Event Notification Report for March 15, 2002

PERSONNEL OVEREXPOSURE POSSIBLE IF UNCHARACTERIZED ALPHA EMITTER ABSORBED BY AIRBORNE INHALATION

During a routine radiological survey, the school found a table in Johnson Hall that was contaminated with 150 DPM/100 centimeters squared [initially estimated to be approximately 30,000 dpm or 14E-3 microcuries] of Americium-241. Johnson Hall, room 222, is normally locked with restricted access and the cause of the contamination is historical in nature. The table was decontaminated and wrapped in plastic for proper disposal. There were no known personnel overexposures due to this event. However, "if 100% was absorbed by airborne contamination and deposited on bone surface, it would exceed the ALI by 2.3."

The licensee discussed this report with R3(Null).


* * * RETRACTION ON 4/15/02 @ 0845 BY LILLY TO GOULD * * *

After reviewing this event with Region 3 personnel it was determined that it was not reportable based on a model which shows that the maximum dose would be about 2 millirem/yr.

Notified REG 3 RDO (Riemer) and NMSS EO (Hickey)

P-32 SOURCE USED IN RESEARCH DISCOVERED MISSING

The following preliminary information was provided by the licensee:

"This is to inform you of an incident that occurred at our facility involving a recent shipment of 250 microcuries of phosphorous-32 [P-32] deoxyguanosine 5 triphosphate. The shipment was delivered to our facility (License # 37-02766-01) on March 8, 2002 as an excepted package, limited quantity [49 CFR173.421]. The package was delivered to the recipient lab and the blue plastic container was placed in a freezer that was locked for storage of the material. On March 11, 2002 when the freezer was unlocked and the blue container was removed for use there was no vial of P-32 inside. The lab worker immediately reported the situation to her Principal Investigator. Initially the assumption was simply that the facility was shortchanged a vial and indeed that is our conclusion after investigation of the incident. The Radiation Safety Officer [RSO] was notified via e-mail at or about the time the purchasing department was notified.

"The RSO immediately began an investigation of the incident. It was determined that the initial recipient did not follow the facilities procedure for opening packages of radioactive material and failed to monitor the surface of the package or look inside and verify the contents. The shipper, Perkin Elmer, was notified and asked to investigate the matter. The distribution coordinator at Perkin Elmer indicated that there might have been other incidents where primary vials have been omitted from a shipment. She declined to give further details until they finish their investigation. The RSO was informed that each package is not routinely surveyed by Parker Elmer even though an exposure rate was indicated on the packing slip.

"Physical inventories of the laboratory concerned and an adjacent laboratory were conducted and there were no discrepancies. Hospital security has been notified and they are conducting an investigation. A radiation survey using a Ludlum Model 3 survey meter with a 44-9 probe was performed of the lab in question, as well as the tissue culture room where the material was stored, and the Principal Investigator's Office. The shelves, drawers, cabinets, sinks, trashcans were surveyed in these areas with no positive results. A water cooler in the vicinity was swipe tested on the advice of our consultant. The water cooler showed no evidence of P-32 contamination. All the bottles next to the water cooler were also surveyed via a meter and no levels were found.

"The Principal Investigator [ ] was interviewed by the RSO. She indicated that she was not aware of any personal conflicts within her lab nor any other labs at the facility. She indicated that not only is their radioactive material kept locked within a freezer dedicated to radioactive materials storage, but that the tissue culture room is kept locked when not in use.

"Access to the building requires an access card and there is a record of all personnel who entered the building during the period March 8-11. They are in the process of interviewing those personnel on the list.

"Shipping and Receiving was checked for other shipments from Perkin Elmer but none were received on March 8.

"We have completed the following corrective actions. A review of package receipt procedures including survey of the package and inspection of the primary vial was done with the personnel in the lab that received the shipment. The lab in question also developed a procedure checklist that includes not only the above but also the step of matching the lot number on the vial with that on the shipping papers. A memo has been sent to all of the other research labs reminding them of the procedures for receiving packages include a survey of the surface of the package even though regulations do not require that for an exempt quantity package and an email send as urgent went to all research areas, Nuclear Medicine and Radiation Oncology. A review of the incident and package receipt procedures will be included in annual inservices and information conveyed during routine inspections of radioactive materials laboratories.

"We have concluded that the primary vial was probably not shipped, because the material was secured within the building, the tissue culture room, and within the freezer from the time delivered until the attempt to use it. No evidence of any irregularity resulted from the investigations conducted by the RSO and Security. But since we cannot rule out that the vial was shipped we are notifying the Nuclear Regulatory Commission. Security has always been a priority at Fox Chase Cancer Center and we are aware of the heightened concerns due to the terrorist attacks of September 11".

NON WORK RELATED FATALITY NOTIFICATION IN ACCORDANCE WITH 10CFR50.72

"At approximately 06:30 MST on March 15, 2002, a non-work related on-site fatality occurred at the Palo Verde Nuclear Generating Station. The fatality was not related to the health and safety of the public or onsite personnel. Specifically, a contract carpenter was found by coworkers in the carpenter shop before work hours with no pulse or life signs. The individual was promptly attended by Palo Verde Emergency Medical Technicians (EMTs) and an air evacuation was completed. The individual was pronounced dead upon arrival at the hospital.

"The individual was outside of the Radiological Controlled Area and no radioactive material or contamination was involved. The work location was outside of the Protected Area.

"Palo Verde has not observed any heightened public, media or government concern as a result of the fatality. Since the fatality is unrelated to Palo Verde's industrial or radiological health and safety, no news release is planned.

"Since the fatality was not work-related, nor the result of an accident, no notification to other government agencies was made at the time. However, Palo Verde is now making a notification to the Arizona Department of Occupational Safety and Health (ADOSH) due to a requirement to report any cardiac arrest on-site. Thus this ENS notification is in response to a notification to another government agency in accordance with10CFR50.72(b)(2)(xi)."

The licensee notified the NRC Resident Inspector.

LOSS OF POLONIUM-210 STATIC ELIMINATOR

"This letter is pertinent to the lost of an anti-static air gun. The model number is P-2021. The serial number A2AW9S4 is on lease number 007136 and was shipped on 3/19/01. The device was used for spraying acrylic and also to prevent dust. The device was used in the Plastic Shop. It was last used during the month of August, 2001. To my knowledge, the device was misplaced or stolen. The efforts that was made was searching of the shop and questioning the shop personnel. This situation has been brought to management attention, The decision was made to not replace the anti-static gun."