Event Notification Report for February 20, 2003

LOW LEVEL RADWASTE INCINERATOR FIRE EVENT AT FRAMATOME

"At approximately 0630 hrs. a cardboard waste box, containing about 9.75 grams of U-235, was being fed into the low level rad waste incinerator. The box entered into the feed box area of the incinerator and the outer door closed, however the inner door, separating the feed box from the incinerator, only partially opened and prevented the waste box from being fed into the incinerator. The waste box caught fire in the feed box area which resulted in damage to the primary HEPA filter and associated pre-filter for the feed box and incinerator shroud (located just above and directly downstream of the feed box area). The final HEPA filters remained undamaged. The ventilation duct upstream of the final HEPA filters is equipped with a fire deluge system, which remained unactivated indicating the temperature seen by the final filters was below the deluge system activation temperature (less than 180 degrees F). The fire self-extinguished when the inner door was fully closed and the waste box and contents were consumed. There was no unusual release of radioactive material from the facility as demonstrated by stack air sample results and samples taken from the roof and surroundings. The two employees in the facility were checked and no detectable contamination, and only minimal (less than .1 DAC hrs.) exposure occurred. An Incident Investigation Board (IIB) has been convened. The equipment is currently shutdown and will remain down until the IIB report is complete and appropriate corrective actions are completed."

ERDS OUT OF SERVICE FOR PLANNED OUTAGE AT FERMI 2

"The safety parameter display system (SPDS) is being removed from service to perform planned upgrades to the system. The removal of the SPDS affects the transmission of data for the emergency response data system (ERDS). The SPDS will be deactivated at approximately 1800 hours on February 20, 2003, and will not be returned to service until the end of April 2003. During this period, the primary plant indicators that supply the SPDS, in conjunction with the other indication and communication systems available to the plant operations staff will be used for emergency response if needed. This condition is reportable in accordance with 10CFR50.72(b)(3)(xiii). The Senior Resident Inspector, appropriate Region III and NRR Staff members, have been briefed on this modification."

The NRC Resident Inspector was notified.

NON-WORK RELATED DEATH OF PLANT EMPLOYEE

"On 2-20-03 at 1530 hours, the Occupational safety and Health Administration (OSHA) was notified of a non-occupational related employee death. The reporting requirement, 29 CFR 1904.39(b)(5), specifically requires employers to notify OSHA when an employee death occurs within thirty (30) days of a heart attack which occurred on plant premises. This is not classified as a work related event.

"This is being reported in accordance with UE2-RA-RE1030 'Nuclear Regulatory Event Reporting,' notification made to another government agency."

This worker had two previous heart attacks. He complained to co-workers of chest pains during a break on 2/17/03. On his way to the site medical facility, he began to feel chest pains and was taken to the local hospital. He died on the morning of 2/20/03 of heart failure.

CALIFORNIA AGREEMENT STATE REPORT FOR MEDICAL EVENT AT UNIVERSITY OF CALIFORNIA

"I took a call on a therapeutic misadministration from the RSO for UCIMC (LN 0278-30). The incident involved the administration (via injection) of Y-90 microspheres (25 microns) for the treatment of unresectable hepatic carcinoma. The intended dosage was 96.2 millicuries, and the administered dosage was approximately 38.48 millicuries (i.e., an underdose of 60%).

"The delivery system consists of an injection system, connected to the vial containing the microspheres, which has one line leading to a receiving vial, and another to the patient. The direction of the flow is determined by position of the valve connecting these two lines. Just beyond the vial containing the microspheres there are also two mounted detectors (like small pocket chambers), which give a visual indication when the microspheres begin moving out of the vial.

"The physicist was priming the system prior to a scheduled treatment. When the priming reaches the point that the microspheres begin to exit the vial, the valve is turned to direct the flow from the "receiving vial" to the patient. In this case, the physicist accidentally over-primed the system and about 60% of the activity washed in the receiving vial. The physician, an authorized user, was also present during the treatment. They completed this treatment, and the physician is still reviewing whether it is necessary to perform another treatment to reach the prescribed dosage, or whether this treatment will be adequate as it stands.

"The licensee is awaiting a report from the physician and physicist as to what might have caused this to occur. At the present time, they think it may simply be that the physicist did not respond quickly enough to the indication on the detectors that activity was passing out of the isotope vial. That is, it may simply be a slow reflex problem. The manufacturer happened to be on site at the time of the incident, and indicated there had been two similar previous events (one allegedly at a hospital in PA), but no further details on the events were obtained by the licensee."

CALIFORNIA AGREEMENT STATE REPORT FOR MEDICAL EVENT AT ALTA BATES MEDICAL CENTER

"Received a call today at about 1430 hours from [ ] who is one of Alta Bate's medical physicists (therapy department), to report a therapeutic misadministration involving I-125. The regular RSO is on leave. The patient was prescribed 0.35 millicuries I-125 for a brachytherapy procedure (prostate implant; involving 80+ seeds) on 2/19/03, but received 0.52 millicuries, or an estimated 50% overdosage, because the calculation [was] done incorrectly."