Event Notification Report for July 16, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/15/2009 - 07/16/2009
General Information or Other
Event Number: 45222
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS
Region: 3
City: RACINE State: WI
County:
License #: 101-1299-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: DONALD NORWOOD
Licensee: WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS
Region: 3
City: RACINE State: WI
County:
License #: 101-1299-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/22/2009
Notification Time: 16:29 [ET]
Event Date: 07/16/2009
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2009
Notification Time: 16:29 [ET]
Event Date: 07/16/2009
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID HILLS (R3DO)
PATRICE BUBAR (FSME)
DAVID HILLS (R3DO)
PATRICE BUBAR (FSME)
AGREEMENT STATE REPORT - MULTIPLE EQUIPMENT ISSUES ASSOCIATED WITH HDR BRACHYTHERAPY UNIT
The following is a summary of information received via fax from the State of Wisconsin. For more details contact the Headquarters Operations Officer.
On July 16, 2009, DHS [Department of Health Services] performed a reciprocity inspection at Wheaton Franciscan Healthcare - All Saints for a source exchange of a 10 Ci, Ir-192 source and routine maintenance of a Nucletron Micro Selectron HDR [High Dose Rate] classic remote afterloader brachytherapy device. During the inspection, three items were identified during testing of the HDR unit: 1) HDR control panel did not operate as designed; 2) the HDR/Linac switch was not wired correctly; and 3) Radiation area monitor was operating sporadically.
On July 16, 2009, DHS informed the licensee that they would not be able to use the HDR unit for patient treatments until all areas of concerns were corrected. The licensee informed DHS that the HDR unit has NOT been used for any patient treatments since the Department authorized the licensee the HDR unit on August 8, 2008.
On July 21, 2009, DHS issued the licensee a Confirmatory Action Letter effective July 17, 2009, that the licensee is not allowed to use the HDR unit for patient treatments until the listed items were corrected
The licensee has committed to address all equipment malfunctions prior to treating patients using the Nucleation HDR unit. DHS plans to conduct an inspection prior to patient treatment.
The State does not anticipate any media attention.
The following is a summary of information received via fax from the State of Wisconsin. For more details contact the Headquarters Operations Officer.
On July 16, 2009, DHS [Department of Health Services] performed a reciprocity inspection at Wheaton Franciscan Healthcare - All Saints for a source exchange of a 10 Ci, Ir-192 source and routine maintenance of a Nucletron Micro Selectron HDR [High Dose Rate] classic remote afterloader brachytherapy device. During the inspection, three items were identified during testing of the HDR unit: 1) HDR control panel did not operate as designed; 2) the HDR/Linac switch was not wired correctly; and 3) Radiation area monitor was operating sporadically.
On July 16, 2009, DHS informed the licensee that they would not be able to use the HDR unit for patient treatments until all areas of concerns were corrected. The licensee informed DHS that the HDR unit has NOT been used for any patient treatments since the Department authorized the licensee the HDR unit on August 8, 2008.
On July 21, 2009, DHS issued the licensee a Confirmatory Action Letter effective July 17, 2009, that the licensee is not allowed to use the HDR unit for patient treatments until the listed items were corrected
The licensee has committed to address all equipment malfunctions prior to treating patients using the Nucleation HDR unit. DHS plans to conduct an inspection prior to patient treatment.
The State does not anticipate any media attention.
Fuel Cycle Facility
Event Number: 45208
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 2 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC SPAETH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/16/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: 17:15 [EDT]
Last Update Date: 07/16/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: 17:15 [EDT]
Last Update Date: 07/16/2009
Emergency Class: ALERT
10 CFR Section:
76.120(a)(4) - EMERGENCY DECLARED
10 CFR Section:
76.120(a)(4) - EMERGENCY DECLARED
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
VICTOR McCREE (DRA)
BRIAN McDERMOTT (IRD)
MIKE WEBER (NMSS)
SAL MORRONI (DOE)
KATHLEEN O'DONOHUE (R2DO)
VICTOR McCREE (DRA)
BRIAN McDERMOTT (IRD)
MIKE WEBER (NMSS)
SAL MORRONI (DOE)
ALERT DECLARED DUE TO A FIRE IN AN ABANDONED COOLING TOWER
An ALERT was declared at 1715 due to a fire lasting greater than 15 minutes. The fire is in an abandoned cooling tower (bldg X-633D) on the Department of Energy portion of the site. The fire is not in proximity to any safety related equipment. A request for assistance was made to Scioto and Adams counties Fire Departments.
At 1917, the licensee reported that the fire was out and the firemen were removing siding and looking for residual hot spots.
* * * UPDATE AT 2046 ON 7/16/2009 FROM TERRY SENSAWAY TO MARK ABRAMOVITZ * * *
The fire is out and the ALERT has been terminated. Recovery operations are in progress and a fire watch will be stationed throughout the night.
Notified R2DO (O'Donohue), R2 Deputy RA (McCree), NMSS (Weber), NMSS EO (Kotzalas), DHS (Kettles), FEMA (Biscoe), DOE (Parsons), HHS (Nunn), USDA (Timmons), and EPA (Threatt).
An ALERT was declared at 1715 due to a fire lasting greater than 15 minutes. The fire is in an abandoned cooling tower (bldg X-633D) on the Department of Energy portion of the site. The fire is not in proximity to any safety related equipment. A request for assistance was made to Scioto and Adams counties Fire Departments.
At 1917, the licensee reported that the fire was out and the firemen were removing siding and looking for residual hot spots.
* * * UPDATE AT 2046 ON 7/16/2009 FROM TERRY SENSAWAY TO MARK ABRAMOVITZ * * *
The fire is out and the ALERT has been terminated. Recovery operations are in progress and a fire watch will be stationed throughout the night.
Notified R2DO (O'Donohue), R2 Deputy RA (McCree), NMSS (Weber), NMSS EO (Kotzalas), DHS (Kettles), FEMA (Biscoe), DOE (Parsons), HHS (Nunn), USDA (Timmons), and EPA (Threatt).
General Information or Other
Event Number: 45209
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RADIOGRAPHIC SPECIALISTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02742
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: RADIOGRAPHIC SPECIALISTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02742
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/17/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VINCENT GADDY (R4DO)
TERRENCE REIS (FSME)
VINCENT GADDY (R4DO)
TERRENCE REIS (FSME)
POSSIBLE RADIOGRAPHER OVEREXPOSURE
Texas Incident #8646
"On July 17, 2009, the Agency [Texas Department of Health] was notified by the licensee that they had been informed by their dosimetry processor that a radiographer had received an exposure exceeding the annual exposure limit. The licensee stated that the individual's thermoluminescent dosimeter was reading 9,000 millirem for the exposure period of June 9, 2009, through July 10, 2009. The licensee conducted a preliminary interview with the employee and was not able to determine how the exposure could have occurred. The radiographer stated that he had not received any dose rate alarms while performing his duties during the monitoring period. He also stated that his self reading pocket dosimeter had never indicated any unusual readings. The licensee's Radiation Safety Officer stated that the individual's duties during the exposure period were almost exclusively dark room operations grading film. The licensee is continuing to investigate and will provide additional information to the Agency [Texas Department of Health] as it becomes available."
* * * UPDATE ON 8/13/2009 AT 1243 FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following report was received via e-mail:
"7/21/09 0830 Contacted the RSO. He stated that they had completed a review of the individuals daily exposure recorded for the previous 6 months and had not found any reason for the exposure. I asked him if they were going to seek any medical assistance for the individual involved. He stated that he was unsure of what action he should take in this area. I provided him with REACTS contact information.
"7/21/09 1320 Received a call from the RSO. He stated that he had just received a call from his dosimetry processor informing him that the same individual's badge for the exposure period of May 10, 2009, and June 9, 2009, was 17,840 millirem. The RSO stated that he was making arrangements to have a medical exam for the individual done. He was also going to contact REACTS again to seek advice on how to proceed.
"7/21/09 1530 The RSO for Radiographic Specialist contacted the Agency [Texas Department of Health] and stated that they had scheduled the worker for blood test and that REACTS had shipped him a study kit to analyze the workers blood to help determine if he had received the dose indicated by his badge. REACTS stated that it would take a few weeks after they received the sample to have the results. I told the RSO that the Agency [Texas Department of Health] is planning to conduct their investigation at his facility on July 29, or 30, 2009, and requested copies of the dosimetry processors reports for the individual.
"7/21/09 1614 Received the dosimetry reports. The report for the June 2009 period indicates 9,470 millirem for the exposure period. The processor states that the reading appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The film for the May exposure period indicates 17,840 millirem and the reading also appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The RSO still believes that this is a badge only exposure.
"Additional information
"On August 6, 2009, the Licensee provided a copy of the Cytogenetic Biodosimetry report from Cytogenetic Biodosimetry Laboratories - REAC/TS performed on their employee reported as receiving the overexposure. The initial report indicated that the dose received was not significantly different from background. The Agency [Texas Department of Health] requested clarification of what REAC/TS used as a background. On August 12, 2009, the licensee provided a copy of a document from REAC/TS, which indicated that their background would be a dose of 14 rad for the study conducted. The Agency [Texas Department of Health] will perform an on-site investigation of the event on or about August 19, 2009."
Notified the R4DO (Whitten) and FSME (McIntosh).
* * * UPDATE ON 8/20/2009 AT1844 FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following report was received via e-mail:
"On August 19, 2009, the Agency [Texas Department of Health] completed an on-site investigation with the licensee. The investigation was not able to determine how that much exposure was recorded on the individual's badge. The licensee presented the Agency [Texas Department of Health] with a copy of an email sent from the Cytogenetic Biodosimetry Coordinator at REAC/TS in which he stated that they found no evidence that an overexposure to this individual had occurred. The licensee stated that he would be requesting a dose assignment of 417 millirem for each of the two exposure periods of May and June 2009, reducing the TEDE for the year of 2009 to less than 5 rem."
Notified the R4DO (Jones) and FSME (Camper).
Texas Incident #8646
"On July 17, 2009, the Agency [Texas Department of Health] was notified by the licensee that they had been informed by their dosimetry processor that a radiographer had received an exposure exceeding the annual exposure limit. The licensee stated that the individual's thermoluminescent dosimeter was reading 9,000 millirem for the exposure period of June 9, 2009, through July 10, 2009. The licensee conducted a preliminary interview with the employee and was not able to determine how the exposure could have occurred. The radiographer stated that he had not received any dose rate alarms while performing his duties during the monitoring period. He also stated that his self reading pocket dosimeter had never indicated any unusual readings. The licensee's Radiation Safety Officer stated that the individual's duties during the exposure period were almost exclusively dark room operations grading film. The licensee is continuing to investigate and will provide additional information to the Agency [Texas Department of Health] as it becomes available."
* * * UPDATE ON 8/13/2009 AT 1243 FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following report was received via e-mail:
"7/21/09 0830 Contacted the RSO. He stated that they had completed a review of the individuals daily exposure recorded for the previous 6 months and had not found any reason for the exposure. I asked him if they were going to seek any medical assistance for the individual involved. He stated that he was unsure of what action he should take in this area. I provided him with REACTS contact information.
"7/21/09 1320 Received a call from the RSO. He stated that he had just received a call from his dosimetry processor informing him that the same individual's badge for the exposure period of May 10, 2009, and June 9, 2009, was 17,840 millirem. The RSO stated that he was making arrangements to have a medical exam for the individual done. He was also going to contact REACTS again to seek advice on how to proceed.
"7/21/09 1530 The RSO for Radiographic Specialist contacted the Agency [Texas Department of Health] and stated that they had scheduled the worker for blood test and that REACTS had shipped him a study kit to analyze the workers blood to help determine if he had received the dose indicated by his badge. REACTS stated that it would take a few weeks after they received the sample to have the results. I told the RSO that the Agency [Texas Department of Health] is planning to conduct their investigation at his facility on July 29, or 30, 2009, and requested copies of the dosimetry processors reports for the individual.
"7/21/09 1614 Received the dosimetry reports. The report for the June 2009 period indicates 9,470 millirem for the exposure period. The processor states that the reading appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The film for the May exposure period indicates 17,840 millirem and the reading also appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The RSO still believes that this is a badge only exposure.
"Additional information
"On August 6, 2009, the Licensee provided a copy of the Cytogenetic Biodosimetry report from Cytogenetic Biodosimetry Laboratories - REAC/TS performed on their employee reported as receiving the overexposure. The initial report indicated that the dose received was not significantly different from background. The Agency [Texas Department of Health] requested clarification of what REAC/TS used as a background. On August 12, 2009, the licensee provided a copy of a document from REAC/TS, which indicated that their background would be a dose of 14 rad for the study conducted. The Agency [Texas Department of Health] will perform an on-site investigation of the event on or about August 19, 2009."
Notified the R4DO (Whitten) and FSME (McIntosh).
* * * UPDATE ON 8/20/2009 AT1844 FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following report was received via e-mail:
"On August 19, 2009, the Agency [Texas Department of Health] completed an on-site investigation with the licensee. The investigation was not able to determine how that much exposure was recorded on the individual's badge. The licensee presented the Agency [Texas Department of Health] with a copy of an email sent from the Cytogenetic Biodosimetry Coordinator at REAC/TS in which he stated that they found no evidence that an overexposure to this individual had occurred. The licensee stated that he would be requesting a dose assignment of 417 millirem for each of the two exposure periods of May and June 2009, reducing the TEDE for the year of 2009 to less than 5 rem."
Notified the R4DO (Jones) and FSME (Camper).