United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2003 > May 8

Event Notification Report for May 8, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           05/07/2003 - 05/08/2003



                              ** EVENT NUMBERS **



39820  39824  39831  



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   39820       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  NC DIV OF RADIATION PROTECTION       |NOTIFICATION DATE: 05/02/2003|

|LICENSEE:  TROXLER                              |NOTIFICATION TIME: 16:32[EDT]|

|    CITY:  RALEIGH                  REGION:  2  |EVENT DATE:        03/24/2003|

|  COUNTY:                            STATE:  NC |EVENT TIME:             [EDT]|

|LICENSE#:  032-0182-1            AGREEMENT:  Y  |LAST UPDATE DATE:  05/02/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |JOEL MUNDAY          R2      |

|                                                |C. MILLER            NMSS    |

+------------------------------------------------+F. BROWN             NMSS    |

| NRC NOTIFIED BY:  JAMES ALBRIGHT               |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| AGREEMENT STATE REPORT - RADIOACTIVE SHIPMENT EXCEEDED LIMITS                |

|                                                                              |

| On 3/24/03 Troxler Electronic Laboratories of Research Triangle Park, NC     |

| received a shipment of two boxes from AEA Technology, Inc. of Burlington,    |

| MA.  Each box contained fifty 40 millicurie Am-241:Be sources.  Following    |

| return of a survey meter from calibration, the RSO at Troxler performed a    |

| survey of the boxes on 3/31/03 and determined that the radiation levels      |

| exceeded limits for the shipment.  Each box measured 315 millirem/hr neutron |

| and gamma at the surface (limit of 200 millirem/hr).  Additionally, the bill |

| of lading and DOT sticker on each box listed the Transportation Index (TI)   |

| at 1.6 which is the limit, however the measured TI was 3.1 (3.0 millirem/hr  |

| neutron and 0.1 millirem/hr gamma at 1 meter).                               |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|General Information or Other                     |Event Number:   39824       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  SC DIV OF HEALTH & ENV CONTROL       |NOTIFICATION DATE: 05/05/2003|

|LICENSEE:  STERIS-ISOMEDIX SERVICES             |NOTIFICATION TIME: 16:25[EDT]|

|    CITY:  SPARTENBURG              REGION:  2  |EVENT DATE:        05/05/2003|

|  COUNTY:                            STATE:  SC |EVENT TIME:        11:30[EDT]|

|LICENSE#:  267                   AGREEMENT:  Y  |LAST UPDATE DATE:  05/05/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |JOEL MUNDAY          R2      |

|                                                |TOM ESSIG            NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  DAVID KING                   |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| MALFUNCTIONING IRRADIATOR CARRIER DOOR HINGE PIN ASSEMBLY                    |

|                                                                              |

| Steris-Isomedix Services reported to the state that they had an incident     |

| where the hinge pin assembly on the carrier door of an irradiator            |

| malfunctioned.  This resulted in the door opening and jamming at the source  |

| rack which in turn left the source in a fully unshielded position.  The      |

| operator then went to the hoist cables for the source rack, which is in a    |

| shielded area, moved the cables around a bit and unjammed the source rack    |

| returning the source to the fully shielded position.  The amount of time     |

| taken to return the source to the fully shielded position was approximately  |

| 20-30 minutes. The licensee is shutting down all irradiators to check the    |

| hinge pin assemblies.  There were no exposures.                              |

+------------------------------------------------------------------------------+



+------------------------------------------------------------------------------+

|Hospital                                         |Event Number:   39831       |

+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  WASHINGTON HOSPITAL CTR              |NOTIFICATION DATE: 05/07/2003|

|LICENSEE:  WASHINGTON HOSPITAL CTR              |NOTIFICATION TIME: 14:57[EDT]|

|    CITY:  WASHINGTON               REGION:  1  |EVENT DATE:        05/06/2003|

|  COUNTY:                            STATE:  DC |EVENT TIME:             [EDT]|

|LICENSE#:  080360403             AGREEMENT:  N  |LAST UPDATE DATE:  05/07/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |EUGENE COBEY         R1      |

|                                                |TOM ESSIG                    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  SHA SHA DHAR MOHAPATRA       |                             |

|  HQ OPS OFFICER:  GERRY WAIG                   |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LOTH 35.3045(a)(3)       DOSE TO OTHER SITE > SP|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT                                   

+------------------------------------------------------------------------------+

| MEDICAL EVENT - BRACHYTHERAPY RADIATION THERAPY NOT ADMINISTERED TO INTENDED |

| SITE                                                                         |

|                                                                              |

| A patient at Washington Hospital Center, being administered brachytherapy    |

| treatment, received the treatment to a non- intended site. Based on          |

| preliminary information, this occurred due to the Strontium 90 source being  |

| placed in the wrong place during treatment. The patient received the         |

| intended 23 gray dose. The patient has been notified and the licensee is     |

| investigating the cause of the event. The licensee has notified the Hospital |

| Chief Medical Physicist, Oncologist, and will also notify the Hospital       |

| Cardiologist.                                                                |

+------------------------------------------------------------------------------+