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Event Notification Report for May 21, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/20/2002 - 05/21/2002

                              ** EVENT NUMBERS **

38922  38923  38930  38931  38932  

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|General Information or Other                     |Event Number:   38922       |
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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE:
05/16/2002|
|LICENSEE:  HUNTINGTON MEMORIAL HOSPITAL         |NOTIFICATION TIME: 17:25[EDT]|
|    CITY:  PASADENA                 REGION:  4  |EVENT DATE:        05/15/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:        11:00[PDT]|
|LICENSE#:  0239-19               AGREEMENT:  Y  |LAST UPDATE DATE:  05/16/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |C.W. (BILL) REAMER   NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BARBARA HAMRICK              |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING THEFT OF LICENSED MATERIAL >1000 TIMES 
    |
|                                                                              |
| "At 11:00 am PDT on May 15, 2002, four packages were stolen from an          |
| unsecured Airborne Express truck parked at 39 Congress Avenue, Pasadena, Ca. |
| Due to a mix-up by the driver, it was not known that one of the packages     |
| contained radioactive material until the next day, when Huntington Memorial  |
| Hospital's Radiation Safety Officer[ ], realized that they had not received  |
| one of the packages of Palladium-103 seeds that they were expecting. [The    |
| RSO] reported the loss to the California Radiologic Health Branch at 12:15   |
| PM PDT on May 16, 2002.                                                      |
|                                                                              |
| "The package was supposed to have contained 72 seeds at 1.54 mCi/seed, or a  |
| total of 110 mCi of Pd-103, which would produce a field of about 230 mR/hr   |
| at one foot from the unshielded material.                                    |
|                                                                              |
| "Los Angeles County personnel took the initial call from the hospital, and   |
| is following up on this incident. Los Angeles County is a Contract County in |
| California's Agreement State Program. The L.A. County inspector talked to    |
| the hospital about issuing a press release, and they are currently preparing |
| one. The inspector will also obtain information on the package dose-rates,   |
| when it was shipped by Imagyn in TX, and the calibration dates for the       |
| seeds.. The seeds were purchased from Theragenics, shipped to Imagyn for     |
| some preparation, then shipped to the California licensee in two packages.   |
| The first package was received in tact. The second was stolen from the       |
| Airborne Express truck. There has been no indication by any of the parties   |
| that the other three packages stolen contained any radioactive material."    |
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|General Information or Other                     |Event Number:   38923       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 05/16/2002|
|LICENSEE:  LUTHERAN MEDICAL CENTER              |NOTIFICATION TIME: 18:29[EDT]|
|    CITY:                           REGION:  4  |EVENT DATE:        05/16/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  05/16/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |C.W. (BILL) REAMER   NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TIM G. BONZER (fax)          |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT ON MEDICAL MISADMINISTRATION                          |
|                                                                              |
| "[ ]Med. Physicist called on the date of this memo. It was regarding the     |
| placing of 111 seeds [of I-125] when the prescribed dose was 110 seeds. Per  |
| the physicist he could not see the additional seed because of the blood.     |
| After doing a source count he believes the additional seed was implanted     |
| into the patient. The additional seeds activity was 0.33 mCi. Additional     |
| information will follow."                                                    |
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|Power Reactor                                    |Event Number:   38930       |
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| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 05/20/2002|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 05:43[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        05/20/2002|
+------------------------------------------------+EVENT TIME:        05:00[CDT]|
| NRC NOTIFIED BY:  GARY OLMSTEAD                |LAST UPDATE DATE:  05/20/2002|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |GREG PICK            R4      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| PLANNED MAINTENANCE RESULTING IN THE LOSS OF AN EMERGENCY RESPONSE
FACILITY  |
| FOR THE DURATION OF THE EVOLUTION                                            |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "During performance of planned maintenance, the Emergency Operation Facility |
| (EOF) will be de-energized.  These maintenance activities, including         |
| electrical isolation and restoration, are expected to last approximately 16  |
| hours.  Contingency plans for emergency situations have been established."   |
|                                                                              |
| "This event is reportable per 10CFR50.72(b)(3)(xiii) since this constitutes  |
| a loss of an emergency response facility for the duration of the             |
| evolution."                                                                  |
|                                                                              |
| "The NRC Resident was previously notified that this activity was scheduled   |
| to occur and will be informed of this ENS notification."                     |
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|Other Nuclear Material                           |Event Number:   38931       |
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| REP ORG:  GILES ENGINEERING                    |NOTIFICATION DATE: 05/20/2002|
|LICENSEE:  GILES ENGINEERING                    |NOTIFICATION TIME: 12:30[EDT]|
|    CITY:  NEW BERLIN               REGION:  3  |EVENT DATE:        05/20/2002|
|  COUNTY:                            STATE:  WI |EVENT TIME:        09:30[CDT]|
|LICENSE#:  48-18547-02           AGREEMENT:  N  |LAST UPDATE DATE:  05/20/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHRISTINE LIPA       R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHARLES GRESSER              |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|IBBE 30.50(b)(2)         SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| DAMAGED MOISTURE DENSITY GAUGE AT CONSTRUCTION SITE IN WISCONSIN            
|
|                                                                              |
| The licensee reported that a moisture density guage was damaged when a       |
| construction vehicle accidentally ran over the guage.  The gauge was         |
| manufactured CPN and was model number MC1DR.  The guage contained 10         |
| millicuries of CS-137 and 50 millicuries of AM-241-BE.  The company          |
| radiation safety officer responded to the site and established a 75 foot     |
| exclusion area. Surveys revealed no release of radioactive materials. The    |
| guage was in the safe position with the ram in the lead shield.              |
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|Other Nuclear Material                           |Event Number:   38932       |
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| REP ORG:  GME CONSUTANTS                       |NOTIFICATION DATE: 05/20/2002|
|LICENSEE:  GME CONSULTANTS                      |NOTIFICATION TIME: 14:57[EDT]|
|    CITY:  NEW HOPE                 REGION:  3  |EVENT DATE:        05/20/2002|
|  COUNTY:                            STATE:  MN |EVENT TIME:        10:00[CDT]|
|LICENSE#:  22-23402-01           AGREEMENT:  N  |LAST UPDATE DATE:  05/20/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHRISTINE LIPA       R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BILL BLOUMENDAL              |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|IBBE 30.50(b)(2)         SAFETY EQUIPMENT FAILUR|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| DAMAGED MOISTURE DENSITY GUAGE AT CONSTRUCTION SITE                          |
|                                                                              |
| A construction vehicle ran over a CPN moisture density guage, model number   |
| MC3.  The radiation safety officer responded to the site.  Radiological      |
| surveys were performed and the damaged guage was collected in an appropriate |
| container.  The guage was then returned to the licensee storage facility     |
| where it will be shipped out for repair.  The guage was closed and locked at |
| the time of the event.  No personnel contaminations were reported.  The      |
| guage contained less than 50 millicuries of AM-241 and less than 10          |
| millicuries of CS-137.                                                       |
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