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Event Notification Report for September 28, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/27/2006 - 09/28/2006

** EVENT NUMBERS **


42855 42856 42858 42862 42863 42865

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General Information or Other Event Number: 42855
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH NUCLEAR PHARMACY
Region: 4
City: SLIDELLE State: LA
County:
License #: LA-10336-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JASON KOZAL
Notification Date: 09/22/2006
Notification Time: 14:44 [ET]
Event Date: 09/22/2006
Event Time: [CDT]
Last Update Date: 09/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JOSEPH HOLONICH (NMSS)

Event Text

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.

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General Information or Other Event Number: 42856
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: PIKEVILLE MEDICAL CENTER RADIATION THERAPY
Region: 1
City: PIKEVILLE State: KY
County:
License #: 20205320
Agreement: Y
Docket:
NRC Notified By: ANGELA BRITTON
HQ OPS Officer: JASON KOZAL
Notification Date: 09/22/2006
Notification Time: 16:13 [ET]
Event Date: 09/22/2006
Event Time: [CDT]
Last Update Date: 09/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
JOSEPH HOLONICH (NMSS)

Event Text

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.

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General Information or Other Event Number: 42858
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City: SLIDELL State: LA
County:
License #: LA-10336-L01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: BILL GOTT
Notification Date: 09/25/2006
Notification Time: 12:19 [ET]
Event Date: 09/22/2006
Event Time: 06:00 [CDT]
Last Update Date: 09/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ZACH DUNHAM (R4)
SANDRA WASTLER (NMSS)

Event Text

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

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Other Nuclear Material Event Number: 42862
Rep Org: HERITAGE VALLEY HEALTH SYSTEM
Licensee: HERITAGE VALLEY HEALTH SYSTEM
Region: 1
City: SEWICKLEY State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: PETE SNYDER
Notification Date: 09/26/2006
Notification Time: 09:42 [ET]
Event Date: 09/21/2006
Event Time: [EDT]
Last Update Date: 09/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRIS HOTT (R1)
SANDI WASTLER (NMSS)

Event Text

MEDICAL EVENT - ONLY ONE CAPSULE OF A TWO CAPSULE DOSE ADMINISTERED

The licensee provided the following information via email:

"On 9/21/06 at Sewickley Valley Hospital, a technician removed a vial of I-131 therapy capsules and measured the dose in the dose calibrator to ensure that the dose measured the expected amount of 25 millicuries. The dose was administered to the patient by emptying the contents of the vial into the patient's hand. Only one of the I-131 capsules came out of the vial instead of two. The vial was placed back into the shipping container
and returned to the pharmacy.

"On 9/25/06, the pharmacy notified Sewickley Valley Hospital that they had returned one of the two capsules to the pharmacy. One of the two capsules had apparently remained in the vial during the administration to the patient. The RSO reported that the dose to the patient was approximately 5 millicuries instead of the 25 millicurie prescribed dose. The hospital has already contacted the referring physician and plans on contacting the patient to make arrangements to administer the rest of the prescribed dose. The hospital will also institute changes in their procedures requiring the vial to be visually inspected and checked in the dose calibrator following use to prevent this from happening in the future."

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.

* * * UPDATE FROM LICENSEE (PERNA) TO HUFFMAN AT 11:17 EDT ON 9/27/06 * * *

The licensee provided an e-mail edit to the original event report to correct some inaccuracies in the information originally reported to the NRC. R1DO (Hott) and NMSS (Wastler) notified.

* * * UPDATE FROM CYNTHIA FLANNERY (NRC) TO GERRY WAIG ON 9/27/06 AT 1532 * * *

Then NRC Medical Radiation Safety reviewed this event and determined it to be a reportable medical event.

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Hospital Event Number: 42863
Rep Org: HERITAGE VALLEY HEALTH SYSTEM
Licensee: HERITAGE VALLEY HEALTH SYSTEM
Region: 1
City: SEWICKLEY State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/26/2006
Notification Time: 16:14 [ET]
Event Date: 09/01/2006
Event Time: [EDT]
Last Update Date: 09/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRIS HOTT (R1)
ELMO COLLINS (NMSS)

Event Text

MEDICAL EVENT - ONLY ONE CAPSULE OF A TWO CAPSULE DOSE ADMINISTERED

"On 9/1/06 at Sewickley Valley Hospital, a technician removed a vial of I-131 therapy capsules and measured the dose in the dose calibrator to ensure that the dose measured the expected amount of 100 millicuries. The dose was administered to the patient by emptying the contents of the vial into the patient's hand. Only one of the I-131 capsules came out of the vial instead of two. The vial was placed back into the shipping container
and returned to the pharmacy.

"On 9/26/06, the pharmacy notified Sewickley Valley Hospital's RSO that the technicians at SVH had returned one of the two capsules to the pharmacy. The notification occurred during the RSO's investigation into a separate medical event that had occurred on 9/21/06 under similar circumstances. The pharmacy had discovered the second capsule on 9/11/06 but there are no records of the pharmacy contacting the hospital about it. The pharmacist who would have made the call is on vacation and not available for questioning until next week.

"One of the two capsules had apparently remained in the vial during the administration to the patient. The RSO reported that the dose to the patient was approximately 35 millicuries instead of the 100 millicurie prescribed dose. The hospital has already contacted the referring physician and plans on contacting the patient to make arrangements to administer the rest of the prescribed dose. The hospital will also institute changes in their procedures requiring the vial to be visually inspected and checked in the dose calibrator following use to prevent this from happening in the future."

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.

* * * UPDATE FROM LICENSEE (PERNA) TO HUFFMAN AT 11:17 EDT ON 9/27/06 * * *

The licensee provided an e-mail edit to the original event report to correct some inaccuracies in the information originally reported to the NRC. R1DO (Hott) and NMSS (Wastler) notified.

* * * UPDATE FROM CYNTHIA FLANNERY (NRC) TO GERRY WAIG ON 9/27/06 AT 1532 * * *

Then NRC Medical Radiation Safety reviewed this event and determined it to be a reportable medical event.

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Power Reactor Event Number: 42865
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK G. GORLEY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/27/2006
Notification Time: 04:26 [ET]
Event Date: 09/27/2006
Event Time: 02:47 [EDT]
Last Update Date: 09/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2)

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

Event Text

TECHNICAL SUPPORT CENTER HVAC REMOVED FROM SERVICE FOR MAINTENANCE

"On 9/27/2006, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned preventive maintenance and inspections and testing activities. These work activities are planned to be performed and completed within a 12 hour work shift. During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity.

"If an emergency condition requiring activation of the TSC occurs during the time these work activities are being performed, then contingency plans call for utilization of the TSC as long as radiological conditions allow. The site Technical Support Center activation procedure provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the TSC so that TSC functions can be continued.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution."

The licensee will notify the NRC Resident Inspector.

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