United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2001

Event Notification Report for May 7, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/04/2001 - 05/07/2001

                              ** EVENT NUMBERS **

37965  37966  37967  37968  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37965       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  NV DIV OF RAD HEALTH                 |NOTIFICATION DATE: 05/04/2001|
|LICENSEE:  LAS VEGAS PAVING                     |NOTIFICATION TIME: 13:40[EDT]|
|    CITY:  NORTH LAS VEGAS          REGION:  4  |EVENT DATE:        05/04/2001|
|  COUNTY:                            STATE:  NV |EVENT TIME:        06:15[PDT]|
|LICENSE#:  00-11-0255-01         AGREEMENT:  Y  |LAST UPDATE DATE:  05/04/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GAIL GOOD            R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STAN MARSHALL (fax)          |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT REGARDING A STOLEN TROXLER GAUGE                      |
|                                                                              |
| The following text is a portion of a facsimile received from the Nevada      |
| Health Division Radiological Health Section regarding a Significant Event    |
| Report:                                                                      |
|                                                                              |
| "1.  Event Report ID No. [-] NV-01-02"                                       |
|                                                                              |
| "2.  License No. [-] 00-11-0255-01"                                          |
|                                                                              |
| "3.  Licensee [-] Las Vegas Paving"                                          |
|                                                                              |
| "4.  Event time, date, location [-] 6:15 a.m., May 4, 2001, 7/11 Convenience |
| Store, Losse & Cheyene Road, North Las Vegas, Nevada."                       |
|                                                                              |
| "5.  Event type (e.g., misadministration, lost source, overexposure, etc.)   |
| [-] Theft of Troxler Model 4640B portable gauge."                            |
|                                                                              |
| "6.  Any notifications i.e., other agencies, patient, press release, FBI,    |
| etc. [-] North Las Vegas Police Dept. notified by licensee."                 |
|                                                                              |
| "7.  Event description:  release, isotope, activity, exposure(s), dose,      |
| contamination level, equipment malfunction, model, serial No., etc. [-]      |
| Chain securing Troxler Model 4640B gauge to pickup bed was cut, and gauge    |
| was stolen from licensee's truck while gauge user was in [convenience]       |
| store.  Gauge is a Troxler Model 4640B, s/n 1658."                           |
|                                                                              |
| "8.  Transport vehicle description if known [-] Pickup truck."               |
|                                                                              |
| "9.  Media attention [-] N/A"                                                |
|                                                                              |
| (Call the NRC operations officer for state contact information.)             |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   37966       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION DATE: 05/05/2001|
|LICENSEE:  UNIVERSITY OF PENNSYLVANIA           |NOTIFICATION TIME: 11:51[EDT]|
|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        05/04/2001|
|  COUNTY:  PHILADELPHIA              STATE:  PA |EVENT TIME:        16:30[EDT]|
|LICENSE#:  37-00118-07           AGREEMENT:  N  |LAST UPDATE DATE:  05/05/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |HAROLD GRAY          R1      |
|                                                |SUSAN FRANT          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT FORREST               |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF A BRACYTHERAPY MISADMINISTRATION INVOLVING A LEAKING IODINE-125 |
| SOURCE AT THE UNIVERSITY OF PENNSYLVANIA IN PHILADELPHIA                     |
|                                                                              |
| At approximately 1000 on 05/04/01, the licensee administered a prostate      |
| implant involving the 94 iodine-125 seeds on the order of about 1/2          |
| millicurie per seed.  (It is currently believed that the intended dosage for |
| the patient was approximately 47 millicuries.  The licensee reported that    |
| the intended dose is received from decay of the seeds which remain in the    |
| patient after treatment.)                                                    |
|                                                                              |
| Surveys were performed after the administration, and one of the implant      |
| needles had readings that were higher than expected.  At that time, it was   |
| assumed that a source was stuck in the applicable needle (a more likely      |
| scenario).  However, at approximately 1630, removable contamination (due to  |
| a leaking source) was discovered on the applicable needle.  It is currently  |
| believed that one of the seeds may have been damaged during the needle       |
| loading process, and that the damaged seed was implanted into the patient    |
| during treatment administration.                                             |
|                                                                              |
| At this time, there is only complication that is expected as a result of the |
| leaking iodine-125 source.  It was reported that the activity from the       |
| leaking source could get into the blood steam and that the thyroid would     |
| filter the radio-iodine.  Therefore, the patient may receive an unintended   |
| thyroid dose.                                                                |
|                                                                              |
| The authorized user was notified, and the patient was informed.  The patient |
| was also prescribed Lugols solution (a potassium iodide solution) to         |
| minimize the unintended iodine-125 thyroid uptake from the leaking seed.     |
| Initial estimates indicate a thyroid activity measurement of 73 nanocuries   |
| (calculated based on normal thyroid turnover) to give a dose of about 320    |
| milleRem over the period that it will take for the iodine-125 to decay.      |
|                                                                              |
| The licensee plans to notify the referring physician.                        |
|                                                                              |
| (Call the NRC operations officer for a licensee contact telephone number.)   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37967       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 05/05/2001|
|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 15:33[EDT]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        05/05/2001|
+------------------------------------------------+EVENT TIME:        15:23[EDT]|
| NRC NOTIFIED BY:  D. EMLING                    |LAST UPDATE DATE:  05/05/2001|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAY HENSON           R2      |
|10 CFR SECTION:                                 |                             |
|*PRE 50.72(b)(2)(xi)     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 DISCOVERY OF AN EMACIATED LOGGERHEAD SEA      |
| TURTLE IN THE INTAKE CANAL                                                   |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "[The licensee] notified [the] Florida Fish & Wildlife Commission of [the    |
| discovery of an] emaciated loggerhead sea turtle in need of rehabilitation.  |
| The State was notified @ 1523 hrs [on] 05/05/01."                            |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37968       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MONTICELLO               REGION:  3  |NOTIFICATION DATE: 05/06/2001|
|    UNIT:  [1] [] []                 STATE:  MN |NOTIFICATION TIME: 06:02[EDT]|
|   RXTYPE: [1] GE-3                             |EVENT DATE:        05/06/2001|
+------------------------------------------------+EVENT TIME:        03:10[CDT]|
| NRC NOTIFIED BY:  SCHMIDT                      |LAST UPDATE DATE:  05/06/2001|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MELVYN LEACH         R3      |
|10 CFR SECTION:                                 |                             |
|*INA 50.72(b)(3)(v)(A)   POT UNABLE TO SAFE SD  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       90       Power Operation  |73       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MAIN TURBINE STOP VALVE FAILED TO CLOSE DURING TESTING                       |
|                                                                              |
| The #4 main turbine stop valve failed to close during the performance of     |
| turbine valve testing procedure.  Failure of the turbine valve to close      |
| affects the turbine stop valve closure scram function of both A&B reactor    |
| protection trip systems.  Reactor power is currently being reduced to less   |
| than 45% power which is required when the minimum conditions for the turbine |
| stop valve closure scram function are not satisfied.  The licensee believes  |
| the cause of the problem is probably due to a bad solenoid valve.            |
|                                                                              |
| The NRC Resident Inspector will be notified.                                 |
+------------------------------------------------------------------------------+