Event Notification Report for September 04, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/03/2003 - 09/04/2003
EVENT NUMBERS
40136401374013240133
General Information or Other
Event Number: 40136
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LITTLE COMPANY OF MARY HOSPITAL
Region: 4
City: TORRANCE State: CA
County:
License #: 090503
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: RICH LAURA
Licensee: LITTLE COMPANY OF MARY HOSPITAL
Region: 4
City: TORRANCE State: CA
County:
License #: 090503
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: RICH LAURA
Notification Date: 09/05/2003
Notification Time: 14:44 [ET]
Event Date: 09/04/2003
Event Time: 08:00 [PDT]
Last Update Date: 09/05/2003
Notification Time: 14:44 [ET]
Event Date: 09/04/2003
Event Time: 08:00 [PDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHARLES MARSCHALL (R4)
TOM ESSIG (NMSS)
CHARLES MARSCHALL (R4)
TOM ESSIG (NMSS)
CALIFORNIA AGREEMENT STATE REPORT ON MEDICAL EVENT
"On September 4, 2003, two patients were scheduled for prostate brachytherapy implants. The first was suppose to be implanted with Iodine 125 and the second with Palladium 103. In anticipation of these procedures both the Palladium 103 and Iodine 125 were brought to the surgical suite.
"The first implant procedure was started and after two strands of Palladium 103 had been implanted it was discovered that an error had been made because the patient was scheduled to be implanted with Iodine 125. The treatment plan had been performed for Iodine 125. The decision was made to continue with the implanting of the Palladium 103 after a new treatment plan was performed. Based on the new plan the appropriate number of Palladium 103 seeds were implanted delivering the prescribed dose. Initial report from (DELETED) was that the patient was scheduled for 7:30 AM, so the event most likely occurred around 8:00 AM. Specific details will be included in his full report to follow. Because the treatment planning equipment was already in the surgical suits, the new plan could be developed with little delay. Specific time frame delays to follow in the full report.
"The second patient, scheduled for Palladium 103 was in the same day surgery suite and had not been prepped nor given an IV. He was rescheduled for another day, as they did not have enough Palladium 103 for both patients."
"On September 4, 2003, two patients were scheduled for prostate brachytherapy implants. The first was suppose to be implanted with Iodine 125 and the second with Palladium 103. In anticipation of these procedures both the Palladium 103 and Iodine 125 were brought to the surgical suite.
"The first implant procedure was started and after two strands of Palladium 103 had been implanted it was discovered that an error had been made because the patient was scheduled to be implanted with Iodine 125. The treatment plan had been performed for Iodine 125. The decision was made to continue with the implanting of the Palladium 103 after a new treatment plan was performed. Based on the new plan the appropriate number of Palladium 103 seeds were implanted delivering the prescribed dose. Initial report from (DELETED) was that the patient was scheduled for 7:30 AM, so the event most likely occurred around 8:00 AM. Specific details will be included in his full report to follow. Because the treatment planning equipment was already in the surgical suits, the new plan could be developed with little delay. Specific time frame delays to follow in the full report.
"The second patient, scheduled for Palladium 103 was in the same day surgery suite and had not been prepped nor given an IV. He was rescheduled for another day, as they did not have enough Palladium 103 for both patients."
General Information or Other
Event Number: 40137
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HBC/TERRACON
Region: 4
City: NEW CASEY State: TX
County:
License #: L05268
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS
HQ OPS Officer: RICH LAURA
Licensee: HBC/TERRACON
Region: 4
City: NEW CASEY State: TX
County:
License #: L05268
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS
HQ OPS Officer: RICH LAURA
Notification Date: 09/05/2003
Notification Time: 18:47 [ET]
Event Date: 09/04/2003
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2003
Notification Time: 18:47 [ET]
Event Date: 09/04/2003
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHARLES MARSCHALL (R4)
JANET SCHLUETER (NMSS)
CHARLES MARSCHALL (R4)
JANET SCHLUETER (NMSS)
TEXAS AGREEMENT STATE REPORT ON STOLEN GAUGE
"A nuclear gauge was stolen during the night from a pickup truck parked at a residence. The chain and lock were cut and the gauge was taken. We are unaware of whether other items were taken. The technician became aware the gauge was missing when he arrived at a jobsite at about 5:30 am on 09/05/2003. The field service manager looked around the neighborhood and at local pawn shops but did not locate the gauge. The Licensee is considering a public announcement and the offering of a reward. The Agency is investigating the incident."
The gauge is a Troxler 3430, serial # 17272, with 39.2 milliCuries of Am-241 (serial # 47-12694) and 6 milliCuries of Cs-137 (serial # 50-6643).
"A nuclear gauge was stolen during the night from a pickup truck parked at a residence. The chain and lock were cut and the gauge was taken. We are unaware of whether other items were taken. The technician became aware the gauge was missing when he arrived at a jobsite at about 5:30 am on 09/05/2003. The field service manager looked around the neighborhood and at local pawn shops but did not locate the gauge. The Licensee is considering a public announcement and the offering of a reward. The Agency is investigating the incident."
The gauge is a Troxler 3430, serial # 17272, with 39.2 milliCuries of Am-241 (serial # 47-12694) and 6 milliCuries of Cs-137 (serial # 50-6643).
General Information or Other
Event Number: 40132
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: Professional Service Industries
Region: 2
City: Pass Christian State: MS
County: Harrison
License #: MS-639-01/02
Agreement: Y
Docket:
NRC Notified By: Mark Langston
HQ OPS Officer: ERIC THOMAS
Licensee: Professional Service Industries
Region: 2
City: Pass Christian State: MS
County: Harrison
License #: MS-639-01/02
Agreement: Y
Docket:
NRC Notified By: Mark Langston
HQ OPS Officer: ERIC THOMAS
Notification Date: 09/04/2003
Notification Time: 09:48 [ET]
Event Date: 09/04/2003
Event Time: 06:00 [CDT]
Last Update Date: 09/05/2003
Notification Time: 09:48 [ET]
Event Date: 09/04/2003
Event Time: 06:00 [CDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHARLES MARSCHALL (R4)
DOUG BROADDUS (NMSS)
PAUL FREDRICKSON (R2)
CHARLES MARSCHALL (R4)
DOUG BROADDUS (NMSS)
PAUL FREDRICKSON (R2)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
At approximately 0600 CDT on 9/4/2003, a 1999 Nissan Altima belonging to an employee of Professional Services Industries (PSI) was stolen while parked at his residence in Pass Christian, MS. The vehicle had a Troxler Moisture/Density gauge Model 3411B, serial number 18549, locked in the trunk. The gauge contained the following isotopes: Cs-137, 8 millicuries, serial number 50899, and Am-241/Be, 40 millicuries, serial number 4714005.
The local PSI office is located in Gulfport, MS.
Local Law Enforcement was notified of the stolen vehicle and gauge.
*****UPDATE ON 9/5/03 AT 1710 FROM LANGSTON TO LAURA*****
The stolen vehicle was located in downtown Gulfport, MS. The gauge was found intact and was transported back to the office for a leak test. It appeared that the gauge was not touched.
Notified R2DO (P. Fredrickson).
At approximately 0600 CDT on 9/4/2003, a 1999 Nissan Altima belonging to an employee of Professional Services Industries (PSI) was stolen while parked at his residence in Pass Christian, MS. The vehicle had a Troxler Moisture/Density gauge Model 3411B, serial number 18549, locked in the trunk. The gauge contained the following isotopes: Cs-137, 8 millicuries, serial number 50899, and Am-241/Be, 40 millicuries, serial number 4714005.
The local PSI office is located in Gulfport, MS.
Local Law Enforcement was notified of the stolen vehicle and gauge.
*****UPDATE ON 9/5/03 AT 1710 FROM LANGSTON TO LAURA*****
The stolen vehicle was located in downtown Gulfport, MS. The gauge was found intact and was transported back to the office for a leak test. It appeared that the gauge was not touched.
Notified R2DO (P. Fredrickson).
General Information or Other
Event Number: 40133
Rep Org: WESTINGHOUSE ELECTRIC COMPANY
Licensee: CUTLER-HAMMER
Region: 1
City: Pittsburgh State: PA
County:
License #:
Agreement: N
Docket:
NRC Notified By: H. A. SEPP
HQ OPS Officer: JOHN MacKINNON
Licensee: CUTLER-HAMMER
Region: 1
City: Pittsburgh State: PA
County:
License #:
Agreement: N
Docket:
NRC Notified By: H. A. SEPP
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/04/2003
Notification Time: 09:57 [ET]
Event Date: 09/04/2003
Event Time: 00:00 [EDT]
Last Update Date: 09/04/2003
Notification Time: 09:57 [ET]
Event Date: 09/04/2003
Event Time: 00:00 [EDT]
Last Update Date: 09/04/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
PAMELA HENDERSON (R1)
CHARLES MARSCHALL (R4)
RONALD GARDNER (R3)
PAUL FREDRICKSON (R2)
JACK FOSTER (NRR)
PAMELA HENDERSON (R1)
CHARLES MARSCHALL (R4)
RONALD GARDNER (R3)
PAUL FREDRICKSON (R2)
JACK FOSTER (NRR)
POTENTIAL DEFECT IN CUTTLER HAMMER CIRCUIT BREAKERS
"DHP-VR350, 1200A, circuit breakers were manufactured by Cutler-Hammer Inc., commercially dedicated for Class 1E applications by Westinghouse and shipped to the Columbia Generating Station. During installation acceptance testing, one breaker charging motor failed to charge. Columbia Generating personal performed, a 100% inspection on all 16 breakers with safety-related functions. There was a loose screw associated with this position switch found in seven of these breakers.
"Westinghouse will be issuing a Nuclear Safety Advisory Letter (NSAL) to all PWR and BWR plants informing them of this issue so they can determine applicability to their plant."
"DHP-VR350, 1200A, circuit breakers were manufactured by Cutler-Hammer Inc., commercially dedicated for Class 1E applications by Westinghouse and shipped to the Columbia Generating Station. During installation acceptance testing, one breaker charging motor failed to charge. Columbia Generating personal performed, a 100% inspection on all 16 breakers with safety-related functions. There was a loose screw associated with this position switch found in seven of these breakers.
"Westinghouse will be issuing a Nuclear Safety Advisory Letter (NSAL) to all PWR and BWR plants informing them of this issue so they can determine applicability to their plant."