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 |
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| NRC NOTIFIED BY: JOSH GRISHAM | |
| HQ OPS OFFICER: MIKE NORRIS | |
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|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 | |
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|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 |
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| NRC NOTIFIED BY: JOHN WILLIAMSON | |
| HQ OPS OFFICER: STEVE SANDIN | |
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|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 | |
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|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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