Event Notification Report for August 27, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/26/2003 - 08/27/2003
EVENT NUMBERS
4010940116401074012040128
Fuel Cycle Facility
Event Number: 40109
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: STEVEN SHAGGS
HQ OPS Officer: JOHN MacKINNON
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: STEVEN SHAGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/27/2003
Notification Time: 22:53 [ET]
Event Date: 08/27/2003
Event Time: 09:00 [CDT]
Last Update Date: 08/27/2003
Notification Time: 22:53 [ET]
Event Date: 08/27/2003
Event Time: 09:00 [CDT]
Last Update Date: 08/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRIS MILLER (R3)
MELVYN LEACH (NMSS)
CHRIS MILLER (R3)
MELVYN LEACH (NMSS)
PROCEDURAL DEFICIENCY OMISSION
NRC BULLETIN 91-01 24 HOUR NOTIFICATION
At 0900 on 8/27/03, it was discovered that the procedure for operation of the C-409 Uranium Precipitation System did not adequately address flowdown requirements specified in NCSA 409-001. NCSA 409-001 control 3.2.39 prevents introduction of organic material to the precipitation system by requiring verification that the solution originated from either the C-710 Laboratory, the C-409 Cylinder Wash, or the C-409 Uranium Precipitation System and that the solution does not contain organic material, as indicated by sampling. The control had been flowed down for solutions originating from the C-710 Laboratory and the C-409 Cylinder Wash, however was not flowed down for solutions originating from the C-409 Uranium Precipitating System.
PGDP Assessment and Tracking Report No. ATR 03-2767, PGDP Event Report No. PAD-2003-017.
SAFETY SIGNIFICANCE OF EVENTS:
Double contingency was not maintained because the independent verification of the origination of solutions from the C-409 Uranium Precipitation System and the independent verification that the solution did not contain organic material had not been performed. However, no oil has been introduced to the operation.
POTENTIAL CRITICALITY PATHWAYS INVOLVED OF HOW CRITICALITY COULD OCCUR:
In order for a criticality to be possible, greater than a safe mass of uranium must be accumulated within the Uranium Precipitation System, facilitated by the presence of organic material and accumulate in the rotary drum filter.
CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.)
Double contingency is maintained by implementing two controls on mass.
ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL:
This system has a process limit of (xx) wt.% U235.
NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OF DEFICIENCIES:
The first leg of double contingency is based on controlling the mass of uranium in the tanks. NCSA 409-001 requires that prior to placing solution in the Uranium Precipitation Operation the solution must be verified to be uranium salvage from C-710 laboratory, C-409 cylinder wash, or the C-409 Uranium Precipitation System and that the solution does not contain organic material. This control prevents the build-up of organic material at the top of the Uranium Precipitation System tanks. If organic material were to get in the tanks it would create a floating uranium/oil layer and result in non-representative sampling of the concentration, since sampling is conducted near the bottom of the tank. This may lead to an unsafe mass reaching the rotary drum filter. The C-710 solution currently in the system was independently verified to be free of organic material prior to initial introduction. However, since no verification was documented for the C-409 Uranium Precipitation system solution, this control was lost. Chemical Operations personnel have subsequently verified that no events have occurred to introduce organic material into the solution from the C-409 Uranium Precipitation System. The control was violated; however the parameter was maintained.
The second leg of double contingency is based on mass. NCSA 409-001 requires that prior to placing solution in the Uranium Precipitation Operation, the solution be independently verified to be uranium salvage from C-710 Laboratory, C-409 Cylinder Wash or the C-409 Uranium Precipitation System and that the solution does not contain organic material. However, since no independent verification was documented for the C-409 Uranium Precipitation system solution, this control was lost. Chemical Operations personnel have subsequently independently verified that no events have occurred to introduce organic material into the solution from the C-409 Uranium Precipitation System. Therefore, this control was violated. Since there are two controls on one parameter, double contingency was not maintained.
Since double contingency is based on two controls on one parameter, and the controls were violated, double contingency was not maintained.
CORRECTIVE ACTIONS TO REESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
Chemical Operations revise procedure CP4-CU-CH2137 to include verification requirements specified in NCSA 409-001. Procedure change was initiated on 8-27-03.
The NRC Senior Resident Inspector has been notified of this event by the licensee.
NRC BULLETIN 91-01 24 HOUR NOTIFICATION
At 0900 on 8/27/03, it was discovered that the procedure for operation of the C-409 Uranium Precipitation System did not adequately address flowdown requirements specified in NCSA 409-001. NCSA 409-001 control 3.2.39 prevents introduction of organic material to the precipitation system by requiring verification that the solution originated from either the C-710 Laboratory, the C-409 Cylinder Wash, or the C-409 Uranium Precipitation System and that the solution does not contain organic material, as indicated by sampling. The control had been flowed down for solutions originating from the C-710 Laboratory and the C-409 Cylinder Wash, however was not flowed down for solutions originating from the C-409 Uranium Precipitating System.
PGDP Assessment and Tracking Report No. ATR 03-2767, PGDP Event Report No. PAD-2003-017.
SAFETY SIGNIFICANCE OF EVENTS:
Double contingency was not maintained because the independent verification of the origination of solutions from the C-409 Uranium Precipitation System and the independent verification that the solution did not contain organic material had not been performed. However, no oil has been introduced to the operation.
POTENTIAL CRITICALITY PATHWAYS INVOLVED OF HOW CRITICALITY COULD OCCUR:
In order for a criticality to be possible, greater than a safe mass of uranium must be accumulated within the Uranium Precipitation System, facilitated by the presence of organic material and accumulate in the rotary drum filter.
CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.)
Double contingency is maintained by implementing two controls on mass.
ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL:
This system has a process limit of (xx) wt.% U235.
NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OF DEFICIENCIES:
The first leg of double contingency is based on controlling the mass of uranium in the tanks. NCSA 409-001 requires that prior to placing solution in the Uranium Precipitation Operation the solution must be verified to be uranium salvage from C-710 laboratory, C-409 cylinder wash, or the C-409 Uranium Precipitation System and that the solution does not contain organic material. This control prevents the build-up of organic material at the top of the Uranium Precipitation System tanks. If organic material were to get in the tanks it would create a floating uranium/oil layer and result in non-representative sampling of the concentration, since sampling is conducted near the bottom of the tank. This may lead to an unsafe mass reaching the rotary drum filter. The C-710 solution currently in the system was independently verified to be free of organic material prior to initial introduction. However, since no verification was documented for the C-409 Uranium Precipitation system solution, this control was lost. Chemical Operations personnel have subsequently verified that no events have occurred to introduce organic material into the solution from the C-409 Uranium Precipitation System. The control was violated; however the parameter was maintained.
The second leg of double contingency is based on mass. NCSA 409-001 requires that prior to placing solution in the Uranium Precipitation Operation, the solution be independently verified to be uranium salvage from C-710 Laboratory, C-409 Cylinder Wash or the C-409 Uranium Precipitation System and that the solution does not contain organic material. However, since no independent verification was documented for the C-409 Uranium Precipitation system solution, this control was lost. Chemical Operations personnel have subsequently independently verified that no events have occurred to introduce organic material into the solution from the C-409 Uranium Precipitation System. Therefore, this control was violated. Since there are two controls on one parameter, double contingency was not maintained.
Since double contingency is based on two controls on one parameter, and the controls were violated, double contingency was not maintained.
CORRECTIVE ACTIONS TO REESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
Chemical Operations revise procedure CP4-CU-CH2137 to include verification requirements specified in NCSA 409-001. Procedure change was initiated on 8-27-03.
The NRC Senior Resident Inspector has been notified of this event by the licensee.
General Information or Other
Event Number: 40116
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: MOUNTAIN ENTERPRISES
Region: 2
City: LEXINGTON State: KY
County:
License #: 201-447-51
Agreement: Y
Docket:
NRC Notified By: RICK HORKY
HQ OPS Officer: STEVE SANDIN
Licensee: MOUNTAIN ENTERPRISES
Region: 2
City: LEXINGTON State: KY
County:
License #: 201-447-51
Agreement: Y
Docket:
NRC Notified By: RICK HORKY
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/29/2003
Notification Time: 14:00 [ET]
Event Date: 08/27/2003
Event Time: 09:15 [CDT]
Last Update Date: 08/29/2003
Notification Time: 14:00 [ET]
Event Date: 08/27/2003
Event Time: 09:15 [CDT]
Last Update Date: 08/29/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CAROLYN EVANS (R2)
FRED BROWN (NMSS)
CAROLYN EVANS (R2)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT INVOLVING A STOLEN/RECOVERED TROXLER GAUGE
"At approximately 9:15 A.M. [on 08/27/03], [ ] the Area Manager of Ashland, KY called and advised [ ], RSO, that [ ] had his truck stolen with a Troxler 3440 gauge (s/n 14782) in it. He also indicated that the Ashland Police Department had been notified along with all other local police departments. Mountain Enterprises offered a $1000 reward for the return of the gauge, and also provided two employees to assist in the search for the gauge. At 1:30 P.M. the Ashland Police Department called and said that they found the truck in a yard at 2513 Newman St. The gauge was still locked in the bed of the truck and the case was still locked with the source locked in place. A survey was performed that showed the source to still be inside. The police said that another vehicle was stolen a block away so the indication is that the truck and gauge were stolen for the transportation and not for the gauge. The gauge will no longer be stored overnight anywhere but at the plant."
KY Item Number: KY030003. This event is closed by the State.
"At approximately 9:15 A.M. [on 08/27/03], [ ] the Area Manager of Ashland, KY called and advised [ ], RSO, that [ ] had his truck stolen with a Troxler 3440 gauge (s/n 14782) in it. He also indicated that the Ashland Police Department had been notified along with all other local police departments. Mountain Enterprises offered a $1000 reward for the return of the gauge, and also provided two employees to assist in the search for the gauge. At 1:30 P.M. the Ashland Police Department called and said that they found the truck in a yard at 2513 Newman St. The gauge was still locked in the bed of the truck and the case was still locked with the source locked in place. A survey was performed that showed the source to still be inside. The police said that another vehicle was stolen a block away so the indication is that the truck and gauge were stolen for the transportation and not for the gauge. The gauge will no longer be stored overnight anywhere but at the plant."
KY Item Number: KY030003. This event is closed by the State.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 40107
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE NEVELOS
HQ OPS Officer: JOHN MacKINNON
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE NEVELOS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/27/2003
Notification Time: 15:22 [ET]
Event Date: 08/27/2003
Event Time: 09:24 [EDT]
Last Update Date: 10/22/2003
Notification Time: 15:22 [ET]
Event Date: 08/27/2003
Event Time: 09:24 [EDT]
Last Update Date: 10/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES TRAPP (R1)
JAMES TRAPP (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROL ROOM ACCESS DOOR LATCH WAS DETERMIEND TO BE NOT FULLY ENGAGING.
At 09:24 am on 08/27/03, a Control Room access door latch was determined to be not fully engaging. The door and latch provide the following functions:
maintain the integrity of the Control Room boundary which is a design feature to maintain Control Room habitability following a design bases accident, and
provide a security barrier to restrict access into the Control Rom complex to only those personnel with preapproved security clearance.
With the latch not engaged, the door was not capable of performing these functions. The appropriate security contingencies were implemented, requiring posting of a Security Force Member at the door controlling access to the Control Room Complex. Technical Specification (TS) 3.0.3 was entered due to the inability of either Control Room ventilation system to maintain Control Room habitability, as required by TS 3.7.2.
At 10:20, the door latch was replaced to re-establish the integrity of the Control Room habitability boundary and TS 3.0.3 was exited. The ability of the latch to properly operate for access and egress was not established; access through the affected door remained restricted until repairs can be completed (there are additional doors to the Control Room that remain fully functional).
At 14:00, the door was again impaired for repair of the door latch. Full functionality of the door was restored at 14:41.
The NRC Resident Inspector was notified of this event by the licensee.
* * * RETRACTION AT 1143 EDT ON 10/22/03 FROM A. BRAEDY TO E. THOMAS * * *
"At the time of the original notification the ability to maintain Control Room habitability, as required by TS 3.7.2 was not assured. Subsequent evaluation has determined that if a postulated accident had occurred during the time that the door latch was impaired, control room dose would be less than the acceptance criteria specified in 10CFR50.67 and Regulatory Guide 1.183 and bounded by our current analysis. The site boundary doses were never affected. The dose impact of the condition as it existed would be bounded by the current analysis. Thus, the safety function would have been fulfilled."
Notified R1DO (L. Doerflein)
At 09:24 am on 08/27/03, a Control Room access door latch was determined to be not fully engaging. The door and latch provide the following functions:
maintain the integrity of the Control Room boundary which is a design feature to maintain Control Room habitability following a design bases accident, and
provide a security barrier to restrict access into the Control Rom complex to only those personnel with preapproved security clearance.
With the latch not engaged, the door was not capable of performing these functions. The appropriate security contingencies were implemented, requiring posting of a Security Force Member at the door controlling access to the Control Room Complex. Technical Specification (TS) 3.0.3 was entered due to the inability of either Control Room ventilation system to maintain Control Room habitability, as required by TS 3.7.2.
At 10:20, the door latch was replaced to re-establish the integrity of the Control Room habitability boundary and TS 3.0.3 was exited. The ability of the latch to properly operate for access and egress was not established; access through the affected door remained restricted until repairs can be completed (there are additional doors to the Control Room that remain fully functional).
At 14:00, the door was again impaired for repair of the door latch. Full functionality of the door was restored at 14:41.
The NRC Resident Inspector was notified of this event by the licensee.
* * * RETRACTION AT 1143 EDT ON 10/22/03 FROM A. BRAEDY TO E. THOMAS * * *
"At the time of the original notification the ability to maintain Control Room habitability, as required by TS 3.7.2 was not assured. Subsequent evaluation has determined that if a postulated accident had occurred during the time that the door latch was impaired, control room dose would be less than the acceptance criteria specified in 10CFR50.67 and Regulatory Guide 1.183 and bounded by our current analysis. The site boundary doses were never affected. The dose impact of the condition as it existed would be bounded by the current analysis. Thus, the safety function would have been fulfilled."
Notified R1DO (L. Doerflein)
General Information or Other
Event Number: 40120
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CORNERSTONE GEOTECHNICAL INC.
Region: 4
City: WOODINVILLE State: WA
County:
License #: WN-I0529-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: NATHAN SANFILIPPO
Licensee: CORNERSTONE GEOTECHNICAL INC.
Region: 4
City: WOODINVILLE State: WA
County:
License #: WN-I0529-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 08/29/2003
Notification Time: 17:52 [ET]
Event Date: 08/27/2003
Event Time: 00:00 [PDT]
Last Update Date: 08/29/2003
Notification Time: 17:52 [ET]
Event Date: 08/27/2003
Event Time: 00:00 [PDT]
Last Update Date: 08/29/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL RUNYAN (R4)
MELVYN LEACH (NMSS)
MICHAEL RUNYAN (R4)
MELVYN LEACH (NMSS)
AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE
"Subject: Event Report # WA-03-034
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention) The license's representative, [...], reported that sometime between the evening of 27 August and the morning of 28 August that a Troxler, Model 3411B, moisture density gauge, Serial Number 13050, was stolen out of the trunk of the operator's transport vehicle parked outside the operator's residence in Everett, Washington. A police report was filed on 29 August and a reward posted.
"The operator violated several DOH requirements that contributed to the theft to the device. DOH requires that portable gauge licensees prohibit operators from taking gauges to residences if the work site is within 50 miles of the primary storage location. The gauges must be returned to that location. This didn't happen. Also DOH requires two independent layers of protection to keep the transport box, with secured gauge inside, secured to the vehicle. The licensee had not been using the two-layer method. And, gauges are not allowed to remain in the transport vehicle overnight as did happen. The licensee will be cited for at least 3 violations as a result of the event.
"A full report provided by the licensee, should be in the office, by the week of 1 September. This report will be updated after that. No media attention noted at present. Corrective actions will be discussed with the licensee.
"What is the notification or reporting criteria involved? 24-hour
"Activity and Isotope(s) involved: 370 megaBq (10 millicuries) Cesium 137 and 1850 megaBq (50 millicuries) Americium 241/Beryllium.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) N/A
"Lost, Stolen or Damaged? STOLEN (mfg., model, serial number) noted above
"Disposition/recovery: pending
"Leak test? Unknown
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) Unknown
"Release of activity? N/A
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A
"Consultant used? N/A
"Subject: Event Report # WA-03-034
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention) The license's representative, [...], reported that sometime between the evening of 27 August and the morning of 28 August that a Troxler, Model 3411B, moisture density gauge, Serial Number 13050, was stolen out of the trunk of the operator's transport vehicle parked outside the operator's residence in Everett, Washington. A police report was filed on 29 August and a reward posted.
"The operator violated several DOH requirements that contributed to the theft to the device. DOH requires that portable gauge licensees prohibit operators from taking gauges to residences if the work site is within 50 miles of the primary storage location. The gauges must be returned to that location. This didn't happen. Also DOH requires two independent layers of protection to keep the transport box, with secured gauge inside, secured to the vehicle. The licensee had not been using the two-layer method. And, gauges are not allowed to remain in the transport vehicle overnight as did happen. The licensee will be cited for at least 3 violations as a result of the event.
"A full report provided by the licensee, should be in the office, by the week of 1 September. This report will be updated after that. No media attention noted at present. Corrective actions will be discussed with the licensee.
"What is the notification or reporting criteria involved? 24-hour
"Activity and Isotope(s) involved: 370 megaBq (10 millicuries) Cesium 137 and 1850 megaBq (50 millicuries) Americium 241/Beryllium.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) N/A
"Lost, Stolen or Damaged? STOLEN (mfg., model, serial number) noted above
"Disposition/recovery: pending
"Leak test? Unknown
"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) Unknown
"Release of activity? N/A
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A
"Consultant used? N/A
General Information or Other
Event Number: 40128
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: TOBEY HOSPITAL
Region: 1
City: WAREHAM State: MA
County:
License #: 44-0034
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: NATHAN SANFILIPPO
Licensee: TOBEY HOSPITAL
Region: 1
City: WAREHAM State: MA
County:
License #: 44-0034
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 09/03/2003
Notification Time: 15:11 [ET]
Event Date: 08/27/2003
Event Time: 11:30 [EDT]
Last Update Date: 09/03/2003
Notification Time: 15:11 [ET]
Event Date: 08/27/2003
Event Time: 11:30 [EDT]
Last Update Date: 09/03/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAMELA HENDERSON (R1)
TOM ESSIG (NMSS)
PAMELA HENDERSON (R1)
TOM ESSIG (NMSS)
MASSACHUSETTS AGREEMENT STATE REPORT -- CONTAMINATED DELIVERY
Upon receiving a package (small gray suitcase) of bulk Techneticum-99m (75 millicuries), a technician at Tobey Hospital detected high surface contamination readings on the case. The case was not open and showed no damage. Hospital staff isolated the case until the shipper could arrive.
The shipper, Mallinckrodt, arrived at the hospital and performed their own tests on the package. There were two "hot spots" detected: one 3.5 to 4.0 millirem/hr on contact on the plastic auxiliary pouch, and one 0.3 to 0.4 millirem/hr on the side of the suitcase. Upon opening the package, a survey of the Tc-99m pig and inside foam showed almost no contamination.
The driver of the delivery truck and the vehicle were immediately surveyed and showed no detectable activity. Surveys of the hospital lab and the lab where the suitcase was packed both showed no evidence of contamination. At this time, it is uncertain as to where the contamination originated. The package has been isolated and will be allowed to decay to background before the case is returned to service.
Upon receiving a package (small gray suitcase) of bulk Techneticum-99m (75 millicuries), a technician at Tobey Hospital detected high surface contamination readings on the case. The case was not open and showed no damage. Hospital staff isolated the case until the shipper could arrive.
The shipper, Mallinckrodt, arrived at the hospital and performed their own tests on the package. There were two "hot spots" detected: one 3.5 to 4.0 millirem/hr on contact on the plastic auxiliary pouch, and one 0.3 to 0.4 millirem/hr on the side of the suitcase. Upon opening the package, a survey of the Tc-99m pig and inside foam showed almost no contamination.
The driver of the delivery truck and the vehicle were immediately surveyed and showed no detectable activity. Surveys of the hospital lab and the lab where the suitcase was packed both showed no evidence of contamination. At this time, it is uncertain as to where the contamination originated. The package has been isolated and will be allowed to decay to background before the case is returned to service.