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Event Notification Report for April 23, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/22/2004 - 04/23/2004

** EVENT NUMBERS **


40685 40687 40696 40697 40698

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General Information or Other Event Number: 40685
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: DECISIVE TESTING
Region: 4
City: SAN DIEGO State: CA
County:
License #: 1836-37
Agreement: Y
Docket:
NRC Notified By: MICHAEL MAY
HQ OPS Officer: JAMIE HEISSERER
Notification Date: 04/19/2004
Notification Time: 20:23 [ET]
Event Date: 04/16/2004
Event Time: 13:15 [PDT]
Last Update Date: 04/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSSELL BYWATER (R4)
ROBERT PIERSON (NMSS)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - EXPOSURE INCIDENT (<1 REM WHOLE BODY) INDUSTRIAL RADIOGRAPHER

At 2023 EDT, the following email was received from Decisive Testing:

"On April 16, 2004, a radiographer was working on a schedule 40 stainless steel 4" pipe. The Ir-192 radiography operation was being conducted inside a shielded x-ray room, but was considered by the licensee to be a temporary jobsite for materials radiography. The camera, the cable and collimator were inside the room while the operator and crank were located approximately 8' from the closed x-ray door. At 1:15 PM, the radiographer finished the 6th shot and reentered the room to prepare for the 7th shot. After setting up the 7th shot, he picked up his survey meter as he left the room (the meter had been placed on top of the camera when he entered the room) and noticed the meter was off scale. He exited the room and checked the position of the radiography source by attempting to crank it out, only to discover that he had failed to crank the source in after the 6th shot. His 0-200 millirem dosimeter was off scale and he was not wearing his alarming ratemeter. His dosimeter was sent in for processing by overnight mail. The licensee did a re-enactment and estimated the radiographer's whole body dose to be under 1 rem. The radiographer's extremity dose is estimated to be under 10 rem.

"Source: Industrial Nuclear, model 7, Ir-192 source assayed 10/16/03 and decayed to 17.9 Curies on 4-16-04). Camera: Amersham, model 660B, serial # B2928. Collimator: Industrial Radiography Maintenance & Supply, model - tungsten mini (side port) collimator (attenuation 1/16 for Ir-192).

"RHB responded to the site on Saturday, April 17, 2004 to interview the radiographer and RSO. The investigation is ongoing, but it does appear that neither the whole body nor extremity regulatory dose limits for the radiographer were exceeded."

* * * UPDATE 1500 EDT ON 4/22/04 FROM ROBERT GREGER TO S. SANDIN VIA FAX * * *

"The dosimeter results were received from Landauer on 4/21/04 and showed a whole body dose of 95 mrem for the radiographer in this event, which is consistent with a reenactment conducted by the licensee. Based on this information, the whole body dose did not exceed regulatory limits. The extremity dose to the radiographer is still under investigation."

Notified R4DO (Bywater) and NMSS (Torres).

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General Information or Other Event Number: 40687
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-01302-001
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/20/2004
Notification Time: 11:55 [ET]
Event Date: 04/13/2004
Event Time: 15:30 [CDT]
Last Update Date: 04/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - ACCIDENTAL SHIPMENT OF RADIOACTIVE MATERIAL

On 4/13/04, at approximately 3:30 PM CDT, the Wisconsin Radiation Protection section received a telephone call from the New York State Labor Department, Radiological Health Department.

New York State Radiological Health Dept. had just been informed by one of their licensees, Mick Radio-Nuclear Instruments, Inc., that a package had been received from St. Nicholas Hospital, Sheboygan, WI. The company had found 2 radioactive brachytherapy seeds within a Mick applicator which had been returned to their company for repairs. The radioactive seeds were stuck in the Mick applicator. Mick Radio-Nuclear Instruments contacted the shipper of the device, St. Nicholas Hospital, to obtain details identifying the radionuclide. The 2 seeds have been identified as containing I-125, 0.370 milli Curies each on 3/12/04. Mick Radio-Nuclear is not licensed to receive this radioactive material which was inadvertently sent by St. Nicholas Hospital. The package was shipped on 4/8/04 and received on 4/13/04.

The Wisconsin Department of Health and Family Services (DHFS) is reporting this item as a "loss of control of radioactive material to an unlicensed entity" and "potential exposure to the general public." DHFS staff are being dispatched on 4/20/04 to investigate.

The radioactive material is now in the possession of the Radiological Health Department for the state of New York. St. Nicholas Hospital is working on identifying a company in New York that can take possession of the radioactive brachytherapy seeds and return them to the manufacturer.

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Hospital Event Number: 40696
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: DAVID KEYS
HQ OPS Officer: BILL GOTT
Notification Date: 04/22/2004
Notification Time: 08:38 [ET]
Event Date: 03/01/2004
Event Time: [CDT]
Last Update Date: 04/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVID HILLS (R3)
LINDA PSYK (NMSS)

Event Text

DOSE TO THE SKIN OTHER THAN THE INTENDED TREATMENT SITE

A female patient received a potential dose to the skin on the inner thigh during a High Dose Rate Treatment. The treatment occurred in late February to early March. This was discovered on 4/21/04, when the patient returned for follow-up and markings on the inner thigh were noticed that were unusual for the intended treatment area. The licensee is determining the actual exposure to the skin. The patient has been notified.

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Power Reactor Event Number: 40697
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: COY BLAIR
HQ OPS Officer: BILL GOTT
Notification Date: 04/22/2004
Notification Time: 10:58 [ET]
Event Date: 03/09/2004
Event Time: 12:42 [CST]
Last Update Date: 04/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RUSSELL BYWATER (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

INVALID SYSTEM ACTUATION DUE TO MOMENTARY POWER INTERRUPTION

This report is being made under 10 CFR 50.73(a)(2)(iv)(A).

Actuations occurred on the following systems (System-Actuation Status)
-Primary Containment (Drywell and Suppression Chamber) Atmospheric Control Isolation Valves - Complete
-Drywell Vent Monitor - Partial
-Off-gas Treatment - Partial
-Secondary Containment - Complete
-Control Room Ventilation - Complete
-Standby Gas Treatment - Complete

System response indicated that the cause was a momentary power interruption to a portion of the Primary Containment Isolation System Division 2 logic. Print verification determined that the system functioned as designed on loss of power.

The Licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 40698
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVID HERRING
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/22/2004
Notification Time: 13:48 [ET]
Event Date: 04/22/2004
Event Time: 10:45 [EDT]
Last Update Date: 04/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CAUDLE JULIAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

SAFETY PARAMETER DISPLAY SYSTEM (SPDS) DECLARED INOPERABLE

"At 1045 hours on 04/22/04, the Safety Parameter Display System (SPDS) portion of the Emergency Response Facility Computer System (ERFCS) was noted to be inoperable due to all outputs being displayed in "magenta" color. Attempts were made to reboot the system, but were unsuccessful. At 1145 hours on 4/22/04, SPDS was returned to service. Therefore, the SPDS had been out of service for 1 hour, which is considered a major loss of emergency assessment capability. This report is being made in accordance with 10CFR50.72(b)(3)(xiii)."

SPDS is not 100% operable, but it does meet the licensee's operability criteria to be declared operable. The licensee is analyzing the problem.

The licensee notified the NRC Resident Inspector.

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Friday, March 30, 2012