Event Notification Report for June 19, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/18/2003 - 06/19/2003
** EVENT NUMBERS **
39933 39934 39935 39936 39948
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|General Information or Other |Event Number: 39933 |
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| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: QUALITY TESTING |NOTIFICATION TIME: 13:00[EDT]|
| CITY: TEMPE REGION: 4 |EVENT DATE: 06/10/2003|
| COUNTY: STATE: AZ |EVENT TIME: 08:00[MST]|
|LICENSE#: AZ07-491 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
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| NRC NOTIFIED BY: GODWIN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
| | |
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EVENT TEXT
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| ARIZONA LICENSEE, QUALITY TESTING, REPORTED A MISSING TROXLER MOISTURE |
| DENSITY GAUGE |
| |
| "At approximately 8:00 AM MST June 10, 2003, Arizona was informed by the |
| Licensee Radiation Safety Officer that they believe a Troxler Model 3411 B |
| SN 4647 moisture-density gauge was missing and had been since 5:00 AM. At |
| approximately 8:30 MST the Agency was informed that gauge fell off of the |
| truck and had been recovered by JSW Concrete Contractor. The gauge was |
| recovered from Price Road under the Fry Road Overpass. The Department of |
| Public Safety and the Chandler Police were notified prior to recovery. The |
| Licensee took possession of the gauge at approximately 9:00AM. There were no |
| indications the gauge had been opened. Inspection by the State Agency |
| revealed several possible violations." |
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|General Information or Other |Event Number: 39934 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: CHRISTUS SANTA ROSA |NOTIFICATION TIME: 14:47[EDT]|
| CITY: SAN ANTONIO REGION: 4 |EVENT DATE: 06/13/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02237-001 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WATKINS | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| WRONG DOSAGE ADMINISTERED TO A PATIENT DUE TO HUMAN ERROR |
| |
| Discovery of right patient/ right radiopharmaceutical but wrong dosage. |
| Patient returned after 48 hours for a scan. Doctor asked the tech for the |
| prescription that was issued. The tech had ordered the wrong dose for the |
| prescribed procedure. A thyroid scan was conducted with 2.3 millicuries of |
| Iodine -131 vs. the required 300 microcuries of I-131. As corrective action |
| any I-131 dose will require concurrence of the physician prior to ordering |
| the dose. The cause was due to human error since the radiopharmacy sent the |
| dose as ordered by the Tech. |
| |
| Both the referring physician and the patient have been informed of the |
| error. The physician has stated that the dose error has caused no injury to |
| the patient. |
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|General Information or Other |Event Number: 39935 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: COLLEGE STATION HOSPITAL |NOTIFICATION TIME: 15:14[EDT]|
| CITY: COLLEGE STATION REGION: 4 |EVENT DATE: 06/11/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L02559 AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WATKINS | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| SIX VIOLATIONS FOUND DURING RECENT INSPECTION AT A TEXAS LICENSED FACILITY |
| |
| On June 11, 2003 the Texas Department of Health, Bureau of Radiation Control |
| conducted a follow up inspection of licensed activities at the Humana |
| Hospital Day Surgery Center DBA The Surgical Center (TSC), Bryan, Texas. The |
| inspection findings were discussed with Dr. Alikhan, Radiation Safety |
| Officer and his staff In a preliminary exit briefing at close of |
| inspection. |
| |
| Based on the results of his inspection., the Inspector has determined that |
| at least 6 violations of the Agency requirements occurred. In addition, the |
| violations were identified by this Agency rather than through the Licensee |
| conducting Radiation Protection Program (RPP) audits. |
| |
| The Inspector reviewed five (5) total patients affected, since the last |
| inspection by this Agency conducted on January 18, 2001. Utilization logs |
| indicate that this number could increase given a review of the patients |
| treated prior to January 18, 2001, with the use of the stroutium-90 eye |
| applicator. Therefore, as discussed with the RSO during the exit briefing, |
| additional information may be required of TSC before the Agency can make a |
| determination to conclude this issue. The Inspector informed the Licensee |
| that the number and characterization of apparent violations could change as |
| a review Is conducted. |
| |
| Inspection Findings: Items of Noncompliance |
| |
| 1. Violation of 25 TAC �289.256(ee)(1)(a)(i): |
| The Licensee failed to report and notify this Agency of a dose that differs |
| from the prescribed dose by more than 5 rem (0.05 Sv) effective dose |
| equivalent, 50 rem (0.5 Sv) to an organ or tissue, or 50 rem (0.5 Sv) |
| shallow dose equivalent to the skin and either: |
| |
| a. the total dose delivered differs from the prescribed dose by 20% or |
| more. |
| |
| 2. Violation of 25 TAC �289.202(e)(1): |
| |
| The Licensee failed to conduct a Radiation Protection Program (RPP), |
| sufficient to ensure compliance with the provisions of �289.202. The RPP was |
| not developed, documented, and implemented. |
| |
| 3. Violation of 25 TAC �289.201(g)(1)(b): |
| |
| The Licensee exceeded the six-month leak test interval for a sealed source |
| of radioactive material for a 100mCi Sr-90 source, S/N 0214, during the time |
| period from January 18, 2001 until June 4, 2003. |
| |
| 4. Violation of 25 TAC �289.256(p)(1)&(2): |
| |
| At the time of the inspection, the Licensee had failed to generate written |
| directives signed and dated by an authorized user prior to administration of |
| Sr-90 Brachytherapy. |
| |
| (i) prior to implantation: the treatment site, the radionuclide, number of |
| sealed sources and dose; and |
| (ii) after implantation but prior to completion of the procedure: the |
| radionuclide, treatment site, number of sealed sources, total sealed source |
| strength and exposure time or, equivalently, the total dose. |
| |
| 5. Violation of 25 TAC�289.256(bb)(6)(A)(B)(C)&(D): |
| |
| The Licensee failed to determine the calibration measurements of |
| Brachytherapy sealed sources. |
| |
| 6. Violation of 25 T,AC �289.256(i)(2)(A)&(B): |
| |
| The Licensee's Radiation Safety Committee has not been composed of the |
| required personnel. By evidence of the January 30, 2003 Radiation Safety |
| Committee minutes that identifies representatives to attendance, the |
| Radiation Safety Officer and an authorized user of type of use permitted |
| (surgery) by the license, were not present. |
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|General Information or Other |Event Number: 39936 |
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| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 06/13/2003|
|LICENSEE: UNITED DAIRYMAN OF AZ |NOTIFICATION TIME: 15:55[EDT]|
| CITY: TEMPE REGION: 4 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: AZ |EVENT TIME: 16:20[MST]|
|LICENSE#: AZ-GL AGREEMENT: Y |LAST UPDATE DATE: 06/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID GRAVES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GODWIN | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| ARIZONA LICENSEE, UNITED DAIRYMEN OF AZ, DISCOVERED A DAMAGED HYDROGEN 3 |
| EXIT SIGN |
| |
| At approximately 4:20 PM MST June 12, 2003, the Agency was informed by the |
| General Licensee that they had discovered an EXIT sign containing Tritium |
| was damaged. The sign contained 11.5 Curies of Tritium when installed. The |
| General Licensee had no idea when the sign was damaged, in fact, he was |
| surprised to learn that it contained radioactive material. The sign was a |
| Safety Light Model XT. When the Agency arrived on scene, it was determined |
| that the light tubes were all missing for this sign. One individual had |
| used a ladder to attempt to replace the "light" bulbs since they were |
| "burned" out. Wet wipes taken of the remains of the sign did not detect |
| hydrogen 3. No one could tell the Agency of the condition of the glow |
| tubes or where they are now located. The sign was located in a 30,000 |
| square foot warehouse storing powdered milk. Evaporative coolers circulate |
| cool air into the warehouse. |
| |
| The Agency continues to investigate this incident. |
| |
| The NRC and FBI will be notified of this event |
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|Power Reactor |Event Number: 39948 |
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| FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 06/18/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 13:27[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 06/18/2003|
+------------------------------------------------+EVENT TIME: 11:44[EDT]|
| NRC NOTIFIED BY: STEVEN NEVELOS |LAST UPDATE DATE: 06/18/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RAYMOND LORSON R1 |
|10 CFR SECTION: | |
|ASHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
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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 |99 Power Operation |
| | |
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EVENT TEXT
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| UNIT COMMENCED A TS REQUIRED SHUTDOWN DUE TO AN INOPERABLE EDG |
| |
| "This 4-hour report is being made pursuant to 10CFR50.72(b)(2)(i). A unit |
| shutdown was commenced at 11:44 on June 18, 2003 to comply with Hope Creek |
| Generating Station Technical Specification (TS) 3.8.1.1 due to the |
| inoperability of the 'A' Emergency Diesel Generator (EDG). |
| |
| "On June 15, 2003 at 04:35am, an excessive seal leak from the engine driven |
| jacket water intercooler pump was identified, rendering the 'A' EDG |
| inoperable and warranting entry into ACTION b of TS 3.8.1.1. That action |
| requires the inoperable 'A' EDG to be returned to an operable condition by |
| June 18, 2003 at 04:35. Corrective actions attempted thus far have been |
| unsuccessful at eliminating leakage from the 'A' EDG jacket water |
| intercooler pump seal. Engineering is continuing to evaluate the |
| acceptability of the leakage from the seal. |
| |
| "All other safety related equipment is operable." |
| |
| The Unit is currently at 65% power and anticipates a full shutdown by |
| 1600EDT. The licensee will inform both local agencies and the NRC resident |
| inspector. |
| |
| * * * UPDATE 1725 EDT on 6/18/03 from Steven Nevelos to Bill Gott * * * |
| |
| "UPDATED: As of June 18, 2003 at 16:17, with reactor power at 42%, the unit |
| shutdown to comply with TS 3.8.1.1 was terminated. The 'A' EDG has been |
| declared operable but degraded with compensatory actions in place to |
| maintain EDG operability. Corrective maintenance to repair the machine and |
| eliminate the need for compensatory measures will be planned and performed |
| in a timely manner." |
| |
| The licensee will inform both local agencies and the NRC resident inspector. |
| Notified R1DO (Raymond Lorson). |
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