Event Notification Report for January 24, 2005

AGREEMENT STATE REPORT OF ADMINISTRATION OF RADIOACTIVE IODINE TO A PREGNANT PATIENT

The following information is a preliminary report provided to the Ohio Department of Health Bureau of Radiation Protection concerning a patient at the Riverside Methodist Hospital in Columbus, Ohio that was administered radioactive iodine while pregnant.

"It has been brought to our attention that a patient that had been treated for hyperthyroidism at our facility was in fact pregnant at the time of the administration. The patient had an uptake study performed on 11/2/04 (205 microcuries of I-123 sodium iodine) pursuant to a diagnosis of hyperthyroidism. The patient was administered 12.7 millicuries of I-131 sodium iodine on 11/16/04 as treatment. The patient was counseled by the Authorized User prior to the administration and received written consent from the patient that she was not or could not be pregnant at that time. A pregnancy test was not performed to confirm or deny this fact.

"The fact that the patient was pregnant was brought to our attention when she saw her family practice physician (who was the referring physician for the uptake and hyperthyroidism treatment procedures) for complaints of abdominal pain. A radiograph of the abdomen was taken and the pregnancy discovered. This occurred sometime within the past week. The fact that the patient was pregnant was relayed to the Authorized User, who, in conjunction with the referring physician, referred the patient to a prenatal specialist to determine the age of the fetus. The specialist determined the delivery date to be 4/25/05, which meant the age of the fetus at the time of the I-131 administration was 17 weeks. This determination was made on January 24, 2005, and the RSO's staff called the [Ohio Department of Health] to report the event after gathering information for a dosimetry study at approximately 10 AM, 25 January, 2005.

"The dosimetry estimate for the fetus was approximately 2.0432 rad to the whole fetus and 22,400 rad to the fetal thyroid from both the I-123 and I-131 administrations. It should be noted that the patient underwent a CT angiogram on 9/24/04 (fetal age 8 weeks), but that this dose and the abdominal x-ray taken last week were not added to the fetal whole body dose since specific technique factors were not available for these studies which were performed elsewhere.

"The patient will be notified of the treatment plan for the continuation of the pregnancy today or tomorrow, once the prenatal specialist receives the dosimetry estimate the RSO provided the Authorized User. The referring physician has been in close contact with the Authorized User throughout this process."

The Ohio Department of Health considers this an "Abnormal Occurrence" and will be conducting an investigation commencing this Friday (1/28/05).


Ohio Dept of Health Report # 2005-001

TWO CHEMICAL AGENT ALARMS DISCOVERED MISSING

During a routine inventory, performed every 6 months, it was discovered that two chemical agent alarms, M8A1, each containing 250 microCuries of Americium-241 were missing at Dover Air Force Base located in Delaware. US Air Force is looking for the missing chemical agent alarms.

FITNESS FOR DUTY REPORT

A non-licensed plant employee was determined to be under the influence of alcohol during a test conducted for cause. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

UNUSUAL EVENT DUE TO UNIDENTIFIED LEAKAGE GREATER THAN 10 GPM

The licensee reported that it had indications of unidentified reactor coolant leakage greater than 10 gpm which placed the licensee into an unusual event emergency action level (EAL). Indication of drywell sump level increase and pump out rate gave an approximate leak rate of 30 gpm. The licensee also indicated that drywell pressure was above the normal range. The unusual event declaration was made at 1610 EST.

At 1619 EST, the licensee manually scrammed the reactor. The scram was uncomplicated with all rods fully inserting and all systems functioning as required. Decay heat is being rejected to the main condenser. There has been no ECCS injection actuation and reactor water level is being maintained by feed pumps. The licensee has no significant safety related equipment out of service.

The licensee stated that there is no indication of further degradation of the leak rate and the source of the leak is still under investigation

The licensee has notified the NRC Resident Inspector along with State, Local, and other government agencies.

* * * UPDATE FROM LICENSEE (SKORBEK) TO NRC (HUFFMAN) AT 1640 EST ON 1/24/05 * * *

At 1640 EST, the licensee upgraded to an ALERT following additional leak rate calculations that indicated the leak rate was approximately 75 - 80 gpm based on drywell sump pump out rate. The licensee's EAL for an alert is RCS leakage greater than 50 gpm. The NRC entered the monitoring mode at 1653 EST. The licensee stated that there has been no increase in drywell radiation levels and that sump water chemistry analysis is in progress.

In addition to the normal government agencies notified, the NRC also notified the Canadian Nuclear Safety Commission Duty Officer (R. Chamberlaine).

* * * UPDATE FROM LICENSEE (VIA MANAGEMENT BRIEFING) AT 1930 EST ON 1/24/05 * * *

The licensee has indications that the leakage may not be reactor coolant leakage. Chemistry results show that the sump water radiation levels are at a level less than would be expected for RCS leakage. In addition, a secondary cooling system was found in a lineup configuration that could have masked leakage from the system. The licensee is waiting to get additional chemistry results on the presence of corrosion inhibitors in the sump water to provide additional confirmation that the leakage is not from the RCS.

* * * UPDATE FROM LICENSEE (VIA MANAGEMENT BRIEFING) AT 2200 EST ON 1/24/05 * * *

The licensee confirmed the presence of corrosion inhibitors in the drywell sump. In addition, based on manipulations of the Reactor Building Closed Cooling Water system and the Emergency Equipment Cooling Water system the licensee believes that the leakage is from the Reactor Building Closed Cooling Water system and not RCS leakage. The plant is stable and the licensee is continuing to cool down with pressure now at 180 psi and decreasing.

* * * UPDATE FROM THE LICENSEE (STROBEL) TO NRC (VIA R3 IRC BRIEFING) AT 22:30 EST ON 1/24/05 * * *

The licensee terminated its Alert and Unusual Event at 22:28 EST based on sump water chemistry, activity, and Reactor Building Closed Cooling Water System manipulations that indicate the leakage is secondary cooling water and not from the RCS. The NRC secured from the monitoring mode at 22:36 EST.

Notified DHS (Belt), FEMA (Caldwell), DOE (Dasilva), EPA (Baumgartner) USDA (Sykes), and HHS( Pyles). The Canadian Nuclear Safety Commission Duty Officer (R. Chamberlaine) was also notified.

REPORT OF LOST SEALED SOURCE

The Radiation Safety Officer (RSO) for the licensee reported that a 0.089 microcurie Co-60 sealed source (manufactured by Isotope Products Lab; serial # 1030152) was found missing during a quarterly inventory at the licensee's facility. The source is used for calibration of a well counter scintillation detector and is stored in a secure location at the facility. The source was last inventoried on 12/13/04 and was discovered missing during an inventory on 1/24/05. A search was conducted throughout the facility. The RSO stated that it is believed that the source is either misplaced or may have been inadvertently disposed of. New procedures for source usage and accountability are going to be implemented.

The RSO stated that the quantity of material is not reportable under 10 CFR Part 20 and the report is for information only.

The RSO has also notified NRC Region 1 (Beardsley)