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Event Notification Report for March 17, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/16/2006 - 03/17/2006

** EVENT NUMBERS **


42409 42410 42418 42419 42425

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General Information or Other Event Number: 42409
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: JOHNS HOPKINS MEDICAL INSTITUTE
Region: 1
City: BALTIMORE State: MD
County:
License #: MD-07-005-03
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: BILL GOTT
Notification Date: 03/13/2006
Notification Time: 11:13 [ET]
Event Date: 03/09/2006
Event Time: [EST]
Last Update Date: 03/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1)
MICHELE BURGESS (NMSS)
ILTAB (email) ()

Event Text

AGREEMENT STATE REPORT - MISSING P-32

On March 9, 2006, Johns Hopkins Medical Institute reported that P-32 was missing from a vial being stored in one of the research facility's freezers. Approximately 10 millicuries is missing. The vial was received on March 2, 2006. Some P-32 (10%) was removed to conduct a research experiment and the vial was replaced in the freezer. When the researcher checked the vial the following day, the vial was empty. The Maryland Department of the Environment and the licensee are conducting investigations. The licensee has performed surveys of the floor that the storage freezer is on, checked for contamination on personnel who work in this area, and water coolers in the facility. All were negative.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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General Information or Other Event Number: 42410
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PRE-TEST LABORATORIES
Region: 4
City: ROUND ROCK State: TX
County:
License #: L02524
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DORIS LEWIS
Notification Date: 03/13/2006
Notification Time: 12:40 [ET]
Event Date: 03/10/2006
Event Time: 15:00 [CST]
Last Update Date: 03/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
MICHELE BURGESS (NMSS)
ILTAB (E-MAIL) ()
MEXICO (E-MAIL) ()

Event Text

STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via fax:

"On Friday evening we received a call from the [after-hour phone] service with instructions to call the SOC concerning a lost nuclear gauge. There were instructions to call [the] RSO for Pre-Test Lab [TXRAML02524] a licensee based in Georgetown, TX with authorization to possess and use a variety of moisture/density (M/D) gauges. The RSO explained that around 1500 hrs on Friday, March 10, 2006, one of his trucks was proceeding to a convenience store in the vicinity of Red Bud and County Road 122 in Round Rock, TX when upon arriving at the store it was noticed that the M/D gauge was missing. He admitted that the tailgate may not have been secured and the shipping container was not chained to the bed of the truck. An extensive search of the area traveled was conducted by Pre-Test as well as Round Rock PD and FD without finding the container. The device is a Troxler Model 3411-B serial number (S/N) 10260 with a 9mCi [milliCurie], Cs-137 source model TEL Dwg. #102112 , S/N 40-7662 and a 44mCi, Am-241source model TEL Dwg. #102451, S/N 46-1663."

Texas Incident No.: I-8312

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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General Information or Other Event Number: 42418
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: MONROE State: LA
County:
License #: LA-5119-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: JOE O'HARA
Notification Date: 03/14/2006
Notification Time: 14:45 [ET]
Event Date: 03/05/2006
Event Time: [CST]
Last Update Date: 03/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
ROBERT PIERSON (NMSS)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED IMPROPER MEDICAL DOSE

The State provided the following information via facsimile:

"On March 5, 2006, a technician at St. Francis North Hospital contacted the Cardinal Health pharmacy to inform them that a scan on a patient had shown lung imaging instead of the expected cardiac imaging after administering a dose labeled Myoview. An investigation revealed that the customer's Tc-99m Myoview dose for cardiac imaging had mistakenly been dispensed as a Tc-99m MAA dose which is for lung imaging.

"The cause of this event was a failure by the dispensing pharmacist to follow proper Cardinal Health compounding procedures. The pharmacist pulled the wrong kit from the refrigerator. The pharmacist performed a QC test on the dose, but failed to label the starting point on the QC chromatography strip, which led to a misinterpretation of the failing test as a passing test.

"In order to prevent a recurrence of this event, the pharmacy is going to begin requiring all employees performing QC tests to label the starting point of all QC strips. Also, the pharmacy is planning to switch brands of MAA since the Drax MAA vial and the Myoview vials are identical in appearance."

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General Information or Other Event Number: 42419
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAKER HUGHS INTEC
Region: 4
City: HOUMA State: LA
County:
License #: LA-6025-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/14/2006
Notification Time: 11:39 [ET]
Event Date: 03/13/2006
Event Time: [CST]
Last Update Date: 03/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CLAUDE JOHNSON (R4)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - WELL LOGGING SOURCE ABANDONED

The State provided the following information via facsimile:

"Baker Hughs Intec abandoned a 2.5 Ci source of Cs-137 and a 5 Ci source of Am-241 down hole on March 13, 2006. The depth of the sources is between 14,423 feet and 14,430 feet. The hole has [been] back filled with cement to a depth of 12,095 feet to prevent reentry into the hole."

Louisiana license number: LA060004

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Power Reactor Event Number: 42425
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOHN BRADY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/17/2006
Notification Time: 01:30 [ET]
Event Date: 03/16/2006
Event Time: 22:50 [EST]
Last Update Date: 03/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MIKE ERNSTES (R2)

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

Event Text

LOSS OF COMMUNICATION - ERDADS COMPUTER FAILED

"On 3/16/2006 at approximately 2010 [EST], the U2 ERDADS computer failed and stopped providing updated plant data to the Unit 2 and Technical Support Center operator consoles, leaving the displays essentially static. Investigation of the failure mode is ongoing and attempts to restore the ERDADS to normal are in progress.

"Loss of the ERDADS output for greater than one hour is reportable as a major loss of assessment and communication capability under 10 CFR 50.72(b)(3)(xiii)."


The licensee notified the NRC Resident Inspector.

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