Event Notification Report for September 25, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
09/24/2002 - 09/25/2002
** EVENT NUMBERS **
39201 39203 39204 39212 39214
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|General Information or Other |Event Number: 39201 |
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 09/19/2002|
|LICENSEE: BUILDING AND EARTH SCIENCES |NOTIFICATION TIME: 16:28[EDT]|
| CITY: REGION: 2 |EVENT DATE: 09/18/2002|
| COUNTY: STATE: AL |EVENT TIME: [CDT]|
|LICENSE#: 1266 AGREEMENT: Y |LAST UPDATE DATE: 09/19/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PAUL FREDRICKSON R2 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: DAVID WALTER | |
| 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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| MOISTURE DENSITY GAUGE STOLEN FROM THE BACK OF A PICKUP TRUCK |
| |
| "The writer received a call from [an employee] of Building and Earth |
| Sciences at approximately 9:00 AM on September 19, 2002. The employee |
| reported that a Troxler Model 3430 gauge (S/N 30199) had been stolen |
| sometime during the night of September 18, 2002, from their truck working |
| under reciprocity in Memphis, Tennessee. |
| |
| "The gauge had been left chained in the back of the truck overnight at [ . . |
| . . . ]. The chain had been cut, and the gauge taken. The licensee's |
| employee had contacted both the State of Tennessee and had filed a report |
| with the local police. |
| |
| "The licensee is continuing their investigation, and considering additional |
| methods to expedite recovery of the gauge." |
| |
| Contact the Headquarters Operations Officer for additional information. |
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|General Information or Other |Event Number: 39203 |
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| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 09/20/2002|
|LICENSEE: SCI ENGINEERING INC |NOTIFICATION TIME: 12:30[EDT]|
| CITY: FAIRVIEW HEIGHTS REGION: 3 |EVENT DATE: 09/17/2002|
| COUNTY: STATE: IL |EVENT TIME: 16:00[CDT]|
|LICENSE#: IL-01413-01 AGREEMENT: Y |LAST UPDATE DATE: 09/20/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK RING R3 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: RICH LAURA | |
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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 INVOLVING A LOST AND FOUND MOISTURE DENSITY GAUGE |
| |
| "The department was contacted on 9/18/02 by SCI Engineering, Inc., regarding |
| an event that happened around 4:00 p.m. the previous day. He reported that |
| one of their drivers noticed when he looked in his rear view mirror after |
| rounding a curve approximately 2 miles from the SCI office, that the |
| Humboldt Model 5001 moisture/density gauge containing approximately 11 |
| millicuries Cs-137 and 44 millicuries Am-241, was no longer in the back of |
| his truck. He then turned around and proceeded down the road to search for |
| the gauge. Meanwhile, an Ameritech employee in a truck was behind the SCI |
| truck and watched the gauge fly out the back. He then stopped to get the |
| device. Nearby was a friend of his that worked for a construction company |
| and was familiar with nuclear gauging devices. He noted the type of the |
| device and the serial number and called SCI to report the find. SCI had, in |
| the interim, already sent two technicians to help look for the device after |
| hearing of the loss from the SCI truck driver. This all occurred in |
| approximately 10 minutes according to SCI. |
| |
| "The State expressed concern to the licensee in the timeliness of the |
| notification and the fact that a gauge was allowed to 'fly' out the back of |
| one of their trucks. The licensee agreed and stated that a report would be |
| filed with the department as soon as possible. The department will take |
| appropriate measures to ensure that there will be no recurrence of this type |
| of an event by this licensee." |
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|General Information or Other |Event Number: 39204 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 09/20/2002|
|LICENSEE: CEDARS-SINAI MEDICAL CENTER |NOTIFICATION TIME: 15:29[EDT]|
| CITY: LA REGION: 4 |EVENT DATE: 05/29/2002|
| COUNTY: STATE: CA |EVENT TIME: [PDT]|
|LICENSE#: 0404-19 AGREEMENT: Y |LAST UPDATE DATE: 09/20/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVE LOVELESS R4 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: STEPHEN DOERFLER | |
| HQ OPS OFFICER: RICH LAURA | |
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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 INVOLVING A MEDICAL DIAGNOSTIC MISADMINISTRATION |
| |
| "Background: On June 12, 2002 the licensee Radiation Safety Officer |
| reported a diagnostic misadministration which occurred on May 29, 2002. An |
| elderly patient had been scheduled for an iodine-123 uptake and scan. When |
| she arrived, the nuclear medicine technologist noticed a scar on her neck |
| from a thyroidectomy. Based on this observation, and interview with the |
| patient, the nuclear medicine technologist presumed that the patient needed |
| a neck and head scan with iodine-131. She was given 3.0 mCi of iodine-131 |
| without discussing it with the physician. It turned out that she only had a |
| partial thyroidectomy, and her partial right lobe had approximately a 22% |
| uptake. There was a delay in notifying this Department because the physician |
| felt it wasn't a misadministration, as the primary care physician had |
| ordered the wrong exam to begin with. Dose with iodine-123 would have been |
| 7.0 rads, dose with 3.0 millicuries of iodine-131 was 3087 rads to the |
| thyroid. |
| |
| "Regulatory Issues: This incident was reported within 15 days as required by |
| the California Code of Regulations, title 17, section 30322. The RSO sent a |
| June 18, 2002 letter describing the root cause of the event and corrective |
| actions to prevent the likelihood of a recurrence. This letter was received |
| in this office on July 10, 2002. During a September 11, 2002 telephone |
| conversation, I was told that the Nuclear Medicine Department procedures |
| were changed so that scheduling for these type of procedures are now |
| performed by nuclear medicine technologists and not clerical personnel. |
| |
| "This was reportable to the NRC because it involved over 39 millicuries of |
| I-131. Cedars-Sinai Medical Center will be cited for violation of the |
| California Code of Regulations, title 17, sections 30521, which requires |
| nuclear medicine technologists to be under General Supervision when |
| performing nuclear medicine technology procedures, and 30502 which defines |
| General Supervision as meaning that the supervisor is responsible for, and |
| has control of all of the following: |
| 1. Quality, technical and medical aspects of all nuclear medicine technology |
| procedures; |
| 2. Radiation health and safety of patients, ancillary personnel and other |
| persons; |
| 3. Ascertaining that nuclear medicine technologists maintain their |
| competency by participation in management sponsored or formal continuing |
| education or training offered by professional organizations or societies, or |
| institutions of higher learning. |
| |
| "Contrary to the above, the nuclear medicine technologist who administered |
| the 3 millicuries of I-131, and under the General Supervision of the |
| authorized user, made decisions regarding the procedure and dose to be |
| administered without consultation with the authorized user. |
| |
| "Health and Safety Concerns: The patient received an unnecessary dose. Her |
| thyroid should have received only about 7 rads had she received 200 |
| microcuries of I-23, but instead she received 3,087 rads. The information |
| needed was obtained, and an additional dose was not given. Because there is |
| a possibility of reduction in thyroid function, Cedars-Sinai Medical Center |
| has said the patient will be followed by her physician. |
| |
| "Conclusion: The referring physician's written order on file at the hospital |
| was not examined during the investigation because neither the document, or a |
| copy of this document, could be released to this office due to a new patient |
| privacy law, according to the RSO." |
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|Power Reactor |Event Number: 39212 |
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| FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 09/23/2002|
| UNIT: [] [] [3] STATE: CT |NOTIFICATION TIME: 23:58[EDT]|
| RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 09/23/2002|
+------------------------------------------------+EVENT TIME: 23:35[EDT]|
| NRC NOTIFIED BY: ROBERT MALONEY |LAST UPDATE DATE: 09/24/2002|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
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|EMERGENCY CLASS: NON EMERGENCY |PETE ESELGROTH R1 |
|10 CFR SECTION: | |
|AMED 50.72(b)(3)(xii) OFFSITE MEDICAL | |
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|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
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|3 N N 0 Refueling |0 Refueling |
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EVENT TEXT
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| CONTAMINATED WORKER TRANSPORTED OFFSITE FOR MEDICAL ASSISTANCE |
| |
| At 2335EDT on 9/23/02 a worker involved in decontamination activities inside |
| the Unit 3 containment was transported offsite to Lawrence and Memorial |
| Hospital in New London, CT for medical assistance. EMTs administered oxygen |
| to the worker who they believed was suffering from heat stress and |
| hypertension. A rad survey conducted onsite showed contamination levels of |
| 1000 ccpm on his right thigh. An HP technician and supervisor accompanied |
| the worker to the hospital where he was decontaminated. |
| |
| * * * UPDATE 0035EDT ON 9/24/02 FROM MALONEY TO S. SANDIN * * * |
| |
| The HP supervisor who accompanied the contaminated worker to the hospital |
| notified the site that rad surveys completed at 0015EDT confirmed that the |
| ambulance, the ambulance travel path and the hospital treatment room were |
| free of contamination and free released. |
| |
| The licensee will inform state/local agencies and the NRC Resident |
| Inspector. |
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|Fuel Cycle Facility |Event Number: 39214 |
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| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION |NOTIFICATION DATE: 09/24/2002|
| RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 13:55[EDT]|
| COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 09/23/2002|
| COMMERCIAL LWR FUEL |EVENT TIME: 18:10[EDT]|
| |LAST UPDATE DATE: 09/24/2002|
| CITY: COLUMBIA REGION: 2 +-----------------------------+
| COUNTY: RICHLAND STATE: SC |PERSON ORGANIZATION |
|LICENSE#: SNM-1107 AGREEMENT: Y |WALTER RODGERS R2 |
| DOCKET: 07001151 |RICHARD WESSMAN IRO |
+------------------------------------------------+JOHN HICKEY NMSS |
| NRC NOTIFIED BY: EDWARD STECK | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| NRC BULLETIN 91-01 24 HOUR REPORT |
| |
| "Facility: Westinghouse Electric Company, Commercial Fuel Fabrication |
| Facility, Columbia SC, PWR fuel fabricator for commercial light water |
| reactors. License: SNM-1107. |
| |
| "Time and Date of Event: Approximately 18:10 hours, Monday, September 23, |
| 2002. |
| |
| "Reason for Notification: Scrubber ventilation ductwork containing gross |
| contamination was stacked without proper spacing. |
| |
| "Summary of Process: The scrubber ventilation system ductwork is |
| non-operational and was being removed. |
| |
| "As Found Condition: A summary of the as found conditions is as follows: |
| -Scrubber ventilation ductwork was found stacked in the Conversion |
| Decontamination Room. |
| -Gross contamination was evident in several sections of ductwork. |
| |
| "Criticality Safety Protection: Criticality safety protection for floor |
| storage of material with 'gross contamination' consists of a 12-inch or |
| greater spacing requirement. Gross contamination is defined as visually |
| observable uranium-bearing material. A criticality would only be possible if |
| an excessive accumulation of uranium occurs, it becomes moderated, and it is |
| not detected before a critical configuration is formed. After assessing the |
| situation, it was determined that this was a nuclear criticality safety |
| event, in an analyzed system, for which less than previously documented . . |
| . protection remains. . . Therefore, the event requires 24-hour |
| notification in accordance with Westinghouse Operating License (SNM-1 107), |
| paragraph 3.7.3 (c.5). |
| |
| "Summary of Activity: |
| -Nuclear Criticality Safety (NCS) was notified by operations. |
| -Removal of the ventilation ductwork was ceased. |
| -NCS visually inspected the ventilation ductwork. |
| -NCS required the ductwork be unstacked and placed in an authorized |
| configuration. |
| |
| "Conclusions |
| -There was a violation of spacing requirements. |
| -At no time was there any risk to the health or safety of any employee or |
| member of the public. No exposure to hazardous material was involved. |
| -The Incident Review Committee (IRC) determined that this is a safety |
| significant incident in accordance with governing procedures. A formal |
| causal analysis will be performed." |
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