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Event Notification Report for July 17, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/16/2002 - 07/17/2002

                              ** EVENT NUMBERS **

39054  39055  39062  39067  
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|General Information or Other                     |Event Number:   39054       |
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| REP ORG:  NE DIV OF RADIOACTIVE MATERIALS      |NOTIFICATION DATE: 07/12/2002|
|LICENSEE:  SYNCOR PHARMACY                      |NOTIFICATION TIME: 11:22[EDT]|
|    CITY:  OMAHA                    REGION:  4  |EVENT DATE:        07/05/2002|
|  COUNTY:                            STATE:  NE |EVENT TIME:        10:00[CDT]|
|LICENSE#:  01-65-01              AGREEMENT:  Y  |LAST UPDATE DATE:  07/12/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |THOMAS ANDREWS       RDO     |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MILLER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| SYNCOR PHARMACY  REPORTED THAT A DELIVERY VEHICLE CONTAINING
TECHNETIUM 99   |
| WAS STOLEN                                                                   |
|                                                                              |
| A courier vehicle carrying a Yellow II labeled  package containing 125       |
| millicuries of Technetium 99M was stolen in Omaha, NE on 7/5/02.  The driver |
| had stopped briefly to perform a personnel errand while he was on a delivery |
| to Norfolk, NE.   As of this date, neither the vehicle nor the nuclear       |
| pharmaceutical have been located.  The local police have been notified and   |
| there has been some media interest.                                          |
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|General Information or Other                     |Event Number:   39055       |
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| REP ORG:  WA DIVISION OF RADIATION PROTECTION  |NOTIFICATION DATE:
07/12/2002|
|LICENSEE:  SWEDISH MEDICAL CENTER               |NOTIFICATION TIME: 17:12[EDT]|
|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        07/12/2002|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:  WN-m008-1             AGREEMENT:  Y  |LAST UPDATE DATE:  07/12/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GAIL GOOD            R4      |
|                                                |M. WAYNE HODGES      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY C. FRAZEE              |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT REGARDING INCORRECT ENTRY OF CATHETER
POSITION/LENGTH |
| INTO THE TREATMENT PLANNING SYSTEM RESULTING IN MISMATCHED HDR DWELL
TIME    |
| AND CATHETER AT SWEDISH MEDICAL CENTER IN SEATTLE, WASHINGTON                |
|                                                                              |
| The following text is a portion of an e-mail received from the WA Department |
| of Health, Division of Radiation Protection:                                 |
|                                                                              |
| "This is notification of an event in Washington state as reported to the WA  |
| Department of Health, Division of Radiation Protection."                     |
|                                                                              |
| "STATUS:  new"                                                               |
|                                                                              |
| "Licensee:  Swedish Medical Center"                                          |
|                                                                              |
| "City and state:  Seattle, WA"                                               |
|                                                                              |
| "License number:  WN-m008-1"                                                 |
|                                                                              |
| "Type of license:  medical broad scope"                                      |
|                                                                              |
| "Date of event:  July 11, 2002"                                              |
|                                                                              |
| "Location of Event:  Seattle, WA"                                            |
|                                                                              |
| "ABSTRACT:  (where, when, how, why; cause, contributing factors, corrective  |
| actions, consequences, DOH onsite investigation; media attention)  Incorrect |
| entry of catheter position/length into the treatment planning system         |
| resulted in mismatched HDR dwell time and catheter.  The error was noted     |
| after the second of four planned treatments.  Estimates of the actual doses  |
| already delivered indicated from 17% to 25% underexposure to certain target  |
| volumes and 25% to 50% additional exposure to adjacent normal tissue.  Each  |
| of the four treatments was intended to deliver 600 centigray through three   |
| catheters with varying dwell times.  In effect, two catheters were           |
| 'reversed' in the planning system and a 'long' dwell was used in a 'short'   |
| catheter, and vice versa.  At the end of the second treatment, a significant |
| volume of the target tissue received only 900 to 1000 centigray instead of   |
| the intended 1200 centigray.  The licensee determined that the overall       |
| therapy was "salvable" and by modifying subsequent treatments would be able  |
| to correct the dose to the target tissue and at the same time minimize any   |
| additional dose to the adjacent normal tissue.  No adverse effects are       |
| anticipated.  The licensee generates a customized plan and treatment         |
| verification flow chart under its quality assurance program for each         |
| patient.  The licensee has determined that the sign-off for 'number of       |
| catheters' needs to be modified to 'number and labeling of catheters' as the |
| appropriate corrective action."                                              |
|                                                                              |
| "What is the notification or reporting criteria involved?   WAC 246-240-050  |
| Notifications, records, and reports of therapy misadministrations."          |
|                                                                              |
| "Activity and Isotope(s) involved:  3.3 Ci Ir-192"                           |
|                                                                              |
| "Device (HDR, etc.) Mfg., Model; computer program:  Nucletron                |
| MicroSelectron-HDR 'Classic' "                                               |
|                                                                              |
| "Exposure (intended/actual); consequences:  1200 centigray intended/900      |
| centigray actual"                                                            |
|                                                                              |
| "Was patient or responsible relative notified?  (will be)"                   |
|                                                                              |
| "Was written report provided?  (not yet)"                                    |
|                                                                              |
| "Was referring physician notified?  YES"                                     |
|                                                                              |
| "Consultant used?  NO"                                                       |
|                                                                              |
| (Contact the NRC operations officer for State contact information.)          |
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|Other Nuclear Material                           |Event Number:   39062       |
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| REP ORG:  JEFF ZELL CONSULTANTS                |NOTIFICATION DATE: 07/16/2002|
|LICENSEE:  JEFF ZELL CONSULTANTS                |NOTIFICATION TIME: 09:52[EDT]|
|    CITY:  CORAOPOLIS               REGION:  1  |EVENT DATE:        07/15/2002|
|  COUNTY:                            STATE:  PA |EVENT TIME:        18:00[EDT]|
|LICENSE#:  37-28531-01           AGREEMENT:  N  |LAST UPDATE DATE:  07/16/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES LINVILLE       R1      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARK WILLIAMS                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| DAMAGED TROXLER MOISTURE GAUGE                                               |
|                                                                              |
| On 07/15/02  in the evening an asphalt roller damaged the side of a Troxler  |
| Moisture Density Gauge, Model # 3411. The sources were not damaged but the   |
| outer casing of the Troxler gauge was damaged and the top of the source rod  |
| was bent.  Normal radiation readings of the gauge of  0.2 mr/hr at 3' were   |
| taken by a Geiger counter.  The gauge was run over near Lancaster, PA.  on   |
| Old Philadelphia Pike.  The gauge is now back at Jeff Zell Consultants       |
| located in Coraopolis, PA.  Jeff Zell Consultant's said that they were going |
| to send the gauge back to Troxler late this week.                            |
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|Power Reactor                                    |Event Number:   39067       |
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| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 07/16/2002|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 18:15[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        07/16/2002|
+------------------------------------------------+EVENT TIME:        13:19[EDT]|
| NRC NOTIFIED BY:  DANIEL J. BOYLE              |LAST UPDATE DATE:  07/16/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES LINVILLE       R1      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| TECH SPEC 3.0.3 ENTERED AFTER DECLARING BOTH TRAINS OF CONTROL ROOM        
 |
| VENTILATION INOPERABLE                                                       |
|                                                                              |
| "On 7/16/02 at 1319 hours, the Hope Creek Generating Station experienced a   |
| trip of the in-service 'B' train of Control Room Ventilation and it's        |
| associated Chiller. The standby 'A' Train attempted to start, but it's       |
| chilled water pump tripped precluding a successful start. This condition     |
| rendered both trains of Control Room Emergency Filtration INOPERABLE. In     |
| accordance with Technical Specifications 3.7.2, both trains were declared    |
| Inoperable and Technical Specification 3.0.3 was entered. At 1400 hours the  |
| 'B' Control Room Ventilation train was successfully restored to service and  |
| Operable status and Technical Specification 3.0.3 was exited. This event is  |
| being reported in accordance with 10CFR50.72(b)(3)(v) because both trains of |
| Control Room Emergency filtration were unavailable for approximately 40      |
| minutes. There was no power reduction associated with this event. No         |
| additional safety related equipment was inoperable at the time of the        |
| event.                                                                       |
|                                                                              |
| "The initiating condition is still under investigation, but is believed to   |
| have been induced as the result of an associated cooling coil fill evolution |
| that caused a low head tank level and potential air induction that resulted  |
| in the trip of the in-service cooling train and subsequently the standby     |
| train. As of the time of this report the 'A' Control Room Emergency          |
| Filtration Train is still inoperable pending completion of fill and vent of  |
| the supporting chilled water system."                                        |
|                                                                              |
| The licensee will inform the Lower Alloways Creek Township and has informed  |
| the NRC Resident Inspector.                                                  |
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