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Event Notification Report for December 18, 2003

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/17/2003 - 12/18/2003

EVENT NUMBERS
404004040140407

General Information or Other
Event Number: 40400
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: SHOPKO STORES
Region: 4
City: BELLEVUE   State: NE
County:
License #: GL0040
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/18/2003
Notification Time: 10:52 [ET]
Event Date: 12/18/2003
Event Time: 00:00 [CST]
Last Update Date: 12/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)
Event Text
AGREEMENT STATE REPORT REGARDING LOST TRITIUM SIGNS

The State of Nebraska reported that one of their licensees could not account for 17 missing tritium exit signs. After performing a store inventory in early December, the licensee notified the state of Nebraska on 12/09/03 of the missing tritium signs. The signs were manufactured in 07/84 and each sign contained 21 curies of tritium at the time of manufacture. Three major renovations have taken place in the store since that time and the licensee believes that is when the signs were lost. Store records indicate that 11 new signs were purchased in 1994. A search of the store did not find any of the missing signs. The State of Nebraska considers this issue closed.


Hospital
Event Number: 40401
Rep Org: SOUTHWESTERN VERMONT MEDICAL CENTER
Licensee: SOUTHWESTERN VERMONT MEDICAL CENTER
Region: 1
City: BENNINGTON   State: VT
County: BENNINGTON
License #: 44-11345-02
Agreement: N
Docket:
NRC Notified By: MATTHEW RATELLE
HQ OPS Officer: ERIC THOMAS
Notification Date: 12/18/2003
Notification Time: 15:33 [ET]
Event Date: 12/18/2003
Event Time: 07:40 [EST]
Last Update Date: 12/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTOPHER CAHILL (R1)
JOHN HICKEY (NMSS)
Event Text
MEDICAL EVENT

At 0740 EST on 12/18/03, a radioactive tracer consisting of 14.6 millicuries of Technetium-99m was administered to a patient for cardiac imaging. After the administration, the technicians called the physician to come complete the examination. The physician informed the technicians that he did not order the administration. This event occurred due to a secretarial error.

The dose was properly administered, and there were no adverse effects on the patient. The patient was notified of the error, and an incident report was submitted by the secretary.


Other Nuclear Material
Event Number: 40407
Rep Org: US AIR FORCE
Licensee: US AIR FORCE
Region: 4
City: Clovis   State: NM
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: DAVID PUGH
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/22/2003
Notification Time: 11:40 [ET]
Event Date: 12/18/2003
Event Time: 16:00 [MST]
Last Update Date: 12/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
LINDA SMITH (R4)
TOM ESSIG (NMSS)
Event Text
MISSING TRITIUM EXIT SIGNS

On 12/18/03 it was determined that two (2) tritium exit signs were missing at Cannon Air Force Base in New Mexico. Contractors were in the process of replacing a number of the signs and two of the signs appearing on the inventory list could not be found. The signs are made by SRB Technology (Sealed Source & Device Registration NC585S103G). The signs were purchased in 1998 with a maximum tritium activity of 25 curies and the current maximum tritium activity is 18 curies. Efforts to locate the signs continue.