Event Notification Report for January 23, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/22/2004 - 01/23/2004
EVENT NUMBERS
404724047340479404684055240502
Power Reactor
Event Number: 40472
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID FRYE
HQ OPS Officer: MIKE RIPLEY
Region: 1 State: MD
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID FRYE
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/23/2004
Notification Time: 17:45 [ET]
Event Date: 01/23/2004
Event Time: 15:29 [EST]
Last Update Date: 03/23/2004
Notification Time: 17:45 [ET]
Event Date: 01/23/2004
Event Time: 15:29 [EST]
Last Update Date: 03/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CLIFFORD ANDERSON (R1)
HERB BERKOW (NRR)
RICHARD WESSMAN (DIRO)
CLIFFORD ANDERSON (R1)
HERB BERKOW (NRR)
RICHARD WESSMAN (DIRO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP WITH SAFETY INJECTION ACTUATION SIGNALS
"At 1529 ET the reactor was manually tripped due to low steam generator level as a result of the loss of the 22 SGFP (Steam Generator Feed Pump). When the reactor was tripped, the turbine bypass and atmospheric dump valves went full open and did not shut. This lead to a SIAS (Safety Injection Actuation Signal) and SGIS (Steam Generator Isolation Signal). At 1718 ET, a second SIAS actuation occurred while reestablishing pressurizer level. The cause of the SGFP trip is unknown. The cause of the over steaming on turbine bypass valves and atmospheric dump valves is unknown."
All control rods fully inserted. Auxiliary Feedwater initiated normally. The licensee stated that there was no actual ECCS injection to the RCS. The plant electrical system responded normally and all emergency diesel generators remain operable. All ECCS systems remain operable. There are no primary to secondary leaks. Decay heat is currently being removed via the steam-driven auxiliary feedwater pump and the atmospheric steam dumps. As of 1830 ET, primary pressure is approximately 2103 psi and pressurizer level is at 242 inches. Plant conditions are being stabilized at normal hot standby values . The licensee notified the NRC Resident Inspector who responded to the Control Room.
* * * UPDATE FROM PACE TO GOTT ON 1/26/04 AT 1438 EST * * *
The licensee reported that their post trip review determined that the reactor received an automatic trip about 2 seconds before the manual trip. The automatic trip was due to low steam generator water level.
The licensee notified the NRC Resident Inspector.
Notified NRR (Reis) and R1DO (Meyer)
* * * UPDATE ON 03/23/04 @ 1604 BY DAVID FRYE TO C. GOULD * * *
During post event review of the 1/23/04 Rx Trip event (40472), it was discovered that Unit 2 met the entry criteria for EOP-4, Excess Steam Demand event. This condition required declaration of an Unusual Event. No declaration was made at the time because of the transitory nature of the condition. Transitory conditions such as this, however, still require reporting per NUREG-1022, Rev. 2. Immediate notification to the NRC via the Emergency Notification System is required per 10 CFR 50.72(a)(1)(i).
The NRC Resident Inspector will be notified.
"At 1529 ET the reactor was manually tripped due to low steam generator level as a result of the loss of the 22 SGFP (Steam Generator Feed Pump). When the reactor was tripped, the turbine bypass and atmospheric dump valves went full open and did not shut. This lead to a SIAS (Safety Injection Actuation Signal) and SGIS (Steam Generator Isolation Signal). At 1718 ET, a second SIAS actuation occurred while reestablishing pressurizer level. The cause of the SGFP trip is unknown. The cause of the over steaming on turbine bypass valves and atmospheric dump valves is unknown."
All control rods fully inserted. Auxiliary Feedwater initiated normally. The licensee stated that there was no actual ECCS injection to the RCS. The plant electrical system responded normally and all emergency diesel generators remain operable. All ECCS systems remain operable. There are no primary to secondary leaks. Decay heat is currently being removed via the steam-driven auxiliary feedwater pump and the atmospheric steam dumps. As of 1830 ET, primary pressure is approximately 2103 psi and pressurizer level is at 242 inches. Plant conditions are being stabilized at normal hot standby values . The licensee notified the NRC Resident Inspector who responded to the Control Room.
* * * UPDATE FROM PACE TO GOTT ON 1/26/04 AT 1438 EST * * *
The licensee reported that their post trip review determined that the reactor received an automatic trip about 2 seconds before the manual trip. The automatic trip was due to low steam generator water level.
The licensee notified the NRC Resident Inspector.
Notified NRR (Reis) and R1DO (Meyer)
* * * UPDATE ON 03/23/04 @ 1604 BY DAVID FRYE TO C. GOULD * * *
During post event review of the 1/23/04 Rx Trip event (40472), it was discovered that Unit 2 met the entry criteria for EOP-4, Excess Steam Demand event. This condition required declaration of an Unusual Event. No declaration was made at the time because of the transitory nature of the condition. Transitory conditions such as this, however, still require reporting per NUREG-1022, Rev. 2. Immediate notification to the NRC via the Emergency Notification System is required per 10 CFR 50.72(a)(1)(i).
The NRC Resident Inspector will be notified.
Power Reactor
Event Number: 40473
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE SCHAEFER
HQ OPS Officer: MIKE RIPLEY
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE SCHAEFER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/23/2004
Notification Time: 19:42 [ET]
Event Date: 01/23/2004
Event Time: 16:16 [CST]
Last Update Date: 01/23/2004
Notification Time: 19:42 [ET]
Event Date: 01/23/2004
Event Time: 16:16 [CST]
Last Update Date: 01/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
LINDA HOWELL (R4)
LINDA HOWELL (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO HIGH-HIGH STEAM GENERATOR LEVEL
"We make the following report per 10CFR50.72(b)(2)(iv)(B). At 16:16 CST Unit 1 Reactor automatically tripped from full power due to [actual] high-high level in 1B Steam Generator. Prior to the trip, vital distribution panel 1201 lost power when it's normal power supply inverter failed. Steam Generators 1A and 1B levels were selected to instruments from this power supply [and therefore generating a false low level output]. Operators were in the process of taking manual control of 1A and 1B Main Feed regulating valves when the Main Turbine trip was actuated due to the high level in 1B Steam Generator. A reactor trip occurred due to the Turbine Trip above 50% power. The unit is stable at 567 degrees and 2235 pslg.
"We also make the following report per 10CFR50.72(b)(3)(iv)(A). Following the reactor trip the Auxiliary Feed Water System automatically actuated on [actual] low steam generator level. This is normal for a trip in the Unit 1 from full power.
"The following information is also provided: All control rods fully inserted. No primary reliefs lifted. Technical Specification 3.8.3.1 action b was entered due to the vital distribution panel not being energized from its normal source. (inverter). It is currently power from it's voltage regulator."
Decay heat is currently being removed via the steam dumps. The plant electrical system responded normally and all emergency diesel generators remain in standby. All ECCS systems remain operable. There are no primary to secondary leaks. The licensee notified the NRC Resident Inspector.
"We make the following report per 10CFR50.72(b)(2)(iv)(B). At 16:16 CST Unit 1 Reactor automatically tripped from full power due to [actual] high-high level in 1B Steam Generator. Prior to the trip, vital distribution panel 1201 lost power when it's normal power supply inverter failed. Steam Generators 1A and 1B levels were selected to instruments from this power supply [and therefore generating a false low level output]. Operators were in the process of taking manual control of 1A and 1B Main Feed regulating valves when the Main Turbine trip was actuated due to the high level in 1B Steam Generator. A reactor trip occurred due to the Turbine Trip above 50% power. The unit is stable at 567 degrees and 2235 pslg.
"We also make the following report per 10CFR50.72(b)(3)(iv)(A). Following the reactor trip the Auxiliary Feed Water System automatically actuated on [actual] low steam generator level. This is normal for a trip in the Unit 1 from full power.
"The following information is also provided: All control rods fully inserted. No primary reliefs lifted. Technical Specification 3.8.3.1 action b was entered due to the vital distribution panel not being energized from its normal source. (inverter). It is currently power from it's voltage regulator."
Decay heat is currently being removed via the steam dumps. The plant electrical system responded normally and all emergency diesel generators remain in standby. All ECCS systems remain operable. There are no primary to secondary leaks. The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 40479
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TAYLOR FORGE ENGINEERED SYSTEMS
Region: 4
City: PAOLA State: KS
County:
License #: 21-B108-01
Agreement: Y
Docket:
NRC Notified By: JAMES JOHNSON
HQ OPS Officer: BILL GOTT
Licensee: TAYLOR FORGE ENGINEERED SYSTEMS
Region: 4
City: PAOLA State: KS
County:
License #: 21-B108-01
Agreement: Y
Docket:
NRC Notified By: JAMES JOHNSON
HQ OPS Officer: BILL GOTT
Notification Date: 01/26/2004
Notification Time: 13:21 [ET]
Event Date: 01/23/2004
Event Time: 17:30 [CST]
Last Update Date: 01/26/2004
Notification Time: 13:21 [ET]
Event Date: 01/23/2004
Event Time: 17:30 [CST]
Last Update Date: 01/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JOHNSON (R4)
DOUG BROADDUS (NMSS)
WILLIAM JOHNSON (R4)
DOUG BROADDUS (NMSS)
AGREEMENT STATE REPORT OF OVEREXPOSURE FROM RADIOGRAPHY SOURCE
"On 1/26/04, about 8:00 am (CST), [Kansas Department of Health and Environment] KDHE staff retrieved a phone message from the Assistant Radiation Safety Officer (ARSO), of Taylor Forge Engineered Systems, Inc (TFES). The ARSO called on 1/23/04, Friday, about 10:20 pm, stating that one of their radiographers may have received an exposure greater than 5 Rem. This was the initial phone call stating that an unusual event may have occurred. Around 5:30 pm, on 1/23/04, a radiographer was performing radiographic operations in the middle bullpen cell, using a Co-60, 62.1 curie source. According to the radiographer, the gamma alarm malfunctioned, thereby the lights, bells and alarms weren't working. He entered the vault to try and determine the cause of the malfunction, but failed to retract the source, resulting in a possible overexposure to himself. The radiographer was in the area about 10 - 15 minutes. The radiographer contacted the ARSO later that evening and related the above events.
"On 1/26/04, about 8:00 am, KDHE staff retrieved a phone message from the Radiation Safety Officer (RSO). The RSO called on 1/24/04, Saturday, about 7:00 am, stating that one of their radiographers had received an overexposure greater than the 5 Rem limit. This was the official 24 hour emergency notification. The radiographer's chirping alarm rate meter and pocket ion chambers (PICs 200 mrems / 500 mrems) were found to be off-scale. The radiographers film badge was overnighted to Landauer dosimetry services for processing. The radiographer has been relieved of his duties as they relate to IR. Preliminary dose calculation estimates, from the RSO, are that radiographer received between 15 - 30 rems whole body and up to 87 rems to the hand. TFES is currently investigating the incident and is trying to recreate the above mentioned conditions (using a dummy source) to determine what happened. KDHE is currently investigating the incident. We will provide updates when they occur."
Source:
Cobalt 60, 62.1 Curies
Manufacturer: AEA Technologies
Model Number: TECHOPS A-424-14
Serial Number: S/N 2899
Device:
Manufacturer: AEA Technologies
Model Number 660-B
Serial Number: S/N B-234
"On 1/26/04, about 8:00 am (CST), [Kansas Department of Health and Environment] KDHE staff retrieved a phone message from the Assistant Radiation Safety Officer (ARSO), of Taylor Forge Engineered Systems, Inc (TFES). The ARSO called on 1/23/04, Friday, about 10:20 pm, stating that one of their radiographers may have received an exposure greater than 5 Rem. This was the initial phone call stating that an unusual event may have occurred. Around 5:30 pm, on 1/23/04, a radiographer was performing radiographic operations in the middle bullpen cell, using a Co-60, 62.1 curie source. According to the radiographer, the gamma alarm malfunctioned, thereby the lights, bells and alarms weren't working. He entered the vault to try and determine the cause of the malfunction, but failed to retract the source, resulting in a possible overexposure to himself. The radiographer was in the area about 10 - 15 minutes. The radiographer contacted the ARSO later that evening and related the above events.
"On 1/26/04, about 8:00 am, KDHE staff retrieved a phone message from the Radiation Safety Officer (RSO). The RSO called on 1/24/04, Saturday, about 7:00 am, stating that one of their radiographers had received an overexposure greater than the 5 Rem limit. This was the official 24 hour emergency notification. The radiographer's chirping alarm rate meter and pocket ion chambers (PICs 200 mrems / 500 mrems) were found to be off-scale. The radiographers film badge was overnighted to Landauer dosimetry services for processing. The radiographer has been relieved of his duties as they relate to IR. Preliminary dose calculation estimates, from the RSO, are that radiographer received between 15 - 30 rems whole body and up to 87 rems to the hand. TFES is currently investigating the incident and is trying to recreate the above mentioned conditions (using a dummy source) to determine what happened. KDHE is currently investigating the incident. We will provide updates when they occur."
Source:
Cobalt 60, 62.1 Curies
Manufacturer: AEA Technologies
Model Number: TECHOPS A-424-14
Serial Number: S/N 2899
Device:
Manufacturer: AEA Technologies
Model Number 660-B
Serial Number: S/N B-234
Power Reactor
Event Number: 40468
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: GLEN MORROW
HQ OPS Officer: MIKE RIPLEY
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: GLEN MORROW
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/23/2004
Notification Time: 13:53 [ET]
Event Date: 01/23/2004
Event Time: 12:20 [CST]
Last Update Date: 01/23/2004
Notification Time: 13:53 [ET]
Event Date: 01/23/2004
Event Time: 12:20 [CST]
Last Update Date: 01/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
ROGER LANKSBURY (R3)
ROGER LANKSBURY (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 95 | Power Operation | 95 | Power Operation |
PLANT SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS
"Dresden Unit 2 is performing a Technical Specification required shutdown due to the loss of the [120 VAC] Essential Service Bus normal electrical feed. This is reportable per 10CFR 50.72(b)(2)(i), SAF 1.2 "Plant Shutdown Required by Technical Specification". The loss of the feed occurred at 02:10 [CST] on 01/23/04 and power swapped to the backup feed. Technical Specification 3.8.7. A. was entered and repairs began on the uninterruptible power supply. Repairs were unsuccessful and Unit 2 shut down began at 12:20 [CST] with unit required to be hot shutdown by 22:10 [CST] 01/23/04 and cold shutdown by 22:10 [CST] 01/24/04. Repairs will continue in parallel will unit shutdown."
The licensee notified the NRC Resident Inspector.
***UPDATE on 01/23/04 at 1742 EST by G. Morrow taken by John MacKinnon****
Unit 2 ESS BUS normal feed was restored to OPERABLE, unit shutdown was secured and preparations for load increase are in progress. Preliminary troubleshooting data taken on the ESS UPS show the most likely cause of the UPS power supply transfer was a static switch component that caused the UPS to swap to the emergency supply. The troubleshooting shows the malfunction that caused the initial power supply transfer to the ESS Emergency supply via the ABT at 0210 this morning originated in the static switch circuitry. The static switch is bypassed in the current configuration and therefore the power supply to the ESS bus is assured. The voltage sensing relays investigated during the troubleshooting on the output of the inverter show no indication that an inverter failure initiated the bus transfer. Operations will continue to monitor the output of the inverter. Troubleshooting of the UPS static switch will continue to determine the cause of the malfunction. R3DO (Roger Lanksbury) notified
NRC Resident Inspector was notified of this update by the licensee.
"Dresden Unit 2 is performing a Technical Specification required shutdown due to the loss of the [120 VAC] Essential Service Bus normal electrical feed. This is reportable per 10CFR 50.72(b)(2)(i), SAF 1.2 "Plant Shutdown Required by Technical Specification". The loss of the feed occurred at 02:10 [CST] on 01/23/04 and power swapped to the backup feed. Technical Specification 3.8.7. A. was entered and repairs began on the uninterruptible power supply. Repairs were unsuccessful and Unit 2 shut down began at 12:20 [CST] with unit required to be hot shutdown by 22:10 [CST] 01/23/04 and cold shutdown by 22:10 [CST] 01/24/04. Repairs will continue in parallel will unit shutdown."
The licensee notified the NRC Resident Inspector.
***UPDATE on 01/23/04 at 1742 EST by G. Morrow taken by John MacKinnon****
Unit 2 ESS BUS normal feed was restored to OPERABLE, unit shutdown was secured and preparations for load increase are in progress. Preliminary troubleshooting data taken on the ESS UPS show the most likely cause of the UPS power supply transfer was a static switch component that caused the UPS to swap to the emergency supply. The troubleshooting shows the malfunction that caused the initial power supply transfer to the ESS Emergency supply via the ABT at 0210 this morning originated in the static switch circuitry. The static switch is bypassed in the current configuration and therefore the power supply to the ESS bus is assured. The voltage sensing relays investigated during the troubleshooting on the output of the inverter show no indication that an inverter failure initiated the bus transfer. Operations will continue to monitor the output of the inverter. Troubleshooting of the UPS static switch will continue to determine the cause of the malfunction. R3DO (Roger Lanksbury) notified
NRC Resident Inspector was notified of this update by the licensee.
General Information or Other
Event Number: 40552
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL X-RAY AND TESTING CORP
Region: 4
City: AMELIA State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: BILL GOTT
Licensee: GLOBAL X-RAY AND TESTING CORP
Region: 4
City: AMELIA State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: BILL GOTT
Notification Date: 02/27/2004
Notification Time: 15:13 [ET]
Event Date: 01/23/2004
Event Time: 01:15 [CST]
Last Update Date: 02/27/2004
Notification Time: 15:13 [ET]
Event Date: 01/23/2004
Event Time: 01:15 [CST]
Last Update Date: 02/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
TOM ESSIG (NMSS)
GARY SANBORN (R4)
TOM ESSIG (NMSS)
AGREEMENT STATE REPORT REGARDING A DAMAGED RADIOGRAPHY DEVICE
The following facsimile was received from the Louisiana Department of Environmental Quality:
"At 1:15 AM [CST] on January 23, 2004, a 90.1 Curie Iridium-192 AEA Model 969 sealed source with serial number 12449B could not be returned to the shielded position. The radiography camera was a SPEC Model 150 with serial number 82. The radiographers secured the area and contacted William Johnston, Radiation Safety Officer (RSO). The source was returned to the shielded position at approximately 1:55 AM on January 23. Apparently the drive cable connector pulled off of the worm. The connector appeared to be old. However, the cable itself is still very flexible/pliable. No overexposures were identified. The dosimeters for the radiographers read 125 millirem, 150 millirem, and 130 millirem. The TLD badges were sent off for emergency processing with readings of 0.715 R, 0.426 R, and 0.688 R."
The following facsimile was received from the Louisiana Department of Environmental Quality:
"At 1:15 AM [CST] on January 23, 2004, a 90.1 Curie Iridium-192 AEA Model 969 sealed source with serial number 12449B could not be returned to the shielded position. The radiography camera was a SPEC Model 150 with serial number 82. The radiographers secured the area and contacted William Johnston, Radiation Safety Officer (RSO). The source was returned to the shielded position at approximately 1:55 AM on January 23. Apparently the drive cable connector pulled off of the worm. The connector appeared to be old. However, the cable itself is still very flexible/pliable. No overexposures were identified. The dosimeters for the radiographers read 125 millirem, 150 millirem, and 130 millirem. The TLD badges were sent off for emergency processing with readings of 0.715 R, 0.426 R, and 0.688 R."
Hospital
Event Number: 40502
Rep Org: MERCY HEALTH SYSTEM
Licensee: MERCY HEALTH SYSTEM
Region: 1
City: DARBY State: PA
County:
License #: 37-00993-05
Agreement: N
Docket:
NRC Notified By: JOHN BABU
HQ OPS Officer: CHAUNCEY GOULD
Licensee: MERCY HEALTH SYSTEM
Region: 1
City: DARBY State: PA
County:
License #: 37-00993-05
Agreement: N
Docket:
NRC Notified By: JOHN BABU
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 02/03/2004
Notification Time: 14:05 [ET]
Event Date: 01/23/2004
Event Time: 00:00 [EST]
Last Update Date: 02/06/2004
Notification Time: 14:05 [ET]
Event Date: 01/23/2004
Event Time: 00:00 [EST]
Last Update Date: 02/06/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN KINNEMAN (R1)
JOHN HICKEY
JOHN KINNEMAN (R1)
JOHN HICKEY
HIGH BACKGROUND READINGS FOUND IN STERILIZATION WATER USED TO STERILIZE THE SEEDS AND CARTRIDGE PRIOR TO USAGE.
The licensee reported that during the completion of a prostate implant a higher than background reading was measured in the sterilization water used to sterilize the seeds and the cartridge prior to the implant. The licensee had two extra seeds left over after the implant, so they returned them to the manufacturer along with a sample of the sterilization water to be analyzed. The manufacturer suspects that one of the seeds may have been a leaking, but that has not yet been verified. A bioassay was also performed on the staff involved with the implant and only the physicist had a higher than background reading. The patient was also given a bioassay, but since they have never done this to a patient, there was no data to compare with.
* * * UPDATE AT 0930 EST ON 2/06/04 FROM J. BABU TO GOTT * * *
The licensee reported that a second patient also had a higher thyroid bioassay but his urine sample tested negative. The licensee is continuing with their investigation.
Notified NMSS (Psyk) and R1DO (Kinneman)
* * * UPDATE AT 1431 EST ON 2/06/04 FROM J. BABU TO A. COSTA * * *
Detectable contamination was found upon surveying the left over seeds (12 to 18) from the second patient. Two swipes were taken of all seeds together and the first swipe indicated 809 counts per minute and the second swipe indicated 1689 counts per minute. Background readings was 4 counts per minute. The contamination was localized to the cartridges and seeds. The appropriate areas of the Hospital were surveyed and no detectable contamination was found. The licensee intends to keep the leaking iodine seeds in storage for decay and future disposal.
Notified NMSS (Hickey) and R1DO (Kinneman)
The licensee reported that during the completion of a prostate implant a higher than background reading was measured in the sterilization water used to sterilize the seeds and the cartridge prior to the implant. The licensee had two extra seeds left over after the implant, so they returned them to the manufacturer along with a sample of the sterilization water to be analyzed. The manufacturer suspects that one of the seeds may have been a leaking, but that has not yet been verified. A bioassay was also performed on the staff involved with the implant and only the physicist had a higher than background reading. The patient was also given a bioassay, but since they have never done this to a patient, there was no data to compare with.
* * * UPDATE AT 0930 EST ON 2/06/04 FROM J. BABU TO GOTT * * *
The licensee reported that a second patient also had a higher thyroid bioassay but his urine sample tested negative. The licensee is continuing with their investigation.
Notified NMSS (Psyk) and R1DO (Kinneman)
* * * UPDATE AT 1431 EST ON 2/06/04 FROM J. BABU TO A. COSTA * * *
Detectable contamination was found upon surveying the left over seeds (12 to 18) from the second patient. Two swipes were taken of all seeds together and the first swipe indicated 809 counts per minute and the second swipe indicated 1689 counts per minute. Background readings was 4 counts per minute. The contamination was localized to the cartridges and seeds. The appropriate areas of the Hospital were surveyed and no detectable contamination was found. The licensee intends to keep the leaking iodine seeds in storage for decay and future disposal.
Notified NMSS (Hickey) and R1DO (Kinneman)