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Event Notification Report for April 20, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/19/2007 - 04/20/2007

** EVENT NUMBERS **


43304 43306 43308

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General Information or Other Event Number: 43304
Rep Org: COLORADO DEPT OF HEALTH
Licensee: PROTECHNICS
Region: 4
City: TRINIDAD State: CO
County:
License #: 545-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/16/2007
Notification Time: 14:49 [ET]
Event Date: 04/13/2007
Event Time: 00:00 [MDT]
Last Update Date: 04/16/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
MICHELL BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - LOST CONTROL OF 2 MILLICURIES OF IR-192

The licensee provided the following information via facsimile:

"This is initial notification that the Department is investigating an incident involving licensed radioactive material that was discovered at a [Grand Junction, CO] landfill on 4/13/07. Apparently, a licensee using radioactive materials for subsurface well tracing activities lost control of 4-10 bottles of resin bead waste containing Ir-192. Radiation readings taken on the waste containers indicated about 2 millirem per hour at one meter. The company believed to be responsible for the waste, Protechnics, responded to the scene and removed the material to their facility for decay. So far, there is no indication that any members of the public were exposed to radiation in excess of established limits. An investigation is in progress."

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General Information or Other Event Number: 43306
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ENERGY SOLUTIONS
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73008
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/17/2007
Notification Time: 12:28 [ET]
Event Date: 04/16/2007
Event Time: 11:45 [EDT]
Last Update Date: 04/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS KOZAK (R3)
MARIE MILLER (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED SHIPMENT EXCEEDING DOT REGULATIONS

The licensee provided the following information via facsimile:

"The Radiation Safety Officer at Energy Solutions waste processing facility [Duratek Radwaste Processing, Oak Ridge ,TN] called the State to report an incoming shipment [open bed trailer] containing 12 boxes [of Dry Active Waste - 323 millicuries] from Dairyland Power Cooperative in Genoa, Wisconsin was surveyed for receipt and found to have greater than 200 Mr/hr on one box. The dose rate exceeded the DOT regulations referenced in 49 CFR 173.441. NRC regions 1 and 3 were notified on 4/16/07."

In further discussions with Dairyland Power Cooperative it was stated that when the shipment left La Cross power plant facility the survey of the boxes was within DOT shipping regulations. During transport the Dry Active Waste most likely settled to the bottom of the box which accounted for the elevated radiation levels. Dairyland Power Cooperative stated the state of TN would be contacting the state of WI about this incident.

TN Report ID Number: TN-07-074

*** UPDATE FROM STATE OF TN (SHULTS) TO KNOKE AT 1600 EDT ON 04/17/07 ***

Spoke to state of TN and they indicated they were not contacting the state of WI since Dairyland Power Cooperative was a NRC licensee.

Notified FSME (Morell) and R1DO (Miller) and R3DO (Kozak).

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Hospital Event Number: 43308
Rep Org: COMMUNITY HOSPITAL INDIANAPOLIS
Licensee: COMMUNITY HOSPITAL INDIANAPOLIS
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-06009-01
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: GERRY WAIG
Notification Date: 04/18/2007
Notification Time: 14:20 [ET]
Event Date: 04/18/2007
Event Time: 13:30 [EDT]
Last Update Date: 04/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
THOMAS KOZAK (R3)
KEITH McCONNELL (FSME)

Event Text

MEDICAL EVENT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED

The following information is taken from a facsimile sent by Community Hospital Indianapolis:

A patient undergoing Yttrium-90 therashpere treatment of the liver received an under dose. The original estimated intended dose was 301 Gray (Gy). The authorized user confirmed the setup during performance of the pre-administrative checklist. The under dose occurred due a mis-positioned stopcock that resulted in part of the intended source material being directed to a waste vial rather than the patient catheter. When the mis-directed (source) liquid was noted in the waste vial tubing, the authorized user re-checked the delivery system and corrected the stopcock orientation. Based on a delivered source activity of 3.28 GigaBecquerel (GBq), the estimated dose received by the patient is 130 Gy.

The patient has been notified of the under dose.

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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Thursday, March 29, 2012