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Event Notification Report for September 23, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/22/2008 - 09/23/2008

** EVENT NUMBERS **


44499 44500 44501 44509

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General Information or Other Event Number: 44499
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/17/2008
Notification Time: 13:52 [ET]
Event Date: 09/17/2008
Event Time: [CDT]
Last Update Date: 09/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHRIS EINBERG ()

Event Text

AGREEMENT STATE REPORT - BROKEN GAUGE

"On September 17, 2008 the licensee reported that a[n] Ohmart/Vega (OV) model SH-F1 has a sheared bolt on the shutter handle which prevents it from closing. This device (S/N 1297GK) contains 20mCi of Cs-137 in a model OV A-2100 sealed source capsule. The manufacturer has been notified and will see to the proper repair or replacement of the gauge. No public exposures are likely to approach regulatory limits and the vessel has been posted to prevent entry."

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 44500
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSAL HEALTH SVC. OF RANCHO SPRINGS, INC.
Region: 4
City: WILDOMAR State: CA
County:
License #: 2811-33
Agreement: Y
Docket:
NRC Notified By: DELIA AQUINO
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/17/2008
Notification Time: 17:39 [ET]
Event Date: 09/11/2008
Event Time: [PDT]
Last Update Date: 09/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
KEVIN HSUEH (FSME)

Event Text

GREATER THAN PRESCRIBED DOSE ADMINSTERED TO PATIENT

"On Wednesday, September 17, 2008, [a Certified Nuclear Medical Technologist] at Universal Health Services of Rancho Springs, Inc., contacted RHB about a diagnostic misadministration, which had occurred on September 11, 2008. The patient was prescribed a 7 milliCurie dose of Tc-99m Hebrofenin for a Hepatobiliary study (HIDA). At approximately 2:10 P.M. on September 11, 2008, the patient was given a dose of 22 milliCuries of Tc-99m Sestamibi, used for cardiac studies. The dose given was 50% greater than the intended dose. No additional Tc-99m was given since the image required was obtained with the dose that was actually given. The technician had grabbed the wrong syringe from the dose cart. The reason given for the misadministration was a heavy workload. The corrective actions to be taken to prevent a recurrence were to implement new procedures for radiopharmaceutical labeling and handling and to reinstruct personnel. Since the dose administered to the patient was 50% greater than the prescribed dose, the reportability of this event is 24 hours. This event will be investigated by RHB South."

California Report #5010-091708

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 AT 1044 ON 9/18/2008 FROM DELIA AQUINO TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

The state of California is retracting this event. "After additional review, we determined that it was not actually a reportable event."

The dose the individual received did not meet the threshold necessary to be reportable under 10CFR35.3045 - Medical Event.

Notified the R4DO (Pick) and FSME (Einberg).

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General Information or Other Event Number: 44501
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: SECOND STREET IRON & METAL
Region: 1
City: EVERETT State: MA
County:
License #:
Agreement: Y
Docket: 09-8006
NRC Notified By: J. THOMAS COULOMBIE
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/18/2008
Notification Time: 15:45 [ET]
Event Date: 08/21/2008
Event Time: 13:15 [EDT]
Last Update Date: 09/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
CHRIS EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - REPORTABLE QUANITY OF RA-226 FOUND IN SCRAP YARD

"A shipment of ferrous scrap metal from a small scrap metal yard set off the radiation alarms at the entrance to the major regional scrap metal and exporting facility. It was immediately rejected, but the Agency (state of MA) was not notified for almost two hours. An Agency investigator responded and traced the shipment back to a smaller scrap yard across town. The operator of the facility had isolated the rejected shipment and was trying to locate their consultant. Upon surveying the roll-off, the Agency investigator tentatively identified the shipment as containing Radium. The background was recorded as 0.06 millirem/hour and the highest reading was measured as 0.1 millirem/hour.

"This company was advised to acquire the services of a competent health physics consultant to arrange for the separation, storage and legal disposition of the radioactive material; and this was agreed upon without hesitation. Their hired consultant responded to the facility on August 25, 2008; and after collecting a spectrum and necessary measurements for identification purposes, separated one metal device from the roll-off, packaged it in a five gallon drum and had the facility operators secure it on-site depending disposal arrangements. Subsequently, the consultant has confirmed the presence of 12 microcuries of Radium-226. Legal transfer and disposition of this radioactive material is pending."

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Power Reactor Event Number: 44509
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: FRANK CLIFFORD
HQ OPS Officer: JASON KOZAL
Notification Date: 09/22/2008
Notification Time: 06:02 [ET]
Event Date: 09/22/2008
Event Time: 06:00 [EDT]
Last Update Date: 09/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY DIMITRIADIS (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

TECHNICAL SUPPORT CENTER AND OPERATIONAL SUPPORT CENTER UNAVAILABLE

"Unavailability of TSC/OSC Charcoal Filter for Scheduled Maintenance.

"At 0600 on Monday, September 22, 2008, the Pilgrim Nuclear Power Station (PNPS) Technical Support Center (TSC) / Operational Support Center (OSC) ventilation system charcoal was removed from service for planned charcoal bed maintenance. The balance of the TSC/OSC ventilation is not affected by the charcoal bed maintenance and remains available.

"Under certain accident conditions the TSC/OSC may become unavailable due to inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC/OSC personnel to the Emergency Operations Facility (EOF) and to the Chiltonville Training Center.

"Charcoal filter maintenance is scheduled to be completed by 1700 hours on Monday September 22, 2008.

"The licensee will be notifying the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10CFR50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE AT 1437 EDT ON 09/22/08 FROM BRUCE CHENARD TO JEFF ROTTON * * *

"The TSC/OSC ventilation system was returned to functional status on Monday, September 22, 2008.

"This follow-up notification is being made to provide closure from the initial notification under 10CFR50.72 (b)(3)(xiii) due to the loss of an emergency response facility.

"The licensee has notified the NRC Resident Inspector."

The licensee also notified the State of Massachusetts Emergency Management Agency.

Notified R1DO (Conte)

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Thursday, March 29, 2012