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Event Notification Report for September 15, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/14/2004 - 09/15/2004

** EVENT NUMBERS **


41031 41032 41033 41034 41036 41039 41040 41041

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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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 41032
Rep Org: PRINCETON UNIVERSITY
Licensee: PRINCETON UNIVERSITY
Region: 1
City: PRINCETON State: NJ
County: MERCER
License #: 2905185-24
Agreement: N
Docket:
NRC Notified By: SUE DUPRE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/09/2004
Notification Time: 14:01 [ET]
Event Date: 09/01/2004
Event Time: [EDT]
Last Update Date: 09/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
HAROLD GRAY (R1)
CHARLIE MILLER (NMSS)

Event Text

TWO TRITIUM EXIT SIGNS MISSING

The two signs were discovered missing when an electrical contractor failed to turn over the exit signs to the University's Radiation Safety Officer. The signs were removed during building renovation that started in June. The contractor apparently stored the signs in a box under his desk and the box was removed and believed disposed of as trash. The licensee will follow-up in a written report.

* * * RETRACTION PROVIDED BY S. DUPRE TO JEFF ROTTON ON 09/14/04 AT 1430 EDT * * *

On 09/13/04 at 1014 EDT, the licensee was notified by the electrical contractor, that the missing exit signs were located in a gang box used for the Alexander Hall job and stored in the contractor's warehouse. The signs were returned to the licensee into the custody of the Environmental Heath and Safety Office, where they are currently stored awaiting return to the manufacturer.

Notified R1DO (Doerflein), and NMSS EO ( Moore )

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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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General Information or Other Event Number: 41034
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF HOUSTON
Region: 4
City: HOUSTON State: TX
County:
License #: L01886-000
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/10/2004
Notification Time: 15:55 [ET]
Event Date: 09/02/2004
Event Time: 11:30 [CDT]
Last Update Date: 09/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHARLES MILLER (NMSS)

Event Text

UNPLANNED CONTAMINATION EVENT

Facility suffered a sewer blockage in the Waste Building on the morning of 09/02/2004. Soil waste removed to discover cause of blockage. It was immediately determined that the line was not connected to the sanitary sewer. The line has been in place for 12 years for the disposal of H-3 and C-14 waste. An estimated total of 100 millicuries of these radioactive materials have been disposed during the last 12 years. Maximum soil contamination discovered was measured at 0.1 millirem per hour. No workers or equipment were contaminated. The University immediately let a contract for cleanup of the contaminated soil and repair of the sewer line. The area was placed behind barrier tape and covered with plastic to prevent blowing or erosion. Initially, the soil was removed and barreled by a licensed Texas decontamination firm. A second break in the line was discovered near the building that may require soil removal by covered roll-off container.

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Other Nuclear Material Event Number: 41036
Rep Org: TRANSNUCLEAR, INC
Licensee: TRANSNUCLEAR, INC.
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN MANGUSI
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/12/2004
Notification Time: 11:37 [ET]
Event Date: 09/10/2004
Event Time: 17:00 [EDT]
Last Update Date: 09/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
HAROLD GRAY (R1)
LARRY CAMPER (NMSS)
GREG PICK (R4)

Event Text

MISPLACED IMPORT RADIOACTIVE SHIPMENT

On September 4, 2004 a radioactive shipment, under a General Licensee, was flown into JFK Airport via Air France Flight # 6492 (flight arrived at 2345 hours). The radioactive shipment, 6 pound Bio Pack package with White Label 1 with a Transportation Index (TI) number of 0 , went through customs. On September 10, 2004 Transnuclear, Inc sent a freight truck to pick up the shipment at Air France. Air France personnel were unable to locate the package and they said that they had misplaced the package. The BioPack contains 4 sample tubes of uranium hexafluoride. The four sample tubes are LEU. Total is 0.038 kg of uranium hexafluoride of which 0.025 kg is LEU uranium. Transnuclear, Inc is supposed to ship the BioPack to Framatome ANP located in Richland, WA.

* * * Update on 09/14/04 at 0926 EDT by John Mangusi taken by MacKinnon * * *

Transnuclear,Inc. was notified by email that the package had been located at the JFK Air France Terminal. Transnuclear, Inc. will arrange to pick up the package and eventually deliver it to Framatone ANP located in Richland, WA.

NRC (John Wray) was notified of this by John Mangusi. NRC R1DO (Larry Doerflein), NRC R4DO (Dale Powers) & NMSS EO (M. Burgess) notified.

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Power Reactor Event Number: 41039
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: FRANK CIGANIK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/14/2004
Notification Time: 16:44 [ET]
Event Date: 09/14/2004
Event Time: 15:00 [EDT]
Last Update Date: 09/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 40 Power Operation 40 Power Operation

Event Text

OFFSITE NOTIFICATION TO STATE OF NEW JERSEY

The following information was received from the licensee via facsimile:

"Notified New Jersey Department of Environmental Protection of a planned shutdown of OCNGS [Oyster Creek Nuclear Generating Station] scheduled to commence at 2000 hrs. [EDT] on 9-14-04."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 41040
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: BERNARD LAJAUNIE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/14/2004
Notification Time: 17:32 [ET]
Event Date: 09/14/2004
Event Time: 16:04 [CDT]
Last Update Date: 09/14/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DALE POWERS (R4)
CATHERINE HANEY (NRR)
PETER WILSON (IRD)
JANNIE EVERETTE (DHS)
STEINDURF (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO HURRICANE WATCH IN ST. CHARLES PARISH

The following information was provided by the licensee via facsimile:

"Waterford 3 entered Unusual Event Emergency Classification due to the National Weather Service declaring a hurricane warning for St. Charles Parish at 1600 CDT."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 41041
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: PHIL SANTINI
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/15/2004
Notification Time: 03:13 [ET]
Event Date: 09/15/2004
Event Time: 01:42 [EDT]
Last Update Date: 09/15/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)
CATHERINE HANEY (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 70 Power Operation 2 Startup

Event Text

NEW YORK STATE NOTIFIED THAT UNIT 2 WAS TAKEN OFFLINE FOR REPAIRS

Unit 2 was taken offline for repairs to "21" Main Feed Discharge Check Valve. The licensee will maintain Unit 2 in mode 2 at approximately 2% power for the duration of repairs.

The licensee informed the NY State Public Services Commission and the NRC Resident Inspector.

* * * UPDATE 1045 EDT ON 9/15/04 FROM JOHN BAKER TO ARLON COSTA * * *

The above report was corrected to remove inaccurate information.

Notified R1DO( Doerflein) and NRR EO (Haney).

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