Event Notification Report for April 20, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/19/2004 - 04/20/2004
EVENT NUMBERS
4098740688406894070742696
General Information or Other
Event Number: 40987
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TULANE UNIVERSITY
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0004-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MIKE RIPLEY
Licensee: TULANE UNIVERSITY
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0004-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/26/2004
Notification Time: 15:20 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/26/2004
Notification Time: 15:20 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
SANDRA WASTLER (NMSS)
WILLIAM JOHNSON (R4)
SANDRA WASTLER (NMSS)
AGREEMENT STATE REPORT - INCORRECT MEDICAL TREATMENT SITE
The following information was received via facsimile:
"The incident occurred on April 20, 2004 at the Tulane Cancer Center. The patient was being treated for cervical cancer. The Nucletron Source Position Simulator had previously been repaired by the service technician by providing a replacement screw. During measurement of correct catheter position with the device, the simulator cable became stuck resulting in underestimation of the required distance. This erroneous number was entered into the Nucletron HDR unit. The 9050 milliCurie source of Ir-192 did not extend to the desired location but remained outside the patient for approximately 2 minutes at 2.6 centimeters from the skin. The dose estimate for this was 270 R. The patient was notified and the treatment plan modified. As of July 21, 2004 there is no effect on the patient. To prevent reoccurrence the procedure was modified to test for looseness in the Source Position Simulator prior to use."
Louisiana Report # LA040007
The following information was received via facsimile:
"The incident occurred on April 20, 2004 at the Tulane Cancer Center. The patient was being treated for cervical cancer. The Nucletron Source Position Simulator had previously been repaired by the service technician by providing a replacement screw. During measurement of correct catheter position with the device, the simulator cable became stuck resulting in underestimation of the required distance. This erroneous number was entered into the Nucletron HDR unit. The 9050 milliCurie source of Ir-192 did not extend to the desired location but remained outside the patient for approximately 2 minutes at 2.6 centimeters from the skin. The dose estimate for this was 270 R. The patient was notified and the treatment plan modified. As of July 21, 2004 there is no effect on the patient. To prevent reoccurrence the procedure was modified to test for looseness in the Source Position Simulator prior to use."
Louisiana Report # LA040007
Power Reactor
Event Number: 40688
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [] []
RX Type: [2] W-3-LP
NRC Notified By: CHUCK BAUCOM
HQ OPS Officer: BILL GOTT
Region: 2 State: SC
Unit: [2] [] []
RX Type: [2] W-3-LP
NRC Notified By: CHUCK BAUCOM
HQ OPS Officer: BILL GOTT
Notification Date: 04/20/2004
Notification Time: 13:56 [ET]
Event Date: 04/20/2004
Event Time: 13:10 [EDT]
Last Update Date: 04/20/2004
Notification Time: 13:56 [ET]
Event Date: 04/20/2004
Event Time: 13:10 [EDT]
Last Update Date: 04/20/2004
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):
CAUDLE JULIAN (R2)
HO NIEH (IRO)
BOB DENNIG (NRR)
CAUDLE JULIAN (R2)
HO NIEH (IRO)
BOB DENNIG (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
OFFSITE NOTIFICATION - NON-WORK RELATED FATALITY
On April 20, 2004, a non-work related fatality occurred at H. B. Robinson. At 0730 EDT, a Progress Energy employee assigned to the main turbine maintenance crew for the current maintenance outage that began on April 20, suffered a condition that required immediate medical attention. Medical assistance was provided by onsite plant employees trained as first responders. The employee was transported by ambulance to a nearby medical facility where additional medical treatment was rendered. At 1310, site personnel were notified that attempts to revive the employee were not successful and that the employee had died. The employee was working in a non-radiological controlled area of the plant and no radioactive material or contamination was involved. Notification of the South Carolina Occupational Safety and Health Agency is planned.
The Licensee notified the NRC Resident Inspector.
On April 20, 2004, a non-work related fatality occurred at H. B. Robinson. At 0730 EDT, a Progress Energy employee assigned to the main turbine maintenance crew for the current maintenance outage that began on April 20, suffered a condition that required immediate medical attention. Medical assistance was provided by onsite plant employees trained as first responders. The employee was transported by ambulance to a nearby medical facility where additional medical treatment was rendered. At 1310, site personnel were notified that attempts to revive the employee were not successful and that the employee had died. The employee was working in a non-radiological controlled area of the plant and no radioactive material or contamination was involved. Notification of the South Carolina Occupational Safety and Health Agency is planned.
The Licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 40689
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF KNISLEY
HQ OPS Officer: JEFF ROTTON
Region: 4 State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF KNISLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/20/2004
Notification Time: 23:26 [ET]
Event Date: 04/20/2004
Event Time: 18:10 [PDT]
Last Update Date: 04/20/2004
Notification Time: 23:26 [ET]
Event Date: 04/20/2004
Event Time: 18:10 [PDT]
Last Update Date: 04/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RUSSELL BYWATER (R4)
RUSSELL BYWATER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
DEGRADED CONDITION - GREATER THAN ONE PERCENT OF STEAM GENERATOR TUBES DEFECTIVE
"On April 08, 2004, during the Unit 1 twelfth refueling outage (1R12), analysis of eddy current data on [Steam Generator] SG 1-4 indicated that greater than one percent of the total tubes inspected in SG 1-4 were defective. Ninety-two (92) defective tubes in SG 1-4 were detected and are being plugged. Most of the [pluggable] indications are due to circumferential primary water stress corrosion cracking in the Rows 5 to 8 U-bend region. Results of the SG tube inspection fall into Category C-3, which requires a four-hour non-emergency report in accordance with Technical Specification (TS) Table 5.5.9-2 and 10 CFR 50.72(b)(3)(ii) (an 8-hour requirement replacing the former (b)(2)(iii)(C), 4-hour requirement). [This was reported in EN#40659 dated 04/08/04.]
"An NRC teleconference in accordance with TS 5.6.10.d to report the results of the voltage-based repair criteria implemented for the tube support plate intersections was conducted on Wednesday April 14, 2004, at 1300 EDT.
"On April 20, 2004, following completion of SG eddy current testing, PG&E identified SG 1-1 had greater than one percent of the total tubes that were defective. Forty (40) defective tubes in SG 1-1 were detected and plugged. Most of the [pluggable] indications are due to outside diameter stress corrosion cracking at the SG tube to support plate intersections. SG 1-2 had twenty-six (26) and SG 1-3 had twenty-seven (27) defective tubes that required plugging.
"A Special Report in accordance with TS 5.6.10.a and e will be submitted prior to returning Unit 1 to power operation.
"A Licensee Event Report in accordance with 10 CFR 50.73(a)(2)(v)(C) will be submitted within 60 days."
The Licensee notified the NRC Resident Inspector.
"On April 08, 2004, during the Unit 1 twelfth refueling outage (1R12), analysis of eddy current data on [Steam Generator] SG 1-4 indicated that greater than one percent of the total tubes inspected in SG 1-4 were defective. Ninety-two (92) defective tubes in SG 1-4 were detected and are being plugged. Most of the [pluggable] indications are due to circumferential primary water stress corrosion cracking in the Rows 5 to 8 U-bend region. Results of the SG tube inspection fall into Category C-3, which requires a four-hour non-emergency report in accordance with Technical Specification (TS) Table 5.5.9-2 and 10 CFR 50.72(b)(3)(ii) (an 8-hour requirement replacing the former (b)(2)(iii)(C), 4-hour requirement). [This was reported in EN#40659 dated 04/08/04.]
"An NRC teleconference in accordance with TS 5.6.10.d to report the results of the voltage-based repair criteria implemented for the tube support plate intersections was conducted on Wednesday April 14, 2004, at 1300 EDT.
"On April 20, 2004, following completion of SG eddy current testing, PG&E identified SG 1-1 had greater than one percent of the total tubes that were defective. Forty (40) defective tubes in SG 1-1 were detected and plugged. Most of the [pluggable] indications are due to outside diameter stress corrosion cracking at the SG tube to support plate intersections. SG 1-2 had twenty-six (26) and SG 1-3 had twenty-seven (27) defective tubes that required plugging.
"A Special Report in accordance with TS 5.6.10.a and e will be submitted prior to returning Unit 1 to power operation.
"A Licensee Event Report in accordance with 10 CFR 50.73(a)(2)(v)(C) will be submitted within 60 days."
The Licensee notified the NRC Resident Inspector.
Hospital
Event Number: 40707
Rep Org: US DEPT OF VETERANS AFFAIRS
Licensee: VA MEDICAL CENTER
Region: 1
City: BIRMINGHAM State: AL
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: MICHAEL SIMMONS
HQ OPS Officer: ARLON COSTA
Licensee: VA MEDICAL CENTER
Region: 1
City: BIRMINGHAM State: AL
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: MICHAEL SIMMONS
HQ OPS Officer: ARLON COSTA
Notification Date: 04/27/2004
Notification Time: 13:20 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [CDT]
Last Update Date: 04/27/2004
Notification Time: 13:20 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [CDT]
Last Update Date: 04/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
RICHARD BARKLEY (R1)
BRUCE BURGESS (R3)
FRED BROWN (NMSS)
RICHARD BARKLEY (R1)
BRUCE BURGESS (R3)
FRED BROWN (NMSS)
DOSE TO AN EMBRYO/FETUS
On April 20, 2004, a female patient was administered 6 microcuries of I-131 sodium iodide orally and on April 21, 2004, 12 millicuries of Tc-99m (Tc04). An investigation was undertaken after it was determined that the patient was pregnant. The duration of gestation was estimated as 10 weeks +/- 1 week.
The dose to the embryo/fetus occurred on April 20-21, 2004, and it was discovered on April 26, 2004. Outside experts estimated that, if the thyroid were functioning, the fetus received a dose of 6.6 rem, and if the thyroid were not functioning, a dose of 0.5 to 1 rem.
The permittee has implemented initial corrective actions to prevent a recurrence of the circumstances that resulted in the dose to the embryo/fetus. The permittee is aware of the requirements for notifying the patient and the referring physician.
The Department of Veterans Affairs will evaluate the circumstances related to this incident and will submit a written report to NRC, Region III, within 15 days.
On April 20, 2004, a female patient was administered 6 microcuries of I-131 sodium iodide orally and on April 21, 2004, 12 millicuries of Tc-99m (Tc04). An investigation was undertaken after it was determined that the patient was pregnant. The duration of gestation was estimated as 10 weeks +/- 1 week.
The dose to the embryo/fetus occurred on April 20-21, 2004, and it was discovered on April 26, 2004. Outside experts estimated that, if the thyroid were functioning, the fetus received a dose of 6.6 rem, and if the thyroid were not functioning, a dose of 0.5 to 1 rem.
The permittee has implemented initial corrective actions to prevent a recurrence of the circumstances that resulted in the dose to the embryo/fetus. The permittee is aware of the requirements for notifying the patient and the referring physician.
The Department of Veterans Affairs will evaluate the circumstances related to this incident and will submit a written report to NRC, Region III, within 15 days.
General Information or Other
Event Number: 42696
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BERKSHIRE MEDICAL CENTER
Region: 1
City: PITTSFIELD State: MA
County:
License #: 60-0005
Agreement: Y
Docket:
NRC Notified By: M. WHALEN
HQ OPS Officer: BILL GOTT
Licensee: BERKSHIRE MEDICAL CENTER
Region: 1
City: PITTSFIELD State: MA
County:
License #: 60-0005
Agreement: Y
Docket:
NRC Notified By: M. WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 07/10/2006
Notification Time: 09:30 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2006
Notification Time: 09:30 [ET]
Event Date: 04/20/2004
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GLENN MEYER (R1)
GREG MORELL (NMSS)
Email to ILTAB
GLENN MEYER (R1)
GREG MORELL (NMSS)
Email to ILTAB
AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The licensee provided the following information via email:
"As a result of a recent routine inspection, the licensee made report on June 12, 2006, of a lost/missing Pd-103 brachytherapy seed originally containing 3.39 millicuries of Pd-103 on April 20, 2004 and discovered lost/missing on the same date (April 20, 2004)
"The seed was never found and was believed to have been disposed of as non-radioactive trash within a cartridge on April 20, 2004. The Pd-103 contained in the seed has a short half-life of 17 days.
"A nurse handling the cartridge with one remaining seed in the operating room likely disposed of the cartridge and seed into non-radioactive trash. The licensee concluded that such disposal of the single seed contained in the cartridge would not generate any noticeable radiation exposure to the general public.
"The licensee provided additional training to nurses who handle cartridges in the operating room."
Report number 06-6414
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
The licensee provided the following information via email:
"As a result of a recent routine inspection, the licensee made report on June 12, 2006, of a lost/missing Pd-103 brachytherapy seed originally containing 3.39 millicuries of Pd-103 on April 20, 2004 and discovered lost/missing on the same date (April 20, 2004)
"The seed was never found and was believed to have been disposed of as non-radioactive trash within a cartridge on April 20, 2004. The Pd-103 contained in the seed has a short half-life of 17 days.
"A nurse handling the cartridge with one remaining seed in the operating room likely disposed of the cartridge and seed into non-radioactive trash. The licensee concluded that such disposal of the single seed contained in the cartridge would not generate any noticeable radiation exposure to the general public.
"The licensee provided additional training to nurses who handle cartridges in the operating room."
Report number 06-6414
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.