Event Notification Report for May 7, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/04/2001 - 05/07/2001
** EVENT NUMBERS **
37965 37966 37967 37968
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|General Information or Other |Event Number: 37965 |
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| REP ORG: NV DIV OF RAD HEALTH |NOTIFICATION DATE: 05/04/2001|
|LICENSEE: LAS VEGAS PAVING |NOTIFICATION TIME: 13:40[EDT]|
| CITY: NORTH LAS VEGAS REGION: 4 |EVENT DATE: 05/04/2001|
| COUNTY: STATE: NV |EVENT TIME: 06:15[PDT]|
|LICENSE#: 00-11-0255-01 AGREEMENT: Y |LAST UPDATE DATE: 05/04/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GAIL GOOD R4 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: STAN MARSHALL (fax) | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT REGARDING A STOLEN TROXLER GAUGE |
| |
| The following text is a portion of a facsimile received from the Nevada |
| Health Division Radiological Health Section regarding a Significant Event |
| Report: |
| |
| "1. Event Report ID No. [-] NV-01-02" |
| |
| "2. License No. [-] 00-11-0255-01" |
| |
| "3. Licensee [-] Las Vegas Paving" |
| |
| "4. Event time, date, location [-] 6:15 a.m., May 4, 2001, 7/11 Convenience |
| Store, Losse & Cheyene Road, North Las Vegas, Nevada." |
| |
| "5. Event type (e.g., misadministration, lost source, overexposure, etc.) |
| [-] Theft of Troxler Model 4640B portable gauge." |
| |
| "6. Any notifications i.e., other agencies, patient, press release, FBI, |
| etc. [-] North Las Vegas Police Dept. notified by licensee." |
| |
| "7. Event description: release, isotope, activity, exposure(s), dose, |
| contamination level, equipment malfunction, model, serial No., etc. [-] |
| Chain securing Troxler Model 4640B gauge to pickup bed was cut, and gauge |
| was stolen from licensee's truck while gauge user was in [convenience] |
| store. Gauge is a Troxler Model 4640B, s/n 1658." |
| |
| "8. Transport vehicle description if known [-] Pickup truck." |
| |
| "9. Media attention [-] N/A" |
| |
| (Call the NRC operations officer for state contact information.) |
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|Other Nuclear Material |Event Number: 37966 |
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| REP ORG: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION DATE: 05/05/2001|
|LICENSEE: UNIVERSITY OF PENNSYLVANIA |NOTIFICATION TIME: 11:51[EDT]|
| CITY: PHILADELPHIA REGION: 1 |EVENT DATE: 05/04/2001|
| COUNTY: PHILADELPHIA STATE: PA |EVENT TIME: 16:30[EDT]|
|LICENSE#: 37-00118-07 AGREEMENT: N |LAST UPDATE DATE: 05/05/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |HAROLD GRAY R1 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ROBERT FORREST | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
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EVENT TEXT
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| DISCOVERY OF A BRACYTHERAPY MISADMINISTRATION INVOLVING A LEAKING IODINE-125 |
| SOURCE AT THE UNIVERSITY OF PENNSYLVANIA IN PHILADELPHIA |
| |
| At approximately 1000 on 05/04/01, the licensee administered a prostate |
| implant involving the 94 iodine-125 seeds on the order of about 1/2 |
| millicurie per seed. (It is currently believed that the intended dosage for |
| the patient was approximately 47 millicuries. The licensee reported that |
| the intended dose is received from decay of the seeds which remain in the |
| patient after treatment.) |
| |
| Surveys were performed after the administration, and one of the implant |
| needles had readings that were higher than expected. At that time, it was |
| assumed that a source was stuck in the applicable needle (a more likely |
| scenario). However, at approximately 1630, removable contamination (due to |
| a leaking source) was discovered on the applicable needle. It is currently |
| believed that one of the seeds may have been damaged during the needle |
| loading process, and that the damaged seed was implanted into the patient |
| during treatment administration. |
| |
| At this time, there is only complication that is expected as a result of the |
| leaking iodine-125 source. It was reported that the activity from the |
| leaking source could get into the blood steam and that the thyroid would |
| filter the radio-iodine. Therefore, the patient may receive an unintended |
| thyroid dose. |
| |
| The authorized user was notified, and the patient was informed. The patient |
| was also prescribed Lugols solution (a potassium iodide solution) to |
| minimize the unintended iodine-125 thyroid uptake from the leaking seed. |
| Initial estimates indicate a thyroid activity measurement of 73 nanocuries |
| (calculated based on normal thyroid turnover) to give a dose of about 320 |
| milleRem over the period that it will take for the iodine-125 to decay. |
| |
| The licensee plans to notify the referring physician. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
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|Power Reactor |Event Number: 37967 |
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| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 05/05/2001|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 15:33[EDT]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 05/05/2001|
+------------------------------------------------+EVENT TIME: 15:23[EDT]|
| NRC NOTIFIED BY: D. EMLING |LAST UPDATE DATE: 05/05/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAY HENSON R2 |
|10 CFR SECTION: | |
|*PRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| OFFSITE NOTIFICATION REGARDING DISCOVERY OF AN EMACIATED LOGGERHEAD SEA |
| TURTLE IN THE INTAKE CANAL |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "[The licensee] notified [the] Florida Fish & Wildlife Commission of [the |
| discovery of an] emaciated loggerhead sea turtle in need of rehabilitation. |
| The State was notified @ 1523 hrs [on] 05/05/01." |
| |
| The licensee plans to notify the NRC resident inspector. |
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|Power Reactor |Event Number: 37968 |
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| FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 05/06/2001|
| UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 06:02[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 05/06/2001|
+------------------------------------------------+EVENT TIME: 03:10[CDT]|
| NRC NOTIFIED BY: SCHMIDT |LAST UPDATE DATE: 05/06/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MELVYN LEACH R3 |
|10 CFR SECTION: | |
|*INA 50.72(b)(3)(v)(A) POT UNABLE TO SAFE SD | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 90 Power Operation |73 Power Operation |
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EVENT TEXT
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| MAIN TURBINE STOP VALVE FAILED TO CLOSE DURING TESTING |
| |
| The #4 main turbine stop valve failed to close during the performance of |
| turbine valve testing procedure. Failure of the turbine valve to close |
| affects the turbine stop valve closure scram function of both A&B reactor |
| protection trip systems. Reactor power is currently being reduced to less |
| than 45% power which is required when the minimum conditions for the turbine |
| stop valve closure scram function are not satisfied. The licensee believes |
| the cause of the problem is probably due to a bad solenoid valve. |
| |
| The NRC Resident Inspector will be notified. |
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