Event Notification Report for April 12, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/11/2002 - 04/12/2002
EVENT NUMBERS
38861388483884938850
General Information or Other
Event Number: 38861
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MEMORIAL MEDICAL CENTER-BAPTIST CAMPUS
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0349-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: LEIGH TROCINE
Licensee: MEMORIAL MEDICAL CENTER-BAPTIST CAMPUS
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-0349-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: LEIGH TROCINE
Notification Date: 04/17/2002
Notification Time: 16:30 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2002
Notification Time: 16:30 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
DON COOL (NMSS)
LINDA SMITH (R4)
DON COOL (NMSS)
AGREEMENT STATE REPORT/MEDICAL MISADMINISTRATIONS INVOLVING THREE PATIENTS AT MEMORIAL MEDICAL CENTER-BAPTIST CAMPUS IN NEW ORLEANS, LOUISIANA
The following text is a portion of a facsimile received from the Louisiana Department of Environmental Quality:
"Event Report ID No.: LA020007"
"License No.: LA-0349-L01"
"Licensee: Memorial Medical Center-Baptist Campus"
"Event [Date] and Time: At the beginning of March 2002"
"Event Location: [... New Orleans, LA ...]"
"Event [Type]: Misadministration"
"Notifications: Notified the patients and physician."
"Event [Description]: On April 12, 2002, it was discovered that [three] patients received a misadministration on a therapy procedure. All three patients were to receive therapy doses to the prostate. While planning the therapy, the Dosimetrist put Nucletron Source Positioning Simulator (Part #111.094) together the wrong way. The design of the Simulator allows it to be put together backwards. The correct distance for the dose was 1408 mm, but the actual distance was 1117 mm. The dose the patient received was calculated as 70 centigray to the knees, thighs, and scrotum of the three patients. As of now, there appears to be no observable effects to the patients. All three patients were notified and agreed to have the therapy again for the correct site. This facility uses a Nucletron Vectrave HDR with a 10-Ci source of Ir-192. The activity during the patient therapy was 8.06 Ci for one patient, 5.45 Ci for another, and 4.8 Ci for the third patient. The policy has been changed so that the physicist will check the position simulator before use. Further details will be placed in the NMED database as soon as the details are available."
"Transport [Vehicle Description]: NA"
"Media [Attention]: NA"
Call the NRC operations officer for state contact information and event location details.
The following text is a portion of a facsimile received from the Louisiana Department of Environmental Quality:
"Event Report ID No.: LA020007"
"License No.: LA-0349-L01"
"Licensee: Memorial Medical Center-Baptist Campus"
"Event [Date] and Time: At the beginning of March 2002"
"Event Location: [... New Orleans, LA ...]"
"Event [Type]: Misadministration"
"Notifications: Notified the patients and physician."
"Event [Description]: On April 12, 2002, it was discovered that [three] patients received a misadministration on a therapy procedure. All three patients were to receive therapy doses to the prostate. While planning the therapy, the Dosimetrist put Nucletron Source Positioning Simulator (Part #111.094) together the wrong way. The design of the Simulator allows it to be put together backwards. The correct distance for the dose was 1408 mm, but the actual distance was 1117 mm. The dose the patient received was calculated as 70 centigray to the knees, thighs, and scrotum of the three patients. As of now, there appears to be no observable effects to the patients. All three patients were notified and agreed to have the therapy again for the correct site. This facility uses a Nucletron Vectrave HDR with a 10-Ci source of Ir-192. The activity during the patient therapy was 8.06 Ci for one patient, 5.45 Ci for another, and 4.8 Ci for the third patient. The policy has been changed so that the physicist will check the position simulator before use. Further details will be placed in the NMED database as soon as the details are available."
"Transport [Vehicle Description]: NA"
"Media [Attention]: NA"
Call the NRC operations officer for state contact information and event location details.
Other Nuclear Material
Event Number: 38848
Rep Org: BRISTOL-MYERS SQUIBB
Licensee: BRISTOL-MYERS SQUIBB RADIOPHARMACEUTICALS, INC.
Region: 2
City: RIO TIADRIS State: PR
County:
License #: 52-25361-01MD
Agreement: N
Docket:
NRC Notified By: FRANCIS ROY
HQ OPS Officer: BOB STRANSKY
Licensee: BRISTOL-MYERS SQUIBB RADIOPHARMACEUTICALS, INC.
Region: 2
City: RIO TIADRIS State: PR
County:
License #: 52-25361-01MD
Agreement: N
Docket:
NRC Notified By: FRANCIS ROY
HQ OPS Officer: BOB STRANSKY
Notification Date: 04/12/2002
Notification Time: 16:15 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2002
Notification Time: 16:15 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
Person (Organization):
KEN BARR (R2)
FRED BROWN (NMSS)
KEN BARR (R2)
FRED BROWN (NMSS)
POTENTIAL OVEREXPOSURE OF EXTREMITIES
While investigating high ring dosimeter readings for two radiopharmacists involved in dispensing doses of Tc-99m, the licensee discovered that these individuals may have exceeded their occupational dose limits to the extremities for 2001. Ring dosimeter readings of 30-40 rem were recorded for the individuals. During followup investigations, a certified health physicist, using fingertip dosimetry, determined that the individuals were receiving fingertip doses 3 to 7 times higher than those recorded on the ring dosimeters. Therefore, the individuals may have exceeded the annual occupational dose limit of 50 rem to the extremities.
The licensee will be providing a report to NRC Region II next week.
While investigating high ring dosimeter readings for two radiopharmacists involved in dispensing doses of Tc-99m, the licensee discovered that these individuals may have exceeded their occupational dose limits to the extremities for 2001. Ring dosimeter readings of 30-40 rem were recorded for the individuals. During followup investigations, a certified health physicist, using fingertip dosimetry, determined that the individuals were receiving fingertip doses 3 to 7 times higher than those recorded on the ring dosimeters. Therefore, the individuals may have exceeded the annual occupational dose limit of 50 rem to the extremities.
The licensee will be providing a report to NRC Region II next week.
General Information or Other
Event Number: 38849
Rep Org: WYLE LABORATORIES
Licensee: WYLE LABORATORIES
Region: 2
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWARD SMITH (FAX)
HQ OPS Officer: BOB STRANSKY
Licensee: WYLE LABORATORIES
Region: 2
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWARD SMITH (FAX)
HQ OPS Officer: BOB STRANSKY
Notification Date: 04/12/2002
Notification Time: 17:05 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [CDT]
Last Update Date: 04/12/2002
Notification Time: 17:05 [ET]
Event Date: 04/12/2002
Event Time: 00:00 [CDT]
Last Update Date: 04/12/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
VERN HODGE (FAX) (NRR)
VERN HODGE (FAX) (NRR)
10 CFR PART 21 REPORT
"Pursuant to the 10 CFR Part 21 requirements, this letter notifies the NRC of a Potential Part 21 condition.
"An error in irradiation dose units is identified in the attached letter from Georgia Tech letter dated March 15, 2002, which was received by Wyle on April 11, 2002. The error applies to all equipment irradiated with the cobalt-60 sources in the Georgia Tech hot cell from 7/24/1997 to 7/6/2001. Georgia Tech reported radiation doses in units of rads-air (absorbed dose in air) instead of Roentgens. Since one Roentgen is equal to 0.877 rad, the actual dose is less than the reported value.
"Wyle will perform an evaluation to determine
"1. Wyle projects that include irradiation with the cobalt-60 sources in the Georgia Tech hot cell from 7/24/1997 to 7/6/2001.
"2. The actual dose absorbed by equipment in said projects.
"3. Whether the actual dose in said projects envelops the customer-specified requirements.
"Wyle Laboratories has the capability and chooses to perform the evaluation to determine if a defect exists. It is the responsibility to Wyle Laboratories to inform the purchaser(s), and any affected licensees.
"Wyle will complete the specified evaluation of the circumstances within sixty (60) days of discovery of the potential defect. The NRC will be provided a copy of Wyle's evaluation report."
"Pursuant to the 10 CFR Part 21 requirements, this letter notifies the NRC of a Potential Part 21 condition.
"An error in irradiation dose units is identified in the attached letter from Georgia Tech letter dated March 15, 2002, which was received by Wyle on April 11, 2002. The error applies to all equipment irradiated with the cobalt-60 sources in the Georgia Tech hot cell from 7/24/1997 to 7/6/2001. Georgia Tech reported radiation doses in units of rads-air (absorbed dose in air) instead of Roentgens. Since one Roentgen is equal to 0.877 rad, the actual dose is less than the reported value.
"Wyle will perform an evaluation to determine
"1. Wyle projects that include irradiation with the cobalt-60 sources in the Georgia Tech hot cell from 7/24/1997 to 7/6/2001.
"2. The actual dose absorbed by equipment in said projects.
"3. Whether the actual dose in said projects envelops the customer-specified requirements.
"Wyle Laboratories has the capability and chooses to perform the evaluation to determine if a defect exists. It is the responsibility to Wyle Laboratories to inform the purchaser(s), and any affected licensees.
"Wyle will complete the specified evaluation of the circumstances within sixty (60) days of discovery of the potential defect. The NRC will be provided a copy of Wyle's evaluation report."
Power Reactor
Event Number: 38850
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KENNY MIDDLEBROOKS
HQ OPS Officer: BOB STRANSKY
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KENNY MIDDLEBROOKS
HQ OPS Officer: BOB STRANSKY
Notification Date: 04/12/2002
Notification Time: 17:37 [ET]
Event Date: 04/12/2002
Event Time: 08:38 [EDT]
Last Update Date: 04/12/2002
Notification Time: 17:37 [ET]
Event Date: 04/12/2002
Event Time: 08:38 [EDT]
Last Update Date: 04/12/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
KEN BARR (R2)
KEN BARR (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT
A contract supervisor tested positive for alcohol use during a for-cause test. The individual's site access has been terminated. Contact the NRC Operations Center for additional information.
A contract supervisor tested positive for alcohol use during a for-cause test. The individual's site access has been terminated. Contact the NRC Operations Center for additional information.