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Event Notification Report for May 5, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/02/2008 - 05/05/2008

** EVENT NUMBERS **


44173 44177 44180 44186

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General Information or Other Event Number: 44173
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER WYOMING VALLEY HOSPITAL
Region: 1
City: WILKES-BARRE State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: DAVE ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/28/2008
Notification Time: 17:15 [ET]
Event Date: 02/07/2008
Event Time: [EDT]
Last Update Date: 04/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1)
KEVIN HSUEH (FSME)

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

Event Text

AGREEMENT STATE REPORT - MEDICAL DOSE NOT IN ACCORDANCE WITH WRITTEN DIRECTIVE

"On Friday April 25, 2008 at approximately 1700 hrs, the Pennsylvania Bureau of Radiation Protection's Central Office Licensing Section was notified by [REDACTED] of a Medical Reportable Event that occurred on February 7, 2008 at Geisinger's Wyoming Valley Hospital located at 1000 East Mountain Drive in Wilkes Barre, PA. (License #37-01421-01; PA-0006) The event was not discovered until Friday April 25, 2008 during a licensee review of Written Directives administered.

"Licensee stated that the written directive for an I-131 treatment of a hyperactive thyroid was incorrectly written as 10 microcuries (0.37 MBq). Licensee stated that the nuclear medicine technician either did not read the directive or misread the directive and administered 10 millicuries. Licensee stated that the dose administered was appropriate for the treatment, however, inconsistent with the written directive. The prescribing physician was notified on the date of discovery. Licensee stated that no adverse health effects are expected as a result of this error. The error most likely occurred because the most common prescriptions for this sort of treatment are 10 - 20 mCi (370 - 740 MBq) I-131 and the technician did not recognize that the written directive stated 10 uCi (0.37 MBq).

"Licensee stated that actions taken to prevent recurrence had not been undertaken at the time of report. Licensee will be sending a written report to PA DEP's SCRO.

"The above information was reported to [REDACTED] PA DEP BRP Director on 4/28/2008."

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: 44177
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL X-RAY & TESTING
Region: 4
City: OFFSHORE State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/29/2008
Notification Time: 15:03 [ET]
Event Date: 04/23/2008
Event Time: [CDT]
Last Update Date: 04/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
RON ZELAC (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

This incident was originally reported in Event Notification #44159 by the licensee due to the uncertainty of the location of the potential overexposure.

The State provided the following information via facsimile:

"On April 23 2008, [DELETED] (RSO) with Global X-Ray & Testing (GXT) reported an excessive exposure on an industrial radiographer's badge. Landauer contacted GXT and reported that a badge had a reading over 1000 rads. The radiographer in question was interviewed by [DELETED] and a LA Department of Environmental Quality inspector. The radiographer was very shocked to hear of the excessive exposure. He was asked if anything unusual occurred during the month. The radiographer did not think anyone exposed the badge intentionally. The radiographer did state that he could not find his badge one morning on a job that occurred on March 20 - 24, 2008. The radiographer had a physical and blood work performed. The physical included CBC and total Lymphocyte count. The blood work came back within normal limits. This incident is still under investigation by the Louisiana Department of Environmental Quality."

Louisiana Report: LA080008

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General Information or Other Event Number: 44180
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: WUESTHOFF HEALTH CENTER
Region: 1
City: ROCKLEDGE State: FL
County:
License #: 0833-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOE O'HARA
Notification Date: 04/30/2008
Notification Time: 16:35 [ET]
Event Date: 04/30/2008
Event Time: [EDT]
Last Update Date: 04/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1)
RICHARD TURTIL (FSME)
ILTAB VIA EMAIL ()

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

Event Text

EIGHT LOST PALLADIUM - 103 SEEDS

The State provided the following information via facsimile:

"[Florida Bureau of Radiation Control was] informed at 1600 hours that (8) Pd-103 seeds and (8) I-125 seeds, all in one box are lost. Box was labeled for a delivery to North American Scientific. Box was left in restricted area over night and was found missing the next day. Housekeeping was suspected of throwing box in the trash. Surveys were performed, dumpster was checked, and North American Scientific was contacted. No further action will be taken on this incident."

Activity of Pd-103 seeds 1.2 milliCuries per seed, I-125 seeds 0.381 microCuries per seed. Licensee is retraining staff on proper disposal procedures.

FL Incident Number: FL08-066

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 44186
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TODD BOHANAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/04/2008
Notification Time: 22:14 [ET]
Event Date: 05/04/2008
Event Time: 15:30 [CDT]
Last Update Date: 05/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
CAROLYN EVANS (R2)

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

Event Text

HPCI DECLARED INOPERABLE

"During the required quarterly oil sample taken following scheduled flow rate surveillance, the Unit 2 HPCI oil system was found to contain excessive amounts of water. HPCI declared inoperable.

"This event is reportable under 10CFR50.72(b)(3)(v)(B), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.'

"Unit 2 remains at 100% power

"14 day TS LCO 3.5.1 has been entered and troubleshooting is in progress.

"NRC Resident has been notified."

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Thursday, March 29, 2012