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Event Notification Report for April 6, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/05/1999 - 04/06/1999

                              ** EVENT NUMBERS **

35544  35545  35546  

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|Hospital                                         |Event Number:   35544       |
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| REP ORG:  BRICK HOSPITAL                       |NOTIFICATION DATE: 04/05/1999|
|LICENSEE:  BRICK HOSPITAL                       |NOTIFICATION TIME: 06:46[EDT]|
|    CITY:  BRICK                    REGION:  1  |EVENT DATE:        04/05/1999|
|  COUNTY:  OCEAN                     STATE:  NJ |EVENT TIME:        06:30[EDT]|
|LICENSE#:  29-20690-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/05/1999|
|  DOCKET:  03020725                             |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KATHLEEN MODES       R1      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+JOSEPH GIITTER       IRO     |
| NRC NOTIFIED BY:  MICHAEL CAPRIO               |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAAA 20.1906(d)           SURFACE CONT/ EXT RAD |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| RECEIPT OF A PACKAGE CONTAINING RADIOPHARMACEUTICALS WITH SURFACE            |
| CONTAMINATION (EXTERNAL RADIATION LEVELS GREATER THAN TRANSPORTATION         |
| LIMITS)                                                                      |
|                                                                              |
| At approximately 0630 on 04/05/99, Brick Hospital (located in Brick, NJ)     |
| received its daily shipment of radiopharmaceuticals from Nycomed Amersham    |
| (located in Livingston, NJ); and the area radiation monitor alarm            |
| annunciated when the delivery agent walked in with the package.  The         |
| shipment/package in question was a Yellow-II container, and it contained 400 |
| mCi of Technetium-99m and 0.1 mCi of Iodine-123.                             |
|                                                                              |
| The licensee surveyed the package and performed wipe tests with the          |
| following results (as measured using a Victoreen #450 ionization chamber):   |
| 960 mR/hour at the surface and 18.5 mR/hour at a distance of 3 feet.  The    |
| contamination level on the outer surface of the shipping package was 26,912  |
| disintegrations per minute.  (NOTE:  External radiation standards require    |
| that each package of radioactive materials offered for transportation must   |
| be designed and prepared for shipment so that, under conditions normally     |
| incident to transportation, the radiation levels do not exceed 200 mR/hour   |
| at any point on the external surface of the package.)                        |
|                                                                              |
| The licensee notified Nycomed Amersham; and at the request of Nycomed        |
| Amersham, Brick Hospital representatives opened the contaminated package to  |
| inspect the contents for breakage.  Although the internal containers         |
| appeared to be sealed in plastic and intact, a wipe test of the outside      |
| surfaces of the lead pigs revealed contamination levels that were too hot to |
| count.  The contaminated package was placed in a shielded leak storage       |
| container (a shielded radioactive waste module).                             |
|                                                                              |
| The licensee reported that there was no spread of contamination at Brick     |
| Hospital.  The status of the delivery agent was unknown.                     |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
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|Hospital                                         |Event Number:   35545       |
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| REP ORG:  HINES VA HOSPITAL                    |NOTIFICATION DATE: 04/05/1999|
|LICENSEE:  HINES VA HOSPITAL                    |NOTIFICATION TIME: 16:09[EDT]|
|    CITY:  CHICAGO                  REGION:  3  |EVENT DATE:        04/05/1999|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|
|LICENSE#:  12-01087-09           AGREEMENT:  Y  |LAST UPDATE DATE:  04/05/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE BURGESS        R3      |
|                                                |FRED COMBS           NMSS    |
+------------------------------------------------+JOSEPH GIITTER       IRO     |
| NRC NOTIFIED BY:  LAWRENCE CASE                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION INVOLVING WRONG PATIENT                            |
|                                                                              |
| AN ELDERLY FEMALE PATIENT SCHEDULED FOR AN ORBITAL DOSE ON 04/02/99 USING A  |
| LINEAR ACCELERATOR RECEIVED 200 cGy SINGLE FRACTION TO AN AREA NEAR THE      |
| INTENDED TREATMENT SITE FROM A THERATRON Co-60 UNIT.  THE REFERRING          |
| PHYSICIAN WAS INFORMED AND NOTIFIED THE PATIENT WHO WAS RELEASED AND SENT    |
| HOME.  THE LICENSEE SUSPECTS THE ERROR WAS DUE TO THE SIMILARITY IN  NAMES   |
| BETWEEN BOTH ELDERLY FEMALE PATIENTS; ONE SCHEDULED FOR TELETHERAPY AND THE  |
| OTHER FOR LINEAR ACCELERATOR TREATMENT.  THE PRESCRIBED DOSE AND CONDITION   |
| WAS NOT AVAILABLE AT THE TIME OF THE REPORT.  THE THERATRON SOURCE WAS       |
| 13,000 CURIES AS OF MARCH 1999.                                              |
|                                                                              |
| THE LICENSEE NOTIFIED NRC REGION 3.                                          |
|                                                                              |
| (CALL THE NRC OPERATIONS OFFICER FOR LICENSEE CONTACT INFORMATION.)          |
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|Power Reactor                                    |Event Number:   35546       |
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| FACILITY: SALEM                    REGION:  1  |NOTIFICATION DATE: 04/05/1999|
|    UNIT:  [] [2] []                 STATE:  NJ |NOTIFICATION TIME: 16:37[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/05/1999|
+------------------------------------------------+EVENT TIME:        15:00[EDT]|
| NRC NOTIFIED BY:  MIKE HOSKINS                 |LAST UPDATE DATE:  04/05/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |FRANK COSTELLO       R1      |
|10 CFR SECTION:                                 |                             |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| CONTAINMENT ISOLATION VALVES FAILED LOCAL LEAKRATE TESTING (LLRT).           |
|                                                                              |
| THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE:   |
|                                                                              |
| "DURING TYPE 'C' LOCAL LEAKRATE TESTING OF A STATION AIR PENETRATION TO      |
| CONTAINMENT, THE AS-FOUND CONDITION OF THE ASSOCIATED VALVES (2SA119-INBOARD |
| CHECK VALVE, 2SA118-OUTBOARD MANUAL VALVE) ALLOWED LEAKAGE BEYOND            |
| MEASUREMENT CAPACITY OF THE TEST EQUIPMENT.  THE ASSOCIATED LEAKAGE WOULD    |
| HAVE BEEN IN EXCESS OF THE TECH SPEC ALLOWABLE LIMIT FOR BOTH TYPE 'B' AND   |
| 'C' (REFERENCE TS 3.6.1.2).  CURRENTLY, THE PLANT IS IN A MODE (MODE 5) IN   |
| WHICH THE LEAKAGE REQUIREMENTS ARE NOT APPLICABLE (TS 3.6.1.2 APPLICABLE     |
| MODES 1 THROUGH 4).  THIS CONDITION HAS BEEN ENTERED INTO THE PLANT'S        |
| CORRECTIVE ACTION PROGRAM, AND CORRECTIVE MAINTENANCE WORK ORDERS ARE BEING  |
| GENERATED.  AT THE TIME OF THE DISCOVERY, THIS CONDITION HAD NO IMPACT ON    |
| PLANT OPERATION."                                                            |
|                                                                              |
| THE LICENSEE PLANS TO INFORM STATE AND LOCAL AGENCIES AND THE NRC RESIDENT   |
| INSPECTOR.                                                                   |
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