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Event Notification Report for April 13, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/12/2001 - 04/13/2001

                              ** EVENT NUMBERS **

37904  37914  37915  

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|General Information or Other                     |Event Number:   37904       |
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| REP ORG:  MARYLAND DEPT OF THE ENVIRONMENT     |NOTIFICATION DATE: 04/10/2001|
|LICENSEE:  CAMPBELL & NOLAN ASSOCIATES          |NOTIFICATION TIME: 08:38[EDT]|
|    CITY:  FALLSTON                 REGION:  1  |EVENT DATE:        04/09/2001|
|  COUNTY:  HARFORD                   STATE:  MD |EVENT TIME:             [EDT]|
|LICENSE#:  MD-25-030-01          AGREEMENT:  Y  |LAST UPDATE DATE:  04/12/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES LINVILLE       R1      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ALAN JACOBSON                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
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|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING A LOST TROXLER MOISTURE DENSITY GAUGE       |
|                                                                              |
| "Baltimore, MD (April 9,2001)-The Maryland Department of the Environment     |
| (MDE) has received a report that a moisture density gauge containing nuclear |
| material is missing from a contractor in Fallston, Harford County, Maryland. |
| Engineering consultants Campbell and Nolan Associates, Inc. reported that    |
| the device apparently fell from the back of a pick-up truck as it was        |
| leaving a construction site in Harford County on the morning of April 9,     |
| 2001.                                                                        |
|                                                                              |
| "The gauge is believed to have been lost between Monmouth Meadows on Singer  |
| Road and the offices of Campbell and Nolan Associates located at 2813 Bel    |
| Air Road in Fallston, Maryland.                                              |
|                                                                              |
| "The portable device is used to measure the moisture and density of soil.    |
| The gauge, a Troxler, model 3430 [S/N 26218], is yellow in color and         |
| approximately 3' X 2' X 2'. The device contains radioactive material         |
| identified as Cesium-137 on an extendable rod and Americium-241 encased in   |
| the device. Campbell and Nolan personnel reported that the device was        |
| secured with a padlock to prevent inadvertent exposure of the radioactive    |
| source. The radioactive material is not a threat to public health and safety |
| as long as it remains intact within the device's shielded enclosure."        |
|                                                                              |
| Call the Operations Center for contact information.                          |
|                                                                              |
| * * * UPDATED AT 1000 EDT ON 4/12/01 BY ALAN JACOBSON TO FANGIE JONES * * *  |
|                                                                              |
| MDE reported that the gauge has been recovered undamaged.                    |
|                                                                              |
| Notified the R1DO (William Ruland) and NMSS (Don Cool).                      |
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|Fuel Cycle Facility                              |Event Number:   37914       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 04/12/2001|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 13:23[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        04/11/2001|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        13:15[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  04/12/2001|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |GEOFFREY WRIGHT      R3      |
|  DOCKET:  0707001                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  E. G. WALKER                 |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| NRC BULLETIN 91-01 24 HOUR NOTIFICATION                                      |
|                                                                              |
| AN NCS ADMINISTRATIVE REQUIREMENT NOT MET.                                   |
|                                                                              |
| On 04/11/01, it was discovered that C-333 Unit 2 Cell 1 freon systems were   |
| at zero freon level without current independent verification documentation   |
| that the cell was less than 1.0 wt% U235 in violation of NCSA CAS.011. An    |
| independent assay verification was performed in May of 2000, however the     |
| cell was subsequently placed onstream and taken back offstream and shutdown  |
| in October of 2000.  Since shutdown, independent assay verification had not  |
| been performed when the freon was drained and prior to implementation of     |
| NCSA CAS.011. Due to independent assay verification not being performed      |
| prior to implementation of NCSA CAS.011, and NCS administrative requirement  |
| was not met. Upon discovery, independent assay verification was immediately  |
| performed and cell assay was determined to be less than 1.0 wt% U235.        |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENT:                                                |
|                                                                              |
| Double contingency was not maintained.  Although the required documentation  |
| was not verified at the tome the R-114 level was removed from the cell, the  |
| assay of the cell was well known through historical process knowledge.  Upon |
| discovery, the historical cascade gradient was reviewed and it was           |
| determined that the cell was less than 1.0 wt% U235.                         |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S)) OF HOW           |
| CRITICALITY COULD OCCUR:                                                     |
|                                                                              |
| In order for criticality to be possible, the shutdown cell would need to     |
| have an unsafe mass of moderated uranium with an enrichment greater than 1.0 |
| wt% U235.                                                                    |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):     |
|                                                                              |
| Double contingency for this scenario is established by implementing two      |
| controls on assay.                                                           |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE CRITICAL MASS):                                       |
|                                                                              |
| 0.7183 wt% U235.                                                             |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| The first leg of double contingency is based on verification that the        |
| equipment contains uranium enriched to less than 1.0 wt% U235. The           |
| verification of assay was not performed.  Therefore, the control was         |
| violated and the first leg of double contingency was lost.                   |
|                                                                              |
| The second leg of double contingency is based on independent verification    |
| that the equipment contains uranium enriched to less than 1.0 wt% U235.      |
| This independent verification was not performed.  Therefore, the control was |
| violated and the second leg of double contingency was lost.                  |
|                                                                              |
| Since double contingency is based on two controls on assay, double           |
| contingency was not maintained.                                              |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:  |
|                                                                              |
| An independent assay verification was performed and documented, which        |
| indicated that the assay was less than 1.0 wt% U235.                         |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the Certificate     |
| Holder.                                                                      |
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|General Information or Other                     |Event Number:   37915       |
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| REP ORG:  ARKANSAS DEPT OF HEALTH              |NOTIFICATION DATE: 04/12/2001|
|LICENSEE:  ST. JOSEPH REGIONAL HEALTH CENTER    |NOTIFICATION TIME: 16:55[EDT]|
|    CITY:  HOT SPRINGS              REGION:  4  |EVENT DATE:        04/12/2001|
|  COUNTY:  GARLAND                   STATE:  AR |EVENT TIME:        15:32[CDT]|
|LICENSE#:  ARK342BP0402          AGREEMENT:  Y  |LAST UPDATE DATE:  04/12/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK SHAFFER         R4      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CATHEY BRADLEY               |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
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|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION                        |
|                                                                              |
| At 1532 CT on 04/12/01, Saint Joseph Regional Health Center located in Hot   |
| Springs, Arkansas, notified the Arkansas Department of Health of the         |
| following Medical Misadministration:                                         |
|                                                                              |
| Since March 7, 2001, a  patient at Saint Joseph Regional Health Center       |
| received a total of 24 treatments, 2 grays each, for a total dose of 48      |
| grays to the back of his left hand instead of to his left knuckle. The       |
| applicator needles were 5 centimeters shorter than the applicator (stopping  |
| shorter than where they were supposed to stop).  The source used for the     |
| radiation treatments was Iridium-192.  State of Arkansas licensee number for |
| the licensee is ARK-342-BP-04-02.  State of Arkansas will send personnel out |
| to investigate this incident.                                                |
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