Event Notification Report for February 21, 2004

MISSING MEDICAL SOURCE FOR 2 HOURS AT UVA HOSPITAL

The licensee at University of Virginia Hospital reported an event where a radioactive medical source was missing for approximately 2 hours. The patient was being treated for uterine cancer. At the end of the treatment, the licensee removed 8 catheters from the patient. Unknown at the time, one ribbon with 8 seeds of Ir-192, with an approximate activity of 5 millicuries, fell onto the floor. The licensee performed a search and radiological surveys, and the missing ribbon was located 2 hours later in a trash compactor. The licensee is performing an assessment of any unplanned exposures that resulted from this event.

* * * UPDATE AT 1530 EST ON 2/24/04 FROM R. ALLEN TO E. THOMAS * * *

The licensee has concluded their assessment of any unplanned exposures from this incident, along with determining its root cause.

In the unlikely case that the patient was laying directly on top of the source (on contact) for the entire 30 minutes from the time the physicians removed the sources until the missing ribbon was discovered, her skin exposure would have been 662 rad. This exposure is less than her skin exposure from other treatments of the tumor thus far, and would result in minimal adverse effects. If the 30 minute exposure occurred at a distance of 1.5 millimeters from the patient, her exposure would have been 41 rad to the skin.

It is highly unlikely that the patient received anywhere near these exposure levels, as the missing ribbon was most likely picked up with other trash shortly after the room was de-posted, and prior to the physicians discovering the loss. In the brief time (1-2 minutes) it took to transport the ribbon with other trash to the dumpster, and during the time the ribbon was in the dumpster, any exposures to additional personnel would have been negligible.

The root cause of the lost ribbon is that the meter used to survey the room following the procedure was defective. Another meter was used to locate the ribbon in the trash compactor.

Notified R1DO (Shanbaky) and NMSS (Essig)

* * * UPDATE AT 1459 ON 3/10/04 FROM ALLEN TO GOTT * * *

Due to skin reddening on the patient, the patient may have received an over exposure to the thigh. It is unknown how long the source was stuck to the patient's skin or the exposure. The licensee is continuing to investigate.

This report is now being classified as a Medical Event reportable under 10 CFR 35.3045(a)(3).

Notified R1DO (Cobey) and NMSS (Brown)

OFFSITE NOTIFICATION OF MEDICAL EVENT AT SUSQUEHANNA

"At 10:05 AM PST, the Susquehanna LLC Shift Manager was notified that a member of the general public required medical assistance. The individual was at a company owned public recreation area adjacent to the Susquehanna LLC River Intake access road. The recreation area is outside the protected area. An ambulance was called to the scene, arriving at 10:28 and leaving at 10:52. The individual was transported to a local hospital. The LLEA and PEMA were notified of the incident."

The NRC Resident Inspector was notified.

RCIC SYSTEM INOPERABLE DUE TO POSSIBLE UNDERVOLTAGE RELAY FAILURE

"This ENS notification is made to report that on February 21, 2004 at 0841 PST Reactor Core Isolation Cooling was rendered inoperable due to RCIC-V-13 (RPV injection valve) motor operator losing power. Preliminary investigation indicates the undervoltage relay may have failed, resulting in a loss of control power for the valve and loss of valve position indication.

"The event is considered reportable to the NRC under 10 CFR 50.72(b)(3)(v)(D) based on guidance contained in NUREG 1022, "Event Reporting Guidelines," and NRC Regulatory Issue Summary (RIS) 2001-14, 'Position on Reportability Requirements for Reactor Core Isolation Cooling System Failure.' A follow-up LER will be issued under 10 CFR 50.73(a)(2)(v)(D)."

This event placed the plant in technical specifications LCO 3.5.3 which has a 14 day duration.

The licensee notified the NRC Resident Inspector.