Event Notification Report for May 11, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/10/2005 - 05/11/2005
Hospital
Event Number: 41693
Rep Org: SHORE MEMORIAL HOSPITAL
Licensee: SHORE MEMORIAL HOSPITAL
Region: 1
City: SOMMERS POINT State: NJ
County:
License #: 29-11642-01
Agreement: N
Docket:
NRC Notified By: JOHNATHAN LAW
HQ OPS Officer: JEFF ROTTON
Licensee: SHORE MEMORIAL HOSPITAL
Region: 1
City: SOMMERS POINT State: NJ
County:
License #: 29-11642-01
Agreement: N
Docket:
NRC Notified By: JOHNATHAN LAW
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/12/2005
Notification Time: 14:33 [ET]
Event Date: 05/11/2005
Event Time: 00:00 [EDT]
Last Update Date: 05/12/2005
Notification Time: 14:33 [ET]
Event Date: 05/11/2005
Event Time: 00:00 [EDT]
Last Update Date: 05/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN KINNEMAN (R1)
RICHARD CORREIA (NMSS)
JOHN KINNEMAN (R1)
RICHARD CORREIA (NMSS)
MEDICAL EVENT - ACTUAL DOSE GREATER THAN PRESCRIBED DOSE
On 05/11/05, a patient in the hospital was scheduled to receive an I-131 dose of 12 millicuries to the thyroid. Due to an error by the nuclear medical technician, a dose of 14.8 millicuries of I-131 was measured and delivered. There were two doses for different patients being measured in the lab at the time and the prescribing physician typically would write nuclear medicine directives with a range, such as 12-14 millicuries. In this specific instance, the physician wrote the directive for exactly 12 millicuries. The physician stated that there would be no unintended damage to the patient. The hospital RSO stated that the prescribing physician would be notifying the patient. The RSO intends to reinforce following proper lab procedures and exercising caution when working with multiple doses to all physicians and lab personnel.
On 05/11/05, a patient in the hospital was scheduled to receive an I-131 dose of 12 millicuries to the thyroid. Due to an error by the nuclear medical technician, a dose of 14.8 millicuries of I-131 was measured and delivered. There were two doses for different patients being measured in the lab at the time and the prescribing physician typically would write nuclear medicine directives with a range, such as 12-14 millicuries. In this specific instance, the physician wrote the directive for exactly 12 millicuries. The physician stated that there would be no unintended damage to the patient. The hospital RSO stated that the prescribing physician would be notifying the patient. The RSO intends to reinforce following proper lab procedures and exercising caution when working with multiple doses to all physicians and lab personnel.
Power Reactor
Event Number: 41688
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF BRADLEY
HQ OPS Officer: JOHN KNOKE
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF BRADLEY
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/11/2005
Notification Time: 02:22 [ET]
Event Date: 05/11/2005
Event Time: 01:35 [EDT]
Last Update Date: 05/11/2005
Notification Time: 02:22 [ET]
Event Date: 05/11/2005
Event Time: 01:35 [EDT]
Last Update Date: 05/11/2005
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):
JAMES MOORMAN (R2)
FRANK GILLESPIE (NRR)
MELVYN LEACH (IRD)
JAMES MOORMAN (R2)
FRANK GILLESPIE (NRR)
MELVYN LEACH (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
NON-WORK RELATED FATALITY AT ONSITE OFFICE AREA
" A contract QC welding inspector suffered an apparent heart attack in an office area around 00:09 on 05/11/05. The on-site emergency medical response team was dispatched to provide assistance. The individual was transported to a local hospital for treatment. The site was notified at 01:35 that the individual had not been revived. This is a non-work related fatality. The employee was not contaminated [and] OSHA will be notified."
The contract worker, who was employed by "The Atlantic Group", was taken to the Piedmont Medical Center in Rockville, SC for medical treatment.
The licensee will be notifying the NRC Resident Inspector, the Emergency Operations Center for the States of NC & SC, and the LLEA for Mecklenburg County.
" A contract QC welding inspector suffered an apparent heart attack in an office area around 00:09 on 05/11/05. The on-site emergency medical response team was dispatched to provide assistance. The individual was transported to a local hospital for treatment. The site was notified at 01:35 that the individual had not been revived. This is a non-work related fatality. The employee was not contaminated [and] OSHA will be notified."
The contract worker, who was employed by "The Atlantic Group", was taken to the Piedmont Medical Center in Rockville, SC for medical treatment.
The licensee will be notifying the NRC Resident Inspector, the Emergency Operations Center for the States of NC & SC, and the LLEA for Mecklenburg County.
General Information or Other
Event Number: 41695
Rep Org: COLORADO DEPT OF HEALTH
Licensee: MIDWEST INSPECTIONS
Region: 4
City: BRIGHTON State: CO
County:
License #: 902-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: PETE SNYDER
Licensee: MIDWEST INSPECTIONS
Region: 4
City: BRIGHTON State: CO
County:
License #: 902-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: PETE SNYDER
Notification Date: 05/12/2005
Notification Time: 17:23 [ET]
Event Date: 05/11/2005
Event Time: 00:00 [MDT]
Last Update Date: 06/16/2005
Notification Time: 17:23 [ET]
Event Date: 05/11/2005
Event Time: 00:00 [MDT]
Last Update Date: 06/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
THOMAS ESSIG (NMSS)
WILLIAM JONES (R4)
THOMAS ESSIG (NMSS)
AGREEMENT STATE - RADIOGRAPHY EQUIPMENT MALFUNCTION
The State provided the following information via facsimile:
"The Colorado Department of Public Health and Environment received notification on 5/12/05 of a radiography equipment malfunction resulting in a stuck radiography source.
"The radiography company, Midwest Inspections, located at 325 Walnut Street, Brighton, Colorado, with the Colorado license number 902-01, reported that a radiography crew was unable to retract a radiography source back into the shielded position while working at a temporary job site near Byers, Colorado on 5/11/05. Per the company's RSO, the crew secured the area and contacted him for assistance when they were unable to fully retract the source. He traveled to the site with shielding equipment and was able to free the source and return it to the shielded position. The cause of the problem is reported to be a dent in the guide tube under the 'bend restrictor' where it was not easily visible to the crew. The RSO reported no excessive exposures to the crew, the public or himself (he estimated an exposure of 50 millirem to himself). Initial corrective action was to remove the defective guide tube from service."
* * * UPDATE PROVIDED BY STROUD TO GOULD AT 1738 EDT ON 06/13/05 * * *
This update provides information that was originally contained in EN 41769 which has been deleted and provided as an update to the original report.
The State provided the following information via facsimile:
The exposure device involved was INC Model IR-100 s/n 4035 with a 38 curie Ir-192 source s/n G862. The RSO attempted to retract the source and encountered the same problem as the crew. The source assembly seemed to hang up as it entered the exit port of the camera. The RSO attached a 0-500 millirem pocket dosimeter to his wrist watch on his left hand to measure any exposure to the hands during the following process. He cranked the source into the collimator and placed (2) 25# lead shot bags over the collimator for shielding. Using a pair of 12 inch channel lock pliers, he disconnected the source tube from the collimator. Keeping the source assembly in the collimator and shot bag shielding, he exposed the drive cable and source pigtail connector. After disconnecting the source pigtail connector and drive cable, he disconnected the exit port end of the source tube from the camera and slid the source tube off of the drive cable. The source tube was replaced with a new one and reconnected to the source assembly. The RSO then retracted the source into the camera. The crew x-rayed the remaining welds while RSO remained on site. The RSO's total whole body exposure was 50 millirem and the dosimeter on his wrist indicated an exposure of 220 millirem. Inspection of the source tube showed a kinked area next to the exit port fitting which apparently would not allow the locking ball on the pigtail assembly to pass back through it.
Notified R4DO (Whitten) and NMSSEO (Holahan)
The State provided the following information via facsimile:
"The Colorado Department of Public Health and Environment received notification on 5/12/05 of a radiography equipment malfunction resulting in a stuck radiography source.
"The radiography company, Midwest Inspections, located at 325 Walnut Street, Brighton, Colorado, with the Colorado license number 902-01, reported that a radiography crew was unable to retract a radiography source back into the shielded position while working at a temporary job site near Byers, Colorado on 5/11/05. Per the company's RSO, the crew secured the area and contacted him for assistance when they were unable to fully retract the source. He traveled to the site with shielding equipment and was able to free the source and return it to the shielded position. The cause of the problem is reported to be a dent in the guide tube under the 'bend restrictor' where it was not easily visible to the crew. The RSO reported no excessive exposures to the crew, the public or himself (he estimated an exposure of 50 millirem to himself). Initial corrective action was to remove the defective guide tube from service."
* * * UPDATE PROVIDED BY STROUD TO GOULD AT 1738 EDT ON 06/13/05 * * *
This update provides information that was originally contained in EN 41769 which has been deleted and provided as an update to the original report.
The State provided the following information via facsimile:
The exposure device involved was INC Model IR-100 s/n 4035 with a 38 curie Ir-192 source s/n G862. The RSO attempted to retract the source and encountered the same problem as the crew. The source assembly seemed to hang up as it entered the exit port of the camera. The RSO attached a 0-500 millirem pocket dosimeter to his wrist watch on his left hand to measure any exposure to the hands during the following process. He cranked the source into the collimator and placed (2) 25# lead shot bags over the collimator for shielding. Using a pair of 12 inch channel lock pliers, he disconnected the source tube from the collimator. Keeping the source assembly in the collimator and shot bag shielding, he exposed the drive cable and source pigtail connector. After disconnecting the source pigtail connector and drive cable, he disconnected the exit port end of the source tube from the camera and slid the source tube off of the drive cable. The source tube was replaced with a new one and reconnected to the source assembly. The RSO then retracted the source into the camera. The crew x-rayed the remaining welds while RSO remained on site. The RSO's total whole body exposure was 50 millirem and the dosimeter on his wrist indicated an exposure of 220 millirem. Inspection of the source tube showed a kinked area next to the exit port fitting which apparently would not allow the locking ball on the pigtail assembly to pass back through it.
Notified R4DO (Whitten) and NMSSEO (Holahan)