| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
03/09/2004 - 03/10/2004 ** EVENT NUMBERS ** |
 | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Hospital | Event Number: 40549 | Rep Org: ST. MARY HOSPITAL
Licensee: ST. MARY HOSPITAL
Region: 1
City: HOBOKEN State: NJ
County:
License #: 2901024-01
Agreement: N
Docket:
NRC Notified By: IRA GARELICK
HQ OPS Officer: ERIC THOMAS | Notification Date: 02/26/2004
Notification Time: 15:43 [ET]
Event Date: 12/15/2003
Event Time: 12:00 [EST]
Last Update Date: 03/09/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
MOHAMED SHANBAKY (R1)
CHARLIE MILLER (NMSS)
| Event Text MEDICAL EVENT
During a Health Physics audit, while reviewing seed implantation cases, the auditor was reviewing a procedure performed on a patient on 2/13/04. The procedure involved an I-125 seed implantation that delivered 5000 Rad to the patient's prostate. The auditor saw a notation in the record that a previous implantation on 12/15/03 had also delivered 5000 Rad to the same patient's prostate.
When the auditor pulled the record for the 12/15/03 implantation, he discovered that the intended dose from the procedure was 10,000 Rad. He proceeded to call Radiation Medicine Center, the licensee who performed both procedures (License # 2902023-06). Radiation Medicine Center stated that, when evaluating the patient in mid-January, they discovered, via CT scan and dosimetry, that the patient had only received 5000 Rad during the first procedure, and that is why the second procedure was performed on 2/13/04.
The auditor is reporting the implantation from 12/15/03 as a Medical Event.
* * * UPDATE ON 03/09/04 @ 0956 BY IRA GARELICK TO C GOULD * * * RETRACTION
The licensee is retracting this event on the basis that further investigation along with consultation and a site visit with Reg 1 NRC personnel determined the implant went as planned. There was some tissue shrinkage resulting in cold spots which were adequately treated in the second implant on 02/13/04.
Notified Reg 1 RDO(Cobey) and NMSS EO(Psyk) |
| Fuel Cycle Facility | Event Number: 40567 | Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: CARL SNYDER
HQ OPS Officer: MIKE RIPLEY | Notification Date: 03/05/2004
Notification Time: 12:08 [ET]
Event Date: 03/04/2004
Event Time: 15:00 [EST]
Last Update Date: 03/09/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
| Person (Organization):
ROBERT HAAG (R2)
FRED BROWN (NMSS)
| Event Text 24-HOUR NOTIFICATION - BULLETIN 91-01 CRITICALITY CONTROL
"A review of incinerator data indicated higher than expected accumulations and concentrations of uranium bearing material in the incinerator off-gas system. Criticality was not possible because the mass corresponding to each concentration was below the minimum critical mass.
"Controlled Parameters: The safety basis for the incinerator off gas-system states that criticality is not credible. This was based on minimal expected carryover and low concentrations of uranium from the incinerator to the off -gas system. The uranium concentrations in the off-gas system were expected to be well below the [deleted] concentration criticality limit for an infinite mass.
"A criticality would be possible in the off-gas system only if a minimum critical mass for a corresponding uranium concentration accumulated in a critical configuration with sufficient moderator.
"Because higher than expected accumulation and concentration of uranium bearing material was detected in the incinerator off gas system, this 24-hour notification is being made.
"Summary of Activity: 1) Incinerator was shut down; 2) The off-gas system is being inspected; 3) Samples from the off-gas system are being obtained for analysis.
"Conclusions: 1). The bounding assumptions for concentration and carryover were exceeded; 2). At no time was there any risk to the health or safety of any employee or member of the public. No exposure to hazardous material was involved & 3). The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. A formal causal analysis will be performed.
The licensee will be notifying NRC Region III.
* * * UPDATE AT 1346 EST ON 3/9/04 SNYDER TO GOTT * * *
The licensee sent the following addendum via facsimile:
"Reason for Addendum:
Higher than expected concentration of uranium bearing material detected in the incinerator ash. The ash from the lower chamber of the incinerator is lifted via a bucket elevator and dumped into a mill feed hopper and then into a fitzmill.
"As Found Condition:
A review of incinerator data indicated higher than expected concentrations of uranium in the incinerator ash.
"Controlled Parameters:
The safety basis for the ash handling system (elevator and fitzmill) states that criticality is not credible based on the ash remaining below 21.6 weight percent uranium.
"Summary of Activity:
-In addition to the previous activities, the formal root cause team has initiated their investigation.
-The incinerator ash elevator and fitzmill safety basis is being re-evaluated.
"Conclusions:
-The bounding assumption for concentration was exceeded.
-At no time was there any risk to the health or safety of any employee or member of the public.
-No exposure to hazardous material was involved.
-The ash handling aspect will be incorporated into the formal causal analysis."
Notified NMSS (Psyk) and R2D) (Ayres). |
| General Information or Other | Event Number: 40568 | Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: CITY OF HOLDREGE, NE
Region: 4
City: HOLDREGE State: NE
County:
License #: GL-0428
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MIKE RIPLEY | Notification Date: 03/05/2004
Notification Time: 12:39 [ET]
Event Date: 02/29/2004
Event Time: [CST]
Last Update Date: 03/05/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GREG PICK (R4)
FRED BROWN (NMSS)
| Event Text AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The City of Holdrege, NE reported that in late February 2004 during an annual inventory, it was discovered that 25 of 40 Tritium exit signs were missing. The signs were installed in stairways in the city auditorium. The signs are SafetyLite Model 2088 (2.2 Curies Tritium each as of the shipment date of March 1990). An investigation did not determine what happened to the signs and the State is closing the report. |
| General Information or Other | Event Number: 40569 | Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: MENARD'S LUMBER
Region: 4
City: OMAHA State: NE
County:
License #: GL-0401
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MIKE RIPLEY | Notification Date: 03/05/2004
Notification Time: 12:39 [ET]
Event Date: 11/01/2003
Event Time: [CST]
Last Update Date: 03/05/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GREG PICK (R4)
FRED BROWN (NMSS)
| Event Text AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
Menard's Lumber reported that following demolition and replacement of their old store building, it was determined that all 13 Tritium exit signs were missing and apparently removed along with the old building debris. The signs were SafetyLite/EvenLite Model 101 (7 Curies Tritium as of the manufacture date of October 1991). An investigation did not determine the final disposition of the signs and the State is closing the report. |
| Power Reactor | Event Number: 40577 | Facility: MAINE YANKEE
Region: 1 State: ME
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY VOGEL
HQ OPS Officer: CHAUNCEY GOULD | Notification Date: 03/09/2004
Notification Time: 11:32 [ET]
Event Date: 03/09/2004
Event Time: 09:55 [EST]
Last Update Date: 03/09/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
EUGENE COBEY (R1)
TOM ESSIG (NMSS)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Decommissioned | 0 | Decommissioned | Event Text OFFSITE NOTIFICATIONS TO STATE AGENCIES DUE TO LIQUID RELEASE
The licensee notified the Maine Emergency Management Agency and the Maine Department of Human Services of an unscheduled liquid release of containing 1.35e-6 Curies that occurred on 3/8/04. This release resulted in a minor exposure of 9e-11millirem.
Site has no resident inspector. |
| Other Nuclear Material | Event Number: 40578 | Rep Org: US DEPT OF VETERANS AFFAIRS
Licensee: VA BOSTON HEALTHCARE SYSTEM
Region: 1
City: BOSTON State: MA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: MIKE RIPLEY | Notification Date: 03/09/2004
Notification Time: 13:06 [ET]
Event Date: 03/08/2004
Event Time: [EST]
Last Update Date: 03/09/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
EUGENE COBEY (R1)
KENNETH RIEMER (R3)
FRED BROWN (NMSS)
| Event Text LOSS OF LICENSED MATERIAL
The Department of Veterans Affairs reported the following via facsimile:
"I am calling to report a loss of licensed material. The loss 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 Boston Healthcare System, Boston, Massachusetts.
"The loss was reported to the permittee Radiation Safety Officer on March 8, 2004.
"The basis for reporting the loss is under 10 CFR 20.2201(a)(i) in that a waste vendor reported that a drum from the permittee triggered a radiation detector at a landfill. The activity involved although unknown at this time could potentially be greater than the reporting limit.
"Specifically, the vendor (New York Environmental Services) indicated that a survey meter reading on contact with the drum was 4.8 millirem per hour. The drum is being returned to the permittee for radionuclide evaluation.
"The Department of Veterans Affairs will evaluate the circumstances related to the loss and submit a written report to NRC, Region III, within 30 days." | |