United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2009 > February 4

Event Notification Report for February 4, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/03/2009 - 02/04/2009

** EVENT NUMBERS **


44813 44816 44818 44827

To top of page
Hospital Event Number: 44813
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA NATIONAL HEALTH PHYSICS PROGRAM
Region: 4
City: LOS ANGELES State: CA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: TOMAS HUSTON
HQ OPS Officer: JASON KOZAL
Notification Date: 01/28/2009
Notification Time: 15:48 [ET]
Event Date: 01/27/2009
Event Time: [PST]
Last Update Date: 01/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHUCK CAIN (R4)
PATTY PELKE (R3)
KEVIN HSUEH (FSME)

Event Text

MEDICAL EVENT - ACTUAL DOSE LESS THAN PRESCRIBED DOSE

"Two medical events were discovered on January 27, 2009, for patients treated during 2005 at VA Greater Los Angeles Healthcare System, Los Angeles, California.

"These two medical events involved patients who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distributions in the patients were associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose.

"These patient circumstances are interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1)(i).

"A 15-day written report for the medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager (Cassandra Frazier, NRC Region III) of the medical events."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

To top of page
General Information or Other Event Number: 44816
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/30/2009
Notification Time: 12:13 [ET]
Event Date: 01/29/2009
Event Time: [CST]
Last Update Date: 01/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PERSONNEL CONTAMINATION FROM I-131 SPILL IN HOT LAB

"The radiation safety officer [RSO] for Northwestern Memorial Hospital called the Agency [State] to advise that a technician had spilled a significant quantity of I-131 in their hot lab. The technician was preparing a radioiodine therapy dose of 100 milliCi for ingestion by a patient when the spill of the liquid occurred. The technician had been removing the vial from the fume hood to perform a dose calibration when the material slipped from his hands and broke on the floor of the hot lab. The technician was contaminated on his hands, torso and legs. The material, although small in volume, was concentrated, such that even small drops of the liquid exhibit high dose rates. Initial decontamination efforts managed to reduce the contamination on the individual such that the contamination only remained on their hands. The initial measured dose rate was approximately 7 milliR/h.

"The spill victim was excluded from the cleanup process to reduce the possibility of a significant uptake to their thyroid. All individuals involved in the clean up as well as the technician took prophylactic KI. According to the RSO, decontamination will continue until only fixed contamination remains. He estimated that as much as 80% of the contamination had been contained/removed by the time of his call a few hours after the event. Dose rates in the area were initially over 50 milliR/h. Additional shielding was moved into the area so that medically necessary nuclear medicine procedures could be completed while the decontamination was finished. Dose rates behind the shielding indicated less than 1 milliR/h. Bioassays will be conducted during subsequent days to determine the extent of any uptake that has occurred for those involved.

"Arrangements were made for the radiopharmacy to be shut down and operations relocated to another temporary facility within the hospital. Waste generated from the initial decontamination effort was secured within the pharmacy hot lab in the fume hood. Access will be restricted to only those granted leave by the RSO to reenter the lab. Arrangements have been made for an Agency [State] inspector to go to the site to ascertain and verify the dose rates in the area, the extent of contamination and ensure that bioassays are being conducted properly. Depending on the results of those assessments, the Agency [State] may take additional action."

Incident number: IL0900010

To top of page
General Information or Other Event Number: 44818
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PRECIX, INC
Region: 1
City: NEW BEDFORD State: MA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/30/2009
Notification Time: 15:31 [ET]
Event Date: 01/28/2009
Event Time: [EST]
Last Update Date: 01/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1)
KEVIN HSUEH (FSME)
ILTAB via e-mail ()

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

Event Text

AGREEMENT STATE REPORT - TWO MISSING STATIC ELIMINATORS

The following report was received from the State via facsimile:

"Precix [the licensee] called the Agency [the State] on 1/28/09 to report 2 missing static eliminator devices. A follow-up letter dated 1/29/09 was received on 1/30/09. The letter indicates the missing devices are 'NRD' model P-2021 devices having serial numbers A2DR562 and A2EZ592. The licensee reports that at the end of their one year useful life, the units were removed from the system along with others and set aside in preparation for returning them to NRD for disposal. The licensee states they have conducted several searches for the missing devices and have not had any success finding them. The licensee thinks the 2 units inadvertently got separated from the other units being held for return to NRD and were disposed off in the non-hazardous waste stream."

This model static eliminator typically contains approximately 10 millicuries of Po-210.

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.

To top of page
Power Reactor Event Number: 44827
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BRIAN FINCH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/03/2009
Notification Time: 14:55 [ET]
Event Date: 02/03/2009
Event Time: 13:37 [EST]
Last Update Date: 02/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN WHITE (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

SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system)'.

"At 0539 EST on Tuesday, February 3, 2009, the Control Room discovered that the plant process computer was not updating and subsequently observed the Safety Parameter Display System (SPDS) Computer Display was not updating data. This was discovered during periodic Control Room monitoring. The last data update on the SPDS display was at 0537 EST.

"Information Technology Department personnel are investigating the cause of the loss of SPDS capability. The Information Technology Department personnel have been unsuccessful in recovering within the 8 hour restriction.

"No other Control Room emergency assessment capabilities have been adversely affected. All Control Room panel indicators and annunciators are responding properly."

The licensee has notified the NRC Resident Inspector.

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