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Event Notification Report for May 4, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/03/2007 - 05/04/2007

** EVENT NUMBERS **


43325 43334 43338 43340

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General Information or Other Event Number: 43325
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee:
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: UNC HOSPITALS
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2007
Notification Time: 08:04 [ET]
Event Date: 04/20/2007
Event Time: 16:00 [EDT]
Last Update Date: 04/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

"North Carolina Radioactive Materials Branch was notified by the radiation safety officer from UNC Hospitals of a possible misadministration involving the administration of MDS Nordion Yttrium 90 microspheres. The licensee initially contacted us immediately on the next business day following the patient administration, but was not certain at the time if the event was a misadministration because calculations and measurements had to be made to determine the percentage of the prescribed dose delivered. The licensee has determined that the patient only received approximately 72% of the prescribed dose (22.6 millicuries), which qualifies the event as a misadministration under current North Carolina Regulations.

"The misadministration occurred because of a leak in the administration set during delivery of the dose. The licensee has been asked to determine if the leak was because of an apparent manufacturing defect with the administration set, or the result of an assembly error by the licensee. The licensee will report the cause of the event in the Misadministration Report that must be submitted within 15 days of the event. No harm is expected to the patient because of this event. The patient's physician and authorized user will determine if an additional administration is necessary to account for the dose not delivered initially."

North Carolina Report Number: NC-07-02


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: 43334
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKIN ELMER LIFE & ANALYTICAL SCIENCES
Region: 1
City: BILLERICA State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/01/2007
Notification Time: 13:37 [ET]
Event Date: 05/01/2007
Event Time: 10:00 [EDT]
Last Update Date: 05/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE- MASSACHUSETTS - EXCESSIVE CONTACT RADIATION LEVEL ON SHIPPING PACKAGE

The State provided the following information via facsimile:

"Licensee received Type A package containing 100 millicuries of Na-22 from Los Alamos National Lab. External Radiation measurement of the package on contact was 360 mrem/hr. The TI on the package was listed as 7 (the licensee measured a TI of 8.5).

"Package was shipped on April 30, 2007 and flown to Boston Logan Airport by Fed Ex, after which it was trucked by Fed Ex to the licensee site at 331 Treble Cove road in Billerica, MA.

"The licensee has informed Fed Ex of the external radiation measurements."

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Power Reactor Event Number: 43338
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/03/2007
Notification Time: 03:09 [ET]
Event Date: 05/03/2007
Event Time: 01:46 [EDT]
Last Update Date: 05/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL HOLODY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

OFFSITE NOTIFICATION - RELEASE TO ENVIRONMENT

"Notified New Jersey Department of Environmental Protection of a release of sodium hypochlorite to the environment. The amount of sodium hypochlorite released was small (11.5 lbs) and well below the Federal (100 lbs) and state reportability limits for quantity."

Leak was from a hose on the chlorination system that supports the Service Water system.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 43340
Rep Org: MATTINGLY TESTING SERVICES
Licensee: MATTINGLY TESTING SERVICES
Region: 4
City: BILLINGS State: MT
County:
License #: 25-21479-01
Agreement: N
Docket:
NRC Notified By: MARK FICEK
HQ OPS Officer: JOE O'HARA
Notification Date: 05/02/2007
Notification Time: 11:18 [ET]
Event Date: 05/01/2007
Event Time: 12:10 [MDT]
Last Update Date: 05/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
NEIL O'KEEFE (R4)
GREG MORELL (FSME)

Event Text

RADIOGRAPHY CAMERA SOURCE TUBE DAMAGED

Approximately 1210 on 05/01/07, the RSO was contacted by one of his radiographers at Cenex in Laurel, MT that he couldn't get the source back into the radiography camera. The area was roped off pending the arrival of the RSO to take corrective action. The camera is an INC Model IR100 with 76 curies of Ir-192. The licensee did not know the serial number.

At 1245 the RSO arrived at the site and noticed a sharp angled cut on the source tube. The RSO shielded the source with lead and lead shot and replaced the source tube then retracted the source back into the camera. The RSO believes the damage to the source tube was caused by the radiographer. The RSO received 16 mrem exposure and the radiographer received 6 mrem.

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Thursday, March 29, 2012