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Event Notification Report for July 24, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/23/2002 - 07/24/2002

                              ** EVENT NUMBERS **

39068  39072  39073  39085  
.
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|General Information or Other                     |Event Number:   39068       |
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| REP ORG:  KENTUCKY DEPT OF RADIATION CONTROL   |NOTIFICATION DATE:
07/18/2002|
|LICENSEE:  MONROE COUNTY MEDICAL CENTER         |NOTIFICATION TIME: 11:40[EDT]|
|    CITY:  TOMPKINSVILLE            REGION:  2  |EVENT DATE:        07/12/2002|
|  COUNTY:                            STATE:  KY |EVENT TIME:        16:00[CDT]|
|LICENSE#:  202-247-24            AGREEMENT:  Y  |LAST UPDATE DATE:  07/18/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHARLIE PAYNE        R2      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOHN A. VOLPE                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION                 |
|                                                                              |
| "The Technologist (S.H) received a request to perform a Bone Scan on an      |
| inpatient.  She selected an MDP Dose (25.1 mCi) and proceeded to the room    |
| listed on requisition.  She approached the patient stated the name.  The     |
| patient acknowledged the name.  The technologist explained  the procedure    |
| and injected the patient.  When the patient presented to the Nuclear         |
| Medicine Department with hospital chart it was discovered that the           |
| misadministration  had occurred.  The technologist notified the authorized   |
| user, the referring physician [and] the Radiation Safety officer.  The       |
| referring physician agreed to notify the patient.  The Technologist was      |
| reinstructed to check the hospital chart for a written order and verify the  |
| patients identity by checking the hospital ORM board."                       |
|                                                                              |
| Used Tc-99m MDP Bone.                                                        |
|                                                                              |
| *****RETRACTED ON 7/18/02 AT 15:27 EDT FROM VOLPE TO LAURA*****              |
|                                                                              |
| The licensee determined the event was NOT reportable since the dose was      |
| below the threshold (greater than 5 REM whole body or greater than 50 REM    |
| for organs) for reportability.                                               |
|                                                                              |
| Notified R2DO (C. PAYNE) and NMSS (F. Brown).                                |
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|General Information or Other                     |Event Number:   39072       |
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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE:
07/19/2002|
|LICENSEE:  ARIZONA HEART HOSPITAL               |NOTIFICATION TIME: 11:30[EDT]|
|    CITY:  PHOENIX                  REGION:  4  |EVENT DATE:        07/17/2002|
|  COUNTY:                            STATE:  AZ |EVENT TIME:        14:30[MST]|
|LICENSE#:  07-443                AGREEMENT:  Y  |LAST UPDATE DATE:  07/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LINDA HOWELL         R4      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  AUBREY V. GODWIN             |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT:  EQUIPMENT FAILURE                                   |
|                                                                              |
|                                                                              |
| "On July 17, 2002, the Arizona Radiation Regulatory Agency was notified by   |
| the Licensee that a Novoste Beta-Cath system utilizing 55mCi (2.04GBq) of    |
| Strontium-90 had failed to retract after completing treatment of a patient.  |
| Within seconds of determining that a failure had occurred, the Licensee      |
| implemented emergency withdrawal procedures and successfully removed the     |
| source without causing a misadministration.  The patient was surveyed and    |
| confirmed that all treatment radioactive material had been removed.          |
|                                                                              |
| "Initial examination by the Licensee did not determine a probable cause of   |
| the failure of the return of the source to the shielded condition.  The      |
| entire system is being returned to the manufacturer for evaluation.  Georgia |
| is aware of this event.                                                      |
|                                                                              |
| "Agency continues to investigate this event.                                 |
| "No press coverage is occurring or expected for this event.                  |
|                                                                              |
| "First Notice:  02-9                                                         |
|                                                                              |
| "The State of Georgia and the U.S. NRC, is being notified of this event."    |
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|General Information or Other                     |Event Number:   39073       |
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| REP ORG:  IOWA RADIATION PROTECTION            |NOTIFICATION DATE: 07/19/2002|
|LICENSEE:  STORK-TWIN CITY TESTING CORPORATION  |NOTIFICATION TIME:
12:03[EDT]|
|    CITY:  OSCEOLA                  REGION:  3  |EVENT DATE:        07/17/2002|
|  COUNTY:                            STATE:  IA |EVENT TIME:        09:00[CDT]|
|LICENSE#:  0282-2-77-IR1         AGREEMENT:  Y  |LAST UPDATE DATE:  07/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MONTE PHILLIPS       R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GEORGE JOHNS                 |                             |
|  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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| BROKEN RADIOGRAPHER CAMERA                                                   |
|                                                                              |
| "As a result of one of our cameras had a source jammed because the camera    |
| fell from a ladder it was sitting on during an exposure, we are submitting   |
| the following response.                                                      |
|                                                                              |
|                                                                              |
| "Project Information:                                                        |
|                                                                              |
| "Date: July 17, 2002 at approx. 9:00 A.M.                                    |
| Rural water tower, south of Osceola, Iowa approx. 4 miles                    |
| Jobsite-  down a dead-end road, in a field                                   |
| Source S.N. 04016B 40.5 curies                                               |
| Contractor: Phoenix Fabricators & Erectors, Inc.                             |
|                                                                              |
| "Stork-Twin City Testing Corporation was at a temporary project site         |
| performing radiographic testing when the camera fell off a ladder the camera |
| was sitting on (approx. 3 feet to the ground).  The source would not crank   |
| back into it's shielded position. I asked him, if they had resecured the     |
| area and his response was that they had and that they had also informed the  |
| contractor at the site of this incident. I told him, I was on my way and     |
| arrived at the site approx. one hour later. I loaded my truck with lead      |
| shielding and tools that might be needed to free up the source. Arriving at  |
| the project site, I surveyed the guide tube from a distance and found that   |
| the source was approx. 1 foot from the camera. They had the crank apart, so  |
| you could pull on the cable, in which I had them do prior to my arrival, but |
| they said it would not move, I then tried this myself. I pushed on the cable |
| and then pulled it and the source went in the camera to it safe position. We |
| surveyed the camera and the guide tube and confirmed it was secured in the   |
| camera. We then unconnected the control cable and checked the source end     |
| with a nogo gauge and found it to be OK, we also cranked the cable out and   |
| checked it for any bends or other damage and found it to be OK. We removed   |
| the bent guide tube and replaced it with a good tube. We then cranked the    |
| source out and made sure everything was functioning properly.                |
|                                                                              |
| "We then had an onsite safety meeting, which concluded that this would be    |
| avoided in the future, by tying the camera to a stationary object so the     |
| camera cannot fall to the ground and bend the guide tube.                    |
|                                                                              |
| "There was no over exposure to the public (contractor's personnel) or to the |
| radiographers during this incident and the radiographers performed their     |
| duties in a satisfactory manner, concerning the safety for all and the       |
| following of our accident procedures."                                       |
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|Power Reactor                                    |Event Number:   39085       |
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| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 07/23/2002|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 17:30[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        07/23/2002|
+------------------------------------------------+EVENT TIME:        16:32[EDT]|
| NRC NOTIFIED BY:  BOB REINER                   |LAST UPDATE DATE:  07/23/2002|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |RICHARD CONTE        R1      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     M/R        Y       100      Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| MANUAL REACTOR SCRAM DUE TO THE LOSS OF CONDENSER VACUUM FOR
UNKNOWN         |
| REASONS                                                                      |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "Limerick Unit 2 was manually scrammed due to a loss of main condenser       |
| vacuum.  All systems functioned as expected during the scram.  No [emergency |
| core cooling system injections] occurred.  All rods fully inserted.  No      |
| [safety relief valves] lifted.  The unit is currently stable in Mode 3.      |
| Investigation into the loss of vacuum is continuing."                        |
|                                                                              |
| The licensee stated that the main steam isolation valves remained open       |
| during the event.  There were no reactor core isolation cooling system       |
| injections, and none were required.  There were no related surveillance or   |
| maintenance activities ongoing at the time of the reactor scram, and there   |
| was nothing unusual or misunderstood with the exception of the cause for the |
| loss of condenser vacuum.                                                    |
|                                                                              |
| The licensee also stated that reactor vessel level and pressure control are  |
| currently being maintained via normal condensate and feedwater and via       |
| normal turbine bypass, respectively.   The main condenser is available as    |
| the heat sink, and main condenser vacuum is being maintained via the steam   |
| jet air ejectors.  The mechanical vacuum pump had also been prepared and is  |
| available to maintain condenser vacuum if needed.  Containment parameters    |
| were reported to be normal.                                                  |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
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