Event Notification Report for June 03, 2008

AGREEMENT STATE REPORT - RADIOPHARMACEUTICALS DELIVERY VEHICLE ACCIDENT

The State provided the following information via facsimile:

"On June 3, 2008, a Cardinal Health delivery vehicle carrying nuclear medicine doses was involved in a vehicle accident. Some of the ammo boxes containing the syringe pigs opened, however the syringe pigs remained intact. No radioactive material was spilled or leaked during this accident."

Louisiana Report: LA0800012

LOUISIANA AGREEMENT STATE REPORT - LOST WELL LOGGING TOOL

"[On the morning of May 29, 2008], a Pulsed Neutron Generator (Source #183619) belonging to Baker Hughes Oilfield Operations, Inc. dba Baker Atlas, containing approximately 900 millicuries of Tritium (H-3) was lost into the waters of the Mississippi River. The events were as follows:

"A commercial hotshot carrying two complete Pulsed Neutron Tools was dispatched to the Hilcorp dock in Cocodrie, La., from the Baker Atlas facility in Broussard, La. at approximately 3 A.M. this morning [5/29/08].

"The tools arrived at the Hilcorp dock at approximately 5 A.M.. The shipment was verified by the Hilcorp dock dispatcher and loaded onto a Hilcorp contracted Crew Boat. Note: there were no Baker Atlas employees included in the transport of this shipment. The Baker Atlas crew was already at the rig when this equipment was ordered.

"The shipment arrived at Hilcorp S/L 3090 #7, in the Little Pass field at approximately 7 A.M.. At arrival, the Hilcorp company representative noted that the aluminum tubes containing the Baker atlas downhole tools were not strapped down and were extended over the rail of the boat.

"The Hilcorp representative alerted the Baker Atlas crew, who conducted an inventory of the equipment and found that one tube containing both the upper section and lower section [containing the 900 milliCurie H-3 source] of a Pulsed Neutron Generator Tool was missing.

"The Hilcorp representative dispatched the crew boat back to the dock to conduct a visual search of the route and dock, but nothing was found. Due to the weight and density of the equipment, it is most likely that the tube (and tools in it) sank to the bottom of the river. Note: the rig is approximately 20 nautical miles from the dock.

"The customer (Hilcorp) has accepted financial responsibility for this loss and does not believe that a search for the missing equipment would be cost effective."

The State of Louisiana considers this event closed.

Louisiana DEQ Event Report ID: LA0800011



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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3"

CALIFORNIA AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEEDS

The following information was received from the State of California Radiologic Health Branch [RHB] via email:

"On Tuesday, June 3, 2008, RHB was notified by NRC Region IV of an incident involving a California licensee. A package had been shipped by the California licensee to an Illinois licensee. The package should have contained 23 iodine-125 seeds used for brachytherapy, with activities of approximately 0.425 millicuries each. Upon receipt, the outer package was undamaged, but was reading 460 millirem/hour on contact. When the package was opened, the inner shielded container was open and some of the seeds were out of the shielded container, and at the bottom of the shipping container. The IL licensee could only account for 19 of the 23 seeds. They notified the IL radiation control program, and contacted [the carrier]. The IL licensee has surveyed the delivery truck, and the loading dock. They are in the process of surveying the [carrier's] terminal at Chicago's O'Hare airport. The California licensee that made the shipment is a small surgical center. Based on the information from IL, the package was not prepared for shipment in accordance with the instructions provided by the IL licensee, and vibrations during the shipment appear to have caused the shielded container to open during the shipment, releasing some of the seeds. RHB will be investigating the root cause of this incident and corrective actions with the California licensee."

CA Incident Number 5010-060308


* * * UPDATE FROM BARBARA HAMRICK TO HOWIE CROUCH VIA EMAIL ON 6/3/08 @ 1626 HRS. EDT * * *

"As of 1:02 pm PDT, we [RHB] received notification from the IL radiation control program that their licensee found the four missing I-125 seeds at the licensed facility in IL, among other packages received that morning. All seeds are now accounted for. California will continue to investigate the root cause of this incident."

Notified R4DO (Whitten) and FSME EO (Chang).

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.

LOSS OF CONTROL ROOM EMERGENCY VENTILLATION SYSTEM FOR 12 MINUTES

"At 1259 hours on June 3, 2008, the Control Room authorized replacement of solenoid valve 1-VA-SV-928, affecting the Unit 1 Cable Spread Room Supply / Exhaust Fan Dampers. This work rendered two subsystems of the Control Room Emergency Ventilation (CREV) system inoperable. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered Technical Specification (TS) 3.7.3, 'Control Room Emergency Ventilation (CREV) System,' Required Action 5.1 (i.e., be in Mode 3 within 12 hours).

"At 1313 hours the three Control Room Air Conditioning subsystems, required by TS 3.7.4, 'Control Room Air Conditioning (AC) System,' tripped during the performance of this planned preventive maintenance activity. Unit 1 and Unit 2 entered TS 3.7.4, Required Action E.1 (i.e., enter LC0 3.0.3 immediately). At 1325 hours, following replacement of solenoid valve 1-VA-SV-928, the Control Room AC subsystems were restored to operable status and LCO 3.0.3 was exited. CREV system operability was restored at 1333 hours.

"No power reduction took place as a result of the LCO 3.0.3 entry. This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented the fulfillment of the safety function of a system needed to mitigate the consequences of an accident.

"The safety significance of this event is considered minimal. The condition existed for 12 minutes. Prior to the maintenance activity, the potential for loss of the Control Room AC system and established compensatory actions to be taken in the event of the loss were briefed. Plant staff took immediate actions to return the Control Room AC subsystems to service. For the brief time the Control Room subsystems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected. The maximum Control Room back panel temperature during this event was approximately 73 degrees F.

"Operability of the Control Room AC system was restored at 1325 hours, following replacement of solenoid valve 1-VA-SV-928. CREV system operability was restored at 1333 hours. Further solenoid valve replacements affecting Control Building Emergency Ventilation have been placed on hold pending the completion of the loss of Control Room AC subsystem investigation."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - PRESCRIBED DOSE DIFFERED BY MORE THAN 20 PERCENT

"A written directive, signed and dated on 5/30/08 by an authorized user was prepared. The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma. An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08. On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied. On 6/03/08 the patient was properly identified, a negative pregnancy status was confirmed and the dosage assayed. A recorded dosage of 2.7 mCi was recorded in the hot lab computer and on the front of the written directive form. The hot lab computer with technologist data input produced a printed label of 2.7 mCi as of 6/03/08 at 1114 hours. However, at the time of dosage administration the calculated dosage available was 2.00 mCi.

"The dosage was administered to the patient and the patient was released with written radiation safety instructions for return 48 hours post administration for performance of the actual scan. At interview today, the technologist confirms that all administrative dosage information was recorded by her and her alone. She could not give any reason as to why a dosage of 2.7 mCi could or would have been administered or recorded.

"A recreation of these events today notes that the hot lab computer advises the technologist that the +/-20% threshold has been exceeded with a visual warning which can be bypassed upon consultation with the authorized user. We can find no documentation of a consultation and neither the authorized user nor the technologist can confirm that one took place. A conservative estimate of organ and EDE doses was made using ICRP 53 and an ultra conservative estimate of a thyroid uptake of 5%."

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.

* * * RETRACTION PROVIDED AT 1050 EDT ON 08/21/08 FROM CHAD MORGAN TO JEFF ROTTON * * *

"Upon further investigation we have determined that a Medical Event did not occur at Oakwood Hospital and Medical Center. We do believe that a documentation error did occur instead and have taken steps internally to prevent a reoccurrence (see below). We would like to retract our report of a medical event. This is due to the following conclusions:

* A written directive, signed and dated on 5/30/08 by an authorized user was prepared.

*The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma.

*An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08.

*On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied.

"Upon further investigation, at the time of dosage administration the calculated dosage available was 2.00 mCi, though the documentation states the dosage given was 2.7mCi. We believe the documentation to be in error and not the actual dose given to the patient.

"Measures to Prevent Reoccurrence:

1. Prior to dosage administration, all documentation will be verified by either a second certified nuclear medicine technologist or an authorized user via review and signature on the written directive.

2. Extensive re-education for all technical staff will be conducted concerning the written directive program and patient release requirements.

3. A written internal time-out retrospective audit will be conducted on a random number of directives on a monthly basis.

4. Medical Physics Consultants, Inc. will continue to perform a full quarterly written directive program audit.

"Summary: It is our belief that the correct patient received the correct prescribed dosage for the ordered procedure, however our internal documentation notes otherwise. This documentation error would not constitute a Medical Event ."

Notified R3DO (Sonia Burgess) and FSME (Michele Burgess)

AGREEMENT STATE REPORT - DISCARDED SOURCE

The following report was received via fax:

"06/11/08 the RSO [Radiation Safety Officer] called to report the inadvertent disposal of a Beckman Liquid Scintillation Counter instrument with the 30 micro-curie source still in place. He was not consulted in March 2008 when the Beckman was removed by a commercial waste hauler. The waste hauler was called to determine the disposition of this instrument.

"On 07/07/08 the report was received from the RSO. The RSO reported that at this time (several months after pick-up) the waste contractor was unable to provide any information on the whereabouts of this instrument. No reward was offered. No press release was issued. Incident Closed."

New York Event: NY-11-19
New York Incident: 617

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf