Event Notification Report for May 31, 2006

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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CRITICALITY EVACUATION ALARM FAILURE

On Wednesday, May 31, 2006, at 1130 hours, it was determined that the criticality accident alarm system (CAAS) was not capable of providing a [DELETED] Complex site-wide evacuation alarm in the event of a criticality. There were no indications on the system control panel indicating a problem with the system. Specifically, the power light was on and there were no trouble alarms at the panel. Preliminary troubleshooting indicates a short in one of the cards in the central panel. The local control panels in each of the buildings appear to be operating normally. However, an alarm at the local control panel will not initiate the [DELETED] Complex site-wide evacuation alarm. This condition may have existed since May 1, 2006.

No actual safety consequences occurred as a result of this event; however, there was a risk of potential health and safety consequences to the occupational workforce, involving significant radiation exposure from an accidental criticality event with no warning alarm to initiate prompt [DELETED] Complex site-wide evacuation. The potential risk was significantly lessened after May 15 when all licensed activities at the [DELETED] Complex stopped except for the operation of the Effluent Processing Building, which contains negligible amounts of uranium.

On May 20, 2006, a severe thunderstorm passed over the [DELETED] Complex, and a lightning strike caused some electronic components throughout the plant to stop working or function erratically.

On May 24, 2006, an indication of a communication system failure in the CAAS was identified. There are two circuits in the system, one is for communications between the individual detectors in each of the buildings and the other circuit is for the alarms. There was no indication of the general system failure that was later observed on May 31. The communication system was repaired and tested successfully.

Between May 24 and May 31, instrument technicians were performing regular calibrations of instruments throughout the plant and identified a few instruments that appeared to be affected by the lightning strike. Based on this evidence, and knowledge of the design of the CAAS, the [DELETED] Complex Maintenance Manager recommended to the Plant Manager that the criticality system be tested to ensure it was not affected prior to performing any licensed activities, although there was no direct evidence at that time that the system was affected. It was decided that this testing should take place on May 31.

[DELETED] Complex operations are in safe standby condition and will not be resumed until the CAAS is fully functional.

The licensee notified the NRC Resident Inspector and Region 2.

* * * UPDATE ON 05/11/08 BY H. Crouch * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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MEDICAL EVENT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED

"The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA.

"The permittee is VA Eastern Colorado Health Care System, Denver, Colorado. The possible medical event occurred on May 31, 2006. The possible medical event was discovered on March 28, 2007.

"The basis for the possible medical event is under 10 CFR 35.3045(a)(1)(i) and involved administration of a dose different from the dose prescribed in the written directive.

"Specifically, the written directive for a patient therapy procedure listed the dose to be 15 millicuries Iodine 131 when in fact 30 millicuries was given to the patient. Since the clinical intent was for the patient to receive 30 millicuries, the possible medical event will not have any adverse impact on the patient.

"The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event.

"The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days."

* * * UPDATE ON 3/30/2007 AT 0720 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO ABRAMOVITZ * * *

This event has been reviewed and determined to be a reportable medical event.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.