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Event Notification Report for October 7, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/06/2009 - 10/07/2009

** EVENT NUMBERS **


45396 45397 45399 45400 45401 45408 45410 45415

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General Information or Other Event Number: 45396
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MARTHA JEFFERSON HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-137-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: JOE O'HARA
Notification Date: 09/30/2009
Notification Time: 15:41 [ET]
Event Date: 09/30/2009
Event Time: [EDT]
Last Update Date: 09/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN A THERAPEUTIC DOSE VICE A DIAGNOSTIC DOSE

The following information was received from the Commonwealth of Virginia by facsimile:

"On September 30, 2009 a patient was given a therapeutic dose of I-131(100 mCi) instead of a diagnostic dose as prescribed (4 mCi). The patient was previously given a therapeutic dose in August of 2008 and a follow up diagnostic visit was scheduled for September 30, 2009. During scheduling, the dose was incorrectly entered as therapeutic instead of diagnostic. The licensee notified the patient's physician and consulted with the patient. The licensee notified their risk management group and has begun an investigation into the event. The licensee was informed to provide RMP [Radioactive Materials Program] with a written report within 15 days.

"Event Report Number: VA-09-04."

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: 45397
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/01/2009
Notification Time: 13:04 [ET]
Event Date: 09/21/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO EMBRYO GREATER THAN 5 REM

The following was received via E-mail:

"On September 30, 2009 the licensee's radiation safety officer contacted the Agency [Illinois EMA] to advise that a dose to an embryo likely to have exceeded 5 Rem occurred as a result of an administration of I-131 to a mother under going thyroid treatment. Twenty five milliCi of I-131 was administered on September 21, 2009. As per hospital protocol, the patient had undergone [pregnancy] screening consisting of interviews and a urine based pregnancy test with negative results. Eight days subsequent to the administration, the patient missed an expected [menstrual] cycle and conducted a home based [pregnancy] test with positive results. Those test results were confirmed with a positive serum based test on that same day administered by her physician.

"The authorized user estimates the embryo would potentially have progressed as much as 3 weeks at that time. TEDE estimates are roughly 6.7 Rem to the embryo, with no thyroid likely to have developed at this stage of pregnancy. The confirmed presence or absence of permanent functional damage is unknown, but the expectation is that there would no effect on the embryo. The patient was advised of this information the same day and further advised that a spontaneous termination was still a potential due to the early developmental stage involved although the radionuclide would not likely play a role in that outcome.

"As a matter of practice, the radiation safety office is investigating details regarding this specific event to ensure all expected procedures were followed. Based on the initial report, no apparent violations are noted, nor any failures made that would have prevented the event from occurring. A formal report will be submitted within the required 15 days. At this time, no general corrective measures are anticipated but the event will be used as an opportunity for refresher training and a risk audit."

Illinois Report #: IL-0900074.

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General Information or Other Event Number: 45399
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL COMPANY
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/01/2009
Notification Time: 15:43 [ET]
Event Date: 09/30/2009
Event Time: 18:00 [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE

The following was received via E-mail:

"On October 1, 2009, the Agency [TX Dept. of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting a routine shutter check on an Ohmart/Vega Corp. SHF1 nuclear gauge containing 20 millicuries of Cesium (Cs) 137, the shutter failed to close. The RSO stated that the gauge had been installed on the vessel in June of 2009. He was performing the check now to get this gauge into the same inspection schedule as the other gauges they use. He stated that the gauge is stuck open in the normal operating position and a survey conducted in the area indicated that dose rates were normal. He stated that there was no other damage to the gauge. He stated that he thought the mechanism may have become fouled from work conducted on a piece of equipment in the area. The manufacturer was contacted and is scheduled to perform repairs and training on October 21, 2009. The gauge is currently tagged 'Do Not Operate.' Additional information will be provided as it is received."

See similar event report EN# 45400 involving an Ohmart gauge with a stuck open shutter.

Texas Incident #: I-8675.

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General Information or Other Event Number: 45400
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: EQUISTAR CHEMICALS LP
Region: 3
City: MORRIS State: IL
County:
License #: IL-01737-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/01/2009
Notification Time: 16:19 [ET]
Event Date: 09/30/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE

The following information from the State of Illinois Emergency Management Agency via e-mail:

"On September 30, the facility's radiation safety officer contacted the Agency to advise that a fixed gauge had failed to operate as intended. While performing routine safety and shutter condition checks, attempts to close the shutter on the level gauge were not successful. The gauge is operated in an elevated, open environment on a polymer process vessel and there are no occupiable workstations in the area. The safety officer reports that they believe the shutter could be rotated to the closed position if additional force were applied to the shutter arm. However, previous experience has shown such actions could result in the arm becoming sheared from the shutter. Attempts to apply additional lubricant and remove debris from the pathway not otherwise readily observed, did not improve the extent of closure.

"The process vessel involved is continuously operated and not scheduled for any routine maintenance at this time. The licensee continues to operate the line at this time with the shutter open. Warning notices have been posted near the gauge regarding the shutter operation and all operational supervisors and personnel responsible for the line have been made aware of the condition. Should an emergency condition exist the licensee is prepared to remove the gauge from the vessel and apply additional shielding. Arrangements are pending with the manufacturer to come on-site to perform an evaluation of the three year old device and make the necessary repairs or replace the device as necessary. Similar failures of this device have been noted in the past. The manufacturer states the common cause for those failures is poor or non-existent maintenance, operation of the gauge outside of its approved conditions and/or attempting to force operation of the shutter handle.

"The licensee indicated the necessary written report would be filed within the next 30 days. "

The gauge involved is an Ohmart Model SHF2 (S/N 74932) with a 80 millicurie Cs-137 source.

See similar event report EN#45399 involving an Ohmart gauge with a stuck open shutter.

Illinois Report Number IL0900075.

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General Information or Other Event Number: 45401
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ONCOLOGY HEMATOLOGY CONSULTANTS PA
Region: 4
City: FORT WORTH State: TX
County:
License #: 05919
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/01/2009
Notification Time: 18:11 [ET]
Event Date: 10/01/2009
Event Time: [CDT]
Last Update Date: 10/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE - ADMINISTERED RADIATION TREATMENT TO WRONG AREA

The following was received via email:

"On October 1, 2009, the Agency was notified by the licensee that a patient had received 13 of 25 fractions to the wrong breast. The patient received 2,340 centigrays by the time the error was discovered. The Radiation Safety Officer stated that he had just fount out about the event and no additional information was available. Additional information will be provided as it is obtained."

Texas Incident #: I-8676

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: 45408
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ROMIG ENGINEER, INC
Region: 4
City: SAN CARLOS State: CA
County:
License #: 7223-41
Agreement: Y
Docket:
NRC Notified By: EPHRIME MEKURIA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/02/2009
Notification Time: 18:00 [ET]
Event Date: 10/02/2009
Event Time: 08:00 [PDT]
Last Update Date: 10/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
TERRENCE REIS (FSME)
ILTAB VIA E-MAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received from the State of California via e-mail:

"On October 2, 2009, the California Radiologic Health Branch was contacted by Romig Engineers, Inc. Radiation Safety Officer via California Department of Public Health duty officer at 09:30 am. The call was to report that one moisture density gauge which belongs to Romig Engineers, Inc, License # 7223-41, office and storage location at San Carlos, CA, was stolen.

"The Radiation Safety Officer stated that on October 1, 2009, the gauge user checked out CPN, model MC1-DR, S/N 30807119, containing a licensed material Cs-137, 10 mCi and Am/Be 15 mCi, moisture density gauge from the storage location, and transported using his personal vehicle to his residence at San Jose , CA, to be used in San Jose area the following day.

"On October 2, 2009, as the gauge user was going to his parking garage he found out that his personal vehicle containing the CPN moisture density gauge was stolen. The gauge user contacted the Radiation Safety Officer and the San Jose Police Department. Police report case number is 09-275-026. Reward to retrieve the gauge is going to be posted in local newspaper and Craigslist. RHB will perform a follow-up on this matter."

CA Report 100209

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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General Information or Other Event Number: 45410
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: TERRACON CONSULTANTS, INC.
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01402-01
Agreement: Y
Docket:
NRC Notified By: PAUL EASTVOLD
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/04/2009
Notification Time: 02:23 [ET]
Event Date: 10/03/2009
Event Time: 14:00 [CDT]
Last Update Date: 10/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
TERRENCE REIS (FSME)
ILTAB (via email) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

At approximately 1400 CDT on 10/3/09, a Terracon Consultants Ford Ranger pickup truck was stolen from the Powell Replacement Elementary School construction site in Chicago, IL. In the bed of the truck was a Troxler Model 3430 Moisture Density Gauge. These gauges typically contain two (2) radioactive sources; 8 millicuries Cs-137 and 40 millicuries Am-241:Be. The Chicago Police Department was informed of the theft and subsequently located the abandoned vehicle approximately two (2) miles away from the construction site at about 2300 CDT on 10/3. The vehicle had been ransacked and both the storage container and gauge were missing.

The Illinois Emergency Management Agency informed the Illinois State Police (ISP) Statewide Terrorism and Intelligence Center (STIC) and will followup with additional details as they become available.

* * * UPDATE FROM PAUL EASTVOLD TO JOE O'HARA AT 0934 ON 10/05/09 * * *

The serial number of the missing Troxler Model 3430 Moisture Density Gauge is S/N 32686. The state also confirmed the quantities of material in the gauge.

Notified R3DO(Daley), FSME(Villamar), and ILTAB via e-mail.

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 45415
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIMOTHY KUDO
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/07/2009
Notification Time: 04:36 [ET]
Event Date: 10/07/2009
Event Time: 03:20 [EDT]
Last Update Date: 10/07/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MIKE ERNSTES (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

OFFSITE NOTIFICATION TO THE STATE OF FLORIDA AND THE NATIONAL RESPONSE CENTER

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to notification of other government agencies at 0320 EDT on 10/7/09.

"Florida Power and Light Company (FPL) has identified a Sodium Hypochlorite spill within the protected area at Plant Saint Lucie. The spill has been terminated and it is estimated that up to 240 lbs of Sodium Hypochlorite was spilled past the secondary containment of the hypochlorite tank. The precise volume of the spill is indeterminate at this time.

"This event poses no health or safety consequences to either on site personnel or the general public. Notification to the State of Florida Emergency Response Commission and the National Response Center was made in accordance with the Plant Saint Lucie hazardous material spill response procedure."

The licensee has notified the NRC Resident Inspector.

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