the equipment, the water has to cause material to relocate and accumulate such that the resulting mixture contains more than a critical mass."
"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): The controlled parameters in the event are Mass and Moderation."
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE OF CRITICAL MASS): The enrichment on cell 33-6-9 Even is 1.431 wt. percent 235U, the enrichment on East 'A' Booster is 1.763 wt. percent 235U, and there is no equipment in the X-333 facility that has a greater than safe mass deposit. The safe mass of uranium at 2 wt. percent is 341.6 pounds."
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The RCW supply block valve was not closed."
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: Required actions were initiated for an NCS Anomalous Condition. Under the direction of NCS personnel, the RCW supply block valves were closed, thus regaining compliance with the NCSA."
Portsmouth personnel notified the NRC resident inspector and plan to notify the Department of Energy site representatives.
The following text is a portion of a facsimile received from the Portsmouth personnel:
"On 04/16/02, [a Recirculating Cooling Water (RCW)]/FREON status walkdown was performed to ensure compliance with the Nuclear Criticality Safety (NCS) controls of NCSA-0333_015A06. During the walkdown, it was found that the R-114 level on cell 33-6-9 Even and the East 'A' Booster could not be seen on the [sight] glass. The RCW supply block valves were found to be open."
"NCSA-0333_015.A06 requires that: 'The liquid R-114 level on shutdown cells shall be monitored weekly unless the R-114 is drained. If the R-114 level is not visible on the level indicator for the coolant system, the RCW supply block valve shall be closed.' "
"Since the R-114 was not visible on the [sight] glasses and the RCW supply block valves were open, the NCSA control was violated."
"SAFETY SIGNIFICANCE OF EVENTS: The safety significant of this event is low. The equipment involved contains less than a safe mass of material, and for water to get to material contained in the process side of the equipment, the condenser tubes must leak (filling the coolant system with water up to the level of the cooler tubes), and the cooler tubes must leak allowing the water to enter the process side of the equipment. The pressure of the coolant system for Cell 33-6-9 Even is approximately 8 psig, and the pressure of the East 'A' Booster coolant is greater than 30 psig. Therefore, neither the condenser nor the cooler tubes appear to be leaking."
"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR): For a criticality to occur, water must leak across the coolant system (i.e., both the condenser and cooler heat exchange tubes must be breached) and into the process side of the equipment. Once on the process side of the equipment, the water has to cause material to relocate and accumulate such that the resulting mixture contains more than a critical mass."
"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): The controlled parameters in the event are Mass and Moderation."
"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE OF CRITICAL MASS): The enrichment on cell 33-6-9 Even is 1.431 wt. percent 235U, the enrichment on East 'A' Booster is 1.763 wt. percent 235U, and there is no equipment in the X-333 facility that has a greater than safe mass deposit. The safe mass of uranium at 2 wt. percent is 341.6 pounds."
"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The RCW supply block valve was not closed."
"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: Required actions were initiated for an NCS Anomalous Condition. Under the direction of NCS personnel, the RCW supply block valves were closed, thus regaining compliance with the NCSA."
Portsmouth personnel notified the NRC resident inspector and plan to notify the Department of Energy site representatives.
General Information or Other
Event Number: 39913
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH HOSPITAL AND MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: ARLON COSTA
Licensee: SWEDISH HOSPITAL AND MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: ARLON COSTA
Notification Date: 06/10/2003
Notification Time: 15:40 [ET]
Event Date: 04/16/2002
Event Time: 00:00 [PDT]
Last Update Date: 06/10/2003
Notification Time: 15:40 [ET]
Event Date: 04/16/2002
Event Time: 00:00 [PDT]
Last Update Date: 06/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID GRAVES (R4)
DOUG BROADDUS (NMSS)
DAVID GRAVES (R4)
DOUG BROADDUS (NMSS)
AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISADMINISTRATION
The following agreement state report was received by the NRC Operations Center via email:
"This is notification of an event in Washington State as reported to the Washington Department of Health, Division of Radiation Protection.
"STATUS: new and closed
"Licensee: Swedish Hospital and Medical Center
"City and State: Seattle, Washington
"License Number: WN-M008-1
"Type of license: Broad B (medium broad)
"Date of event: 16 April 2002 (the department was notified on 16 May 2003 after the licensee performed a standard QA case review. The licensee submitted a full report of the incident, dated 29 May 2003).
"Location of Event: 747 Summit Avenue, Seattle, Washington
"ABSTRACT: An error occurred due to incorrect determination of treatment time. Treatments are planned by use of a graph. This treatment called for a 3.0 mm vessel. When the graph was used to determine treatment time, a time for using a larger vessel was incorrectly selected. This resulted in an extended treatment causing a 25% overexposure to the patient.
"When licensee staff discovered the error, the treatment protocol was changed to require two qualified people to independently verify that the treatment/dwell time has been correctly established. This changed was made as a result of their case review procedure.
"There was no media coverage. A Departmental investigation was not performed due to the length of time between incident and notification, and that the licensee had performed a self-imposed corrective action. The department will follow-up during routine visits to ensure that the licensee is operating per the new protocol.
"What is the notification or reporting criteria involved? Misadministration
"Activity and Isotope(s) involved: 53.5 mCi (maximum), Strontium-90/Yttrium-90 as sealed sources.
"Overexposures? The patient was the only person overexposed. There was no overexposure to any member of the treatment team, staff, or general public.
"Lost, Stolen or Damaged? Not Applicable
"Disposition/recovery: Treatment procedures were amended to require written review of the intended treatment by both Radiation Oncologist and Radiological Physicist.
"Leak test: 21 February 2002, by the manufacturer.
"Vehicle: Not Applicable
"Release of activity? None
"Activity intended: Not Applicable
"Misadministered activity received: Not Applicable
"Device: Novoste Beta-Cath, source train # 484/00.
"Exposure: (intended/actual); 18.4 Gy/23 Gy
"Consequences: Licensee now uses protocol that requires two people who independently verify the correct vessel size, dwell time, and intended dose. The excess exposure is not expected to produce any undesirable effects.
"Was patient or responsible relative notified? Yes
"Was written report provided? Yes
"Was referring physician notified? Yes
"Consultant used? No
The following agreement state report was received by the NRC Operations Center via email:
"This is notification of an event in Washington State as reported to the Washington Department of Health, Division of Radiation Protection.
"STATUS: new and closed
"Licensee: Swedish Hospital and Medical Center
"City and State: Seattle, Washington
"License Number: WN-M008-1
"Type of license: Broad B (medium broad)
"Date of event: 16 April 2002 (the department was notified on 16 May 2003 after the licensee performed a standard QA case review. The licensee submitted a full report of the incident, dated 29 May 2003).
"Location of Event: 747 Summit Avenue, Seattle, Washington
"ABSTRACT: An error occurred due to incorrect determination of treatment time. Treatments are planned by use of a graph. This treatment called for a 3.0 mm vessel. When the graph was used to determine treatment time, a time for using a larger vessel was incorrectly selected. This resulted in an extended treatment causing a 25% overexposure to the patient.
"When licensee staff discovered the error, the treatment protocol was changed to require two qualified people to independently verify that the treatment/dwell time has been correctly established. This changed was made as a result of their case review procedure.
"There was no media coverage. A Departmental investigation was not performed due to the length of time between incident and notification, and that the licensee had performed a self-imposed corrective action. The department will follow-up during routine visits to ensure that the licensee is operating per the new protocol.
"What is the notification or reporting criteria involved? Misadministration
"Activity and Isotope(s) involved: 53.5 mCi (maximum), Strontium-90/Yttrium-90 as sealed sources.
"Overexposures? The patient was the only person overexposed. There was no overexposure to any member of the treatment team, staff, or general public.
"Lost, Stolen or Damaged? Not Applicable
"Disposition/recovery: Treatment procedures were amended to require written review of the intended treatment by both Radiation Oncologist and Radiological Physicist.
"Leak test: 21 February 2002, by the manufacturer.
"Vehicle: Not Applicable
"Release of activity? None
"Activity intended: Not Applicable
"Misadministered activity received: Not Applicable
"Device: Novoste Beta-Cath, source train # 484/00.
"Exposure: (intended/actual); 18.4 Gy/23 Gy
"Consequences: Licensee now uses protocol that requires two people who independently verify the correct vessel size, dwell time, and intended dose. The excess exposure is not expected to produce any undesirable effects.
"Was patient or responsible relative notified? Yes
"Was written report provided? Yes
"Was referring physician notified? Yes
"Consultant used? No