Event Notification Report for September 22, 2006

AGREEMENT STATE REPORT - TRAFFIC ACCIDENT INVOLVING A TRUCK CARRYING RADIOACTIVE MATERIAL

The State provided the following information via email:

"The Division of Radiation Health (DRH) received notification on 9-22-06 from Mississippi Emergency Management Agency about a traffic accident that occurred at 6:00 AM on Highway 43 North of Picayune, MS. The vehicle was delivering radiopharmaceuticals to area hospitals and clinics. The road was wet due to rain and the driver lost control of vehicle and collided with 2 other vehicles. Several of the shipping containers were ejected from the vehicle and some of the contents were deposited outside the shipping containers. Local sheriff department and fire departments responded to the accident scene. DRH responded to the scene of the accident as well as Cardinal Health personnel. Cardinal Health personnel discovered that no contamination had leaked from the containers and no personnel were contaminated. Vehicle was transporting 6 boxes (ammo boxes used as shipping containers) containing a total of 892 millicuries of Technetium-99m and Xenon-133. Some boxes contained used doses that had already decayed to near background radiation levels."

Mississippi Incident Report number: MS 06011

See Louisiana Agreement State Report: Event Number 42855

AGREEMENT STATE REPORT

"A Cardinal Health vehicle from the Slidell, LA location was carrying 1214 mCi of Tc-99 and 40 mCi of Xe-133 to a Mississippi facility when it was involved in an accident on Highway 43 in Mississippi. Cardinal Health notified the appropriate authorities in Mississippi. Emergency Response in Mississippi took control of the vehicle."

Louisiana event report ID number: LA060017

See Mississippi Agreement State Report: Event Number 42858.

AGREEMENT STATE REPORT - OVEREXPOSURE

This event involves a mis-administration of a therapeutic dose of Sm-153. The written directive was to administer 74 millicuries of Sm-153. This dose was exceeded by at least 58%.

The state will provide updated information as it becomes available.

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.

REPORTED UNDER NRC BULLETIN 91-01 24 HOUR NOTIFICATION

"On September 22, 2006, during a heavy rain storm, the water level in the C-310 position #4 scale pit reached 3 5/8 inches (3.625 inches). The scale pit liquid sensor alarm system did not function as credited, in violation of NCSA 310-004. The water was found by operators by visual inspection. NCSA 310-004 credits the liquid sensor alarm to provide notification of water in the pit in excess of 2.5 inches.

At the time of the event, the water level was measured to be less than 3 5/8 inches (3.625 inches) deep. However, subsequent measurements accounting for slope in the scale pit floor show that the water could actually have been as deep as 4 3/8 inches (4.375 inches).


The two process conditions relied upon for double contingency are mass and geometry.

"The first leg of double contingency is based on preventing a release of fissile material containing greater than a safe mass of uranium from getting into the scale pits. This is controlled through reliance on the integrity of the UF6 cylinder, liquid UF6 piping, pigtail, and liquid UF6 handling equipment. Since a UF6 release containing greater than a safe mass has not occurred, the mass parameter has been maintained Therefore, this leg of double contingency is maintained.

"The second leg of double contingency relies on the scale pit liquid sensor alarm system to provide notification of water in the pit in excess of 2.5 inches. Requiring the liquid sensor to alarm at 2.5 inches allows ample time to react and prevent the accumulation of more than 3.68 inches water. Although the alarm system did not function, operators performed a surveillance of the scale pits and identified water in the #4 scale pit in excess of 2.5 inches. NCSE 032 shows that the 'subcritical' slab height of UO2F2 solution in the C-310 scale pit is 4.1 inches at (deleted) wt% U235. The NCSE determined that an unsafe geometry slab height (is., greater than 4.1 inches) cannot form if the initial water height is less than 3.6 inches. The as-found water height corrected for the scale pit slope was determined to be as deep as 4 3/8 inches (4.375 inches). Therefore, the parameter limit specified in NCSE 032 was exceeded and double contingency was not maintained.

"The NRC Senior Resident Inspector has been notified of this event. PGDP Problem Report No. ATRC-06-3103; PGDP Event Report No. PAD-2007-01: NRC Worksheet No.


SAFETY SIGNIFICANCE OF EVENTS:

Although the scale pit liquid sensor alarm system failed to alarm when water in the pit exceeded 2.5 inches, an insufficient amount of water was available to achieve a criticality. The assay of the product withdrawal system at the time of the event was less than (deleted) wt%. Additional KENO and bucking calculations were included in design analysis calculation to illustrate the margin of conservatism. Those calculations show that the scale pit would have remained below the PGDP USL even for UO2F2 slab heights up to 7.75 inches at (deleted) wt%. In addition, a UF6 release containing greater than a safe mass did not occur.

POTENTIAL CRITICALITY PATHWAYS INVOLVED:

In order for criticality to be possible, a large UF6 release containing greater than a critical mass of uranium would have to form in the scale pit, and the pit would have to contain a sufficient amount of water.

CONTROLLED PARAMETERS:

The two process conditions relied upon for double contingency are mass and geometry.


ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL:

Product withdrawal assay at the time of the event was less than (deleted) wt% U235. However, no UF6 release occurred.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

All C-310 scale pit sensor alarming systems have been repaired and verified to work properly and put back in service.


The NRC Resident Inspector was notified of this report.

PATIENT RECEIVED RADIATION THERAPY AND LATER DETERMINED TO BE PREGNANT

The following report was received via e-mail:

"Patient had thyroidectomy in 2005 and came into nuclear medicine dept. on Sept. 8, 2006 for consultation for I-131 treatment, the nuclear medicine [NM] resident interviewed her, explained precautions, stated importance of not becoming pregnant. A pregnancy test was performed on September 21, 2006 and the results were negative. The patient was then treated with 95 mCi of I-131 on September 22, 2006.

"After missing one of her Endocrine clinic appointments following the radioactive iodine therapy treatment, on December 22, 2006, the patient went to the Endocrine clinic for a follow up visit. Following that visit, NM was informed by endocrinology that the patient was pregnant. NM contacted OB/GYN and learned that the patient visited her OB/GYN physician and that ultrasound confirmed that the patient was pregnant. The ultrasound revealed that the patient was approximately 8-weeks pregnant, putting the date of conception at approximately September 1-6, so the patient was already 2-3 weeks pregnant at the time of the pregnancy test.

"It was estimated that the fetus received about 25 rad of radiation exposure. Upon discovery of the incident, patient was advised to see a genetic specialist immediately at the Montefiore Medical Park to discuss the radiation exposure to the fetus and possible consequences as a result of the radiation exposure.

"An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health."