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Event Notification Report for June 25, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/22/2007 - 06/25/2007

** EVENT NUMBERS **


43431 43432 43440

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General Information or Other Event Number: 43431
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: THYRO-CAT, LLP
Region: 1
City: WALPOLE State: MA
County:
License #: 44-0550
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/19/2007
Notification Time: 14:41 [ET]
Event Date: 06/13/2007
Event Time: 11:00 [EDT]
Last Update Date: 06/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT FROM MASSACHUSETTS - CONTAMINATION DUE TO IODINE-131

This Agreement State report from the Commonwealth of Massachusetts was received via facsimile:

"Cat moved (kicked) during I-131 injection resulting in a couple of drops on veterinarian gloved hands, exam table, and floor. Contaminated Area subsequently mopped which seemed to spread more than clean the area. Contaminated area covered with plastic and access was restricted for more than 24 hours. Inside the room, the highest measurements on the floor, with a Ludlum 44-88 GM, was 12 Mr/hr on one spot, and 2-5 Mr/hr in all other floor areas - all measurements are at 1 cm. There was no personal contaminations and one small spot on a technicians sweatshirt sleeve which measured 15 mR/hr at 1 cm. With the 44-88 GM. All thyroid measurements indicate no internal intake of I-131. "

Event type Description: Contaminated Area restricted for more than 24 hours.

Cause of Description: Cat moved (kicked) during I-131 injection resulting in a couple of drops on veterinarian gloved hands, exam table, and floor.

Contributing Factor: Contaminated Area subsequently mopped which seemed to spread more than clean the area.

Docket No.: 06-7113

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General Information or Other Event Number: 43432
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: WEST MONROE State: LA
County:
License #: LA-5119-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/19/2007
Notification Time: 14:37 [ET]
Event Date: 05/16/2007
Event Time: [CDT]
Last Update Date: 06/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
GREG MORELL (FSME)

Event Text

LOUISIANA AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DISPENSING ERROR

The State provided the following information via facsimile:

"Description of Event - A customer called the [Cardinal Health] pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent.

"Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error.

"Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary.

LA event Report ID No.: LA070015

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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Power Reactor Event Number: 43440
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TERRY DAMASHEK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/22/2007
Notification Time: 03:34 [ET]
Event Date: 06/21/2007
Event Time: 20:00 [CDT]
Last Update Date: 06/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAIR SPITZBERG (R4)

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

"SPDS (SAFETY PARAMETER DISPLAY SYSTEM) INOPERABLE DUE TO PLANT COMPUTER INOPERABILITY

"The Wolf Creek Nuclear Plant Information System (NPIS; Plant Computer) was conservatively declared inoperable at 2000 (CDT) on 06/21/2007 due to questions concerning accuracy of some of the computer point outputs. Initial troubleshooting and investigation identified that some computer points may be reading 0.1% to 0.2% lower than actual process parameter. Investigation is ongoing to determine the scope and cause for this condition and to correct the problem. Compensatory measures for loss of NPIS are being implemented in accordance with procedure OFN RJ-023, NPIS Malfunctions. The plant is stable with power being maintained at or below 100% based on Nuclear Instruments."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012