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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 **


40385 40465

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General Information or Other Event Number: 40385
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: WASTE CONTROL SPECIALIST
Region: 4
City: Andrews State: TX
County:
License #: L04971
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/11/2003
Notification Time: 11:30 [ET]
Event Date: 12/09/2003
Event Time: [CST]
Last Update Date: 01/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ROBERTO TORRES (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT INVOLVING FIRE WITH RADIOACTIVE MATERIAL

"On December 10, 2003, [the licensee's RSO at] Waste Control Specialist reported a fire involving radioactive material that occurred on December 9, 2003. There was no excessive exposure to individuals nor was there any off-site airborne release.

"The waste processing company believes reactive metals (lithium, sodium, potassium) oxidized in water to start the fire. Packing materials were placed in a shredder that feeds into a hopper containing mixed waste. The system is closed with HEPA filters in place. Vibrations from the hopper may have resulted in the ignition. The material burned for about 20 seconds and was extinguished. When more materials were poured into a mix pan, the fire reignited and again was quickly extinguished.

"According to the Licensee's preliminary calculations, the affected or burned radioactive material exceeded the reportable quantity of five times an ALI [annual limit on intake]. The total radioactive material in the mix pan was under 50 microcuries. The shredder contained about 2.4 microcuries. There were 12 to 14 radionuclides involved. The Licensee will send a detailed written report within 30 days to include specifics on radionuclides and activities.

"The most serious consequence was the unplanned fire. The building is pressurized and the smoke from the fire was pulled through HEPA filters and a monitored exhaust system. The workers wear PPE [personal protective equipment) and airlines with protection factors of 1000."

Texas Incident # I-8024.

* * * * UPDATE ON 1/21/4 AT 1651 EST TO M. RIPLEY FROM HELEN WATKINS VIA FACSIMILE * * * *

The following information was provided in a letter dated 1/6/2004 from Waste Control Specialists (WCS) to the Texas Department of Health:

"On December 9, 2003 at approximately 1400 hrs a small fire occurred in the Permacon building at our facility located 30 miles West of Andrews, Texas. This fire occurred in the hopper beneath the waste shredder. There was a small quantity of untreated water reactive radioactive waste (WP-019224) that caught fire after passing through the shredder above. Two employees at the scene quickly extinguished the fire within the hopper using hand-held halon fire extinguishers. The hopper was pulled from underneath the shredder and then the waste was put into the mix pan where it re-ignited. It was extinguished by dropping water on the materials using the prentice arm.

"The personnel who were in the immediate area were wearing anti-contamination clothing and respiratory protection equipment in accordance with the Radiation Work Permit. The air sample that was being collected at the time of the incident indicated approximately 85% of the DAC for Th-228. The respiratory protection equipment used has a protection factor of 1000. There was no significant internal or external radiological exposure to personnel."

"The radioactive distribution of the material involved is enclosed."

Additionally, the licensee provided the following information to the State in response to a question about any action the licensee may have taken to prevent a reoccurrence of a fire. The licensee stated the following in an email to the State:

"WCS issued a Stop Work Order on December 9, 2003. The Stop Order included a corrective action of 'Evaluate the treatment methodology for reactive metals prior to receipt of new shipments of reactive metals for processing.' WCS will not receive any new shipments of reactive metals for processing until such time that a different treatment methodology is developed to process these wastes without subsequent ignition of waste materials."

Notified R4DO (L. Howell) and NMSS EO (L. Kokajko)

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Hospital Event Number: 40465
Rep Org: US DEPT OF VETERAN AFFAIRS
Licensee: VA MED CENTER ANN ARBOR, MI
Region: 3
City: ANN ARBOR State: MI
County:
License #: 21-00159-01
Agreement: N
Docket:
NRC Notified By: JOSEPH WISSING
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/22/2004
Notification Time: 15:19 [ET]
Event Date: 12/29/2003
Event Time: [EST]
Last Update Date: 01/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
ROGER LANKSBURY (R3)
TOM ESSIG (NMSS)

Event Text

POSSIBLE MEDICAL EVENT

"The possible medical event occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Medical Center, Ann Arbor, Michigan (Permit # 21-00159-01).

"The possible medical event occurred on December 29, 2003. The possible medical event was discovered on January 21, 2004.

"The basis for the possible medical event is under 10 CFR 35.3045(a)(2)(i) and involved administration of a wrong radiopharmaceutical drug. Specifically, the written directive for a patient therapy procedure incorrectly listed Strontium 90 when in fact Strontium 89 was administered to the patient.

"Since the clinical intent was for the patient to receive Strontium 89, the possible medical event will not have any adverse impact on the patient.

"The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event. The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days."

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