United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2000

Event Notification Report for November 9, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/08/2000 - 11/09/2000

                              ** EVENT NUMBERS **

37503  37504  37505  37506  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37503       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 11/08/2000|
|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 12:10[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        11/08/2000|
+------------------------------------------------+EVENT TIME:        11:37[EST]|
| NRC NOTIFIED BY:  CALVIN WARD                  |LAST UPDATE DATE:  11/08/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |KERRY LANDIS         R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE  NOTIFICATION REGARDING THE CAPTURE OF AN INJURED GREEN SEA TURTLE   |
| IN THE PLANT'S INTAKE NET                                                    |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "At 1137 on 11/08/00, a notification was made to the Florida Fish and        |
| Wildlife Conservation Commission regarding a live green sea turtle found in  |
| the plant's intake net.  The turtle will be sent to an offsite               |
| rehabilitation facility.  [...]  The notification to a State Government      |
| Agency requires a notification to the NRC per 10CFR50.72(b)(2)(vi)."         |
|                                                                              |
| The licensee stated that the turtle was apparently injured by a boat         |
| propeller before entering the plant's intake.                                |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37504       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  OHIO BUREAU OF RADIATION PROTECTION  |NOTIFICATION DATE: 11/08/2000|
|LICENSEE:  AULTMAN HOSPITAL                     |NOTIFICATION TIME: 14:10[EST]|
|    CITY:  CANTON                   REGION:  3  |EVENT DATE:        11/04/2000|
|  COUNTY:                            STATE:  OH |EVENT TIME:        13:00[EST]|
|LICENSE#:  02120770003           AGREEMENT:  Y  |LAST UPDATE DATE:  11/08/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GEOFFREY WRIGHT      R3      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARK LIGHT                   |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TWO PATIENTS GIVEN INCORRECT DELIVERED DOSE                                  |
|                                                                              |
| The Radiation Safety Officer from Aultman Hospital, on November 4, 2000 at   |
| 1300 hours, notified the Ohio Department of Health, that two patients        |
| received brachytherapy doses involving Ir-192 temporary implants in excess   |
| of 20% of the prescribed dose.  The misadministration were discovered during |
| an internal audit of the licensee's Quality Management Program on November   |
| 3, 2000, by the Radiation Safety Officer and Radiation Protection Staff.     |
|                                                                              |
| One patient received two courses of brachytherapy treatments with Ir-192     |
| temporary implants.  On September 18, 2000, the delivered dose was 3330 cGy, |
| while the prescribed dose was 2000 cGy.  This represents a delivered dose    |
| discrepancy of 67%.  On October 9, 2000, the prescribed dose was 2250 cGy,   |
| while the delivered dose was 3500 cGy.  This represents a delivered dose     |
| discrepancy of 56%.  The patient also had external beam therapy treatment    |
| from a linear accelerator that was not considered in this                    |
| misadministration.                                                           |
|                                                                              |
| Another patient received two courses of brachytherapy treatments, with only  |
| one brachytherapy treatment qualifying as a misadministration.  On August    |
| 22, 2000, the delivered dose from Ir-192 was 3500 cGy, while the prescribed  |
| dose was 1980 cGy.  This represents a delivered dose discrepancy of 78%.     |
| The patient also had external beam therapy treatment from a linear           |
| accelerator  that was not considered in this misadministration.              |
|                                                                              |
| The primary notification from the licensee indicates that the                |
| misadministration are due to operator error in data entry of the source      |
| strength in the treatment computer.  The facility has recently acquired a    |
| new computer, and the operator mistakenly entered the source strengths into  |
| the computer as milligram-Radium equivalent (mg-Ra-eq) strengths instead of  |
| units of millicuries.                                                        |
|                                                                              |
| The licensee does not anticipate any adverse effects to the patients as a    |
| result of the additional doses.  One patient was notified of the             |
| misadministration on November 3, 2000.  The other patient will be notified   |
| later this week by the radiation oncologist, as the referring physician was  |
| not immediately available.                                                   |
|                                                                              |
| The Licensee shall submit a written report to the Ohio Department of Health, |
| Bureau of Radiation Protection, within 15 days after discovery of the        |
| misadministration, as delineated in 10 CFR 35.33(2).                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37505       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 11/08/2000|
|LICENSEE:  DESIGN FUELS CORPORATION             |NOTIFICATION TIME: 15:34[EST]|
|    CITY:  HUEYTOWN                 REGION:  2  |EVENT DATE:        11/07/2000|
|  COUNTY:                            STATE:  AL |EVENT TIME:             [CST]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  11/08/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |MICHELE EVANS        R1      |
+------------------------------------------------+JOHN HICKEY          NMSS    |
| NRC NOTIFIED BY:  DONALD C. WILLIAMSON         |CHARLES MILLER       IRO     |
|  HQ OPS OFFICER:  LEIGH TROCINE                |PAUL LOHAUS          OSP     |
+------------------------------------------------+FRED COMBS           OSP     |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PRELIMINARY INCIDENT NOTIFICATION OF THE DISCOVERY OF A TN TECHNOLOGIES      |
| SOURCE HOLDER (WITH A 1-CURIE CESIUM-137 SOURCE AND THE SHUTTER LOCKED OPEN) |
| NEAR HUEYTOWN, AL, AND POSSIBLE ILLEGAL TRANSPORT OF THE DEVICE FROM DESIGN  |
| FUELS CORPORATION IN McMURRY, PA, DURING THE EARLY 1990s                     |
|                                                                              |
| The following text is a portion of a facsimile received from the State of    |
| Alabama Department of Public Health, Alabama Office of Radiation Control:    |
|                                                                              |
| "Subject:  Preliminary Notification of a Found Source"                       |
|                                                                              |
| "Members of the staff of the Alabama Office of Radiation Control (the        |
| Agency) traveled to Hueytown, AL, on November 7, 2000, to investigate the    |
| finding of a TN Technologies Model-5191 source holder containing 1,000       |
| millicuries of Cs-137 (as of 1985)."                                         |
|                                                                              |
| "Circumstances of the Event"                                                 |
|                                                                              |
| "Based on initial information, it appears that the general licensed device   |
| was illegally transported by Design Fuels Corporation from their facility in |
| McMurry, PA, to Alabama in the early 1990s.  During this transport, and      |
| until the time it was discovered, the device shutter was locked in the open  |
| position.  The device was discovered in a wooded area away from personnel,   |
| on private property not accessible to the general public.  It is believed    |
| the device had been in that location since early 1992."                      |
|                                                                              |
| "The device shutter has subsequently been locked in the closed position, and |
| the device [has been] moved to a secure storage location near Hueytown, AL,  |
| pending determination of final disposition.  Maximum exposure readings with  |
| the shutter open were 2.6 rem/hr at near contact with the pipe opposite the  |
| source holder.  After closing the shutter, maximum readings are 1.8 mrem/hr  |
| at contact with the pipe opposite the source holder, 0.5 mrem/hr at 30 cm,   |
| and 7.0 mrem/hr at contact with the source holder.  The source was tested    |
| for leakage.  Leak test results were negative."                              |
|                                                                              |
| The Alabama Office of Radiation Control notified the NRC Region II office    |
| (Richard Woodruff).  At this time, the NRC Region II office plans to clarify |
| this information with the State, notify the Environmental Protection Agency, |
| and issue a Preliminary Notification of Event or Unusual Occurrence.         |
|                                                                              |
| (Call the NRC operations officer for contact information.)                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37506       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 11/08/2000|
|LICENSEE:  QORE, INC.                           |NOTIFICATION TIME: 18:16[EST]|
|    CITY:  HUNTSVILLE               REGION:  2  |EVENT DATE:        11/08/2000|
|  COUNTY:                            STATE:  AL |EVENT TIME:             [CST]|
|LICENSE#:  1022                  AGREEMENT:  Y  |LAST UPDATE DATE:  11/08/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |E. WILLIAM BRACH     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID TURBERVILLE            |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MOISTURE DENSITY GAUGE MISSING FROM QORE, INC., IN HUNTSVILLE, ALABAMA.      |
|                                                                              |
| The following text is a portion of a facsimile received from the Alabama     |
| Office of Radiation Control:                                                 |
|                                                                              |
| "FROM:  David Turberville, Radiation Physicist II"                           |
|                                                                              |
| "SUBJECT:  Alabama Incident File #00-30 - Lost Moisture Density Gauge."      |
|                                                                              |
| "On the morning of November 8, 2000, Shane Kirby, Radiation Safety Officer   |
| for Qore, Inc., of Huntsville, Alabama, notified the Alabama Office of       |
| Radiation Control stating that it appears that they have lost a CPN model    |
| MC-1 moisture density gauge, serial number M1310598? or M13105089?           |
| containing 10 millicuries of Cs-137 and 50 millicuries of Am-241/Be.  Qore,  |
| Inc. is authorized to possess and use the device under Alabama Radioactive   |
| Material License No. 1022.  The missing device is one of sixteen devices on  |
| the licensee's inventory."                                                   |
|                                                                              |
| "Mr. Kirby stated that his records indicate that the device was last used in |
| May of 1999 and was last leak tested on May 16, 1999.  Mr. Kirby explained   |
| the reason the gauge had not been leak tested or inventoried since May of    |
| 1999 was because the file for this device was lost since that time and it    |
| did not come to his attention until the file was recently found.  Mr. Kirby  |
| has no records of transfer since August of 1998."                            |
|                                                                              |
| "The Agency last inspected this licensee on January 26, 2000 [...]."         |
|                                                                              |
| "The licensee continues to search the facilities, notify other branches and  |
| licensees, and review records of accountability in an effort to locate the   |
| device."                                                                     |
|                                                                              |
| (Call the NRC operations officer for contact information.)                   |
+------------------------------------------------------------------------------+