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Event Notification Report for July 31, 2002

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/30/2002 - 07/31/2002

                              ** EVENT NUMBERS **

39090  39091  39094  39096  39101  
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|General Information or Other                     |Event Number:   39090       |
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| REP ORG:  MISSISSIPPI DIV OF RAD HEALTH        |NOTIFICATION DATE: 07/25/2002|
|LICENSEE:  BURNS, COOLEY AND DENNIS, INC        |NOTIFICATION TIME: 11:30[EDT]|
|    CITY:  JACKSON                  REGION:  2  |EVENT DATE:        07/24/2002|
|  COUNTY:                            STATE:  MS |EVENT TIME:             [CDT]|
|LICENSE#:  MS61901               AGREEMENT:  Y  |LAST UPDATE DATE:  07/25/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK LESSER          R2      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOSH GRISHAM                 |                             |
|  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 A STOLEN TROXLER GAUGE                      |
|                                                                              |
| A Troxler gauge model 3440, serial number 31621, was stolen out of the bed   |
| of a truck in front of a private residence.  The vehicle was parked at 2300  |
| on 7/24/02 and the gauge was found missing at 0700 on 7/25/02.   The gauge   |
| contains 8 millicuries of Cs-137 and 40 millicuries of Am-241:Be.  Local law |
| enforcement has notified and a press release is planned for the local        |
| newspaper.                                                                   |
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|General Information or Other                     |Event Number:   39091       |
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| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE:
07/25/2002|
|LICENSEE:  ATLANTIC DRILLING SUPPLY             |NOTIFICATION TIME: 12:00[EDT]|
|    CITY:  ORLANDO                  REGION:  2  |EVENT DATE:        07/03/2002|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EDT]|
|LICENSE#:  2830-1                AGREEMENT:  Y  |LAST UPDATE DATE:  07/25/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK LESSER          R2      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+RICHARD WOODRUFF     R2      |
| NRC NOTIFIED BY:  CHARLIE ADAMS                |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - MISSING SOIL DENSITY GAUGE                          |
|                                                                              |
| Atlantic Drilling Supply shipped a CPN Model NC3 moisture density gauge      |
| (serial number M310800431, containing 10 millicuries Cs-137 and 50           |
| millicuries Am-241:Be) to CPN International in Martinez, CA for calibration. |
| The gauge was shipped via Conway Southern Express.  The shipment has been    |
| traced to Jacksonville where there is paperwork indicating shipment on to    |
| Atlanta.  There is no paperwork or other indication of the shipment arriving |
| in Atlanta.  There is an investigation ongoing to determine the actual       |
| location of the shipment.                                                    |
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|General Information or Other                     |Event Number:   39094       |
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| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE:
07/26/2002|
|LICENSEE:                                       |NOTIFICATION TIME: 08:44[EDT]|
|    CITY:                           REGION:     |EVENT DATE:        07/26/2002|
|  COUNTY:                            STATE:     |EVENT TIME:             [EST]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  07/26/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK LESSER          R2      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOHN WILLIAMSON              |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING CRASH OF AIRCRAFT CARRYING RAD
MATERIAL     |
|                                                                              |
| The Florida Bureau of Radiation Control was notified that a FEDEX aircraft   |
| carrying Rad I/II material, isotopes and quantities unknown, had crashed at  |
| the Tallahassee airport between 0745-0800EDT on 7/26/02.  The State of       |
| Florida was responding and did not request NRC assistance at this time.      |
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|General Information or Other                     |Event Number:   39096       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/26/2002|
|LICENSEE:  ST. MARY'S HOSPITAL                  |NOTIFICATION TIME: 19:30[EDT]|
|    CITY:  GRAND JUNCTION           REGION:  4  |EVENT DATE:        07/26/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:        16:45[MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/26/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |MELVYN LEACH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  P. V. EGIDI                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT - MISSING I-125 SEEDS                                 |
|                                                                              |
| The following is from a facsimile report:                                    |
|                                                                              |
| "At approximately 4:45 PM Friday July 26, 2002, I [Colorado Department of    |
| Health and Environment] received a call from ..., RSO and Medical Physicist  |
| at St. Mary's Hospital in Grand Junction, Colorado.                          |
|                                                                              |
| "[RSO] informed us he is missing 3, I-125 prostrate seeds (approx. 0.36 mCi  |
| [millicuries] each). He was made aware of the loss late this morning.        |
| Surveys were conducted in all suspect areas of the hospital to no avail. It  |
| is possible that either the seeds never arrived due to poor inventory        |
| control of the supplier, or that the seeds went to the trash, which left the |
| hospital around 7:00 A.M. Since the seeds are shielded, they would probably  |
| not be detected at the landfill."                                            |
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|Hospital                                         |Event Number:   39101       |
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| REP ORG:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION DATE: 07/30/2002|
|LICENSEE:  WILLIAM BEAUMONT HOSPITAL            |NOTIFICATION TIME: 09:49[EDT]|
|    CITY:  ROYAL OAK                REGION:  3  |EVENT DATE:        07/29/2002|
|  COUNTY:                            STATE:  MI |EVENT TIME:        12:30[EDT]|
|LICENSE#:  2101333-01            AGREEMENT:  N  |LAST UPDATE DATE:  07/30/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRUCE BURGESS        R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHERYL SCHULTZ               |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33               MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| A coronary brachytherapy of the intermediate artery was performed with a     |
| Sr-90, 40 mm source train.  The written directions called for a treatment    |
| time of 2 minutes and 52 seconds which would result in a total dose of 18.4  |
| Grays.  The catheter had a kink near the proximal marked location which      |
| caused the source train to get stuck before the distal portion of the        |
| catheter. This caused an unintended treatment of an area proximal to the     |
| treatment site.  The source was observed out of position by panning the      |
| table and using the fluoroscopy tube, at this time the source was retracted. |
| The source was in the patient for 2 minutes and 32 seconds, resulting in a   |
| total dose of 16.4 Grays.                                                    |
|                                                                              |
| The hospital has implemented process improvements to prevent another         |
| occurrence.                                                                  |
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