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Event Notification Report for October 2, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/01/2008 - 10/02/2008

** EVENT NUMBERS **


44514 44522 44523 44524

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Fuel Cycle Facility Event Number: 44514
Facility: BWX TECHNOLOGIES, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: CHERYL GOFF
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/23/2008
Notification Time: 13:01 [ET]
Event Date: 09/23/2008
Event Time: 12:15 [EDT]
Last Update Date: 09/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
MIKE ERNSTES (R2)
LARRY CAMPBELL (NMSS)
FUELS OUO GRP email ()

Event Text

MEDIA INQUIRY CONCERNING UPCOMING LICENSEE PERFORMANCE REVIEW

"Below are the responses to questions BWXT received from [DELETED] at the News & Advance of Lynchburg, VA, and the BWXT responses.

"Q: In the past year, there have been a number of 'notices of violation' from NRC regarding events at BWXT. Several of these violations or apparent violations involved Raschig Ring-filled Vacuum Cleaners - one overturned from a forklift last year and spilled some nuclear material; later there was a situation in which one of the RRVCs did not have enough raschig rings in it, etc.-and one other incident involved an employee being splashed with a solution that contained some nuclear material. In what ways has the company responded to these events? What measures have been taken to correct procedures and prevent further occurrences?

"A: The company has performed detailed incident investigations and identified corrective actions to prevent reoccurrence of these types of incidents. For example, in the case of the RRVCs we have developed and are implementing a new vacuum cleaner design that no longer requires the use of Raschig rings. In the case of the chemical spill, the company has strengthened its chemical spill response procedures.

"Q: How does the company anticipate the performance review to go?

"A: We appreciate the opportunity to receive feedback from the NRC on our performance on an annual basis. This feedback is valuable to us as we strive to continuously improve our operating and safety performance. We look forward to discussing our safety and operational successes and improvements at the meeting.

"Q: Some of BWXT's operations are classified; Do you know how detailed the performance review presentation will be?

"A: For specifics about the NRC's presentation, it would be better to contact the NRC. I can tell you that the information we plan to present will be detailed enough to explain our successes and improvements without revealing any classified information.

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Hospital Event Number: 44522
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/25/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: [CDT]
Last Update Date: 09/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)

Event Text

MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE

"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.

"As the result of these ongoing reviews, possible medical events were discovered on September 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.

"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)

"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients are under review by medical experts.

"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"Additional Information

"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.

"VHA permit number of permittee involved in event: Permit No. 23-08786-01."

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: 44523
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GROUND TECHNOLOGY INC
Region: 4
City: HOUSTON State: TX
County:
License #: 05125
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/26/2008
Notification Time: 17:24 [ET]
Event Date: 09/26/2008
Event Time: [CDT]
Last Update Date: 09/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
REBECCA TADESSE (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

"The licensee's Radiation Safety Officer (RSO) called and informed the Agency [Texas Department of State Health Services] that a moisture density gauge had been damaged while it was being used at a work site. The worker had stored the sources in the safe condition and left the gauge at the side of the road he was working on to get a drink of water. Before he returned to the gauge, it was struck by a truck passing by on the road and the gauge rod on the top side of the gauge was bent and the gauge case was damaged. The sources both remained shielded. A service company (Component Sales) has been called to pick up the gauge and conduct an inspection of the device. The gauge is a Troxler Model 3440 ser # 23586 containing a 8 millicurie Cesium (Cs) 137 source and a 40 millicurie Americium (Am) - 241 Beryllium source."

Texas Incident # I-8566

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Hospital Event Number: 44524
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER WASHINGTON DC
Region: 1
City: WASHINGTON State: DC
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/26/2008
Notification Time: 18:15 [ET]
Event Date: 09/26/2008
Event Time: [EDT]
Last Update Date: 09/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)

Event Text

MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE

"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.

"As the result of these ongoing reviews, possible medical events were discovered on September 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC.

"These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)

"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients will be reviewed by medical experts.

"A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"The US Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: VA Medical Center, 50 Irving Street NW, Washington DC 20422.

"The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."

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.

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