Event Notification Report for September 01, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/31/2006 - 09/01/2006
Power Reactor
Event Number: 42824
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: JASON KOZAL
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: JASON KOZAL
Notification Date: 09/01/2006
Notification Time: 12:01 [ET]
Event Date: 09/01/2006
Event Time: 11:15 [EDT]
Last Update Date: 09/01/2006
Notification Time: 12:01 [ET]
Event Date: 09/01/2006
Event Time: 11:15 [EDT]
Last Update Date: 09/01/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
JAMES DWYER (R1)
CINDY FLANNERY (NMSS)
JAMES DWYER (R1)
CINDY FLANNERY (NMSS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
SHIPMENT EXERNAL RADIATION LEVELS IN EXCESS OF LIMITS
"At 1115 EDT on 9/01/2006, Susquehanna LLC personnel became aware that a shipment received from another site exceeded the 10CFR71.47(b)(2) limit of 200 mr/hr contact dose rate. Contact dose rates on the bottom of the shipment are 820 mr/hr, and therefore reportable per the requirements of 10CFR20.1906(d)(2).
"There is no identified surface contamination on the shipment, and the shipment only exceeded the dose rate limit on the bottom once it was lifted off the transport trailer. Doses under the trailer prior to lifting the shipment did not exceed the limit"
"The transport company and the originating site have been notified. The transport vehicle left the Vermont Yankee facility on 8/31/06 and was received by SSES on 9/1/06 at 0805." . . . The driver has been contacted by the transport company.
"The vehicle made two stops during transport. The first was at the first rest stop traveling west on the Massachusetts Turnpike. The second was at the first rest stop on I-87 south after exiting I-90. No one to the knowledge of the driver came in contact with the shipment. The driver arrived at Susquehanna on 8/31/06 at 2045, and slept in the truck. The driver was wearing dosimetry [TLD]."
The licensee will notify State of Pennsylvania Emergency Management and has notified the NRC Resident Inspector.
"At 1115 EDT on 9/01/2006, Susquehanna LLC personnel became aware that a shipment received from another site exceeded the 10CFR71.47(b)(2) limit of 200 mr/hr contact dose rate. Contact dose rates on the bottom of the shipment are 820 mr/hr, and therefore reportable per the requirements of 10CFR20.1906(d)(2).
"There is no identified surface contamination on the shipment, and the shipment only exceeded the dose rate limit on the bottom once it was lifted off the transport trailer. Doses under the trailer prior to lifting the shipment did not exceed the limit"
"The transport company and the originating site have been notified. The transport vehicle left the Vermont Yankee facility on 8/31/06 and was received by SSES on 9/1/06 at 0805." . . . The driver has been contacted by the transport company.
"The vehicle made two stops during transport. The first was at the first rest stop traveling west on the Massachusetts Turnpike. The second was at the first rest stop on I-87 south after exiting I-90. No one to the knowledge of the driver came in contact with the shipment. The driver arrived at Susquehanna on 8/31/06 at 2045, and slept in the truck. The driver was wearing dosimetry [TLD]."
The licensee will notify State of Pennsylvania Emergency Management and has notified the NRC Resident Inspector.
Hospital
Event Number: 42863
Rep Org: HERITAGE VALLEY HEALTH SYSTEM
Licensee: HERITAGE VALLEY HEALTH SYSTEM
Region: 1
City: SEWICKLEY State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: JOHN MacKINNON
Licensee: HERITAGE VALLEY HEALTH SYSTEM
Region: 1
City: SEWICKLEY State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/26/2006
Notification Time: 16:14 [ET]
Event Date: 09/01/2006
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2006
Notification Time: 16:14 [ET]
Event Date: 09/01/2006
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2006
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):
CHRIS HOTT (R1)
ELMO COLLINS (NMSS)
CHRIS HOTT (R1)
ELMO COLLINS (NMSS)
MEDICAL EVENT - ONLY ONE CAPSULE OF A TWO CAPSULE DOSE ADMINISTERED
"On 9/1/06 at Sewickley Valley Hospital, a technician removed a vial of I-131 therapy capsules and measured the dose in the dose calibrator to ensure that the dose measured the expected amount of 100 millicuries. The dose was administered to the patient by emptying the contents of the vial into the patient's hand. Only one of the I-131 capsules came out of the vial instead of two. The vial was placed back into the shipping container
and returned to the pharmacy.
"On 9/26/06, the pharmacy notified Sewickley Valley Hospital's RSO that the technicians at SVH had returned one of the two capsules to the pharmacy. The notification occurred during the RSO's investigation into a separate medical event that had occurred on 9/21/06 under similar circumstances. The pharmacy had discovered the second capsule on 9/11/06 but there are no records of the pharmacy contacting the hospital about it. The pharmacist who would have made the call is on vacation and not available for questioning until next week.
"One of the two capsules had apparently remained in the vial during the administration to the patient. The RSO reported that the dose to the patient was approximately 35 millicuries instead of the 100 millicurie prescribed dose. The hospital has already contacted the referring physician and plans on contacting the patient to make arrangements to administer the rest of the prescribed dose. The hospital will also institute changes in their procedures requiring the vial to be visually inspected and checked in the dose calibrator following use to prevent this from happening in the future."
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
* * * UPDATE FROM LICENSEE (PERNA) TO HUFFMAN AT 11:17 EDT ON 9/27/06 * * *
The licensee provided an e-mail edit to the original event report to correct some inaccuracies in the information originally reported to the NRC. R1DO (Hott) and NMSS (Wastler) notified.
* * * UPDATE FROM CYNTHIA FLANNERY (NRC) TO GERRY WAIG ON 9/27/06 AT 1532 * * *
Then NRC Medical Radiation Safety reviewed this event and determined it to be a reportable medical event.
"On 9/1/06 at Sewickley Valley Hospital, a technician removed a vial of I-131 therapy capsules and measured the dose in the dose calibrator to ensure that the dose measured the expected amount of 100 millicuries. The dose was administered to the patient by emptying the contents of the vial into the patient's hand. Only one of the I-131 capsules came out of the vial instead of two. The vial was placed back into the shipping container
and returned to the pharmacy.
"On 9/26/06, the pharmacy notified Sewickley Valley Hospital's RSO that the technicians at SVH had returned one of the two capsules to the pharmacy. The notification occurred during the RSO's investigation into a separate medical event that had occurred on 9/21/06 under similar circumstances. The pharmacy had discovered the second capsule on 9/11/06 but there are no records of the pharmacy contacting the hospital about it. The pharmacist who would have made the call is on vacation and not available for questioning until next week.
"One of the two capsules had apparently remained in the vial during the administration to the patient. The RSO reported that the dose to the patient was approximately 35 millicuries instead of the 100 millicurie prescribed dose. The hospital has already contacted the referring physician and plans on contacting the patient to make arrangements to administer the rest of the prescribed dose. The hospital will also institute changes in their procedures requiring the vial to be visually inspected and checked in the dose calibrator following use to prevent this from happening in the future."
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
* * * UPDATE FROM LICENSEE (PERNA) TO HUFFMAN AT 11:17 EDT ON 9/27/06 * * *
The licensee provided an e-mail edit to the original event report to correct some inaccuracies in the information originally reported to the NRC. R1DO (Hott) and NMSS (Wastler) notified.
* * * UPDATE FROM CYNTHIA FLANNERY (NRC) TO GERRY WAIG ON 9/27/06 AT 1532 * * *
Then NRC Medical Radiation Safety reviewed this event and determined it to be a reportable medical event.