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Event Notification Report for August 14, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/13/2009 - 08/14/2009

** EVENT NUMBERS **


45176 45209 45250 45257 45260 45262

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General Information or Other Event Number: 45176
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2009
Notification Time: 17:27 [ET]
Event Date: 06/30/2009
Event Time: 11:30 [EDT]
Last Update Date: 08/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL WORKER OVEREXPOSURE

The following information was received via facsimile:

"A worker was working in a hot cell when a F-18 [radio-isotope] was mistakenly delivered to the hot cell. [The] initial estimated worker dose [was] 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. [The] worker has been taken off Rad work and is being monitored"

A Commonwealth of Massachusetts investigation is pending.

* * * UPDATE ON 8/13/2009 AT 1130 FROM TONY CARPENITO TO MARK ABRAMOVITZ

The following report was received via e-mail:

"On 6/30/09, 1.6 Curies of Fluorine-18 was mistakenly delivered to a shielded vial within the cyclotron facility hot cell while a worker was performing routine maintenance within the hot cell. Delivery was intended for a different hot cell. The total worker exposure time was less than 3 minutes. The worker was removed from radiation work and dosimeters were sent out for immediate processing. Same day notification was made from the licensee to the Agency [Massachusetts Radiation Control Program]. The licensee submitted an independent consultant written report, dated 7/8/09, to the Agency [Massachusetts Radiation Control Program] on 7/27/09. The worker's effective dose equivalent was conservatively determined to be not more than 0.170 Rem, the maximum extremity not more than 26.9 Rem, and the eye dose equivalent not more than 1.2 Rem. These dose values were assigned to the worker. The worker was returned to radiation work with cumulative dose closely monitored.

"Licensee's formal descriptions of cause, contributing and precipitating factors, and corrective actions are pending.

"The Agency [Massachusetts Radiation Control Program] considers this situation to still be OPEN."

Notified the R1DO (Cook) and FSME (McIntosh).

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General Information or Other Event Number: 45209
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RADIOGRAPHIC SPECIALISTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02742
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/17/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: [CDT]
Last Update Date: 08/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
TERRENCE REIS (FSME)

Event Text

POSSIBLE RADIOGRAPHER OVEREXPOSURE

Texas Incident #8646

"On July 17, 2009, the Agency [Texas Department of Health] was notified by the licensee that they had been informed by their dosimetry processor that a radiographer had received an exposure exceeding the annual exposure limit. The licensee stated that the individual's thermoluminescent dosimeter was reading 9,000 millirem for the exposure period of June 9, 2009, through July 10, 2009. The licensee conducted a preliminary interview with the employee and was not able to determine how the exposure could have occurred. The radiographer stated that he had not received any dose rate alarms while performing his duties during the monitoring period. He also stated that his self reading pocket dosimeter had never indicated any unusual readings. The licensee's Radiation Safety Officer stated that the individual's duties during the exposure period were almost exclusively dark room operations grading film. The licensee is continuing to investigate and will provide additional information to the Agency [Texas Department of Health] as it becomes available."

* * * UPDATE ON 8/13/2009 AT 1243 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"7/21/09 0830 Contacted the RSO. He stated that they had completed a review of the individuals daily exposure recorded for the previous 6 months and had not found any reason for the exposure. I asked him if they were going to seek any medical assistance for the individual involved. He stated that he was unsure of what action he should take in this area. I provided him with REACTS contact information.

"7/21/09 1320 Received a call from the RSO. He stated that he had just received a call from his dosimetry processor informing him that the same individual's badge for the exposure period of May 10, 2009, and June 9, 2009, was 17,840 millirem. The RSO stated that he was making arrangements to have a medical exam for the individual done. He was also going to contact REACTS again to seek advice on how to proceed.

"7/21/09 1530 The RSO for Radiographic Specialist contacted the Agency [Texas Department of Health] and stated that they had scheduled the worker for blood test and that REACTS had shipped him a study kit to analyze the workers blood to help determine if he had received the dose indicated by his badge. REACTS stated that it would take a few weeks after they received the sample to have the results. I told the RSO that the Agency [Texas Department of Health] is planning to conduct their investigation at his facility on July 29, or 30, 2009, and requested copies of the dosimetry processors reports for the individual.

"7/21/09 1614 Received the dosimetry reports. The report for the June 2009 period indicates 9,470 millirem for the exposure period. The processor states that the reading appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The film for the May exposure period indicates 17,840 millirem and the reading also appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The RSO still believes that this is a badge only exposure.

"Additional information

"On August 6, 2009, the Licensee provided a copy of the Cytogenetic Biodosimetry report from Cytogenetic Biodosimetry Laboratories - REAC/TS performed on their employee reported as receiving the overexposure. The initial report indicated that the dose received was not significantly different from background. The Agency [Texas Department of Health] requested clarification of what REAC/TS used as a background. On August 12, 2009, the licensee provided a copy of a document from REAC/TS, which indicated that their background would be a dose of 14 rad for the study conducted. The Agency will perform an on-site investigation of the event on or about August 19, 2009."

Notified the R4DO (Whitten) and FSME (McIntosh).

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Hospital Event Number: 45250
Rep Org: VALLEY HOSPITAL
Licensee: VALLEY HOSPITAL
Region: 1
City: RIDGEWOOD State: NJ
County: BERGEN
License #: 29-03845-01
Agreement: N
Docket:
NRC Notified By: TKI CHAK
HQ OPS Officer: VINCE KLCO
Notification Date: 08/07/2009
Notification Time: 17:32 [ET]
Event Date: 08/06/2009
Event Time: 17:00 [EDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
MEL GRAY (R1DO)
KEITH McCONNELL (FSME)

Event Text

POTENTIAL DOSE TO WRONG SITE

A patient with radiation seed prostate implants came back to the facility to have a CAT Scan. Based on the CAT Scan results, the physician suspects the improper positioning of the radiation seed implants. Due to the patient's medical condition the hospital cannot conduct a verification CAT Scan with contrast material. The patient plans to return to the hospital at a later date. A hospital review of the patient's treatment is ongoing.


* * * UPDATE FROM TKI CHAK TO JOHN KNOKE AT 1530 ON 08/11/09 * * *

The licensee confirmed that the patient had improper positioning of the radiation seed implants. This was considered an under dose to the patient since the seeds went into the tissue and not the prostate. The patient was advised by the physician and will receive a follow-on treatment with a tomotheraphy procedure.

Notified FSME (Andrew Mauer) and R1DO (William Cook).

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: 45257
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: PARKDALE MILLS, INC.
Region: 1
City: GASTONIA State: NC
County:
License #: 036-0521-OG
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JASON KOZAL
Notification Date: 08/11/2009
Notification Time: 14:50 [ET]
Event Date: 08/11/2009
Event Time: [EDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE - LOST STATIC ELIMINATORS

The State of North Carolina discovered 2 missing static eliminators containing 500 microCi of Po-210 and 80 microCi of Am-241. The licensee was billed for the annual fees related to these gages and notified the State that they no longer had the gages in their possession. The State sent an inspector to investigate the situation.

The inspector discovered that the manufacturing facility had been relocated to Vietnam 3 years ago. When this occurred the licensee believes it is possible that the sources were relocated with the majority of the manufacturing facility assets to the Vietnam location at that time.

The State is continuing to follow-up with the licensee to determine disposition of these sources.

* * * UPDATE ON 8/13/09 AT 1022 EDT FROM BARNES TO HUFFMAN * * *

A representative of the State of North Carolina provided the following additional information about the lost sources:

The Am-241 source was manufactured by Pyrotronics. Model number F315A. Serial Number 1000635. Date received - 1971

The Po-210 source was manufactured by Nuclear Products. Model number 2U500. Serial Number Unknown. Date received - 1989

R1DO (Cook) and FSME (McIntosh) have been notified of this update.

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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Power Reactor Event Number: 45260
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY CHITWOOD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/13/2009
Notification Time: 17:25 [ET]
Event Date: 08/13/2009
Event Time: 13:04 [PDT]
Last Update Date: 08/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JACK WHITTEN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 0 Hot Standby

Event Text

POTENTIAL MEDIA INTEREST DUE TO PLANNED MAINTENANCE OUTAGE

"On August 13, 2009, at 1304 PDT, Unit 2 was shut down in accordance with established plant procedures to perform more in-depth analysis of the main electrical transformer 'A' phase 500 kV bushing. Diablo Canyon Unit 2 was taken off line in a planned maintenance outage to investigate a power-factor condition currently identified by the 500 kV bushing monitoring instrumentation. The main electrical transformer 'A' phase 500 kV bushing will be replaced if warranted by the results of testing.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 45262
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETE LARA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/13/2009
Notification Time: 19:35 [ET]
Event Date: 08/13/2009
Event Time: 15:41 [CDT]
Last Update Date: 08/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM COOK (R1DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO A GRASS FIRE IN THE OWNER CONTROLLED AREA

"A fire was reported to the unit-2 control room at 1541 Central time [CDT]. The fire was reported in the Owner Controlled Area. Local [Bay City] fire department was dispatched to fight the fire. The fire occupied approximately 2 acres. The fire was reported to be under control at 1635 [CDT]. No plant equipment was damaged nor was the operations of the unit affected. Region 12 of the Texas Commission of Environmental Quality was notified at 1721 [CDT] and no further actions were required by the Agency [Texas Department of Environmental Quality]."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012