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Event Notification Report for July 7, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/03/2008 - 07/07/2008

** EVENT NUMBERS **


44321 44328 44330 44331 44332 44333 44334 44336 44337

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General Information or Other Event Number: 44321
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UCLA
Region: 4
City: WESTWOOD State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/27/2008
Notification Time: 11:33 [ET]
Event Date: 06/23/2008
Event Time: [PDT]
Last Update Date: 06/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4)
CINDY FLANNERY (FSME)

Event Text

POTENTIAL UNDERDOSE TO PATIENT UNDERGOING WHOLE BODY RADIATION

The following report was received from the state via e-mail:

"On June 25, 2008 at approximately 3 pm, RHB received preliminary notification of a medical event, which occurred June 23, 2008, involving a 50% under-dose to a patient undergoing whole-body irradiation with a Co-60 teletherapy unit. The event was discovered at approximately 2 pm on June 25, 2008. RHB held the initial report to NRC until additional details could be provided by the licensee, who was still reviewing the situation with the radiation oncology department. The prescription was for total body irradiation at 17.12 minutes AP (anterior posterior), then 17.13 minutes AP, then 17.12 minutes PA (posterior anterior), then 17.13 minutes PA, for a total of 34.25 minutes AP and 34.25 minutes PA, and a total of 300 cGy. The therapist only treated 17.13 minutes AP and 17.13 minutes PA for a total dose of 150 cGy. The patient was seen by the attending physician on 6/25/08, with no known medical effects observed. There is currently no plan to re-treat the patient per the attending physician. The licensee is following up with a written report.

"5010 Number - 062508"

The attending physician and patient have been notified.

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: 44328
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: ST MARY MEDICAL CENTER
Region: 4
City: WALLA WALLA State: WA
County:
License #: WN-M0101-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/30/2008
Notification Time: 14:14 [ET]
Event Date: 06/09/2008
Event Time: [PDT]
Last Update Date: 06/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
MICHELE BURGESS (FSME)

Event Text

WASHINGTON AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

The following information was received from the State of Washington via email:

"On 9 June 2008 a patient presented for a prescribed bone scan (normally, Tc-99m, 30mCi, MDP), but instead received 23mCi of Tc-99m Sestamibi (heart scan).

"The dose was administered. No useful imaging or diagnostic information could be obtained from this procedure. The bone scan will be rescheduled. The licensee will submit a written report, containing cause and proposed corrective actions within 15 days. The licensee's written report dated 23 June 2008 indicates the cause to be human error by the nuclear medicine technologist. The licensee believes current procedures in place are adequate, providing staff adheres to those procedures. The technologist in question will now 'take a time out' prior to each injection to review the dose to be injected, the dose ordered, and to fully and thoroughly check the markings in place on syringes and vials to prevent such an occurrence. No media attention thus far.

"According to the manufacturer's product insert, the patient in this case could be expected to receive a maximum of: 4.14R to the Upper Large Intestinal Wall (the most for any single organ), and a whole body dose of 383 mR. No physical consequences are anticipated."

Licensee notified patient and referring physician.

* * * UPDATE ON 06/30/2008 AT 1644 EST FROM FSME (ZELAC) TO ROTTON * * *

The NRC has reviewed this event and determined it is not a reportable medical event.

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General Information or Other Event Number: 44330
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SEAGATE TECHNOLOGY LLC
Region: 4
City: MILPITAS State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/01/2008
Notification Time: 15:50 [ET]
Event Date: 06/23/2008
Event Time: [PDT]
Last Update Date: 07/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)

Event Text

AGREEMENT STATE - LEAKING STATIC ELIMINATOR SOURCES

The state submitted this report via e-mail.

"Seagate leases static discharging (elimination) devices from a licensed manufacturer, NRD LLC. These static dischargers are Po-210 based alpha emitters. Seagate employees noticed oxidation/discoloration on these static discharges within 2-3 months after installation in their clean rooms. They were concerned about possible flaking of any particulates onto their micro sensitive products and cost of swapping the devices more frequently than every 12 months (lease period). Seagate removed these units from the clean rooms and wipe tested them and sent them for processing to Sterling & Associates. On 6/23/08, the CIH from Sterling & Associates informed Seagate that 4 of the 5 fans exhibiting discoloration, exceeded the limit (0.005 microcuries) 'leaking' with sample results ranging from 0.009-0.01 microcuries. These units included Model # P-2063 with S/Ns A2FD498 (0.02 microcuries), A2FH895 (0.01 microcuries), A2FD505 (0.02 microcuries) & A2FH915 (.009 microcuries). In addition, the remaining 12 fans sampled collectively showed results of 0.3 microcuries. All these 12 units were same Model # P-2063. After the findings, Seagate wipe tested 5 more units (1 brand new, 1 clean looking, & 3 discolored) and the nearby work areas of leaking sources, and the results were non-detect. Seagate notified NRD and all the units that were tested (5+12) were shipped to NRD for further verification. NRD believed that the wipe sampling of the unit, if not done properly might affect the ultra-thin gold encapsulation layer and thereby pick up some imbedded Po-210.

"07/01/08 - Per NRD RSO, they still have not received the units from Seagate. He also stated that these units contain a very thin layer of plating and if wipes are not done properly, wipes will pick up imbedded Po-210 indicating contamination. NRD will be wipe testing all the units as soon as they are received and will be calling RHB to notify their findings."

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General Information or Other Event Number: 44331
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA0153-1
Agreement: Y
Docket:
NRC Notified By: JOEL MINF
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/01/2008
Notification Time: 16:10 [ET]
Event Date: 05/31/2008
Event Time: [EDT]
Last Update Date: 07/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)

Event Text

AGREEMENT STATE - POSSIBLE OVEREXPOSURE

"Emory University Health Physics Department received notification of a film badge reading with a Beta Dose Reading of 49919mR. This report is only preliminary at this point."

Period of exposure: 5/1/2008 to 5/31/2008
Deep Dose: 240 mR
Lens Dose: 240 mR
Beta Dose: 49919 mR

"The assigned shallow dose was changed to 50,160 mrem due to the beta reading of 49,919 mrem. The other doses, including the ring badge reading, are not out of line with what she and her coworkers in PET-CT receive regularly.

"[The employee] typically only works with [F-18]FDG [fleurodeoxyglucose]. These readings are consistent with a contaminated badge. I will confer with Landauer as to whether contamination with FDG might result in a reading like this, as I suspect."

The employee is currently vacationing out of the country and will return July 10, 2008. The investigation will be completed at that time.

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General Information or Other Event Number: 44332
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WASHINGTON STATE UNIVERSITY
Region: 4
City: PULLMAN State: WA
County:
License #: WN-C003-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/02/2008
Notification Time: 15:00 [ET]
Event Date: 06/24/2008
Event Time: [PDT]
Last Update Date: 07/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
RON ZELAC (FSME)

Event Text

WASHINGTON AGREEMENT STATE REPORT - LEAKING CS-137 SEALED SOURCE

The following information was provided via email from the State of Washington:

"On June 26th, WSU reported that a Cesium-137 sealed source used to test operation of radiation detection instrumentation was found, by WSU staff, to be leaking. The source had recently been used at a WSU research facility. The staff noticed that two of the detectors were indicating higher than expected radiation readings after the source had been returned to storage. Subsequently, WSU staff found the radiation detection instrumentation they had been testing had become contaminated. The source appears to have been abraded during use.

"The source, an Isotope Products Lab, model not yet known, Serial Number 687-87-7 and its wooden storage box were taken out of service when the leak was discovered. The source and box are scheduled for disposal as radioactive waste. WSU staff are looking into the specific cause of the abrasion. WSU will then determine if additional corrective actions will be made to keep this from reoccurring.

"The licensee reported that surveys were performed in all areas where the source had been used and stored. Three WSU staff were found to have between 200 to 300 counts per minute of contamination on their fingers. WSU staff also found contamination levels of up to 300 counts per minute on a hand-rail and other associated equipment in the facility. Decontamination of the staff, areas and equipment was successfully performed.

"Notification Reporting Criteria: WAC 246-221-265, leaking source.

"Isotope and Activity involved: Cs-137 check source, 0.37 MBq (10 microcuries) as of February 1, 2000.

"Finger contamination was noted, but no overexposures should be realized.

"Washington State Report WA-08-046."

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Hospital Event Number: 44333
Rep Org: HELEN NEWBERRY JOY HOSPITAL
Licensee: HELEN NEWBERRY JOY HOSPITAL
Region: 3
City: NEWBERRY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: CHAD BRUNO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/02/2008
Notification Time: 16:40 [ET]
Event Date: 07/02/2008
Event Time: 15:00 [EDT]
Last Update Date: 07/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
RONALD BELLAMY (R1)
THOMAS KOZAK (R3)
ANDREW PERSINKO (FSME)

Event Text

MOLYBDENUM-99 PACKAGE WITH EXTERNAL CONTAMINATION

A nuclear medicine technologist from Helen Newberry Joy Hospital reported receiving a package containing a Molybdenum-99 generator (148 GBq) that had an external radiation of 30 mR/hr and 23,985 dpm (with a background of 11695 dpm). The external contamination was removable using a wipe test. The Molybdenum generator will not be used until next Tuesday and will be stored in a room requiring entry through three locked doors. The Nuclear Technologist will be informing the package carrier of the contamination. He was uncertain where the packaged originated or who the licensed shipper of the package was at the time of the report but would attempt to determine the information and contact the responsible party.

* * * UPDATE BY HUFFMAN AT 0930 EDT ON 7/3/08 * * *

Thi event was updated to make some minor editorial corrections and clarifications.

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Power Reactor Event Number: 44334
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: CARL SUCHTING
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/03/2008
Notification Time: 09:06 [ET]
Event Date: 07/03/2008
Event Time: 05:40 [EDT]
Last Update Date: 07/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RONALD BELLAMY (R1)

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

LOSS OF COMMERCIAL TELEPHONE AND DEDICATED EP LANDLINES

"Reportable Event SAF 1.10

"Major loss of offsite communications capability was experienced at 0540 on 7/3/08. Conventional phones and the EP [Emergency Preparedness] notification lines were lost. Cell phones were available for offsite communications. Offsite communications capability via landlines was restored at 0550 on 7/3/08 with the exception of EP lines, however the ability to contact State and Local authorities using landlines was verified at 0621 on 7/3/08. At 0714 on 7/3/08 the auto ring down EP lines were restored and tested. Source of the problem appears to be failure of Verizon equipment offsite to automatically transfer to alternate when one path was interrupted by a car pole accident."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 44336
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RICK ROBBINS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/03/2008
Notification Time: 21:42 [ET]
Event Date: 07/03/2008
Event Time: 19:45 [CDT]
Last Update Date: 07/04/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
FREDERICK BROWN (NRR)
ERIC LEEDS (NRR)
CINDY PEDERSON (R3)
BRIAN McDERMOTT (IRD)
TOM BARNES (DHS)
DAN SULLIVAN (FEMA)

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

Event Text

SODIUM HYPOCHLORITE LEAK

"At 1945 Point Beach declared a UE based on HU 3.1, 'Report or detection of toxic or flammable gases that has or could enter the site area boundary in amounts that can affect NORMAL PLANT OPERATIONS.'

"This Emergency Action Level (EAL) was entered based on a confirmed Sodium Hypochlorite tank leak to the tanks diked area. The leak is located below the current tank level and will continue to drain to the dike until equilibrium level is reached. The dike is designed to contain the entire tank contents. There are no signs of any leakage outside of the dike. The vapors in the immediate area are not significant at this time and extra ventilation has been provided by opening an overhead roll up door in the area. The NRC Senior Resident Inspector has been notified."

The sodium hypochlorite is used in the screen house to chlorinate the service water and circulating water systems to eliminate Zebra Mussels. The concrete diked area is designed to contain the entire contents of the tank.

* * * UPDATE AT 0831EDT ON 7/4/08 FROM KILE HESS TO S. SANDIN * * *

"At 0646 [CDT] on 7/4/08 Point Beach terminated the UE that was declared at 1945 CDT on 7/3/08, based on HU 3.1. The leaking Sodium Hypochlorite tank and leak control dike have been drained and the over flow leak control area cleaned. The hazard no longer exists and the area has been released to normal access."

The licensee informed State and local agencies and the NRC Resident Inspector. Notified R3DO (Kozak), EO (Brown), IRD (Gott), FEMA (Canupp) and DEHS (Inzer).

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Power Reactor Event Number: 44337
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM ANDERSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/04/2008
Notification Time: 10:04 [ET]
Event Date: 07/04/2008
Event Time: 08:39 [EDT]
Last Update Date: 07/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARVIN SYKES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM ON TURBINE TRIP

"A Turbine Trip greater than 30% power caused a Reactor Trip (Scram), both Recirculation Pumps tripped. A low level [Reactor Vessel Water Level] of approximately 2 inches caused a Group 2 containment valve isolation signal, all valves closed as required.

"The cause of the Turbine Trip is under investigation"

All control rods fully inserted with no ECCS actuations. Unit 1 is currently stable in mode 3 (Hot Shutdown) with decay heat being removed via the bypass. Following the scram, one SRV lifted and reseated. At the time of the transient, an EHC pump autostart was in progress, however, there is no indication that this was the cause of the turbine trip. Unit 1 is in a normal shutdown electrical lineup.

The licensee informed the NRC Resident Inspector.

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