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Event Notification Report for April 28, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2009 - 04/28/2009

** EVENT NUMBERS **


44750 45005 45007 45014 45024

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General Information or Other Event Number: 44750
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GEORGIA PACIFIC CORPORATION
Region: 4
City: CROSSETT State: AR
County:
License #: GL-0074
Agreement: Y
Docket:
NRC Notified By: STEVE E. MACK
HQ OPS Officer: JOE O'HARA
Notification Date: 01/02/2009
Notification Time: 16:05 [ET]
Event Date: 12/18/2008
Event Time: [CST]
Last Update Date: 04/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
GLENN DENTEL (R1)
PATRICE BUBAR (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIALLY LEAKING SOURCE

The following information was provided by the state via e-mail:

"On December 18, 2008, the Arkansas Department of Health, Radioactive Materials Program received a written report of a potentially leaking source at Georgia Pacific Corporation in Crossett, Arkansas, General License Number GL-0074.

"The Source is a Generally Licensed Device, Honeywell, Model 4201 Series Thickness Gauge, Serial Number OV522.

"On November 8, 2008 a Field Services Specialist noted abnormal readings from the device and a hole in the kapton window.

"Although it appears that upon arrival at the Honeywell facility in Duluth, Georgia the source is potentially leaking it is unknown exactly when the source began to leak. According to Honeywell, no contamination was found at the licensee's facility in Crossett, Arkansas.

"There is possible personnel contamination (Field Services Specialist) and the Department is continuing to investigate this event and will provide a follow up when more information is confirmed."

A subsequent conversation with the State of Arkansas revealed that the source is Promethium (Pm-147) with an activity level of approximately 18.5 GBq (500 milliCuries) and the State of Georgia was notified by Honeywell of the potentially leaking source.

* * * UPDATE FROM STEVE MACK TO DONALD NORWOOD VIA E-MAIL ON APRIL 27, 2009 AT 1552 HOURS * * *

"The kapton window was found to be torn. The Field Services Specialist appears to have damaged the source capsule window when attempting to remove a piece of kapton window, using an unapproved procedure.

"The root cause of this event appears to be a failure to follow procedures. The Field Services Specialist exceeded his procedures and appears to have damaged the source capsule. Corrective actions included re-training the Field Services Specialist and a Safety Alert was sent to all personnel.

"The analysis of the potentially leaking sealed source appeared to be less than 0.005 microcuries (185 Bq). It is believed that there was no personnel contamination. The initial reports of contamination were believed to have been caused by misinterpretation of survey results.

"The department considers this event closed."

Notified R1DO (Miller), R4DO (Walker), and FSME EO (White).

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General Information or Other Event Number: 45005
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HAHNEMANN UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0927
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/21/2009
Notification Time: 10:26 [ET]
Event Date: 12/22/2008
Event Time: [EDT]
Last Update Date: 04/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
ANGELA MCINTOSH (FSME)

Event Text

MIS-ADMINISTRATION OF I-125 SUBCUTANEOUSLY VICE INTRAVENOUSLY

The following abnormal occurrence information was received via e-mail:

"PA NMED PA090013.

"Date and Place: 12-22-2008; Hahnemann University Hospital, Philadelphia, PA.

"Procedure/Dose (Actual vs. Intended), Nature, and Probable Consequences: Patient prescribed 50 mCi of Iodine-125 monoclonal antibody to be administered intravenously. On December 22, 2008 the injection was made subcutaneously when patient's port was not located properly during the injection. Estimated skin dose is 360-710 rads.

"Notification: Patient was notified at the time of the event that the injection was subcutaneous rather than intravenous.

"Health Effect: Doctor is confident that the therapeutic effects of this dosage have still been received by the patient. There have been no noted skin effects reported to date.

"Cause or Causes: The nurse did not have the port completely visualized and admitted to not palpating the site as well as possible

"Actions Taken to Prevent Recurrence: Staff was retrained in December 2008 that patients with ports are to disrobe completely and be palpated to ensure that the injection is occurring within the port.

"State Agency: Just received notification of medical event, follow-up inspection to be performed by the State.

"This event is closed for the purpose of this report."

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: 45007
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CANCER CARE NORTHWEST PET CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: M0227
Agreement: Y
Docket:
NRC Notified By: BRANDON KETTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/21/2009
Notification Time: 14:39 [ET]
Event Date: 04/14/2009
Event Time: [PDT]
Last Update Date: 04/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION

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

"On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.

"The aluminum connector to needle 13 detached from the plastic guide tube. It is possible that the source wire or the dummy wire, during retraction, snagged on the seam between the aluminum connector and the plastic guide tube. The HDR is connected to the plastic guide tube, the plastic guide tube is attached (glued) to the aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.

"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.

Isotope and Activity involved: Iridium-192, 185.2 GBq (5.0 curies). Source serial number: 02-01-0080-001-0121.

Overexposures: The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient.

Washington Incident Number: WA-09-015

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: 45014
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: COVANTA HAVERHILL
Region: 1
City: HAVERHILL State: MA
County:
License #: N/A
Agreement: Y
Docket: 04-8427
NRC Notified By: J. THOMAS COULOMBE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/23/2009
Notification Time: 14:49 [ET]
Event Date: 04/16/2009
Event Time: [EDT]
Last Update Date: 04/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

COMMINGLED WASTE

The following was received from the commonwealth via fax:

"On April 16, 2009, the Covanta Haverhill trash-to-energy plant requested a routine DOT-E 11406 for the rejection of a shipment of commingled commercial and industrial trash. The shipment was returned to the point of origin in Peabody, which was the Casella Waste Systems facility at 295 Forest Street. The load was secured at 295 Forest Street in Peabody until their competent consultant could survey and process the load on April 21, 2009. The consultant separated out over 150 industrial smoke detectors from the front end loader. These devices were industrial smoke detectors. Most models contained Am-241 80 micro curies each; but many others contained 40 micro curies each of Radium-226. The consultant faxed a preliminary report to the [MA state] Agency on April 22, 2009 and pledged to follow-up with an accurate breakdown of the exact RAM and total activities involved as the information is developed. Complete information was not available as of the time of this report. This same consultant is also arranging for the legal disposition of the smoke detectors and assisting the Casella Waste Systems management in tracking down the source of the RAM."

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Power Reactor Event Number: 45024
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN E BOWLES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/27/2009
Notification Time: 17:34 [ET]
Event Date: 04/27/2009
Event Time: 15:00 [EDT]
Last Update Date: 04/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BINOY DESAI (R2DO)

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

FITNESS FOR DUTY INVOLVING A NON-LICENSED CONTRACT SUPERVISOR

A non-licensed contract supervisor had a confirmed positive for a controlled substance during a random fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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