U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/07/2003 - 05/08/2003
** EVENT NUMBERS **
39820 39824 39831
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|General Information or Other |Event Number: 39820 |
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| REP ORG: NC DIV OF RADIATION PROTECTION |NOTIFICATION DATE: 05/02/2003|
|LICENSEE: TROXLER |NOTIFICATION TIME: 16:32[EDT]|
| CITY: RALEIGH REGION: 2 |EVENT DATE: 03/24/2003|
| COUNTY: STATE: NC |EVENT TIME: [EDT]|
|LICENSE#: 032-0182-1 AGREEMENT: Y |LAST UPDATE DATE: 05/02/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOEL MUNDAY R2 |
| |C. MILLER NMSS |
+------------------------------------------------+F. BROWN NMSS |
| NRC NOTIFIED BY: JAMES ALBRIGHT | |
| HQ OPS OFFICER: MIKE RIPLEY | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - RADIOACTIVE SHIPMENT EXCEEDED LIMITS |
| |
| On 3/24/03 Troxler Electronic Laboratories of Research Triangle Park, NC |
| received a shipment of two boxes from AEA Technology, Inc. of Burlington, |
| MA. Each box contained fifty 40 millicurie Am-241:Be sources. Following |
| return of a survey meter from calibration, the RSO at Troxler performed a |
| survey of the boxes on 3/31/03 and determined that the radiation levels |
| exceeded limits for the shipment. Each box measured 315 millirem/hr neutron |
| and gamma at the surface (limit of 200 millirem/hr). Additionally, the bill |
| of lading and DOT sticker on each box listed the Transportation Index (TI) |
| at 1.6 which is the limit, however the measured TI was 3.1 (3.0 millirem/hr |
| neutron and 0.1 millirem/hr gamma at 1 meter). |
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|General Information or Other |Event Number: 39824 |
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| REP ORG: SC DIV OF HEALTH & ENV CONTROL |NOTIFICATION DATE: 05/05/2003|
|LICENSEE: STERIS-ISOMEDIX SERVICES |NOTIFICATION TIME: 16:25[EDT]|
| CITY: SPARTENBURG REGION: 2 |EVENT DATE: 05/05/2003|
| COUNTY: STATE: SC |EVENT TIME: 11:30[EDT]|
|LICENSE#: 267 AGREEMENT: Y |LAST UPDATE DATE: 05/05/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOEL MUNDAY R2 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID KING | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| MALFUNCTIONING IRRADIATOR CARRIER DOOR HINGE PIN ASSEMBLY |
| |
| Steris-Isomedix Services reported to the state that they had an incident |
| where the hinge pin assembly on the carrier door of an irradiator |
| malfunctioned. This resulted in the door opening and jamming at the source |
| rack which in turn left the source in a fully unshielded position. The |
| operator then went to the hoist cables for the source rack, which is in a |
| shielded area, moved the cables around a bit and unjammed the source rack |
| returning the source to the fully shielded position. The amount of time |
| taken to return the source to the fully shielded position was approximately |
| 20-30 minutes. The licensee is shutting down all irradiators to check the |
| hinge pin assemblies. There were no exposures. |
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|Hospital |Event Number: 39831 |
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| REP ORG: WASHINGTON HOSPITAL CTR |NOTIFICATION DATE: 05/07/2003|
|LICENSEE: WASHINGTON HOSPITAL CTR |NOTIFICATION TIME: 14:57[EDT]|
| CITY: WASHINGTON REGION: 1 |EVENT DATE: 05/06/2003|
| COUNTY: STATE: DC |EVENT TIME: [EDT]|
|LICENSE#: 080360403 AGREEMENT: N |LAST UPDATE DATE: 05/07/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |EUGENE COBEY R1 |
| |TOM ESSIG |
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| NRC NOTIFIED BY: SHA SHA DHAR MOHAPATRA | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
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| | |
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EVENT TEXT
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| MEDICAL EVENT - BRACHYTHERAPY RADIATION THERAPY NOT ADMINISTERED TO INTENDED |
| SITE |
| |
| A patient at Washington Hospital Center, being administered brachytherapy |
| treatment, received the treatment to a non- intended site. Based on |
| preliminary information, this occurred due to the Strontium 90 source being |
| placed in the wrong place during treatment. The patient received the |
| intended 23 gray dose. The patient has been notified and the licensee is |
| investigating the cause of the event. The licensee has notified the Hospital |
| Chief Medical Physicist, Oncologist, and will also notify the Hospital |
| Cardiologist. |
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