Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 49166 | 1 July 2013 18:07:00 | The following report was received via facsimile: Notifications: On June 28, 2013 the licensee informed the PA Department of Environmental Protection's (DEP) Central Office of an explosion that occurred the previous night. The event is reportable within 24 hours per 10 CFR40.60(b)(4). (Note: a voice message was left for a DEP staff person who was off from work on the 28th, thus, the delay in notification to NRC.) Event Description: The licensee received a call from the Pymatuning Township Fire department's emergency response team at approximately 11:15 (EDT) on June 27, 2013 reporting an explosion inside the operating area of the Whittaker Corp. remediation project site. This is a decommissioning / clean-up site where rare earth metals had been recovered, and the resultant low-level radioactive waste is being removed for license termination. The initial theory is (perhaps) a chemical and exothermic reaction resulted in a contained fire with material being ejected from the waste pile and outside the remediation area boundary. Since the site was shut down and unoccupied at the time of the event, no injuries were reported. The responding fire department did not enter the area; and there are conflicting reports on the use water or other fire-fighting agents. Due to the very low radioactivity concentrations of uranium / thorium series within the waste pile materials - release of licensed material offsite is unlikely. All work at the site has been suspended pending an investigation into the event. Radioactivity surveys and air samples were being made and collected on the 28th to confirm no off site release took place. The material that was ejected from the waste pile during the explosion was surveyed, with no significant activity identified. A sample of this material was sent to an off-site lab to determine a chemical and radiological content. Lastly, the licensee has established a 24 hour fire watch until a cause can be identified. More details will be provided when available. Cause of the Event: Currently unknown Actions: The licensee has suspended all work, and has restricted access to the area. The PA DEP NW and SW Regional Offices are performing reactive ES&H (Environment, Safety, and Health) and Radiation Protection Program inspections on July 1st and 2nd respectively. Media Attention: None at this time. PA Event Report ID No: PA130016 |
| ENS 45241 | 3 August 2009 20:10:00 | The following report was sent from the State of Pennsylvania via facsimile: During the patient's treatment, it was determined that the wrong side of the patient's head was being treated (using a gamma knife). The patient treatment was halted at 47.40 minutes out of the prescribed 55.63 minutes. The prescribed dose was 42.5 Gy to the 50% isodose line. Patient received 34.5 Gy to the 50% isodose. PA DEP (The Pennsylvania Department) Bureau of Radiation Protection was notified in writing, dated July 29, 2009. Their suggestion for improvement is while all treatment team members are present during a 'time out' procedure, to have the patient state the side of his/her lesion or treatment and place an imaging marker to designate the treatment side. The State (of Pennsylvania) will continue to keep NRC informed of the status of the investigation. Pennsylvania Report PA090027.
Regarding the Lehigh Valley Hospital Medical Event (PA090027) reported to the HOO via fax on 8-3-09, please be advised of our (Pennsylvania Department of Environmental Protection) intent to retract this report. Based on our inspection and follow-up with the licensee, it was determined that, although the initial written directive was prepared in error, all radiation treatments received by the patient were, in fact, delivered in accordance with a written directive. However, the licensee has taken corrective actions to avoid a similar event occurring in the future. Notified R1DO (White) and FSME EO (Suber). 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. |
| ENS 45182 | 2 July 2009 23:28:00 | The following report was received via facsimile: Patient was administered 54.1 mCi of I-131 on 3/30/2009. Patient had a false negative pregnancy test on 3/30/2009. Patient found out on May 13, 2009 that she was 9.5 weeks pregnant. Therefore, the therapy dose was given 5 days post-conception. Dose Eq to embryo/fetus = 11.9cGy. Dose Eq to fetal thyroid = 0.97cGy PA DEP Bureau of Radiation Protection was notified in writing, dated May 22, 2009, (from) the Radiation Safety Officer. The State has an inspection scheduled sometime in the future and will continue to keep NRC informed of the status of our investigation. PA event: PA090024 |
| ENS 44173 | 28 April 2008 17:15:00 | On Friday April 25, 2008 at approximately 1700 hrs, the Pennsylvania Bureau of Radiation Protection's Central Office Licensing Section was notified by (REDACTED) of a Medical Reportable Event that occurred on February 7, 2008 at Geisinger's Wyoming Valley Hospital located at 1000 East Mountain Drive in Wilkes Barre, PA. (License #37-01421-01; PA-0006) The event was not discovered until Friday April 25, 2008 during a licensee review of Written Directives administered. Licensee stated that the written directive for an I-131 treatment of a hyperactive thyroid was incorrectly written as 10 microcuries (0.37 MBq). Licensee stated that the nuclear medicine technician either did not read the directive or misread the directive and administered 10 millicuries. Licensee stated that the dose administered was appropriate for the treatment, however, inconsistent with the written directive. The prescribing physician was notified on the date of discovery. Licensee stated that no adverse health effects are expected as a result of this error. The error most likely occurred because the most common prescriptions for this sort of treatment are 10 - 20 mCi (370 - 740 MBq) I-131 and the technician did not recognize that the written directive stated 10 uCi (0.37 MBq). Licensee stated that actions taken to prevent recurrence had not been undertaken at the time of report. Licensee will be sending a written report to PA DEP's SCRO. The above information was reported to (REDACTED) PA DEP BRP Director on 4/28/2008. 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. |