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Event Notification Report for August 26, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2008 - 08/26/2008

** EVENT NUMBERS **


44424 44426 44427 44428 44429 44430 44435 44439

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General Information or Other Event Number: 44424
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GREATER BALTIMORE MEDICAL CENTER
Region: 1
City: BALTIMORE State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BARBARA PARK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2008
Notification Time: 14:49 [ET]
Event Date: 08/17/2008
Event Time: 18:00 [EDT]
Last Update Date: 08/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
PATRICE BUBAR (FSME)
ILTAB EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOSS OF Ir-192 SEEDS

"At 1:30pm on Monday, August 18, 2008, a Maryland Department of the Environment radioactive material licensee, Greater Baltimore Medical Center, reported by phone to MDE RHP a loss of 5 Iridium-192 seeds of 0.59 millicuries each seed. The seeds were in a ribbon implanted in a cancer patient's neck along with 5 other strands of seeds. Numerous checks and plain films were obtained to verify correct location. The seeds had been implanted on Wednesday, August 13, 2008 and were checked daily. The loss of a strand of seeds was discovered on Sunday, August 17, 2008 at approximately 6pm, when the seeds strands were being removed.

"Investigative action: The patient was moved to a new room. The licensee reports extensive monitoring of all linens, surfaces, sink drain, other rooms in the unit, nurses station, hallways and the loading dock, where trash was monitored (even though a monitor is located on the loading dock.) A relative's car was also monitored. Being that the patient shaved with a non-electric razor, the outcome of the investigation was that during shaving the strand must have come loose and had fallen into the toilet.

"The RSO and radiation oncologists and physicists were involved in the investigation. Preventive action is for two radiation workers, (i.e. physician and physicist) to independently check the button crimped on the end of the ribbon strand to insure that the ribbon cannot slide out of the catheter.

"The written report from the licensee was received by fax on August 19, 2008, at 3:33 pm. Further investigation by MDE RHP is pending."


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.

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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General Information or Other Event Number: 44426
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS ONCOLOGY P.A. - KLABZUBA
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2008
Notification Time: 16:13 [ET]
Event Date: 08/19/2008
Event Time: [CDT]
Last Update Date: 08/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
PATRICE BUBAR (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT TREATMENT CALCULATION

"Hospital cited for current calibration of SR-90 eye applicator. During previous inspection, after calibration, recalculation of recent treatments indicated 3 patients received 50% overdose over the past year. RSO reports Oncologist and referring physician were pleased with patients response to treatment."

Texas Incident # I 8539

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: 44427
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NOT APPLICABLE
Region: 4
City: DALLAS State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/20/2008
Notification Time: 08:57 [ET]
Event Date: 08/17/2008
Event Time: 10:00 [CDT]
Last Update Date: 08/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
MICHELE BURGESS (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - SURFACE CONTAMINATION AT LUFTHANSA CARGO FACILITY

The following information was provided by the State of Texas via email:

" On 8/18/08 at 0655 CDT, [State of Texas] received a call from the answering service at approximately 10 PM on 8/17/08 requesting that [the State] call Lufthansa Cargo at DFW Airport. [State] contacted [Deleted] and he [reported] that customs had been at their facility and had found a spot on their concrete floor reading 132 microrem. The area [approximately 16' x 20' ] had been used to store a container from Protechnics out of Houston, Texas. The package had originated from Spectro Services in Albuquerque, NM. The package had been sent on to Germany on 8/14/08. The radionuclide was identified as Iridium (Ir) - 192 by the Dallas Fort Worth Fire Department. The area is currently roped off and posted no entry. A decontamination service [was scheduled] to decontaminate the area Monday 8/18/08 in the afternoon. [Deleted] agreed to contact us when the area was decontaminated. Copies of the surveys conducted were also requested. An Agency inspector performed a survey of the area and identified the contamination as Ir - 192. On 8/19/08 at 1410 CDT, NNSI was been contracted to decontaminate the area. The contractor states that the area should be released by this evening.

"Contamination appears to be in the form of dust. Several packages were in the contaminated area and were decontaminated prior to releasing for shipment. The contamination is readily removable. NNSI stated that they were going to survey the transportation area in Houston. The shipper stated that they had surveyed the location in Houston (Transaction Packaging 2928 B Greens Rd Suite 250) where the package was stored waiting to be sent to Dallas/Fort Worth and found no direct readings above background. NNSI has not provided the Agency with any of their readings. The original survey conducted by the state inspector found removable contamination levels of 4000 cpm/smear on 8/18/08 in the area in question. Shoes of all workers who could have traveled thru the area were surveyed and found to be free of contamination.

"The package originated in Albuquerque NM and was flown from there thru Memphis, TN To Houston, TX and then trucked to Dallas Fort Worth airport.

"The material first considered as the source was Ir - 192 tracer material. Surveys of the package when it arrived in Germany indicated that there was no contamination outside of the package. An engineer is waiting for the package in India. He will survey the package, then open the package to verify that there has been no damage. The engineer will take pictures of the boxes and forward to the Agency. There was a statement from NNSI that they had heard that there may have been a problem with the package in Houston and that it may have been over packed. Protechniques stated that this was not true.

"An Agency inspector will survey the transport trailer used to move the material to DFW on 8/20/08.

"The material first thought to create the problem was packaged in 20 mil vials, placed inside a lead shield, which was placed inside a plastic bag and placed in a DOT shipping container.

"The Agency has requested the records on all RAM passing thru this facility in the last 90 days from Lufthansa Cargo."

Texas Incident number: I-8536

* * * UPDATE ON 8/20/08 AT 1221 FROM A. TUCKER TO V. KLCO * * *

" At 0915, NNSI reported that the area at Lufthansa Cargo was released for unrestricted use at 9 PM on 8/19/08. They also reported that they conducted surveys at Lufthansa's warehouse in Houston, Texas and found no uncontrolled radioactive material. "

Notified R4DO (V. Gaddy) and FSME (M. Burgess) and e-mailed OIP (S. Dembek).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44428
Rep Org: OAKWOOD HOSPITAL & MEDICAL CENTER
Licensee: OAKWOOD HOSPITAL & MEDICAL CENTER
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: THOMAS KUMPURIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2008
Notification Time: 15:16 [ET]
Event Date: 06/03/2008
Event Time: 11:14 [EDT]
Last Update Date: 08/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
SONIA BURGESS (R3)
MICHELE BURGESS (FSME)

Event Text

MEDICAL EVENT - PRESCRIBED DOSE DIFFERED BY MORE THAN 20 PERCENT

"A written directive, signed and dated on 5/30/08 by an authorized user was prepared. The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma. An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08. On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied. On 6/03/08 the patient was properly identified, a negative pregnancy status was confirmed and the dosage assayed. A recorded dosage of 2.7 mCi was recorded in the hot lab computer and on the front of the written directive form. The hot lab computer with technologist data input produced a printed label of 2.7 mCi as of 6/03/08 at 1114 hours. However, at the time of dosage administration the calculated dosage available was 2.00 mCi.

"The dosage was administered to the patient and the patient was released with written radiation safety instructions for return 48 hours post administration for performance of the actual scan. At interview today, the technologist confirms that all administrative dosage information was recorded by her and her alone. She could not give any reason as to why a dosage of 2.7 mCi could or would have been administered or recorded.

"A recreation of these events today notes that the hot lab computer advises the technologist that the +/-20% threshold has been exceeded with a visual warning which can be bypassed upon consultation with the authorized user. We can find no documentation of a consultation and neither the authorized user nor the technologist can confirm that one took place. A conservative estimate of organ and EDE doses was made using ICRP 53 and an ultra conservative estimate of a thyroid uptake of 5%."

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.

* * * RETRACTION PROVIDED AT 1050 EDT ON 08/21/08 FROM CHAD MORGAN TO JEFF ROTTON * * *

"Upon further investigation we have determined that a Medical Event did not occur at Oakwood Hospital and Medical Center. We do believe that a documentation error did occur instead and have taken steps internally to prevent a reoccurrence (see below). We would like to retract our report of a medical event. This is due to the following conclusions:

* A written directive, signed and dated on 5/30/08 by an authorized user was prepared.

*The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma.

*An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08.

*On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied.

"Upon further investigation, at the time of dosage administration the calculated dosage available was 2.00 mCi, though the documentation states the dosage given was 2.7mCi. We believe the documentation to be in error and not the actual dose given to the patient.

"Measures to Prevent Reoccurrence:

1. Prior to dosage administration, all documentation will be verified by either a second certified nuclear medicine technologist or an authorized user via review and signature on the written directive.

2. Extensive re-education for all technical staff will be conducted concerning the written directive program and patient release requirements.

3. A written internal time-out retrospective audit will be conducted on a random number of directives on a monthly basis.

4. Medical Physics Consultants, Inc. will continue to perform a full quarterly written directive program audit.

"Summary: It is our belief that the correct patient received the correct prescribed dosage for the ordered procedure, however our internal documentation notes otherwise. This documentation error would not constitute a Medical Event ."

Notified R3DO (Sonia Burgess) and FSME (Michele Burgess)

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General Information or Other Event Number: 44429
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 25-1323-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2008
Notification Time: 16:36 [ET]
Event Date: 08/19/2008
Event Time: [CDT]
Last Update Date: 08/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - FIRE IN RESEARCH LABORATORY

This information was received from the state via fax:

"The afternoon of 8/19/2008 DHS [Department of Health Services] staff became aware a fire had occurred at a licensee facility the previous evening. Reports indicated the local fire department and hazardous materials teams had responded to a fire in a molecular biology lab on the campus of the University of Wisconsin - Madison. The fire was extinguished within 15 minutes. Reports also indicated the Hazardous Incident Team used instruments to rule out the presence of any radioactive materials. Although no contamination was detected, fire equipment was rinsed with water to remove any reside from the fire.

"DHS contacted the licensee. The licensee indicated staff members from radiation safety had responded to the incident the next morning. The research lab performs molecular biology research using P-32. The safety department staff performed surveys of the fire scene and identified areas of contamination on the floor. The areas had been decontaminated. Initial information from the licensee indicates approximately 0.5 to 0.7 millicuries of P-32 in waste containers was involved.

"The licensee did not report the incident to DHS. DHS inspectors were dispatched to investigate."

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General Information or Other Event Number: 44430
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County: USA
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHAR
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/21/2008
Notification Time: 08:19 [ET]
Event Date: 08/20/2008
Event Time: 16:41 [EDT]
Last Update Date: 08/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
PATTY BUBAR (FSME)

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT POTENTIAL OVEREXPOSURE

"[A] technician working with a 113 Ci Ir-192 source set off high radiation alarms at [the QSA Global facility] which caused the immediate evacuation of the building. Radiation surveys outside the building indicated a dose rate of approximately 3 mR/hr at a distance of 25 feet from the exterior of the building. Radiation safety staff performed a source retrieval to recover the source and place it in a shielded container; the building was reoccupied approximately 30 minutes later.

"Preliminary investigation of the technician indicated his electronic dosimeter (worn on the side of the body closest to the source) showed an exposure of 720 mRem. The technician was not wearing his extremity ring badge at the time, however the radiation safety officer calculated a maximum exposure to the tips of the maximally exposed fingers to be approximately 2 Rem. Dosimetry for both the technician involved and another that was nearby when the incident occurred have been sent to the vendor for immediate processing.

"Radiation Safety staff from QSA are performing additional investigations and will report back to the [MA Radiation Control Program Office] when more information becomes available."

State of Massachusetts was notified by the licensee of this incident at 0621 on August 21, 2008.

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Fuel Cycle Facility Event Number: 44435
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/22/2008
Notification Time: 14:46 [ET]
Event Date: 08/21/2008
Event Time: 22:30 [EDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
STEVE ROSE (R2)
ABY MOHSENI (NMSS)
FUELS OUO via Email ()

Event Text

MATERIALS CONTROL & ACCOUNTABILITY ALARM PROCEDURE INITIATED

"10CFR74.57(f)(2) requires notification within 24 hours that an MC&A [Material Control & Accountability] alarm resolution procedure has been initiated. Because an alarm investigation was initiated, a notification to the NRC Operations Center was made. Additional sampling later indicated the value was below the abrupt alarm value and this was communicated to the NRC Operations Center. There is no indication that a material loss has occurred.

"There were no actual or potential safety consequences to workers, the public, or the environment. MC&A alarm tests were run as specified by applicable procedures and requirements. Based on the alarm test for the Building 333 Oxide Dissolution area, the alarm test value was exceeded. Additional sampling later indicated that the input minus the output value is below the alarm value. An investigation was initiated and additional sampling has indicated that the input minus the output value is below the alarm value."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 44439
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GARY MERKA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2008
Notification Time: 16:27 [ET]
Event Date: 06/28/2008
Event Time: 19:04 [CDT]
Last Update Date: 08/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
VIVIAN CAMPBELL (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 95 Power Operation

Event Text

60-DAY OPTIONAL REPORT FOR AN INVALID ACTUATION OF UNIT 1 TDAFW PUMP

"This report describes an invalid actuation of the Unit 1 Turbine Driven Auxiliary Feedwater (TDAFW) pump that occurred on June 28, 2008. This report is being made in accordance with 10CFR50.73(a)(1), which states, in part, 'In the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than actuation of the Reactor Protection System (RPS) when the reactor is critical, the licensee may, at its option, provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.'

"On June 28, 2008, Comanche Peak Nuclear Power Plant Unit 1 was in Mode 1 operating at 100% power. At 1904 CDT, the steam supply valve from Main Steam Line 1-04 to the TDAFW pump opened due to a failed diaphragm. Turbine load was subsequently reduced from 1207MWe to 1150MWe per Operations procedures. The upstream isolation valve for the steam supply to the TDAFW pump was closed and the TDAFW pump was stopped. Unit 1 was returned to full power at 2120 CDT and the failed diaphragm was subsequently replaced.

"The specific train and system that actuated was the third AFW train on Unit 1. The train actuation was complete and during the TDAFW start the system started and functioned correctly."

The licensee has notified the NRC Resident Inspector.

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Thursday, March 29, 2012