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. | +------------------------------------------------------------------------------+
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Page Last Reviewed/Updated Thursday, March 25, 2021