Event Notification Report for February 13, 2001

LOST SOURCE - SEED USED FOR PROSTATE PROCEDURE

The hospital discovered that one seed out of 110 seeds, apparent activity is .311 mCi I-125 (full activity is .587 mCi) was missing after the completion of an implant procedure. An extensive search of the operating room, equipment, drains, laundry, and hallways failed to discover the missing seed. The patient was scanned and the best analysis is that the patient received the proper number of seeds. There is little or no threat to the public health or safety. The hospital contacted NRC Region 3.

AGREEMENT STATE REPORT OF A STOLEN TROXLER GAUGE

"This first notice constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is that which is available after preliminary investigation and is basically all that is known by the Agency Staff at this time.

"Date: 02/13/01
Time: 0430-0815 AM, MST
First Notice No.: 01-01

"Arizona Licensee: Ricker-Atkinson-McBee & Assoc.
License: No. 07-406

"Description of the event: Between the hours of 0430 AM and 0815 AM a Troxler Moisture Density Gauge, Model #3440, S/N 26981 was stolen from the licensee's facility while locked and chained in the bed of the users 2000 Dodge Dakota Pickup Truck, Arizona Lic. #523FCY. The gauge and scatter block were removed from the transport case and the case remained in the pickup. A reward of $500.00 is being offered by the licensee upon return of the gauge.

"The states of Utah, California, Colorado, New Mexico, and U.S. NRC Region IV, USNRC-DC, U.S. FBI and the governor's office are being informed of this incident."

*** UPDATE AT 1108 EST ON 02/15/01 VIA FACSIMILE FROM AUBREY V. GODWIN TO LEIGH TROCINE ***

The following text is a portion of a facsimile received from the Arizona Radiation Regulatory Agency:

"This Supplemental Notice constitutes EARLY additional informational notice of events of POSSIBLE safety or public interest significance. The information is as initially received WITHOUT verification or evaluation and is basically all that is known by the Agency Staff at this time."

"Date: February 15, 2001
Time: 9:00 AM (MST)
First Notice: 01-01
Arizona Licensee: Ricker-Atkinson-McBee & Associates [in] Tempe, AZ
License No.: 07-406 [...]"

"On February 13, 2001, the LICENSEE reported the [theft] of a Troxler Model 3440 moisture density gauge. A First Notice No. 01-01 was issued to report this event to appropriate agencies. Late February 14, 2001, a pawn shop in Phoenix reported that they had obtained a nuclear gauge and wished to release it to the proper authorities. The gauge was recovered from the pawn shop with locks intact. The Phoenix PD is investigating the circumstances of the transfer of the device to the pawn shop."

"The LICENSEE and the Agency continue to investigate this event."

"The states of Utah, California, Colorado, New Mexico, and Nevada together with the U.S. NRC, the U.S. FBI, and Mexico are being notified of this event."

(Call the NRC operations officer for both State and licensee contact information.)

The NRC operations officer notified the R4DO (Pick) and NMSS EO (Cool).

AUTOMATIC REACTOR TRIP DURING TURBINE VALVE TESTING

"On 2/13/2001 at 1654 CST Waterford 3 sustained a reactor trip from 82% RTP. The reactor trip was most probably caused by variable over power trip, which is a core protection calculator auxiliary trip. Actuation of the emergency feedwater system also occurred due to shrinkage of coolant in the steam generator caused by the reactor trip; however, no emergency feedwater was actually fed into the steam generators. Actuation of the emergency feedwater system is a normal occurrence following a reactor trip. This condition is reportable under 10CFR50.72(b)(2)(iv)(B), any event or condition that results in actuation of the reactor protection system when the reactor is critical, which is a 4 hour report; and 10CFR50.72(b)(3)(iv)(A), any event or condition that results in valid actuation of the emergency feedwater system, which is an 8 hour report. At the time of the trip Waterford 3 was performing turbine valve testing per OP-903-007. Governor Valve 3 was being tested and sporadically started opening and closing."

The plant is stable in Hot Standby with excess heat removed via forced circulation to the steam generators and steam released through the bypasses to the main condensers.

The licensee notified the NRC Resident Inspector.

POSSIBLE MISADMINISTRATION AT MERCY HOSPITAL IN PORT HURON, MICHIGAN

A patient was receiving a treatment with a gynecological implant containing two cesium-137 sources (with 13.74 milligrams radium equivalent each). The patient was reportedly restless and moving around quite a bit, and the applicator was in its proper position at 2100. However, when nurses checked on positioning of applicator at 2330 on 02/13/01, it was discovered that the applicator had gotten past the sutures and come out completely. The implant treatment procedure was terminated at that time.

Based on the minimum and maximum amount of time that the applicator may have been in the proper position, the patient received between 66% and 71% of the intended dose. Conservative calculations (assuming that the applicator came out at 2100) revealed doses to unintended areas were not anticipated to cause adverse health complications as a result of this exposure. The patient has been informed.

(Call the NRC operations officer for a licensee contact telephone number.)

FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION WAS NOTIFIED THAT A SICK SEA TURTLE NEEDED REHABILITATION.

The licensee rescued a sea turtle from the intake canal. As a result, the licensee notified the Florida Fish and Wildlife Conservation Commission that the turtle had been rescued and needed rehabilitation.

The resident inspector was notified of this event by the licensee.