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Event Notification Report for May 3, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/02/2002 - 05/03/2002

                              ** EVENT NUMBERS **

38883  38884  38892  38893  

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|General Information or Other                     |Event Number:   38883       |
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| REP ORG:  LOUISIANA RADIATION PROTECTION DIV   |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  TULANE UNIVERSITY                    |NOTIFICATION TIME: 11:03[EDT]|
|    CITY:  NEW ORLEANS              REGION:  4  |EVENT DATE:        04/22/2002|
|  COUNTY:                            STATE:  LA |EVENT TIME:        10:25[CDT]|
|LICENSE#:  LA-0004-L01           AGREEMENT:  Y  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BLAIR SPITZBERG      R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT BLACKWELL              |                             |
|  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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| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| The following event description is taken from a facsimile:                   |
|                                                                              |
| "On April 22, 2002, the technologist injected a patient with a syringe       |
| labeled Tc-99m MAG 3 in order to image the kidneys. The gamma camera showed  |
| uptake in the liver-kidney indicating a sulfur colloid dose. The patient was |
| prescribed a 4.5 mCi dose of Tc-99m MAG 3, but received a 4.5 mCi dose of    |
| Tc-99m Sulfur Colloid. The patient and the pharmacy were notified of the     |
| error. The dose for a patient receiving 5 mCi of Tc-99m Sulfur Colloid is    |
| estimated as the following:                                                  |
| Liver - 12.15 Rad, Spleen - 7.65 Rad, Bone Marrow - 0.05 Rad, Testes - 0.02  |
| Rad, Ovaries - 0.2 Rad,                                                      |
| and Total Body - 0.675 Rad."                                                 |
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|General Information or Other                     |Event Number:   38884       |
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| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 04/30/2002|
|LICENSEE:  LONGVIEW INSPECTION                  |NOTIFICATION TIME: 15:05[EDT]|
|    CITY:  CHANNAHON                REGION:  3  |EVENT DATE:        06/01/2000|
|  COUNTY:                            STATE:  IL |EVENT TIME:             [CDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  04/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+PAUL LOHAUS          STP     |
| NRC NOTIFIED BY:  JOSEPH KLINGER               |TIM MCGINTY          IRO     |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT OF RADIOGRAPHER OVEREXPOSURE FROM TWO
YEARS AGO       |
|                                                                              |
| "On April 29, 2002, the department completed its investigation into a        |
| reported radiography incident that may have occurred in June 2000. After a   |
| review of all available information, the department cannot definitively      |
| eliminate the possibility that an industrial radiographer received a         |
| radiation burn while performing industrial radiography at a temporary        |
| jobsite near Channahon, Illinois. The radiographer was using an 81.2 Ci      |
| lr-192 source while performing radiographs on 8-inch pipe welds. The         |
| radiographer alleges that after cranking the source back in, he approached   |
| the area without looking at his survey meter. He set the meter behind the    |
| camera and knelt down in front of the camera, He changed out the film and    |
| then changed out the band and numbers for the next shot. He then             |
| disconnected the guide tube and saw 4-6 inches of the drive cable. He looked |
| over at the survey meter and saw that it was pegged. He then immediately     |
| went to the controls and cranked the source fully into the camera. He        |
| performed a survey of the area and saw that the source was shielded          |
| properly. He looked at his alarming rate meter and saw that the battery      |
| indicator showed low battery. His self-reading pocket dosimeter showed       |
| off-scale. What happened after that is even more unclear but the             |
| radiographer continued working for the rest of the day. The radiographer did |
| not report the incident to the RSO nor did the other radiographer on the two |
| certified radiographer team. In fact, the other radiographer denies knowing  |
| anything about the reported incident. The allegedly overexposed radiographer |
| states that after one or two weeks, he noticed a red area, about the size of |
| a nickel, on his leg. He stated that it was a red area with what appeared to |
| be white scar tissue in the center. It was not until May or June of 2001     |
| that he realized that it may have been a radiation burn. During August or    |
| September 2001 his condition apparently worsened and the area would not      |
| heal. In early January 2002 the Radiation Safety Officer finally became      |
| aware of this matter, and notified the department on January 15, 2002. In    |
| early January 2002 the radiographer was apparently examined by a physician.  |
| The radiographer stated that the physician took a biopsy and the diagnosis   |
| was either sarcoma or radiodermatitis. A preliminary report was provided to  |
| the department by the licensee on January 16, 2002. The department           |
| recommended the licensee seek assistance from the REAC/TS Center in Oak      |
| Ridge, which they did. The information pertaining to this incident was       |
| provided to REAC/TS by the licensee and REAC/TS concluded that the medical   |
| condition could be attributed to the event in June 2000. After thoroughly    |
| reviewing all the information available and scheduling interviews for        |
| involved out of state personnel, the department conducted interviews and     |
| time in motion studies on February 25, 2002. Subsequent to the interviews    |
| and time in motion studies, careful review was performed as well as          |
| additional clarifying information was requested and reviewed. Finally on     |
| April 29, 2002, the department concluded that it could not definitively      |
| eliminate the possibility that this industrial radiographer received a       |
| radiation burn while performing industrial radiography at a temporary job    |
| site near Chanson, Illinois in June 2000. The radiographer underwent skin    |
| grafting on February 26, 2002, and was released after several days. The      |
| radiographer currently remains under medical surveillance and reports that   |
| the graft was less than successful. The licensee has been issued a Notice of |
| Violation and will take appropriate actions to prevent a recurrence. The     |
| radiographer may be subject to additional department enforcement action      |
| related to his industrial radiographer certification resulting from this     |
| event."                                                                      |
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|Power Reactor                                    |Event Number:   38892       |
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| FACILITY: DUANE ARNOLD             REGION:  3  |NOTIFICATION DATE: 05/02/2002|
|    UNIT:  [1] [] []                 STATE:  IA |NOTIFICATION TIME: 15:22[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        03/22/2002|
+------------------------------------------------+EVENT TIME:             [CDT]|
| NRC NOTIFIED BY:  JOHN KARRICK                 |LAST UPDATE DATE:  05/02/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |                             |
|AINV 50.73(a)(1)         INVALID SPECIF SYSTEM A|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| GROUP 3A CONTAINMENT ISOLATION AT DUANE ARNOLD                               |
|                                                                              |
| "While operating in Mode 1, a fuel pool exhaust radiation monitor spiked,    |
| resulting in a Group 3A Primary Containment Isolation System (PCIS)          |
| actuation.  Radiation levels in the area of the monitor were normal and the  |
| actuation was considered invalid.  The "A" train of the Standby Gas          |
| Treatment System (SBGT) auto-started and the Group 3A isolation functioned   |
| as designed.  The isolation was reset 14 minutes after the trip."            |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
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|Other Nuclear Material                           |Event Number:   38893       |
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| REP ORG:  MAXIM TECHNOLOGIES INCORPORATED      |NOTIFICATION DATE:
05/02/2002|
|LICENSEE:  MAXIM TECHNOLOGY INCORPORATED        |NOTIFICATION TIME:
22:00[EDT]|
|    CITY:  INDEPENDENCE             REGION:  3  |EVENT DATE:        05/02/2002|
|  COUNTY:                            STATE:  MO |EVENT TIME:             [CDT]|
|LICENSE#:  22-C-250-01           AGREEMENT:  N  |LAST UPDATE DATE:  05/02/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DUSTIN BINGHAM               |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|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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| STOLEN TROXLER DENSITY GAUGE                                                 |
|                                                                              |
| The licensee reported a stolen troxler density gauge which was secured in    |
| the rear of a work truck located in Independence, Missouri.  The licensee    |
| reported the theft to the Independence Police Department.  The gauge was     |
| model number 3340 with a serial number of 22323.  The isotopes and           |
| activities used in the gauge are 8.0 millicuries of CS-137 and 40            |
| millicuries of AM-241.                                                       |
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