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Event Notification Report for August 19, 2004

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Event Reports For
08/18/2004 - 08/19/2004

** EVENT NUMBERS **


40947 40961

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General Information or Other Event Number: 40947
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE (HOSPITAL)
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: MATT MCKINLEY
HQ OPS Officer: ARLON COSTA
Notification Date: 08/13/2004
Notification Time: 11:03 [ET]
Event Date: 08/11/2004
Event Time: 10:45 [CDT]
Last Update Date: 08/13/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
TOM ESSIG (NMSS)

Event Text

KENTUCKY AGREEMENT STATE NOTIFICATION

University of Louisville Hospital physicians were injecting a prescribed treatment of Yttrium-90 (Therasphere) 3.32 GBq (GigaBecquerel) into a patient's liver and only 0.72 Gbq was actually administered (22%). The licensee is investigating the cause of the misadministration. Initial investigation points to a tubing extension modification made to carry the dose to the targeted organ since the majority of the flow remained in the tubing. Hospital physicians have used the equipment 5 to 6 times without any incident. The licensee will send the tubing back to the manufacturer for further investigation. The physician notified the patient.

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General Information or Other Event Number: 40961
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: PADUCAH BJC WASTE GENERATOR SERVICES
Region: 4
City: FLAGSTAFF State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: BILL GOTT
Notification Date: 08/16/2004
Notification Time: 13:25 [ET]
Event Date: 08/15/2004
Event Time: 13:20 [MST]
Last Update Date: 08/16/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - LEAKING RADIOACTIVE SHIPMENT

"Background: T-hopper containers holding approximately 5 tons of depleted UF4 were packaged for shipment to Nevada Test Site (NTS) as radioactive low specific activity waste. The T-hoppers are over packed in a sealand box holding either two or three T-hoppers depending on the total weight. The shipment package is prepared by spreading an absorbent material around the floor to absorb any condensation. After placement of absorbent, bags of vemiculite are added to fill void space. Sealands are loaded onto flat-bed trucks or pin-type trailers, one sealand per truck. NTS shipments #PDL-04-161, #PDL-04-163, #PDL-04-164, #PDL-04-165, and #PDL-04-166 left the Paducah site on Friday, August 13, 2004, via Tri-State Motor Transit. Each truck was loaded with one sealand. The T-hoppers and all internal materials were surveyed prior to leaving the site and no contamination was found.

"Incident and Response Chronology: At approximately 1030 hrs. on Sunday, August 15, 2004, the driver of the truck carrying shipment #PDL-04-161 reported finding a small quantity of a white, granular solid and a clear, gel-like material on the bed of the truck. The truck was stopped in Rio Puerco, New Mexico at a truck stop off Interstate 40 (I-40) West. The driver notified the Paducah Bechtel Jacobs Company (BJC) Transportation Specialist who instructed him to remain at his current location. The Transportation Specialist notified Paducah BJC Waste Generator Services personnel at 1130 hrs. Paducah team consisting of the Project Manager, Waste Generator Services, and Health Physics was assembled to determine appropriate actions.

"At approximately 1100 hrs on August 15, 2004, the BJC Transportation Specialist received a call from the driver of shipment #PDL-04-163 reporting similar conditions. This driver was located at Gallup, NM, Exit 16 off of I-40 West. Two other trucks carrying shipments #PDL-04-164 and #PDL-04-166 arrived at Gallup shortly after Paducah received the notification from the first driver. The drivers of these trucks were also instructed to remain in Gallup. Upon inspections by the drivers, one truck, shipment #PDL-04-164, also had material on the bed of the truck. At approximately 1400 hrs. the driver of the fifth truck, shipment #PDL-04-165, was contacted. He was located in Flagstaff, AZ and instructed to remain there. Upon inspection, the driver of this truck also reported seeing the white, granular solid and clear gel-like material.

"At 1330 hrs. BJC Oak Ridge Waste Operations personnel notified the Oak Ridge ETTP Park Shift Superintendent (PSS) who initiated emergency response actions. At approximately 1500 hrs, the DOE Region 2 Radiological Assistance Program (RAP) Coordinator notified Paducah that teams of radiological technicians from DOE sites in the area were being dispatched to survey the trucks. A DOE Region IV RAP Coordinator notified Paducah that he would make notifications to the State Police in AZ and NM.

"Environmental, Safety and Health Impact: None Identified at the time of the initial report. Based on the initial information from the truck drivers, the description of the material matches that of the absorbent material (Quik-Solid) placed in the containers to absorb any condensation that might form. This material in non-hazardous."

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