Event Notification Report for April 08, 2005

TWO AMERICIUM-241 SOURCES BEING SHIPPED TO AUSTRALIA WERE REPORTED POTENTIALLY LOST

Report # MA050006

"AEA Technology QSA Inc is reporting a potentially lost radioactive material shipment. The shipment contains two Type A packages each containing a 1 Ci AmBe source US model number AMN. PE2. The source serial numbers are 1865NN and 1858NN.

"The sources were shipped from AEA Technology on 30 Mar 05 and were designated to leave on a flight to Australia on 2 Apr 05 with arrival scheduled on 5 Apr 2005. AEA was notified on 7 Apr 05 that the shipment had not arrived. The shipment was sent to Surtech Systems Pty Ltd, in Wangara Perth, WA 6055 Australia.

"Indication from the airline (Qantas) in New York (JFK) that the packages were on the plane, however the airline in Perth cannot confirm that [they] have the packages.

"Discussions with the carrier and freight forwarders indicate that they have so far been unsuccessful in locating the packages. A conference call is currently being arranged between all parties to try and locate the packages."

The sources were finally found today (04/12/04) at a Qantas airlines facility in Melbourne, Australia.

POTENTIAL MEDICAL EVENT INVOLVING A THERAPEUTIC ADMINISTRATION OF YTTRIUM-90

The licensee provided the following information via facsimile (licensee text in quotes):

"On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. [HFS 157.72 (1) (a) 1.]

"On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records.

"The licensee is investigating the incident. The ordering physician has been notified

"HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'.

"DHFS, RPS staff plan to investigate. "

MAIN STEAMLINE ISOLATION VALVES CLOSED ON VALID SIGNAL

The following information was provided by facsimile (licensee quotes in text):

"Valid actuation of main steam isolation valves that was not a part of pre-planned testing. Actuation was caused by going above pressurizer high pressure block (1955 psig) with steamline pressure less than 775 psig. Main steam isolation signal was reset. Main steam isolation valves reopened. No plant transient."

The NRC Resident Inspector will be notified.

AGREEMENT STATE REPORT OF POTENTIAL MEDICAL MISADMINISTRATION

The following information was provided by the State of CA via e-mail (text in quotes):

"At 12:35 pm [the] manager of the [Saddleback Memorial Hospital] Imaging Department contacted [the CA Radiological Health Branch] to report a therapy misadministration involving HDR and Ir-192. [The hospital manager] knew few details, other than to report that the source was apparently implanted 8 cm short of its desired location. At this time it is not known how much under treatment there was to the tumor site, nor how much exposure there was to healthy tissue. [It has] not been determined if this is a CA SS&D [Sealed Source and Device]. [The hospital manager] is obtaining this information and will be reporting it back, via fax, as soon as possible. [The CA Radiological Health Branch] has requested narrative as to flow of events.

"This form will be updated and forwarded to NRC Ops Center as information comes in."

OFFSITE NOTIFICATION OF WATER DISCHARGE CONTAINING HYDRAZINE

The following information was provided by facsimile (licensee quotes in text):

"The licensee made notification to the New Jersey Department of Environmental Protection of a discharge of approximately 5000 gallons of water containing 7 parts per million of hydrazine. [The discharge went] to the Delaware river, via the storm drain system. The water originated from a feedwater system clearance that had an isolation valve leak by. The discharge was terminated at the time of discovery.

"There were no personnel injuries as a result of this event."

The licensee has notified the NRC Resident Inspector.