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Event Notification Report for April 28, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2004 - 04/28/2004

** EVENT NUMBERS **


40693 40706 40707 40709

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Other Nuclear Material Event Number: 40693
Rep Org: BAXTER HEALTH CARE
Licensee: BAXTER HEALTH CARE
Region: 1
City: AIBONITO State: PR
County:
License #: 52-21175-01
Agreement: N
Docket:
NRC Notified By: ANGEL ALICEA
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/21/2004
Notification Time: 16:54 [ET]
Event Date: 04/21/2004
Event Time: 12:00 [EDT]
Last Update Date: 04/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
36.83(a)(1) - UNSHIELD STUCK SOURCE
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
DAVID SILK (R1)
TOM DECKER (R2)
CHARLIE MILLER (NMSS)
JOSEPH GIITTER (NMSS)

Event Text

IRRADIATOR SOURCE RACK JAMMED IN THE UP POSITION

At 1200 EDT operators were lowering a source rack when it jammed due to a maintenance ladder. The licensee entered their emergency procedure and contacted the manufacturer, i.e., MDS Nordion, for assistance. MDS Nordion is expected onsite at 1040 EDT tomorrow 4/22 to help the licensee develop a recovery plan. The stuck source rack contains approximately 2,030 curies of Co-60. The maze is closed restricting personnel access. There were no personnel exposures associated with this occurrence.

A conference call with the Baxter Plant Manager and NRC staff was established to discuss the details of this report.

* * * UPDATE ON 04/24/04 @ 1424 BY ANGEL ALICEA TO CHAUNCEY GOULD * * *

The licensee reported that at 2000 on 04/23/04 the source was placed in the shielded position submerged in 25 ft of water in the pool. They are terminating this event.

Notified Tom Decker, George Pangburn, Frank Costello, Cathy Modes, and Betsey Ullrich

* * * UPDATE ON 4/27/04 @ 1129 EDT FROM A. ALICEA TO HOWIE CROUCH * * *

The licensee reported that a re-enactment of the event indicates that two plant employees may have been over-exposed during the initial event. The licensee is conservatively reporting this update under 10 CFR 20.2202 (b)(1) since the exposure value is unknown but believed to be less than 5 rem. Personnel dosimetry is being analyzed and the calculations are being verified by the contractor at the site. The licensee will update this event when the exposure data is known. The licensee has informed the on site Regional Materials Inspector (Diaz).

Notified NMSS (Fred Brown) and R1DO (Richard Barkley).

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Power Reactor Event Number: 40706
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN JENKINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2004
Notification Time: 09:21 [ET]
Event Date: 04/26/2004
Event Time: 09:30 [EDT]
Last Update Date: 04/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
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

NON-LICENSED EMPLOYEE TESTED POSITIVE FOR CONTROLLED SUBSTANCE

A non-licensed employee was determined to be under the influence of an illegal drug during a random urinalysis. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 4/27/0 JENKINS TO GOULD * * *
Contact the Headquarters Operations Officer for details of update.

Notified the Reg 2DO (Ernstes) of update.

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Hospital Event Number: 40707
Rep Org: US DEPT OF VETERANS AFFAIRS
Licensee: VA MEDICAL CENTER
Region: 1
City: BIRMINGHAM State: AL
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: MICHAEL SIMMONS
HQ OPS Officer: ARLON COSTA
Notification Date: 04/27/2004
Notification Time: 13:20 [ET]
Event Date: 04/20/2004
Event Time: [CDT]
Last Update Date: 04/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
RICHARD BARKLEY (R1)
BRUCE BURGESS (R3)
FRED BROWN (NMSS)

Event Text

DOSE TO AN EMBRYO/FETUS

On April 20, 2004, a female patient was administered 6 microcuries of I-131 sodium iodide orally and on April 21, 2004, 12 millicuries of Tc-99m (Tc04). An investigation was undertaken after it was determined that the patient was pregnant. The duration of gestation was estimated as 10 weeks +/- 1 week.

The dose to the embryo/fetus occurred on April 20-21, 2004, and it was discovered on April 26, 2004. Outside experts estimated that, if the thyroid were functioning, the fetus received a dose of 6.6 rem, and if the thyroid were not functioning, a dose of 0.5 to 1 rem.

The permittee has implemented initial corrective actions to prevent a recurrence of the circumstances that resulted in the dose to the embryo/fetus. The permittee is aware of the requirements for notifying the patient and the referring physician.

The Department of Veterans Affairs will evaluate the circumstances related to this incident and will submit a written report to NRC, Region III, within 15 days.

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Power Reactor Event Number: 40709
Facility: MAINE YANKEE
Region: 1 State: ME
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: DOUGLAS KINNEY
HQ OPS Officer: ARLON COSTA
Notification Date: 04/27/2004
Notification Time: 18:50 [ET]
Event Date: 04/27/2004
Event Time: 17:14 [EDT]
Last Update Date: 04/27/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD BARKLEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned

Event Text

LOSS OF COMMUNICATION CAPABILITY THROUGH ENS LINE

The licensee was notified by the phone communications provider of a loss of all communications that affected the licensee's Emergency Notification System (ENS) line. The licensee has provided the NRC Operations Center with a back up cell phone. The ENS capability is expected to be restored by 23:00 tonight and after restoration of the phone lines, the licensee will verify ENS functionality. It is believed that the loss of communications was due to maintenance work being performed by the provider on the fiber optics lines.

The NRC Resident Inspector was notified by the licensee via voice mail phone message.

* * * UPDATE ON 04/27/04 AT 20:24 EDT FROM D. KENNEY TO A. COSTA * * *

The ENS line has been restored at 19:33 on 04/27/04. Communications with the US NRC Operations Center was tested satisfactorily. The NRC Resident Inspector will be notified by the licensee via voice mail phone message.

Notified the R1DO (Barkley).

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012