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Event Notification Report for September 14, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/13/2004 - 09/14/2004

** EVENT NUMBERS **


41031 41033 41038

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General Information or Other Event Number: 41031
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SAINT MARY MEDICAL CENTER
Region: 4
City: WALLA WALLA State: WA
County:
License #: WN-M0101-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/09/2004
Notification Time: 11:45 [ET]
Event Date: 09/07/2004
Event Time: [PDT]
Last Update Date: 09/09/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
JOHN HICKEY (NMSS)

Event Text

WASHINGTON STATE AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was received from Washington State Department of Health:

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"STATUS: new

"Licensee: Saint Mary Medical Center
"City and State: Walla Walla, Washington
"License Number: WN-M0101-1
"Type of License: Medical Combination

"Date of Event: September 7, 2004
"Location of Event: Licensees facility in Walla Walla, Washington

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"The licensee's radiation safety officer notified the department that licensee staff had observed an anomaly after injecting a patient with Technetium (Tc) 99m, intended for a bone scan study. They had injected the proper patient with the apparent proper dose of 37.4 millicuries, Tc-99mHDP. When the patient returned approximately three hours later for the study, the patient showed no bone uptake but did have uptake in the liver and cardiac muscle.

"Two unit doses were received on September 3rd from the nuclear pharmacy for two different patients. Both patients were injected on the same day. The second patient showed a nominal bone uptake and the study was performed per procedure.

"The shipping documents and dose calibrator check indicated the dose was as ordered. The nuclear pharmacy was called and asked about the doses. The two doses had been drawn-up consecutively by the same pharmacist. The pharmacy was certain the order had been drawn, delivered and documented accurately. The licensee and pharmacy were unable to explain the anomalous first study. All information appears to corroborate that the study should have been as expected.

"A repeat scan was performed. This dose localized as expected and the study gave diagnostic quality images.

"On-site investigation by the department is not planned.

"No media attention noted.

"Notification Reporting Criteria: 10 CFR Part 35.33(a)

"Isotope and Activity involved: Technetium (Tc) 99mHDP, 37.4 mCi

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Liver and Cardiac Muscle, dose estimate to be determined, the licensee indicated that the patient should receive adverse consequences as a result of the anomaly.

"Lost, Stolen or Damaged? (mfg., model, serial number): N/A

"Disposition/recovery: A second study was ordered and performed as expected.

"Leak test? N/A

"Vehicle: N/A

"Release of activity? N/A

"Activity and pharmaceutical compound intended: 37.4 mCi, Tc-99mHDP
"Misadministered activity and/or compound received: [as far as could be determined] 37.4 mCi, Tc-99mHDP
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: It is anticipated that the patient will receive no adverse health effect from the anomalous dose.
"Was patient or responsible relative notified? Both were notified.
"Was written report provided? Yes, dated September 8, 2004.
"Was referring physician notified? Yes

"Consultant used? No"

This event is assigned Washington event number WA-04-053 and is entered in NMED.

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General Information or Other Event Number: 41033
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GEOTEST ENGINEERING, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: L02735-011
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR.
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/09/2004
Notification Time: 16:10 [ET]
Event Date: 09/09/2004
Event Time: 08:45 [CDT]
Last Update Date: 09/09/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
SCOTT MOORE (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was received from Texas Department of State Health Services:

"At approximately 8:45 a.m. the gauge operator had just completed a density test on the site of Wheatley High School, where a new high school is being constructed, when a bulldozer, belonging to another contractor working at the job site, made a sudden and unexpected move toward the operator, who was performing calculations beside the gauge. During the movement the bulldozer operator dropped the blade of the vehicle which impacted the Troxler Model 3430, Serial No. 25129 moisture density gauge. The gauge was crushed with damage to the housing. The gauge contained two sealed sources: Cs-137, nominal 8 millicuries, Serial No. 75-7305 and Am-241/Be, nominal 40 millicuries, Serial No. 47-21337. The sources were not damaged nor leaking. The gauge control rod was in the up and locked. A survey of the area determined that no leakage where the gauge was crushed or to the blade of the bulldozer. The gauge was transported to Component Sales and Services (L02243-000) for leak testing and determination of possible repair. The gauge was determined to be not repairable. The gauge was transferred to Component Sales and Services for disposal. The gauge was last leak tested on April 4, 2004, with negative test results."

Texas Incident No. I-8161.

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Power Reactor Event Number: 41038
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES MURAIDA
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/13/2004
Notification Time: 18:32 [ET]
Event Date: 09/13/2004
Event Time: 15:46 [CDT]
Last Update Date: 09/13/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3)

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

OFFSITE NOTIFICATION DUE TO MINOR OIL SPILL

"While performing routine ditch cleaning maintenance (on Sept. 13, 2004), a faulty hydraulic hose on a bulldozer caused a small release of hydraulic oil near a drainage ditch adjacent to Braidwood Station property. The hose was intact prior to maintenance beginning on the morning of Sept. 13.

"It is estimated that 10-15 gallons of oil spilled on the ground, with a very small portion of the oil (less than one gallon) going into the drainage ditch itself. The oil on the ground has been removed. A compensatory oil boom was placed downstream of the spill in the ditch to collect the small amount of oil that went into the ditch. A thorough walk down of the ditch, downstream from the spill, revealed no evidence of oil. The Station will investigate why the hose failed and what actions can be taken in the future to prevent recurrence.

"Per Station procedures, official notifications were made to the Illinois Emergency Management Agency, and the National Response Center. In addition, Exelon communications notified the Village of Godley, the Godley Park District, the Village of Braceville, and the Braceville Fire Department District. Residents in the area were notified through personal visits."

The licensee notified the NRC Resident Inspector.

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Friday, March 30, 2012