Event Notification Report for February 06, 2003

AGREEMENT STATE REPORT INVOLVING FIVE MISSING I-125 SEEDS

The following information was received from the Arizona Radiation Regulatory Agency:

"Date: February 6, 2003
"Time: 3:00 PM (MST)

"First Notice: 03-03

"Arizona Licensee:

"Scottsdale Memorial Health Services, Co., Inc.
"9003 E. Shea Blvd.
"Scottsdale, AZ 85260

"License. No. 07-265

"On January 29, 2003, a Bracytherapy procedure using Iodine-125 seeds (3M, Model 6500 Series) was conducted at the above named hospital. On February 6, 2003, it was discovered that five seeds containing approximately 0.39 mCi each could not be accounted for. A survey of the source storage area, source use area, linens, and waste was conducted and could not account for the missing sources.

"The Agency and licensee will continue to investigate this occurrence and report further.

"The U.S. NRC and the U.S.FBI are being notified of this event."

Call the Headquarters Operations Officer for contact information.

AGREEMENT STATE REPORT INVOLVING MISSING 62 MILLICURIE STRONTIUM-90 SOURCE

The following information was received from the Arizona Radiation Regulatory Agency:

"Date: February 6, 2003
"Time: 3:00 PM (MST)

"First Notice: 03-04

"Arizona Location
"Tucson FEDEX
"Phoenix, AZ 85040

"License No. Transportation to
"AZ 10-44

"At approximately 2:00 PM the Agency was informed by the University of Arizona that on 1/23/2003 they shipped a 90-Sr sealed source [62 mCi] to Novoste at Norcross, GA. At approximately 11:30 MST the University was contacted by Novoste and informed that a package with the University waybill did not have the 90-Sr sources but contained airplane parts. FEDEX reported to the University that the shipment left Tucson, AZ 6:44 PM on 1/23/03 arriving in Memphis TN around 1:07 AM 1/24/03. The log indicates 'Missing Paperwork.' Subsequently the package went to Atlanta and the Decatur Station. The package was back in Memphis on 1/26/03, then back the Atlanta and Decatur on 1/27/03. At approximately 9:07 AM, 1/27/03 the package was delivered to Novoste. The shipping package was a 12 by 13 inch metal pail weighing 35 pounds. It was shipped standard overnight on waybill # 838483848672.

"The Agency and the University continue to look for the source.

"The states of GA, and TN and U.S. NRC and FBI are being notified of this event."

Call the Headquarters Operations Officer for contact information.


*** UPDATE ON 2/7/03 1500 EST FROM ROD HARRELL TO ARLON COSTA ***

The Sr-90 source was held by FEDEX at Memphis pending completion of paperwork and was subsequently sent to Novoste at Norcross, GA. The source was delivered to Novoste on 01/27/03 at 0930 EST.

Notified NMSS EO (Leach), TAS (Hann), R4DO (Johnson), R4 IAT (Boland) and FEMA, DOE, USDA, HHS, EPA, DOT(NRC) via fax.

UNANALYZED CONDITION FOR CABLE SEPARATION CRITERIA AT INDIAN POINT 2

"At 1600 hours on February 6, 2003, IP determined that CR IP-2002.00765, issued to identify that the routing of charging pump power supply and control cables does not meet the cable separation criteria specified in 10CFR50 App R section III.G.1, was reportable as a potentially unanalyzed condition. This condition was discovered during the re-baseline of the 10CFR50 Appendix R analysis. A fire in Fire Area F could potentially disable all 3 charging pumps as a result of the loss of the 23 charging pump alternate power feed transfer switch; loss of the 23 charging pump 'alternate' power feed cable, and the alternate/normal power feed cable between the transfer switch and the pump; loss of 22CHP power feed cable; loss of local/remote control cable, PL2, disabling remote operation for all 3 charging pump breakers; and loss of Control cables and pneumatics 22 and 23 charging pumps. Fire protection impairment actions were implemented per Procedure SAO-703. This condition was determined to be reportable using the guidance of NUREG-1022 which cites the absence of adequate separation between redundant shutdown trains to be reportable as a significant degradation of plant safety. Although it is possible that this condition was previously identified and dispositioned, an analysis is not readily available."

The NRC Resident Inspector has been notified.

* * * UPDATE ON 2/12/03 @ 1757 BY DURR TO GOULD * * *

Event notification 39571 made on February 6, 2003 identified an unanalyzed cable separation issue discovered during the re-baseline of the 10 CFR 50, Appendix R, analysis. As part of the on-going re-baseline, CR-IP-2003-867 was written at 1353 hours on February 12, 2003 to identify the potential failure of normal power supply cables for the six service water pumps to meet the separation criteria of 10 CFR 50, Appendix R, Section III,G. 1. The cables are potentially vulnerable to the effects of a single postulated fire in fire area J. The specific location of this common vulnerability is Manhole 23, located on the 15 foot elevation of the turbine building adjacent to the northwest corner of the 6.9 kV switchgear cabinets. Manhole 23 is covered by a checkered plate that is open to the 15 foot elevation and has not been credited as a fire barrier. The normal power supply cables are credited for a fire in Fire Area J to supply power to at least one service water pump. The normal power supplies for the six service water pumps are routed from the 480 V Switchgear Room through manhole 23. Fire protection impairment actions are taken per Procedure SAO-703. Although it is possible this condition was also previously identified and dispositioned, the analysis is not readily available for assessment as part of the re-baseline.

The licensee notified the NRC Resident Inspector.

Notified R1 DO (Meyer) and NRR EO (Zwolinski).

AGREEMENT STATE NOTIFICATION OF RADIATION OVER - EXPOSURE

"Abstract:
On January 31, 2003, the Radiation Safety Officer from the University contacted our office to notify us that a physician, who works in the Radiation Oncology Department at the University's Medical Center-Hillcrest, received a whole body dose of 5700 mrem for CY 2002, exceeding the occupational worker limit of 5000 mrem/year. The 5700 mrem was all received during the dosimeter wear period of October to December 2002.

"The RSO states that this exposure appears to be real and therefore qualifies as an overexposure. The matter is being investigated by UCSD's Environmental, Health and Safety office with a formal report to be submitted within
30 days.

"The physician has been interviewed by UCSD and feels the dose may have occurred during Cs-137 seed implants. UCSD is currently in the process of researching how many seed implants this doctor was involved in during this time period (they think the doctor was involved with at least 2-3 seed implants between October 1 through December 31, 2002).

"In the years 2000, 2001 and for the first three quarters of 2002, this individual's reported dose was 0 DDE, LDE, SDE (note: This individual lost the ring badges for the first three quarters of 2002 and there are no ring badge records available for 2002). UCSD is having a special session of the Radiation Safety Committee next week to discuss this overexposure and will do their own investigation. They will also ask the doctor what happened to the ring badges.

"Summary:
At approximately 0900, the Brea office received a call from John Zummo, RSO and John Olson, ARSO from The Regents of the University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0920, RAML# 1339-37, (858) 534-1069 to give notice that dosimetery readings indicate an overexposure to a staff physician. The physician works in the Radiation Oncology Department of Hillcrest Medical Center, San Diego, and received a dose of 5700 mrem whole-body for CY 2002, exceeding the occupational worker limit of 5000 mrem/year. The 5700 mrem was all received during the dosimeter wear period of October to December 2002.

"A preliminary report was e-mailed to the office (sent 0912, on 1-31-03). That report relays that, based on the information known so far, the 5700 mrem appears to be real and therefore qualifies as an overexposure. The matter is being investigated by UCSD's Environmental, Health and Safety office with a formal report to be submitted within 30 days."

AGREEMENT STATE REPORT - MEDICAL EVENT

The Iowa Department of Public Health provided the following via fax:

"Here is a summary of the event that occurred a week ago:

"The University of Iowa (Iowa Radioactive Materials License No. 0037-1 -52-AAB) provided a 700 Rad (7 Gy [Gray]) dose to an unintended site using a Varian-TEM Ltd. Model VariSource HDR Remote Afterloader. The planned area of treatment was a tumor in the bronchial area.

"The licensee measured and tested a catheter using the dummy source. After the test, the catheter was placed in a box and sent for sterilization. On February 6, 2003. the licensee used what they thought was the correct catheter during one fraction.

"When the patient returned on February 13, 2002, for the second fraction, a medical physicist discovered that the catheter was 30 centimeters too short.

"The dose was delivered to the skin in the nasal passages rather than the bronchial area. The attending physician was present at the time the error was discovered and has been informed. The patient has been advised of the error and given the option of discontinuing treatment. The patient has elected to undergo treatment for the correct site.

"The cause of the error is currently under investigation and the licensee's report, which is due to IDPH by February 28, 2003, will address corrective actions."

OFFSITE NOTIFICATION TO STATE AND LOCAL AGENCIES REGARDING TRITIUM SPILL

"Notification was made to the state of New Jersey to report a spill of radioactive material, specifically, tritium at a concentration of 6.92 E-5 microcuries/ml. The material is presently contained on the property of Salem Generating Station and was discovered at 0945 on February 6, 2003.

"Soil samples obtained at a depth of 20 feet from 2 monitoring wells indicates the presence of tritium. The monitoring wells are adjacent to Salem Unit 1 and within the protected area. We recently sampled all domestic water supplies and the results were negative. There is no indication of any offsite release, there is no threat to the public or company employees. We cannot determine at this time if this is an existing or historic condition. We are continuing with additional analysis to determine the source and extent of the condition."

The licensee informed state agencies and the NRC resident inspector and will inform the local agency of LAC.


* * * UPDATE ON 07/25/03 @ 1553 BY RUDOLPH CHAN TO CHAUNCEY GOULD * * *

On July 25, 2003, PSEG made an update notification to the New Jersey Department of Environmental Protection on the results of PSEG's ongoing remediation work investigation plan for the previously reported tritium spill. The update stated that additional samples from test wells have identified presence of tritium at levels above background. Specifically, sample results obtained from a new well placed as part of the ongoing investigation indicated a tritium concentration of 3.5 E-3 microcuries/milliliter. Additionally, a sample from an existing well indicated a result of 1.25 E-4 microcuries/milliliter, which was higher than previously observed at this location although from a different type of well. Gamma scans of samples from both locations detected no other radionuclides. There is no indication of any offsite release and there is no threat to the public or company employees. We cannot determine at this time if this is an existing or historic condition. We are reviewing the situation with our expert panel to determine the proper location for additional test wells to determine the source and extent of the condition.

The NRC resident and regional inspectors have been made aware of the test results.

The NRC REG1 RDO (Daniel Holody) was informed.