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Event Notification Report for March 26, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/25/2002 - 03/26/2002

                              ** EVENT NUMBERS **

38753  38797  38798  38799  

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|General Information or Other                     |Event Number:   38753       |
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| REP ORG:  ARKANSAS DEPARTMENT OF HEALTH        |NOTIFICATION DATE:
03/07/2002|
|LICENSEE:  ST BERNARDS REGIONAL HEALTH CTR      |NOTIFICATION TIME: 14:57[EST]|
|    CITY:  JONESBORO                REGION:  4  |EVENT DATE:        02/26/2002|
|  COUNTY:                            STATE:  AR |EVENT TIME:             [CST]|
|LICENSE#:  365-BP-07-97          AGREEMENT:  Y  |LAST UPDATE DATE:  03/25/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVE LOVELESS        R4      |
|                                                |JANET SCHLUETER      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KIM WIEBECK                  |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| ST BERNARD'S REGIONAL MEDICAL CENTER MEDICAL MISADMINISTRATION               |
|                                                                              |
| The following event description is taken from a faxed report.                |
|                                                                              |
| "Description of Event:                                                       |
|                                                                              |
| Following initial source send, the proximal gold marker could not be         |
| discerned under fluoroscopy due to wire suture in the patients sternum.      |
| Twenty-four seconds elapsed between the arrival of the distal marker at the  |
| treatment site to source return to the delivery device. Two additional       |
| source sends were attempted with  immediate return of the sources due to the |
| inability to discern the proximal marker. Upon return of the sources to the  |
| delivery device, all sources were visible in the source chamber but the      |
| distal marker was not visualized. The treatment catheter was removed from    |
| the patient while still attached to the delivery device. The catheter and    |
| delivery device were placed into the bail-out box. The sources and distal    |
| cold marker were successfully returned to the delivery device following      |
| conclusion of the case."                                                     |
|                                                                              |
| ***EVENT UPDATED 3/25/02 1135 EST BY FAX TO MIKE NORRIS***                   |
|                                                                              |
| The following was taken from a facsimile received from the Arkansas          |
| Department of Health, Radiation Control and Emergency Management on          |
| 3/25/02:                                                                     |
|                                                                              |
| "The Department received the licensee's written report via facsimile on      |
| March 19, 2002, with the original mailed hardcopy received on March 21,      |
| 2002.                                                                        |
|                                                                              |
| "The Department arranged for two qualified medical experts, a Radiation      |
| Oncologist and an Interventional Cardiologist, both approved for the Novoste |
| Beta-Cath Devise, to review hardcopy cine images as well as a CD copy of the |
| cine film. Neither expert could visualize the proximal marker on the images. |
| In addition, one expert stated that they were unable to locate the source    |
| beads on the images and therefore could not determine their location in the  |
| body. In the final report, however, the licensee maintains that although the |
| proximal marker could not be visualized they believe that the entire source  |
| train was delivered to the treatment site.                                   |
|                                                                              |
| "The licensee also submitted a dose calculation based on a 24-second dwell   |
| time. This dwell time equated to a dose of 2.4 Gy delivered at a distance of |
| 2 mm from the centerline of the sources. The license's final report          |
| indicated that the written directive had been revised to note a delivered    |
| dose of 2.4 Gy to the target. The Department requested this revised written  |
| directive, however, it was not provided.                                     |
|                                                                              |
| "Based on the information provided to the Department by the two qualified    |
| experts, the Department does not agree with the licensee's determination     |
| that the dose was delivered to the target area. Therefore, the Department is |
| classifying the event as a misadministration based on a 2.4 Gy dose          |
| delivered to an unintended and undetermined area of the body.                |
|                                                                              |
| "The licensee's report indicated that the suggested cause of the device      |
| failure was an inadequate connection of the treatment catheter or the fluid  |
| management system. This conclusion was supported by the amount of fluid      |
| accumulated in the sterile bag as well as the lack of pressure experienced   |
| by the radiation oncologist during the case. In order to prevent further     |
| occurrence, the licensee will perform an additional test run using the       |
| active source. This test run will be conducted outside the patient on a      |
| table located away from the cath lab staff.                                  |
|                                                                              |
| "In accordance with Department regulations, both the patient and the         |
| referring physician were notified of the misadministration. A copy of the    |
| licensee's final report was sent to the referring physician.                 |
|                                                                              |
| "The Department considers this event closed."                                |
|                                                                              |
| The NRC operations officer notified the R4DO (Chuck Cane) and NMSS EO (Janet |
| Schlueter).                                                                  |
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|Other Nuclear Material                           |Event Number:   38797       |
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| REP ORG:  SPECTRUM PHARMACIES INCORPORATED     |NOTIFICATION DATE:
03/25/2002|
|LICENSEE:  SPECTRUM PHARMACIES INCORPORATED     |NOTIFICATION TIME:
10:48[EST]|
|    CITY:                           REGION:  3  |EVENT DATE:        03/25/2002|
|  COUNTY:  ST JOE                    STATE:  IN |EVENT TIME:        09:40[CST]|
|LICENSE#:  13-26367-01MD         AGREEMENT:  N  |LAST UPDATE DATE:  03/25/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PATRICK HILAND       R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT VANHEEFBERKE           |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAA1 20.1906(d)(1)       SURFACE CONTAM LEVELS >|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| SHIPPING CONTAINER WITH REMOVABLE SURFACE CONTAMINATION EXCEEDING
THE        |
| LIMITS                                                                       |
|                                                                              |
| The licensee received a shipping container (i.e., return ammunition can)     |
| that had external contamination on the latch.  An incoming survey found that |
| a contamination level of 227,345 DPM/300 centimeters squared of Tc-99m. The  |
| can was opened and segregated and no internal contamination was found. The   |
| driver and the steering wheel of the shipping vehicle was being surveyed.    |
| The package originated from Memorial Hospital in South Bend, Indiana.  The   |
| licensee notified Memorial Hospital of the event.  There were no known       |
| personnel contamination at this time.                                        |
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|Other Nuclear Material                           |Event Number:   38798       |
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| REP ORG:  LANGAN ENGINEERING                   |NOTIFICATION DATE: 03/25/2002|
|LICENSEE:  LANGAN ENGINEERING                   |NOTIFICATION TIME: 12:01[EST]|
|    CITY:  GREENWICH                REGION:  1  |EVENT DATE:        03/25/2002|
|  COUNTY:  WARREN                    STATE:  NJ |EVENT TIME:        07:00[EST]|
|LICENSE#:  29-15786-2            AGREEMENT:  N  |LAST UPDATE DATE:  03/25/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RICHARD CONTE        R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MATHEW OLSEN                 |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| TROXLER MOISTURE DENSITY GAUGE STOLEN FROM A CONSTRUCTION TRAILER        
   |
|                                                                              |
| A Troxler moisture density gauge containing 8 microcuries of Cs-137 and 40   |
| microcuries of Am-241/Be was stolen from a construction trailer located on   |
| the corner State Highway 22 and Greenwich Street.  The gauge was last seen   |
| on 3/23/02 at 1330 EST when it was locked up in a construction trailer.  It  |
| was discover missing 3/25/02 at 0700.  Greenwich NJ police department have   |
| been notified.  The gauge was a Troxler model 3440, serial number 29562.     |
| The Licensee notified R1 (Lodhi).                                            |
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|Power Reactor                                    |Event Number:   38799       |
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| FACILITY: MAINE YANKEE             REGION:  1  |NOTIFICATION DATE: 03/25/2002|
|    UNIT:  [1] [] []                 STATE:  ME |NOTIFICATION TIME: 16:08[EST]|
|   RXTYPE: [1] CE                               |EVENT DATE:        10/29/2001|
+------------------------------------------------+EVENT TIME:             [EST]|
| NRC NOTIFIED BY:  DON PENDAGAST                |LAST UPDATE DATE:  03/25/2002|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD CONTE        R1      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Decommissioned   |0        Decommissioned   |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| OFFSITE NOTIFICATION REGARDING UNPLANNED EFFLUENT RELEASES                   |
|                                                                              |
| The licensee notified the State of Maine regarding three separate            |
| inadvertent liquid releases which occurred during the period from 10/29/2001 |
| through 11/12/2001. Each release involved approximately 1800 gallons of      |
| water, with a combined total activity of 0.03 Ci.                            |
|                                                                              |
| The licensee stated that the official notification had been delayed due to   |
| disagreements regarding the wording of the notification with the state. NRC  |
| Region I has been informed of this notification.                             |
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