Event Notification Report for February 07, 2008

AGREEMENT STATE REPORT - MEDICAL DOSE NOT IN ACCORDANCE WITH WRITTEN DIRECTIVE

"On Friday April 25, 2008 at approximately 1700 hrs, the Pennsylvania Bureau of Radiation Protection's Central Office Licensing Section was notified by [REDACTED] of a Medical Reportable Event that occurred on February 7, 2008 at Geisinger's Wyoming Valley Hospital located at 1000 East Mountain Drive in Wilkes Barre, PA. (License #37-01421-01; PA-0006) The event was not discovered until Friday April 25, 2008 during a licensee review of Written Directives administered.

"Licensee stated that the written directive for an I-131 treatment of a hyperactive thyroid was incorrectly written as 10 microcuries (0.37 MBq). Licensee stated that the nuclear medicine technician either did not read the directive or misread the directive and administered 10 millicuries. Licensee stated that the dose administered was appropriate for the treatment, however, inconsistent with the written directive. The prescribing physician was notified on the date of discovery. Licensee stated that no adverse health effects are expected as a result of this error. The error most likely occurred because the most common prescriptions for this sort of treatment are 10 - 20 mCi (370 - 740 MBq) I-131 and the technician did not recognize that the written directive stated 10 uCi (0.37 MBq).

"Licensee stated that actions taken to prevent recurrence had not been undertaken at the time of report. Licensee will be sending a written report to PA DEP's SCRO.

"The above information was reported to [REDACTED] PA DEP BRP Director on 4/28/2008."

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.

OSC HVAC SYSTEM DID NOT START AS REQUIRED

"In preparation for scheduled Motor Control Center (MCC) cleaning activities, the Health Physics normal HVAC system had to be shutdown and the Health Physics emergency HVAC was to be started while the MCC that supplies power to the normal HVAC would be out of service. When the emergency HVAC system was started per the system operating procedure (34S0-Z41-006-0), the air handling unit (1Z41-B100) started, but neither compressor units (1Z41-B101) started. Maintenance has been notified and is currently working to restore the system to operable status.

"This event is reportable per 10CFR50,72 (b)(3)(xiii) as described in NUREG-1022, rev. 2 as an emergency facility (Plant Hatch Operational Support Center) is affected with the Health Physics emergency HVAC out of service.

"Update: maintenance cleaned electrical contactors and have both compressors running at 0436 hours."

The licensee notified the NRC Resident Inspector.

INJURED CARPENTER TRANSPORTED TO APPLING COUNTY HOSPITAL

"At 0230 EST an injured contract worker who was potentially contaminated was transported by ambulance to an offsite medical facility. The contract employee fell approximately 15 feet from a scaffold in the Unit 1 condenser bay. Unit 1 is presently shutdown (Mode 5) for a refueling outage. The worker was placed on a stretcher for transport and was partially frisked prior to release. However, due to concerns for a potential back injury, the worker was not removed from the stretcher for a back survey and was transported, with HP escort, as a contaminated person. After arriving at the hospital, a complete survey was performed and the worker was found to be free of contamination."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - LOST ELECTRON CAPTURE CELL CONTAINING NICKEL - 63 SOURCE

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"The Boeing Company reported February 7th they are unable to find one gas chromatograph electron capture cell that contains 555 MBq (15 millicuries) of nickel-63. The Licensee became aware of the missing source on January 7, 2008, during a routine survey and inventory of their radioactive waste area. Based on their investigation, the licensee thinks the source was disposed of as radioactive waste in a shipment sent to the Low Level Radioactive Waste site in December 2007. The licensee attributes this to staff not following the established procedures for the transfer and disposal of the source. The person assigned waste area duties in December has subsequently left employment with Boeing. Confirming this directly is unlikely to happen. The Boeing RSO has reviewed the procedures and believes that when they are followed they are adequate to prevent loss of a source. However, the RSO will now require two people to be involved in the radioactive waste packaging process with both signing shipment documents before they are complete. The Boeing RSO reviewed the new procedure with the radiation safety staff. We are told, the discussion emphasized the importance of following the procedures. The RSO will have the waste manifest changed to show addition of the source.

"Event Report #WA-08-011."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.