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Event Notification Report for April 4, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/03/2008 - 04/04/2008

** EVENT NUMBERS **


44105 44110 44113 44117 44118

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Hospital Event Number: 44105
Rep Org: WILLIAMSPORT HOSPITAL
Licensee: WILLIAMSPORT HOSPITAL
Region: 1
City: WILLIAMSPORT State: PA
County:
License #: 37-04185-01
Agreement: N
Docket: 03003037
NRC Notified By: JUDITH GOULDIN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/28/2008
Notification Time: 15:35 [ET]
Event Date: 03/28/2008
Event Time: 13:00 [EDT]
Last Update Date: 03/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
RONALD BELLAMY (R1)
DUNCAN WHITE (FSME)

Event Text

UNPLANNED DOSE TO FETUS

"A written directive was completed on 3/18/08 prescribing 18 mCi of I-131 (capsule) for the treatment of hyperthyroidism on 3/28/08. The [prescribing physician] indicated on the form that pregnancy test was negative and she was not breastfeeding. The pregnancy test result was attached to the directive.

"Upon arrival the patient completed an assessment form and consent form and she indicated in writing that she was not pregnant or breastfeeding. Staff and authorized user verified patient identity (name and birth date), dose, dose calibrator setting, and route of administration. The patient received the dose as prescribed.

"Nuclear Medicine was contacted by the lab shortly after the administration with a positive pregnancy result that was done on the day of the therapy. The patient's physician was notified. The patient was notified to increase fluids and void frequently and advised to make an appointment with her OBGYN physician. [A] Health Physicist Consultant was also notified and [the hospital] is awaiting the dose calculation to the embryo."

At the time of the report, the hospital had not calculated a dose to the unborn child. The hospital will provide the calculated dose when it is available but the Radiation Safety Officer believes that the result will be less than 50 milliSieverts (< 5 rem).

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General Information or Other Event Number: 44110
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PROVIDENCE EVERETT MEDICAL CENTER
Region: 4
City: EVERETT State: WA
County:
License #: WN-M0135-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2008
Notification Time: 18:19 [ET]
Event Date: 03/28/2008
Event Time: [PDT]
Last Update Date: 03/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
KEITH McCONNELL (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A PARTIAL EQUIPMENT FAILURE OF AN HDR UNIT DURING A SOURCE EXCHANGE

The following information was received from the State of Washington via email (quotations omitted for ease of reading):

STATUS: New

Licensee: Providence Everett Medical Center
City and State: Everett, WA
License Number: WN-M0135-1
Type of License: Medical
Date and time of Event: 28 March 2008
Location of Event: Everett, WA

ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

A Varian Medical Systems (varian) representative was attempting a routine source exchange at the licensee's facility. There were no patients or Medical Center staff involved in the source exchange process. The varian rep noted some trouble with making the "old" source enter the exchange container. After several attempts the rep realized the transfer was not proceeding as expected. The rep telephoned staff at Varian Corporate headquarters for assistance. The decision was made to cut the source wire near the source and place the source assembly into the emergency shielded source container (emergency pig). After the wire was snipped and the cut piece placed into the emergency pig, the rep performed a survey and noticed that the radiation levels were less than expected. At this time the licensee and the Varian rep both notified the Office of Radiation Protection of the event by telephone.

The room was locked and barrier tape placed across the door. A Varian recovery team was called for and arrived at the Medical Center, with the source designer, on Saturday, 29 March 2008.

An Office of Radiation Protection investigator also joined the team on Saturday to direct the onsite investigation and recovery.

The investigation determined that both the dummy wire and the source wire had tried to exit the HDR unit simultaneously. The wires become stuck in the "home switch" part of the HDR. When a wire was cut it had been the dummy wire and not the source assembly wire. The cutoff dummy wire had been placed into the emergency pig which had given lower then the expected dose rate readings.

On Saturday, the recovery team successfully retracted the source into the HDR. Testing is underway to determine why the HDR source exchange process had allowed both wires to be sent out at once. A comprehensive written report is expected from the manufacturer within the next few days.

Notification Reporting Criteria: WAC 246-220-250 Equipment Failure.

Isotope and Activity involved: HDR Sealed Source: Ir-192, approximately 185 GBq (5 Curies).

Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None

Lost, Stolen or Damaged? (mfg., model, serial number): Varian HDR source model VS2000 (not lost, not stolen, possibly damaged).

Disposition/recovery: Source recovered 29 March 2008 by Varian recovery team.

Leak test? No "official" leak test yet but several contamination wipe surveys were performed during the course of the recovery. All of these were negative.

Vehicle: N/A

Release of activity? None

Activity and pharmaceutical compound intended: N/A

Misadministered activity and/or compound received: N/A

Device (HDR, etc.) Mfg., Model; Varian VariSource iX (Trademark) HDR

Exposure (intended/actual); consequences: None to patients and the public. The highest exposure received by a recovery team member was 87 mRem.

Was patient or responsible relative notified? N/A

Was written report provided to patient? N/A

Was referring physician notified? N/A

Consultant used? No

Event Report # WA-08-020.

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General Information or Other Event Number: 44113
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: TIGUE CONSTRUCTION COMPANY, INC.
Region: 4
City: GLENWOOD State: AR
County:
License #: ARK-0867
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/01/2008
Notification Time: 10:52 [ET]
Event Date: 03/31/2008
Event Time: 15:30 [CDT]
Last Update Date: 04/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
GREG MORELL (FSME)
ILTAB (via email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was received from the State of Arkansas via email (quotations omitted for readability):

The Arkansas Department of Health, Radioactive Materials Program, is reporting that one of their licensees, Tigue Construction Company, Inc., has a Troxler moisture/density gauge that is stolen/missing from a pickup truck some time during the day in or near Brinkley, Arkansas. The licensee became aware of the missing gauge at 15:30 on March 31, 2008 after loading the gauge in the truck at the office in Glenwood, Arkansas that morning. The licensee has stated that the gauge, transport case and chains are missing. The licensee made one stop in Little Rock and observed that gauge in the truck during that stop. The licensee has filed a police report with the Brinkley Police Department.

The Troxler gauge is a Model 3440, S/N 27381, and contains 40 milliCuries of Am-241:Be and 8 milliCuries of Cesium-137.

The Arkansas Department of Health prepared a press release on the event.

The licensee verbally indicated that the gauge was properly secured in the truck at the time. The Arkansas Department of Health is investigating the circumstances surrounding this event.

Arkansas Department of Health notified Brinkley Police Department, Monroe County Sheriff's Office, Arkansas Department of Emergency Management (Arkansas State Police, Arkansas Highway Patrol), State of Mississippi, State of Tennessee [and] NRC Region IV.

Arkansas has assigned Event Report ID No: AR-03-08-01

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Other Nuclear Material Event Number: 44117
Rep Org: PONZE INM ENGINEERING LAB, INC.
Licensee: PONZE INM ENGINEERING LAB, INC.
Region: 1
City: COTO LAUREL State: PR
County:
License #: 52-24908-02
Agreement: N
Docket:
NRC Notified By: JOSE IRIZARRY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/03/2008
Notification Time: 08:23 [ET]
Event Date: 04/03/2008
Event Time: [EDT]
Last Update Date: 04/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
SAM HANSELL (R1)
GREG MORELL (FSME)
ILTAB (via e-mail) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

STOLEN CPN MOISTURE DENSITY GAUGE

The licensee Radiation Safety Officer reported that a company pick-up truck, that had a moisture density gauge stored in the bed, was stolen from in front of the apartment complex of the Authorized User. The apartment was located in Guaynabo, Puerto Rico, which is remotely located from the licensee home office located in Coto Laurel, Puerto Rico.

The gauge is a CPN Model MC-1DRP, S/N 60703285, which contains 10 mCi of Cs-137 and 50 mCi of Am: Be. The gauge was last leak checked on October 15, 2007. The gauge was secured to the truck in a metal case mounted to the chassis of the truck and secured with the gauge lock, the gauge case lock and two locks on the metal storage case.

The stolen truck was a white 1996 Ford Ranger pick-up with Puerto Rican tag number 557-167.

The licensee notified the Puerto Rico State Police of the theft of the truck and gauge.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Power Reactor Event Number: 44118
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DENNIS MAY
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/03/2008
Notification Time: 14:57 [ET]
Event Date: 04/03/2008
Event Time: 14:00 [EDT]
Last Update Date: 04/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
SAM HANSELL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 50 Power Operation 50 Power Operation

Event Text

LOSS OF ABILITY TO TELEPHONE OUT OF STATE

"When it was discovered that numerous plant personnel could not make telephone calls out of state, attempts were made to contact the states of Vermont, New Hampshire, and Massachusetts, as well as the NRC through the FTS phone. The NRC, as well as the state of Vermont were contacted but the NAS phone system was inoperable as well as the land lines to the states of NH and MA. Alternate means to contact the states were available via the microwave system."

At 1430 all communications that were lost were restored. At 1445 all testing of communications were completed.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012