Event Notification Report for August 19, 2002

AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION

"The licensee reported that a patient received 2640 cGy (rad) during a cardiac intravascular brachytherapy treatment instead of the intended 2000 cGy (rad), a 32% overexposure. The patient was being treated with the Guidant Corporation Galileo intravascular brachytherapy high dose rate remote afterloader device (serial #27958502) with a model GDT-P32-2 source wire (serial #020807016) containing 4.44 GBq (119.9 [millicuries]) of P-32 at time of treatment. The patient's vessel size was larger than the automatically calculated maximum diameter treatment. A manual calculation of dwell time was required, based on the dose rate tables available in the Guidant Manual (section 6.13 table 5). However, the dose rate for a 4.6 mm diameter (3.30 mm treatment depth) was inadvertently used instead of 4.05 mm diameter (3.03 mm treatment depth). This resulted in a delivered dose of 2640 cGy (rad) at 3.03 mm. The cause of the event is human error. The licensee's corrective action is to have a second independent calculation performed by Physics and Dosimetry staff prior to treatment whenever a manual calculation using the dose rate tables is necessary. No adverse consequences are expected. The referring physician and the patient were notified of the overexposure."

REACTOR BUILDING EMERGENCY RECIRCULATION UNIT COOLER ANOMALY IDENTIFIED DURING ROUTINE SURVEILLANCE TEST

"On August 19, 2002 at 0232, Reactor Building Emergency Recirculation Unit Cooler, 2HVR*413A, was declared inoperable due to Reactor Building Emergency Recirculation Unit Cooler Inlet Damper, 2HVR*AOD6A, not reaching its full open position during testing. Failure of 2HVR*AOD6A to fully open may affect the flow-rate through the Reactor Building Emergency Recirculation Unit Cooler and may prevent the Standby Gas Treatment System from performing its Post-LOCA Secondary Containment drawdown function. The manual operating mechanism was returned to its withdrawn position and 2HVR*AOD6A was verified to be capable of being fully opened. Opposite train components were inspected to confirm that a similar condition does not exist on Train "B". This notification is being made as a conservative measure. Evaluation coritinues into the actual affect on Post-LOCA drawdown function."

The NRC Resident Inspector was notified.

* * * 1410EDT on 8/22/02 from Dave Richardson to S. Sandin * * *

The licensee is retracting this report based on the following:

"The purpose of this communication is to retract event report number 39136 which was initiated at 1030 hours on 08-19-2002, by Nine Mile Point Unit 2. This event, reported under 10CFR50.72 (b)(3)(v)(C), involved unplanned inoperability of a Reactor Building Emergency recirculation unit cooler due to its inlet damper being found partially overridden shut.

"Evaluation revealed that, when called upon to reposition to its emergency position, the damper was approximately 97% open. Based on Engineering analysis, with the damper in this position, there is 'no appreciable increase in system resistance' that would adversely impact the HVR (reactor building ventilation) or GTS (standby gas treatment) system flowrates. As a result, this condition would not have precluded the aforementioned systems from performing their respective safety functions."

The licensee informed the NRC Resident Inspector. Notified R1DO(Anderson).

AGREEMENT STATE REPORT INVOLVING THEFT OF MOISTURE/DENSITY GAUGE

"The licensee reported the theft of a Campbell Pacific Nuclear moisture/density gauge (model MC-1DRP, serial number MD01005902). The gauge contained a 1.85 GBq (50 [millicuries]) Am-Be source and a 0.37 GBq (10 [millicuries]) Cs-137 source. An authorized user had been working at a temporary job site for two weeks. On Sunday, August 18 at 8:00 p.m. the authorized user parked his pick-up truck in the parking lot of a local motel in Centralia. The gauge was in back under the locked canopy, but visible. The gauge box was locked but not secured within the bed of the truck. When the authorized user went out to his truck at 6:00 a.m. on Monday the 19th the gauge was gone. The back window of the canopy had been forced open. Nothing else was missing from the truck (not much else of value was in the truck). The theft was reported to the Centralia police and to the licensee's RSO. The RSO notified the Department."

* * * * UPDATE FROM STATE (A. SCROGGS) VIA EMAIL 02/14/05 1800 EST * * * *

The following information was received from the State via email:

"On Friday February 4, 2005 an employee of another engineering firm noticed the gauge at a garage sale in Centralia, Washington. The employee noted the gauge ID specifics and had his RSO contact the gauge manufacturer for information. When informed by the manufacturer that it had been stolen, the employee was able to involve the police and secure the gauge. The individual responsible for the garage-sale was subsequently arrested. The owner, URS Corporation was notified and is presently having the gauge serviced and leak tested by a licensed technical service provider. They plan to retake ownership when this work is completed."

Notified R4 DO (J. Whitten) and NMSS EO (W. Reamer)