Event Notification Report for March 31, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/30/2003 - 03/31/2003
EVENT NUMBERS
3972139715397163971739723
Hospital
Event Number: 39721
Rep Org: MEDICAL CENTER OF BEAVER, PA
Licensee: MEDICAL CENTER OF BEAVER, PA
Region: 1
City: BEAVER State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: TONY COMBINE
HQ OPS Officer: CHAUNCEY GOULD
Licensee: MEDICAL CENTER OF BEAVER, PA
Region: 1
City: BEAVER State: PA
County:
License #: 37-11562-01
Agreement: N
Docket:
NRC Notified By: TONY COMBINE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/02/2003
Notification Time: 08:51 [ET]
Event Date: 03/31/2003
Event Time: 14:00 [EST]
Last Update Date: 04/02/2003
Notification Time: 08:51 [ET]
Event Date: 03/31/2003
Event Time: 14:00 [EST]
Last Update Date: 04/02/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
RONALD BELLAMY (R1)
TOM ESSIG (MNSS)
RONALD BELLAMY (R1)
TOM ESSIG (MNSS)
PATIENT RECEIVED A DOSAGE TO AN UNINTENDED TISSUE AREA
The patient had a HDR (High Dose Rate) treatment using 4-9 curies of Ir-192 when the tube was inserted into the treatment area it was 6 cms short of going to the planned area to be treated. This was caused by the wrong numbers being entered. It is estimated that the patient received between 500 and 1,000 Rads to the wrong area. The patient and prescribing physician were informed. There apparently was no adverse affects to the patient from this error.
The patient had a HDR (High Dose Rate) treatment using 4-9 curies of Ir-192 when the tube was inserted into the treatment area it was 6 cms short of going to the planned area to be treated. This was caused by the wrong numbers being entered. It is estimated that the patient received between 500 and 1,000 Rads to the wrong area. The patient and prescribing physician were informed. There apparently was no adverse affects to the patient from this error.
Power Reactor
Event Number: 39715
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROBERT RINK
HQ OPS Officer: ARLON COSTA
Region: 2 State: VA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROBERT RINK
HQ OPS Officer: ARLON COSTA
Notification Date: 03/31/2003
Notification Time: 15:40 [ET]
Event Date: 03/31/2003
Event Time: 12:59 [EST]
Last Update Date: 03/31/2003
Notification Time: 15:40 [ET]
Event Date: 03/31/2003
Event Time: 12:59 [EST]
Last Update Date: 03/31/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RUDOLPH BERNHARD (R2)
RUDOLPH BERNHARD (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO A MAIN FEEDWATER REGULATING VALVE FAILING CLOSED
"While Unit 2 was operation at 100% power steady state, 'C' MFRV [Main Feedwater Regulating Valve] failed closed due to a failed driver card at 1259 [EST]. The reactor automatically tripped 13 [thirteen] seconds later due to steam flow greater than feed flow coincident with a low SG [Steam Generator] level in the 'C' SG as expected. This is a 4 [four] hour notification.
"All 3 [three] AFW [Auxiliary Feedwater] pumps auto started due to a low-low SG level in 'C' SG as expected. This is an 8 [eight] hour notification.
"The unit is stable in Mode 3. Expect to re-start after repairs are made to 'C' MFRV circuitry."
All rods inserted normally. All safety and electrical systems operated as designed during and after the reactor trip. There was nothing unusual or not understood.
The NRC Resident Inspector has been notified.
"While Unit 2 was operation at 100% power steady state, 'C' MFRV [Main Feedwater Regulating Valve] failed closed due to a failed driver card at 1259 [EST]. The reactor automatically tripped 13 [thirteen] seconds later due to steam flow greater than feed flow coincident with a low SG [Steam Generator] level in the 'C' SG as expected. This is a 4 [four] hour notification.
"All 3 [three] AFW [Auxiliary Feedwater] pumps auto started due to a low-low SG level in 'C' SG as expected. This is an 8 [eight] hour notification.
"The unit is stable in Mode 3. Expect to re-start after repairs are made to 'C' MFRV circuitry."
All rods inserted normally. All safety and electrical systems operated as designed during and after the reactor trip. There was nothing unusual or not understood.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 39716
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICK LULLING
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICK LULLING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/31/2003
Notification Time: 18:03 [ET]
Event Date: 03/31/2003
Event Time: 16:25 [CST]
Last Update Date: 03/31/2003
Notification Time: 18:03 [ET]
Event Date: 03/31/2003
Event Time: 16:25 [CST]
Last Update Date: 03/31/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
RUDOLPH BERNHARD (R2)
CATHY HANEY (IAT)
RUDOLPH BERNHARD (R2)
CATHY HANEY (IAT)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOST/MISSING SAFEGUARDS INFORMATION
Compensatory measures not required at this time.
The licensee will be informing the NRC Resident Inspector.
Contact the Headquarters Operations Officer for additional details.
Compensatory measures not required at this time.
The licensee will be informing the NRC Resident Inspector.
Contact the Headquarters Operations Officer for additional details.
General Information or Other
Event Number: 39717
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CTL/THOMPSON TEXAS, LLC
Region: 4
City: Dallas State: TX
County:
License #: L04900-001
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: HOWIE CROUCH
Licensee: CTL/THOMPSON TEXAS, LLC
Region: 4
City: Dallas State: TX
County:
License #: L04900-001
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/01/2003
Notification Time: 12:49 [ET]
Event Date: 03/31/2003
Event Time: 20:00 [CST]
Last Update Date: 04/01/2003
Notification Time: 12:49 [ET]
Event Date: 03/31/2003
Event Time: 20:00 [CST]
Last Update Date: 04/01/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY GODY (R4)
SUSAN FRANT (NMSS)
JOHN DAVIDSON (IAT)
ANTHONY GODY (R4)
SUSAN FRANT (NMSS)
JOHN DAVIDSON (IAT)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was received from the Texas Department of Health, Bureau of Radiation Control via facsimile:
"The gauge operator was working a night assignment. After completion he took his company vehicle to the company office to complete paperwork at approximately 11:20 p.m. After completion of the paperwork he returned to his vehicle at approximately 11:40 p.m. and discovered that his assigned CPN nuclear density gauge (Model MC1-DR, Serial No. MD0129983) with two sealed radiation sources: a 10 millicurie Amersham, Model CPN 131, cesium-137 capsule, Serial No. 2870, that is engraved on the source rod as "CS9983" (source type plus the last four digits of the gauge Serial No.); and a 50 millicurie Amersham, Model CPN131, americium-241/beryllium, Serial No. 0992, that is engraved on the gauge's internal source pedestal as "AM9983" (source type plus the last four digits of the gauge Serial No.), was missing from the truck. The Licensee's security chain had been cut and was left in the vehicle. The 'red' transport case had been locked but the Licensee reports finding a piece of it's lock, also cut, in the bed of the truck. However, the transport case was also missing. In addition, the gauge's rod handle was also locked within the case before the gauge was stolen. The Licensee also reported that nothing except the gauge and it's case were removed from the truck. This Agency has searched Agency Open Records requests back through January 2002, with no suspicious request noted."
There is no media attention at this time. The Licensee is considering whether or not to post a reward for return of the gauge.
The following information was received from the Texas Department of Health, Bureau of Radiation Control via facsimile:
"The gauge operator was working a night assignment. After completion he took his company vehicle to the company office to complete paperwork at approximately 11:20 p.m. After completion of the paperwork he returned to his vehicle at approximately 11:40 p.m. and discovered that his assigned CPN nuclear density gauge (Model MC1-DR, Serial No. MD0129983) with two sealed radiation sources: a 10 millicurie Amersham, Model CPN 131, cesium-137 capsule, Serial No. 2870, that is engraved on the source rod as "CS9983" (source type plus the last four digits of the gauge Serial No.); and a 50 millicurie Amersham, Model CPN131, americium-241/beryllium, Serial No. 0992, that is engraved on the gauge's internal source pedestal as "AM9983" (source type plus the last four digits of the gauge Serial No.), was missing from the truck. The Licensee's security chain had been cut and was left in the vehicle. The 'red' transport case had been locked but the Licensee reports finding a piece of it's lock, also cut, in the bed of the truck. However, the transport case was also missing. In addition, the gauge's rod handle was also locked within the case before the gauge was stolen. The Licensee also reported that nothing except the gauge and it's case were removed from the truck. This Agency has searched Agency Open Records requests back through January 2002, with no suspicious request noted."
There is no media attention at this time. The Licensee is considering whether or not to post a reward for return of the gauge.
General Information or Other
Event Number: 39723
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS DEPT OF TRANSPORTATION
Region: 4
City: ABILENE State: TX
County:
License #: L00197
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR
HQ OPS Officer: ERIC THOMAS
Licensee: TEXAS DEPT OF TRANSPORTATION
Region: 4
City: ABILENE State: TX
County:
License #: L00197
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR
HQ OPS Officer: ERIC THOMAS
Notification Date: 04/03/2003
Notification Time: 12:21 [ET]
Event Date: 03/31/2003
Event Time: 22:00 [CST]
Last Update Date: 04/03/2003
Notification Time: 12:21 [ET]
Event Date: 03/31/2003
Event Time: 22:00 [CST]
Last Update Date: 04/03/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY GODY (R4)
ANTHONY GODY (R4)
ATTEMPTED THEFT OF A TROXLER GAUGE
The Texas Department of Health reported the attempted theft of a Troxler Model 3430, (serial # unknown), on the night of 3/31/03 from a secure storage trailer at a Texas Department of Transportation construction site in Abilene, TX. Site personnel discovered the gauge in an open case on the floor of a construction trailer with its lock cut. The trailer and its storage closet had been broken into. The sealed source contains 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be. Gauge is currently secured in a different area awaiting results of leak and serviceability tests. An investigation is in process to determine whether other items were stolen, or whether this gauge was the only target of the attempted theft.
This event is technically not reportable, but was entered as an attempted theft due to three other similar incidents that did result in stolen gauges in the Dallas-Fort Worth area under similar circumstances. The Texas Department of Transportation notified all other licensee's possessing portable nuclear gauges in the Abiline and Dallas-Fort Worth regions, along with local police and the Dallas FBI office.
The Texas Department of Health reported the attempted theft of a Troxler Model 3430, (serial # unknown), on the night of 3/31/03 from a secure storage trailer at a Texas Department of Transportation construction site in Abilene, TX. Site personnel discovered the gauge in an open case on the floor of a construction trailer with its lock cut. The trailer and its storage closet had been broken into. The sealed source contains 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be. Gauge is currently secured in a different area awaiting results of leak and serviceability tests. An investigation is in process to determine whether other items were stolen, or whether this gauge was the only target of the attempted theft.
This event is technically not reportable, but was entered as an attempted theft due to three other similar incidents that did result in stolen gauges in the Dallas-Fort Worth area under similar circumstances. The Texas Department of Transportation notified all other licensee's possessing portable nuclear gauges in the Abiline and Dallas-Fort Worth regions, along with local police and the Dallas FBI office.