Event Notification Report for February 14, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/13/2007 - 02/14/2007
Power Reactor
Event Number: 43165
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: AL DEES
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: AL DEES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/14/2007
Notification Time: 13:27 [ET]
Event Date: 02/14/2007
Event Time: 10:05 [EST]
Last Update Date: 02/14/2007
Notification Time: 13:27 [ET]
Event Date: 02/14/2007
Event Time: 10:05 [EST]
Last Update Date: 02/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
PAUL FREDRICKSON (R2)
PAUL FREDRICKSON (R2)
| 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 | N | 0 | Refueling | 0 | Refueling |
FITNESS FOR DUTY - SUPERVISOR CONFIRMED POSTIVE FOR ALCOHOL
An employee supervisor had a confirmed positive for alcohol during a for cause fitness-for-duty test. The employee's access to the plant has been revoked. A work review is in progress. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
An employee supervisor had a confirmed positive for alcohol during a for cause fitness-for-duty test. The employee's access to the plant has been revoked. A work review is in progress. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other
Event Number: 43201
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2007
Notification Time: 12:07 [ET]
Event Date: 02/14/2007
Event Time: 00:00 [CST]
Last Update Date: 03/13/2007
Notification Time: 12:07 [ET]
Event Date: 02/14/2007
Event Time: 00:00 [CST]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DALE POWERS (R4)
GREG MORELL (FSME)
DALE POWERS (R4)
GREG MORELL (FSME)
AGREEMENT STATE REPORT - DISPENSING ERROR FOR THALLIUM -201 DOSE
The following information was provided by the state via facsimile:
"Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity.
"An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay.
"Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded.
"Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct."
LA Event Report ID No.: LA070003
* * * UPDATE AT 0915 EDT ON 3/13/07 FROM RICHARD PENROD TO S. SANDIN * * *
The State of Louisiana is retracting this report following a review which concluded that their reporting criteria was not met. Notified R4DO (Shannon) and FSME (Morell).
The following information was provided by the state via facsimile:
"Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity.
"An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay.
"Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded.
"Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct."
LA Event Report ID No.: LA070003
* * * UPDATE AT 0915 EDT ON 3/13/07 FROM RICHARD PENROD TO S. SANDIN * * *
The State of Louisiana is retracting this report following a review which concluded that their reporting criteria was not met. Notified R4DO (Shannon) and FSME (Morell).
Hospital
Event Number: 43299
Rep Org: US DEPARTMENT OF VETERANS AFFAIRS
Licensee: US DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: AMARILLO State: TX
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Licensee: US DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: AMARILLO State: TX
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/11/2007
Notification Time: 20:03 [ET]
Event Date: 02/14/2007
Event Time: 11:10 [CDT]
Last Update Date: 04/25/2007
Notification Time: 20:03 [ET]
Event Date: 02/14/2007
Event Time: 11:10 [CDT]
Last Update Date: 04/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
SONIA BURGESS (R3)
ABY MOHSENI (FSME)
THOMAS FARNHOLTZ (R4)
SONIA BURGESS (R3)
ABY MOHSENI (FSME)
THOMAS FARNHOLTZ (R4)
TRANSPORTATION PACKAGE SURFACE EXCEEDING SURFACE CONTAMINATION LIMITS
"Pursuant to 10 CFR 20.1906, a receipt wipe test of a package of radioactive material indicated that removable radioactive contamination of the package surface exceeded the limits in 10 CFR 71.87(i). The package was received at the VA Medical Center, 6010 Amarillo Boulevard West, Amarillo, TX, at about 1110 on February 14, 2007. This VA Medical Center is a site of use listed on Master Material License Permit No. 30-01747-02 held by the New Mexico VA Health Care System, 1501 San Pedro SE, Albuquerque, New Mexico 87108. A wipe test sample of the exterior of the package was measured as containing 107,000 dpm shortly after package receipt.
"The package was received from Panhandle Nuclear Pharmacy, 6700 West 9th Street, Amarillo, TX 79106. The package contained 11 millicuries of Tc-99m for use by the nuclear medicine department.
"The commercial radiopharmacy, which was the final delivery carrier, was promptly notified. However, the staff of the nuclear medicine department did not notify the Radiation Safety Officer (RSO). The RSO discovered today [04/11/07] that the package contamination had exceeded an amount requiring notification of the NRC.
"The VA National Health Physics Program will follow up on this event and will also notify the NRC project manager for our master material license."
* * * UPDATE FROM LEIDHOLDT TO HUFFMAN AT 1915 EDT ON 4/25/07 * * *
The licensee provided the following information via email:
"As a followup review to this event, the facility Radiation Safety Officer has discovered that receipt wipe tests of the outer surfaces of two other packages of radioactive material indicated removable radioactive contamination exceeding the limits in 10 CFR 71.87(i). A wipe test of a package received on June 12, 2006, was assayed as 33,200 dpm and a wipe test of a package received on January 10, 2007, was assayed as containing 28,600 dpm.
"The packages were received from Cardinal Health, 27 Medical Drive, Suite A, Amarillo TX 79106 [information redacted]. The packages both contained Tc-99m for use by the nuclear medicine department.
"In both cases, the commercial radiopharmacy, which was the final delivery carrier, was promptly notified. The small amounts of removable contamination, less than two percent of a microcurie on either wipe sample, make it unlikely that any harm was caused in either case.
"The VA National Health Physics Program will follow up on this incident. We will also notify the NRC project manager for our master material license."
This is a supplement to the original report in that, similar to the initial report, the Amarillo facility staff did not notify the RSO and the required NRC notifications were not made at the time of occurrence.
R3DO(Passehl), R4DO(Smith), and NMSS EO (Pierson) have been notified.
"Pursuant to 10 CFR 20.1906, a receipt wipe test of a package of radioactive material indicated that removable radioactive contamination of the package surface exceeded the limits in 10 CFR 71.87(i). The package was received at the VA Medical Center, 6010 Amarillo Boulevard West, Amarillo, TX, at about 1110 on February 14, 2007. This VA Medical Center is a site of use listed on Master Material License Permit No. 30-01747-02 held by the New Mexico VA Health Care System, 1501 San Pedro SE, Albuquerque, New Mexico 87108. A wipe test sample of the exterior of the package was measured as containing 107,000 dpm shortly after package receipt.
"The package was received from Panhandle Nuclear Pharmacy, 6700 West 9th Street, Amarillo, TX 79106. The package contained 11 millicuries of Tc-99m for use by the nuclear medicine department.
"The commercial radiopharmacy, which was the final delivery carrier, was promptly notified. However, the staff of the nuclear medicine department did not notify the Radiation Safety Officer (RSO). The RSO discovered today [04/11/07] that the package contamination had exceeded an amount requiring notification of the NRC.
"The VA National Health Physics Program will follow up on this event and will also notify the NRC project manager for our master material license."
* * * UPDATE FROM LEIDHOLDT TO HUFFMAN AT 1915 EDT ON 4/25/07 * * *
The licensee provided the following information via email:
"As a followup review to this event, the facility Radiation Safety Officer has discovered that receipt wipe tests of the outer surfaces of two other packages of radioactive material indicated removable radioactive contamination exceeding the limits in 10 CFR 71.87(i). A wipe test of a package received on June 12, 2006, was assayed as 33,200 dpm and a wipe test of a package received on January 10, 2007, was assayed as containing 28,600 dpm.
"The packages were received from Cardinal Health, 27 Medical Drive, Suite A, Amarillo TX 79106 [information redacted]. The packages both contained Tc-99m for use by the nuclear medicine department.
"In both cases, the commercial radiopharmacy, which was the final delivery carrier, was promptly notified. The small amounts of removable contamination, less than two percent of a microcurie on either wipe sample, make it unlikely that any harm was caused in either case.
"The VA National Health Physics Program will follow up on this incident. We will also notify the NRC project manager for our master material license."
This is a supplement to the original report in that, similar to the initial report, the Amarillo facility staff did not notify the RSO and the required NRC notifications were not made at the time of occurrence.
R3DO(Passehl), R4DO(Smith), and NMSS EO (Pierson) have been notified.