United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2004 > November 4

Event Notification Report for November 4, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/03/2004 - 11/04/2004

** EVENT NUMBERS **


41159 41161 41162 41169 41170 41171

To top of page
General Information or Other Event Number: 41159
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: BARD BRACHYTHERAPY
Region: 3
City: CAROL STREAM State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 15:10 [ET]
Event Date: 10/29/2004
Event Time: [CDT]
Last Update Date: 11/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD GARDNER (R3)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT

"On October 29, the radiation safety officer (RSO) for Bard Brachytherapy, Mr. Ed Zduenk called the Division to report an excessive radiation level from a package that they had received. Federal Express had delivered a container that was shipped by Northwest Hospital, Randallstown, Maryland on October 26, 2004. The maximum measured radiation level on the surface of the package was 500 milliRem/h. At a distance of 3 feet, the measured radiation level was indistinguishable from background.

"After verifying that the package was intact and undamaged, the RSO proceeded to take measurements in the delivery vehicle. No elevated radiation levels were noted. With the package repositioned in the vehicle as described by the driver, additional measurements were made. There were no elevated readings detected on the exterior of the truck nor at the driver's position. As such, the RSO estimated the driver's exposure to be minimal from handling the package and briefly working at the rear of the delivery vehicle. The carrier was subsequently contacted with this information as well.

"After the package was accepted and moved to a safe location at the facility, additional measurements were taken. The maximum dose rate measured at 1 foot was 10 milliRem/h and at 2 feet was 2 milliRem/h. The container was expected to have 112 sealed sources of I-125 with an actual activity of 0.476 milliCurie each for a total of 53.3 milliCurie. After the package was opened and its contents inventoried, it was determined that all of the sources were accounted for. When the package was opened, the RSO observed that the lid of the interior primary shielded container was not in its expected position. Although some of the sources remained in the shielded container, the other sources were only in their shielded applicator. No sources were 'loose' in the box.

"Considering the shipper, the state of Maryland was notified of this event. This item is still open pending investigation to determine the cause of the event."

IL report number IL040068

To top of page
General Information or Other Event Number: 41161
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County: FAYETTE
License #: 20126696
Agreement: Y
Docket:
NRC Notified By: ROB GRESHAM
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 16:52 [ET]
Event Date: 10/22/2004
Event Time: 14:00 [CDT]
Last Update Date: 10/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT

During the interlock check of a JL Shephard Model 1 Number 68-10 Irradiator, the source rod was lifted with the machine in the off position, indicating a failure of the interlock. Exposure determinations of the technicians present indicated an exposure less than reportable limits. An investigation is in progress.

To top of page
General Information or Other Event Number: 41162
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: LDS HOSPITAL
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800102
Agreement: Y
Docket:
NRC Notified By: JULIE FELICE
HQ OPS Officer: BILL GOTT
Notification Date: 10/29/2004
Notification Time: 18:25 [ET]
Event Date: 10/26/2004
Event Time: 11:30 [MDT]
Last Update Date: 10/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"This event involved an HDR brachytherapy unit [Varian Medical Systems, Inc. Model GammaMed plus, serial number E159; with sealed source Model GammaMed 232, serial number 24-07-4445-004-082504-11622-71 (connector serial number D24E445)]. The female patients larynx cancer treatment plan called for four HDR brachytherapy treatments. On October 26, 2004, two HDR brachytherapy treatments were given. Before the third treatment was to be given, on October 27, 2004, an error was discovered. The prescribing physician stopped the treatment until dosimetry information was completed. The third treatment was not given. The error was caused because a circular tool was used to mark the treatment site. The diameter of the circle was used when the radius should have been applied. As a result, the area treated was 2 cm away from the defined locus instead of 1 cm. The total source length treated was 11 cm, (approximately 1 cm diameter cylinder surrounding the brachytherapy source placed inside a tracheotomy tube). The prescribed dose was 500 cGy (centiGray) to the entire 11 cm length. The worse case patient dose scenario was that the patient received 2,756 cGy at one dwell position out of 23 dwell positions along the 11 cm treatment length. The dose delivered would have been 551% greater than the prescribed dose at the position respective to the worst-case scenario. The licensee does not anticipate any adverse health affects to the patient. The Utah Division of Radiation Control is currently investigating this event."

To top of page
Power Reactor Event Number: 41169
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUANE GARTNER
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/03/2004
Notification Time: 05:15 [ET]
Event Date: 11/03/2004
Event Time: 03:10 [EST]
Last Update Date: 11/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
DAVID SILK (R1)

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

Event Text

OFFSITE MEDICAL TREATMENT FOR INJURED CONTAMINATED WORKER

"On 11/03/04 at approximately 0256 hrs, a refueling bridge operator was injured when his gloved right hand became entangled in the refuel bridge mast during the performance of core alterations. The moving mast sections crushed two of the operator's fingers, and the bridge was immediately shutdown by the spotter. An irradiated fuel bundle had just been removed from the reactor core at the time of the incident, and was being raised to the full up position for transport to the spent fuel pool. The refueling SRO directed the bridge power be turned on to lower the mast slightly and release the operator's hand. The bridge operator was escorted off of the refuel floor by radiation protection and site medical personnel. A bridge relief crew completed the movement of the irradiated fuel bundle to its target location in the spent fuel pool, and core alterations were stopped pending completion of an accident investigation.

"The injured bridge operator was contaminated with approximately 5000 counts per minute on the injured hand, and was transported offsite by radiation protection and site medical personnel at approximately 0310 hrs. The operator was subsequently de-contaminated inside of the ambulance under the care of the emergency room physician, and the contaminated material was returned to site inside the ambulance. Once decontaminated, the operator was admitted to the Salem Memorial Hospital emergency room in Salem, New Jersey."

The licensee informed the Lower Alloways Creek Township and the NRC Resident Inspector and does not plan a press release.

To top of page
Other Nuclear Material Event Number: 41170
Rep Org: OXFORD INSTRUMENTS
Licensee: ABBEY METAL CORPORATION
Region: 1
City: MOONACHIE State: NJ
County:
License #:
Agreement: N
Docket:
NRC Notified By: LAURA ZIEGLER
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/03/2004
Notification Time: 11:21 [ET]
Event Date: 06/16/2004
Event Time: [EST]
Last Update Date: 11/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID SILK (R1)
JOHN HICKEY (NMSS)

Event Text

GENERAL LICENSED RADIOACTIVE MATERIAL LOST DURING BUILDING FIRE

During a fire in the licensee building on 06/16/04, a XMET model 2000 instrument, serial # 500577 was destroyed completely. The instrument probe (serial # 501888) contained two sealed sources, 20 millicuries Cd-109 and 30 millicuries Am-241. The local fire department and Hazmat team responded to the scene. The licensee RSO conducted a survey and found no contamination or radiation. NRC Region 1 office was notified on 6/30/04.

To top of page
Fuel Cycle Facility Event Number: 41171
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PIKETON State: OH
County: PIKE
License #: GDP-2
Agreement: Y
Docket: 0707002
NRC Notified By: JAMES McCLEERY
HQ OPS Officer: ARLON COSTA
Notification Date: 11/03/2004
Notification Time: 13:11 [ET]
Event Date: 11/02/2004
Event Time: 17:35 [EST]
Last Update Date: 11/03/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
STEPHEN CAHILL (R2)
JOHN HICKEY (NMSS)

Event Text

24 HOUR BULLETIN 91-01 REPORT INVOLVING TANKER TRUCK ASSAY RESULTS EXCEEDING VALUES

"DESCRIPTION:
11/2/04 at 1735 the Plant Shift Superintendent (PSS) office was notified of a tanker truck located outside the east corner of the X-700 has uranium results at 322.0 +/- 64.4 PPM and 4.87 +/- 0.49 U-235 assay. No NCSA applies to this operation. This is reportable per NRCB 91-01 as a 24 hour event.

"SAFETY SIGNIFICANCE:
Very Low Safety Significance. The amount and concentration of uranium involved cannot possibly achieve a critical configuration.

"POTENTIAL CRITICALITY:
There are no criticality pathways involved due to the limited mass and concentration of material.

"CONTROLLED PARAMETERS:
No NCSA was established for this operation, so there are no control parameters. However, the limited mass and concentration of the solution does not warrant double contingency control because a criticality is not credible.

"NUCLEAR CRITICALITY SAFETY CONTROLS:
No NCSA controls were established for this operation.

"CORRECTIVE ACTIONS:
Upon discovery the PSS office directed entering an anomalous condition. Additional samples are being taken to confirm results. Contents of tanker are to be removed.

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