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 +------------------------------------------------------------------------------+ |Hospital |Event Number: 35544 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35545 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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.) | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35546 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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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