Event Notification Report for June 25, 2003

DAMAGED TROXLER DENSITY GAUGE

At 1020 EDT on 6/25/03, the NC Radiation Protection Section was notified that a portable nuclear gauge being used was run over by a passenger van at the intersection of Faivon and Bucchaneer Roads (near Hwy 40 and the 55 interchange). The Authorized User is on site and has the gauge cordoned off as per emergency procedures require. The van involved in the collision is being detained.. Both the RSO and Alt RSO are enroute to perform surveys (1 hour).

NC Radiation Protection Section personnel are responding to the scene to perform surveys (30 mins).

The device is described as a Troxler Gauge containing 8 millicuries Cs-137. NC Incident Report No.: 03-27.

* * * UPDATE 0952 EDT ON 6/26/03 FROM NC RAD PROTECTION VIA FAX * * *

The following additional information was provided by NC:

Incident Location: Chapel Hill, NC . Intersection of Faison and Buckner Roads. Take 40 West from Raleigh to the NC54 exit towards Chapel Hill. Take a right onto Meadowmont, then a left onto Sprunt. Follow Sprunt to Weaver Lane and take a right onto Weaver Lane. Take a right on Faison off of Weaver lane, go downhill to the intersection of Faison and Buckner.

Brief Description of Incident: Paving contractor in a commercial van was not watching where he was driving and ran over the instrument panel part of a Troxler model 4640B thin lift density gauge. The licensee was performing a standardization count on the gauge at the time of the accident so the source was in the shielded position when it was run over. The gauge was pushed off the standardization plate and dragged about 3 feet. The gauge then rolled onto it's side and the source handle was shoved into the asphalt. The licensee stopped the van and detained it and the driver until the gauge could be surveyed and it was determined that there were no loose source or contamination concerns. The area was cordoned off with pink surveyors' tape and controlled until the gauge and accident area was surveyed and the gauge returned to the Troxler shipping container. Survey results of the gauge done by both the licensee and the NCDENR RAM Branch were consistent with an undamaged gauge. The licensee placed the gauge into the Troxler transportation case for delivery to Troxler for leak testing and servicing. The damage appears to be cosmetic with some damage to be expected to the electronics.

Radiological Information: Isotope(s): Cesium-137, Activity: 8 millicuries, Device: Troxler Gauge, model 4640B

Notified R2DO (C. Ogle) and NMSS (Broaddus).

SMALL OIL SPILL AT HADDAM NECK PROMPTS OFFSITE NOTIFICATION

The licensee reported an offsite notification to the Connecticut Department of Environmental Protection concerning a 1 pint oil spill. Apparently, a hydraulic hose on a forklift failed and spilled oil onto the dirt. The licensee indicated they will clean-up the oil spill.

Notified R1DO (K. Jenison)

UNANALYZED CONDITION DUE TO DISLODGED ACCESS PANEL IN THE CONTROL BUILDING VENTILATION SYSTEM

"An access panel cover for the Control Building Ventilation System supply duct was found to be dislodged on June 24, 2003. The access panel was immediately realigned upon discovery of the condition and secured. The probable cause of the event is that vibration of the ductwork caused the panel closure camlocks to vibrate from a closed position to an open position. A walkdown is being performed to ensure that other access panels are secure. The corrective action to this event will address additional actions to ensure these closure camlocks and other similar camlocks are positively secured to prevent an event recurrence.

"The review of the potential impact of this system configuration determined on June 25, 2003 that conditions may have existed as defined in 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(D) and that the event requires reporting. On Tuesday, June 25, 2003, further Engineering evaluation determined that the dislodged panel access cover for the Control Building Ventilation System may have reduced the systems capability to maintain a positive pressure in the Control Building Habitability Envelope. This condition could have lead to increased unfiltered in-leakage of airborne radioactive material beyond the previously analyzed condition in the event of a design basis accident. Further analysis may determine that the system would have been able to perform its design basis function.

"The NRC Resident Inspector has been notified. No other state, local or other government agencies have been notified. There has been no media press release issued."

INCORRECT PATIENT GIVEN A DOSE

"On June 25, 2003, a nuclear medicine technologist gave a 243 microcurie iodine-123 capsule to the wrong patient. There were two patients with the same last name and middle initial but different first names in the outpatient waiting room. The wrong patient responded when the technologist took the patient into the nuclear medicine department, explained the procedure, and had him fill out a thyroid questionnaire. After the patient swallowed the capsule, he informed the technologist that he was not at the hospital for a thyroid study. The patient was informed of the misadministration. The licensee did not report whether the referring physician was informed.

"Cause: The technologist failed to fully identify the patient.

"Corrective Action: The technologist was counseled. To prevent a recurrence, the technologists will question the patient's full name and match their date of birth in the future. The technologist will also ask the patient what examination or procedure they are scheduled for before initiating any test."

Texas Incident No.: I-8042.