Event Notification Report for May 3, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/02/2002 - 05/03/2002
** EVENT NUMBERS **
38883 38884 38892 38893
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|General Information or Other |Event Number: 38883 |
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| REP ORG: LOUISIANA RADIATION PROTECTION DIV |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: TULANE UNIVERSITY |NOTIFICATION TIME: 11:03[EDT]|
| CITY: NEW ORLEANS REGION: 4 |EVENT DATE: 04/22/2002|
| COUNTY: STATE: LA |EVENT TIME: 10:25[CDT]|
|LICENSE#: LA-0004-L01 AGREEMENT: Y |LAST UPDATE DATE: 04/30/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: SCOTT BLACKWELL | |
| HQ OPS OFFICER: GERRY WAIG | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| The following event description is taken from a facsimile: |
| |
| "On April 22, 2002, the technologist injected a patient with a syringe |
| labeled Tc-99m MAG 3 in order to image the kidneys. The gamma camera showed |
| uptake in the liver-kidney indicating a sulfur colloid dose. The patient was |
| prescribed a 4.5 mCi dose of Tc-99m MAG 3, but received a 4.5 mCi dose of |
| Tc-99m Sulfur Colloid. The patient and the pharmacy were notified of the |
| error. The dose for a patient receiving 5 mCi of Tc-99m Sulfur Colloid is |
| estimated as the following: |
| Liver - 12.15 Rad, Spleen - 7.65 Rad, Bone Marrow - 0.05 Rad, Testes - 0.02 |
| Rad, Ovaries - 0.2 Rad, |
| and Total Body - 0.675 Rad." |
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|General Information or Other |Event Number: 38884 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: LONGVIEW INSPECTION |NOTIFICATION TIME: 15:05[EDT]|
| CITY: CHANNAHON REGION: 3 |EVENT DATE: 06/01/2000|
| COUNTY: STATE: IL |EVENT TIME: [CDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 04/30/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |FRED BROWN NMSS |
+------------------------------------------------+PAUL LOHAUS STP |
| NRC NOTIFIED BY: JOSEPH KLINGER |TIM MCGINTY IRO |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT OF RADIOGRAPHER OVEREXPOSURE FROM TWO
YEARS AGO |
| |
| "On April 29, 2002, the department completed its investigation into a |
| reported radiography incident that may have occurred in June 2000. After a |
| review of all available information, the department cannot definitively |
| eliminate the possibility that an industrial radiographer received a |
| radiation burn while performing industrial radiography at a temporary |
| jobsite near Channahon, Illinois. The radiographer was using an 81.2 Ci |
| lr-192 source while performing radiographs on 8-inch pipe welds. The |
| radiographer alleges that after cranking the source back in, he approached |
| the area without looking at his survey meter. He set the meter behind the |
| camera and knelt down in front of the camera, He changed out the film and |
| then changed out the band and numbers for the next shot. He then |
| disconnected the guide tube and saw 4-6 inches of the drive cable. He looked |
| over at the survey meter and saw that it was pegged. He then immediately |
| went to the controls and cranked the source fully into the camera. He |
| performed a survey of the area and saw that the source was shielded |
| properly. He looked at his alarming rate meter and saw that the battery |
| indicator showed low battery. His self-reading pocket dosimeter showed |
| off-scale. What happened after that is even more unclear but the |
| radiographer continued working for the rest of the day. The radiographer did |
| not report the incident to the RSO nor did the other radiographer on the two |
| certified radiographer team. In fact, the other radiographer denies knowing |
| anything about the reported incident. The allegedly overexposed radiographer |
| states that after one or two weeks, he noticed a red area, about the size of |
| a nickel, on his leg. He stated that it was a red area with what appeared to |
| be white scar tissue in the center. It was not until May or June of 2001 |
| that he realized that it may have been a radiation burn. During August or |
| September 2001 his condition apparently worsened and the area would not |
| heal. In early January 2002 the Radiation Safety Officer finally became |
| aware of this matter, and notified the department on January 15, 2002. In |
| early January 2002 the radiographer was apparently examined by a physician. |
| The radiographer stated that the physician took a biopsy and the diagnosis |
| was either sarcoma or radiodermatitis. A preliminary report was provided to |
| the department by the licensee on January 16, 2002. The department |
| recommended the licensee seek assistance from the REAC/TS Center in Oak |
| Ridge, which they did. The information pertaining to this incident was |
| provided to REAC/TS by the licensee and REAC/TS concluded that the medical |
| condition could be attributed to the event in June 2000. After thoroughly |
| reviewing all the information available and scheduling interviews for |
| involved out of state personnel, the department conducted interviews and |
| time in motion studies on February 25, 2002. Subsequent to the interviews |
| and time in motion studies, careful review was performed as well as |
| additional clarifying information was requested and reviewed. Finally on |
| April 29, 2002, the department concluded that it could not definitively |
| eliminate the possibility that this industrial radiographer received a |
| radiation burn while performing industrial radiography at a temporary job |
| site near Chanson, Illinois in June 2000. The radiographer underwent skin |
| grafting on February 26, 2002, and was released after several days. The |
| radiographer currently remains under medical surveillance and reports that |
| the graft was less than successful. The licensee has been issued a Notice of |
| Violation and will take appropriate actions to prevent a recurrence. The |
| radiographer may be subject to additional department enforcement action |
| related to his industrial radiographer certification resulting from this |
| event." |
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|Power Reactor |Event Number: 38892 |
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| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 05/02/2002|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 15:22[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 03/22/2002|
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| NRC NOTIFIED BY: JOHN KARRICK |LAST UPDATE DATE: 05/02/2002|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| GROUP 3A CONTAINMENT ISOLATION AT DUANE ARNOLD |
| |
| "While operating in Mode 1, a fuel pool exhaust radiation monitor spiked, |
| resulting in a Group 3A Primary Containment Isolation System (PCIS) |
| actuation. Radiation levels in the area of the monitor were normal and the |
| actuation was considered invalid. The "A" train of the Standby Gas |
| Treatment System (SBGT) auto-started and the Group 3A isolation functioned |
| as designed. The isolation was reset 14 minutes after the trip." |
| |
| The NRC Resident Inspector was notified. |
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|Other Nuclear Material |Event Number: 38893 |
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| REP ORG: MAXIM TECHNOLOGIES INCORPORATED |NOTIFICATION DATE:
05/02/2002|
|LICENSEE: MAXIM TECHNOLOGY INCORPORATED |NOTIFICATION TIME:
22:00[EDT]|
| CITY: INDEPENDENCE REGION: 3 |EVENT DATE: 05/02/2002|
| COUNTY: STATE: MO |EVENT TIME: [CDT]|
|LICENSE#: 22-C-250-01 AGREEMENT: N |LAST UPDATE DATE: 05/02/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |ERIC LEEDS NMSS |
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| NRC NOTIFIED BY: DUSTIN BINGHAM | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
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EVENT TEXT
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| STOLEN TROXLER DENSITY GAUGE |
| |
| The licensee reported a stolen troxler density gauge which was secured in |
| the rear of a work truck located in Independence, Missouri. The licensee |
| reported the theft to the Independence Police Department. The gauge was |
| model number 3340 with a serial number of 22323. The isotopes and |
| activities used in the gauge are 8.0 millicuries of CS-137 and 40 |
| millicuries of AM-241. |
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