Event Notification Report for May 29, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/28/2002 - 05/29/2002
Fuel Cycle Facility
Event Number: 38949
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: KURT SISLER
HQ OPS Officer: STEVE SANDIN
Region: 3 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: KURT SISLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/29/2002
Notification Time: 20:59 [ET]
Event Date: 05/29/2002
Event Time: 17:05 [EDT]
Last Update Date: 05/29/2002
Notification Time: 20:59 [ET]
Event Date: 05/29/2002
Event Time: 17:05 [EDT]
Last Update Date: 05/29/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS KOZAK (R3)
E. WILLIAM BRACH (NMSS)
THOMAS KOZAK (R3)
E. WILLIAM BRACH (NMSS)
OFFSITE NOTIFICATION TO OHIO EPA DUE TO EXCEEDING OPACITY LIMIT
"On 5/29/02 at 1705 hours, the voltage and current failed to zero on X-600 #1 Precipitator B-side. This equipment failure caused two opacity readings (six minute averages) to be above 20% within one hour. The opacity was 38.1% for 12 minutes. This requires a verbal notification to the Ohio Environmental Protection Agency (OEPA).
"At 2025 hours, the Plant Shift Superintendent notified OEPA of the X-600 Steam Plant opacity exceedance. UE2-RA-RE1030, App D, section P requires a 4 hour NRC event [report] when other government agencies are notified."
Operations informed both the NRC Resident Inspector and the DOE Site Representative.
"On 5/29/02 at 1705 hours, the voltage and current failed to zero on X-600 #1 Precipitator B-side. This equipment failure caused two opacity readings (six minute averages) to be above 20% within one hour. The opacity was 38.1% for 12 minutes. This requires a verbal notification to the Ohio Environmental Protection Agency (OEPA).
"At 2025 hours, the Plant Shift Superintendent notified OEPA of the X-600 Steam Plant opacity exceedance. UE2-RA-RE1030, App D, section P requires a 4 hour NRC event [report] when other government agencies are notified."
Operations informed both the NRC Resident Inspector and the DOE Site Representative.
Power Reactor
Event Number: 38948
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: BRUCE ADAMS
HQ OPS Officer: RICH LAURA
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: BRUCE ADAMS
HQ OPS Officer: RICH LAURA
Notification Date: 05/29/2002
Notification Time: 11:15 [ET]
Event Date: 05/29/2002
Event Time: 00:00 [EDT]
Last Update Date: 05/29/2002
Notification Time: 11:15 [ET]
Event Date: 05/29/2002
Event Time: 00:00 [EDT]
Last Update Date: 05/29/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KERRY LANDIS (R2)
KERRY LANDIS (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION AT TURKEY POINT 3 INVOLVING A DEAD SEA TURTLE
"Site personnel notified the State of Florida, Florida Fish and Wildlife Commission, of finding a dead green sea turtle on FPL property. FPL will also be notifying the U.S. Fish and Wildlife service."
The NRC Resident Inspector was notified. Notified the R2DO (K. Landis).
"Site personnel notified the State of Florida, Florida Fish and Wildlife Commission, of finding a dead green sea turtle on FPL property. FPL will also be notifying the U.S. Fish and Wildlife service."
The NRC Resident Inspector was notified. Notified the R2DO (K. Landis).
General Information or Other
Event Number: 39204
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CEDARS-SINAI MEDICAL CENTER
Region: 4
City: LA State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: STEPHEN DOERFLER
HQ OPS Officer: RICH LAURA
Licensee: CEDARS-SINAI MEDICAL CENTER
Region: 4
City: LA State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: STEPHEN DOERFLER
HQ OPS Officer: RICH LAURA
Notification Date: 09/20/2002
Notification Time: 15:29 [ET]
Event Date: 05/29/2002
Event Time: 00:00 [PDT]
Last Update Date: 09/20/2002
Notification Time: 15:29 [ET]
Event Date: 05/29/2002
Event Time: 00:00 [PDT]
Last Update Date: 09/20/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVE LOVELESS (R4)
FRED BROWN (NMSS)
DAVE LOVELESS (R4)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT INVOLVING A MEDICAL DIAGNOSTIC MISADMINISTRATION
"Background: On June 12, 2002 the licensee Radiation Safety Officer reported a diagnostic misadministration which occurred on May 29, 2002. An elderly patient had been scheduled for an iodine-123 uptake and scan. When she arrived, the nuclear medicine technologist noticed a scar on her neck from a thyroidectomy. Based on this observation, and interview with the patient, the nuclear medicine technologist presumed that the patient needed a neck and head scan with iodine-131. She was given 3.0 mCi of iodine-131 without discussing it with the physician. It turned out that she only had a partial thyroidectomy, and her partial right lobe had approximately a 22% uptake. There was a delay in notifying this Department because the physician felt it wasn't a misadministration, as the primary care physician had ordered the wrong exam to begin with. Dose with iodine-123 would have been 7.0 rads, dose with 3.0 millicuries of iodine-131 was 3087 rads to the thyroid.
"Regulatory Issues: This incident was reported within 15 days as required by the California Code of Regulations, title 17, section 30322. The RSO sent a June 18, 2002 letter describing the root cause of the event and corrective actions to prevent the likelihood of a recurrence. This letter was received in this office on July 10, 2002. During a September 11, 2002 telephone conversation, I was told that the Nuclear Medicine Department procedures were changed so that scheduling for these type of procedures are now performed by nuclear medicine technologists and not clerical personnel.
"This was reportable to the NRC because it involved over 39 millicuries of I-131. Cedars-Sinai Medical Center will be cited for violation of the California Code of Regulations, title 17, sections 30521, which requires nuclear medicine technologists to be under General Supervision when performing nuclear medicine technology procedures, and 30502 which defines General Supervision as meaning that the supervisor is responsible for, and has control of all of the following:
1. Quality, technical and medical aspects of all nuclear medicine technology procedures;
2. Radiation health and safety of patients, ancillary personnel and other persons;
3. Ascertaining that nuclear medicine technologists maintain their competency by participation in management sponsored or formal continuing education or training offered by professional organizations or societies, or institutions of higher learning.
"Contrary to the above, the nuclear medicine technologist who administered the 3 millicuries of I-131, and under the General Supervision of the authorized user, made decisions regarding the procedure and dose to be administered without consultation with the authorized user.
"Health and Safety Concerns: The patient received an unnecessary dose. Her thyroid should have received only about 7 rads had she received 200 microcuries of I-23, but instead she received 3,087 rads. The information needed was obtained, and an additional dose was not given. Because there is a possibility of reduction in thyroid function, Cedars-Sinai Medical Center has said the patient will be followed by her physician.
"Conclusion: The referring physician's written order on file at the hospital was not examined during the investigation because neither the document, or a copy of this document, could be released to this office due to a new patient privacy law, according to the RSO."
"Background: On June 12, 2002 the licensee Radiation Safety Officer reported a diagnostic misadministration which occurred on May 29, 2002. An elderly patient had been scheduled for an iodine-123 uptake and scan. When she arrived, the nuclear medicine technologist noticed a scar on her neck from a thyroidectomy. Based on this observation, and interview with the patient, the nuclear medicine technologist presumed that the patient needed a neck and head scan with iodine-131. She was given 3.0 mCi of iodine-131 without discussing it with the physician. It turned out that she only had a partial thyroidectomy, and her partial right lobe had approximately a 22% uptake. There was a delay in notifying this Department because the physician felt it wasn't a misadministration, as the primary care physician had ordered the wrong exam to begin with. Dose with iodine-123 would have been 7.0 rads, dose with 3.0 millicuries of iodine-131 was 3087 rads to the thyroid.
"Regulatory Issues: This incident was reported within 15 days as required by the California Code of Regulations, title 17, section 30322. The RSO sent a June 18, 2002 letter describing the root cause of the event and corrective actions to prevent the likelihood of a recurrence. This letter was received in this office on July 10, 2002. During a September 11, 2002 telephone conversation, I was told that the Nuclear Medicine Department procedures were changed so that scheduling for these type of procedures are now performed by nuclear medicine technologists and not clerical personnel.
"This was reportable to the NRC because it involved over 39 millicuries of I-131. Cedars-Sinai Medical Center will be cited for violation of the California Code of Regulations, title 17, sections 30521, which requires nuclear medicine technologists to be under General Supervision when performing nuclear medicine technology procedures, and 30502 which defines General Supervision as meaning that the supervisor is responsible for, and has control of all of the following:
1. Quality, technical and medical aspects of all nuclear medicine technology procedures;
2. Radiation health and safety of patients, ancillary personnel and other persons;
3. Ascertaining that nuclear medicine technologists maintain their competency by participation in management sponsored or formal continuing education or training offered by professional organizations or societies, or institutions of higher learning.
"Contrary to the above, the nuclear medicine technologist who administered the 3 millicuries of I-131, and under the General Supervision of the authorized user, made decisions regarding the procedure and dose to be administered without consultation with the authorized user.
"Health and Safety Concerns: The patient received an unnecessary dose. Her thyroid should have received only about 7 rads had she received 200 microcuries of I-23, but instead she received 3,087 rads. The information needed was obtained, and an additional dose was not given. Because there is a possibility of reduction in thyroid function, Cedars-Sinai Medical Center has said the patient will be followed by her physician.
"Conclusion: The referring physician's written order on file at the hospital was not examined during the investigation because neither the document, or a copy of this document, could be released to this office due to a new patient privacy law, according to the RSO."