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Event Notification Report for August 29, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/28/2006 - 08/29/2006

** EVENT NUMBERS **


42794 42796 42798 42799 42810

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General Information or Other Event Number: 42794
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: ALPHA TESTING LABS, INC
Region: 4
City: SANDY State: UT
County:
License #: UT 1800485
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/23/2006
Notification Time: 11:01 [ET]
Event Date: 08/21/2006
Event Time: 18:00 [MDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHIC CAMERA DISCONNECTED SOURCE

The State provided the following information via facsimile:

"This event involved a Source Production & Equipment Company radiographic exposure device (model SPEC 150, serial number 948; with sealed source model SPEC G-60, serial number NH0807). The activity contained in the radiographic exposure device at the time of the incident was 4.912 terabecquerels (133 Ci) of Iridium-192. The radiographer noticed that the crank turned out more turns than normal when he exposed the source. He then realized that the guide tube was not connected tightly to the device. The radiographer cranked the source in with the guide tube not connected. The pigtail hit against the radiographic exposure device and disconnected. The radiographer followed the licensee's emergency procedures and controlled the area until the radiation safety officer arrived. The radiation safety officer began and completed the source retrieval procedures without further incident. The licensee contacted the manufacturer regarding the disconnect. The manufacturer informed the licensee that when the source was outside the guide tube, and oriented 90 degrees to the travel direction of the cable, the source can disconnect.

"Event Location: Chevron Refinery VGO Unit, 2351 N 1100 W, Salt Lake City, Utah 84116"

The Utah Division of Radiation Control was notified by the licensee in a telephone call on August 22, 2006.

Utah Event Report ID No.: UT-06-0003

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General Information or Other Event Number: 42796
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: FLAGSTAFF MEDICAL CENTER
Region: 4
City: FLAGSTAFF State: AZ
County:
License #: 03-03
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 13:20 [ET]
Event Date: 08/18/2006
Event Time: 12:30 [MST]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
MICHELE BURGESS (NMSS)

Event Text

ARIZONA AGREEMENT STATE REPORT - TRASH CONTAINING IODINE -131 TAKEN TO LANDFILL

The State provided the following information via e-mail:

"At approximately 12:30 PM 8/18/2006 the Agency was informed by the Licensee that a patient receiving Iodine 131 therapy was discharged 8/16/2006. The Radiation Safety Staff proceeded to clean the patient's room. The containment items were placed into a plastic bag. The bag was transported to the waste storage area, where the Staff was unable to unlock the door. Security was called and they were unable to open the door. The Staff then moved the materials to the nuclear medicine preparation room which could be locked. The trash read 1.3mr/hr at the surface. The trash was not marked as being radioactive.

"Upon arrival the next day, the Staff discovered that the cleaning crew had removed the trash. The cleaning crew were trained that if the trash is not marked 'Radioactive' they were to remove it. They attempted to catch the trash before removal to the landfill, but they were unsuccessful. The Staff also went to the landfill and attempted to recover the trash but were unsuccessful.

"The material represents minimal public health risk if disposed into the landfill.

"The Agency continues to investigate the event.

"Press coverage is not anticipated."

First Notice: 06-07

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General Information or Other Event Number: 42798
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PORVIDENCE PORTLAND MEDICAL CENTER
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90946
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 19:35 [ET]
Event Date: 10/03/2005
Event Time: 00:00 [PDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

OREGON AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO THE INCORRECT AREA OF THE PATIENT

The State provided the following information via facsimile:

"Doctor treated wrong Trigeminal nerve. Patient received 32 Gray before error was noted. Doctor informed patient of error then proceeded to treat correct nerve.

"In order to prevent a reoccurrence of this mistake, there will be three different double checks undertaken on the day of treatment. Prior to being sedated, the patient will be asked which side his or her pain is on. When the patient, is framed the nurse shall ask the neurosurgeon which side is to be treated. This will be verified with the patient. Lastly, just prior to treatment, both the neurosurgeon and the radiation oncologist will be once again asked which side is to be treated on the patient. This triple check system should prevent this mistake from happening again."

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General Information or Other Event Number: 42799
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90731
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/23/2006
Notification Time: 19:35 [ET]
Event Date: 02/24/2006
Event Time: 00:00 [PDT]
Last Update Date: 08/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TROY PRUETT (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

OREGON AGREEMENT STATE REPORT - VIAL CONTAINING IODINE-125 THROWN IN TRASH DUMPSTER

The State provided the following information via facsimile:


Event Description: "A researcher reported that a vial containing I-125 labeled hormones is missing. They had received a shipment from another university that was supposed to have had 3 vials. The person who checked in the package did not realize there were supposed to be three vials. The material was packaged with dry-ice. Only two vials were removed from the package and the package was placed in the trash. When it was discovered that they were supposed to be three vials, the trash had already been removed and the dumpster taken away. The estimated amount is 237 microCuries of I-125.

Corrective Actions: "Licensee will double check inventory of each box during unloading.

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Power Reactor Event Number: 42810
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL PLETCHER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/28/2006
Notification Time: 18:39 [ET]
Event Date: 08/28/2006
Event Time: 13:00 [EDT]
Last Update Date: 08/28/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES DWYER (R1)

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

Event Text

HIGH PRESSURE COOLANT INJECTION OVERSPEED TRIP MECHANISM FAILED TO RESET

"The High Pressure Coolant Injection system (HPCI) over-speed trip tappet did not reset as expected during the trip tappet test after securing from a successful HPCI operability run, thereby preventing a re-start of the HPCI system. The Automatic Depressurization System (ADS), Core Spray sub-systems, Low Pressure Coolant Injection (LPCI) and the Reactor Core Isolation Cooling (RCIC) systems are operable."

The unit is in a 14 day LCO for this event. The licensee will notify the NRC Resident Inspector.

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