United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2002

Event Notification Report for September 25, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/24/2002 - 09/25/2002

                              ** EVENT NUMBERS **

39201  39203  39204  39212  39214  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39201       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ALABAMA RADIATION CONTROL            |NOTIFICATION DATE: 09/19/2002|
|LICENSEE:  BUILDING AND EARTH SCIENCES          |NOTIFICATION TIME: 16:28[EDT]|
|    CITY:                           REGION:  2  |EVENT DATE:        09/18/2002|
|  COUNTY:                            STATE:  AL |EVENT TIME:             [CDT]|
|LICENSE#:  1266                  AGREEMENT:  Y  |LAST UPDATE DATE:  09/19/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PAUL FREDRICKSON     R2      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID WALTER                 |                             |
|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MOISTURE DENSITY GAUGE STOLEN FROM THE BACK OF A PICKUP TRUCK                |
|                                                                              |
| "The writer received a call from [an employee] of Building and Earth         |
| Sciences at approximately 9:00 AM on September 19, 2002. The employee        |
| reported that a Troxler Model 3430 gauge (S/N 30199) had been stolen         |
| sometime during the night of September 18, 2002, from their truck working    |
| under reciprocity in Memphis, Tennessee.                                     |
|                                                                              |
| "The gauge had been left chained in the back of the truck overnight at [ . . |
| . . . ]. The chain had been cut, and the gauge taken. The licensee's         |
| employee had contacted both the State of Tennessee and had filed a report    |
| with the local police.                                                       |
|                                                                              |
| "The licensee is continuing their investigation, and considering additional  |
| methods to expedite recovery of the gauge."                                  |
|                                                                              |
| Contact the Headquarters Operations Officer for additional information.      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39203       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ILLINOIS DEPT OF NUCLEAR SAFETY      |NOTIFICATION DATE: 09/20/2002|
|LICENSEE:  SCI ENGINEERING  INC                 |NOTIFICATION TIME: 12:30[EDT]|
|    CITY:  FAIRVIEW HEIGHTS         REGION:  3  |EVENT DATE:        09/17/2002|
|  COUNTY:                            STATE:  IL |EVENT TIME:        16:00[CDT]|
|LICENSE#:  IL-01413-01           AGREEMENT:  Y  |LAST UPDATE DATE:  09/20/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MARK RING            R3      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOE KLINGER                  |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A LOST AND FOUND MOISTURE DENSITY GAUGE     |
|                                                                              |
| "The department was contacted on 9/18/02 by SCI Engineering, Inc., regarding |
| an event that happened around 4:00 p.m. the previous day. He reported that   |
| one of their drivers noticed when he looked in his rear view mirror after    |
| rounding a curve approximately 2 miles from the SCI office, that the         |
| Humboldt Model 5001 moisture/density gauge containing approximately 11       |
| millicuries Cs-137 and 44 millicuries Am-241, was no longer in the back of   |
| his truck. He then turned around and proceeded down the road to search for   |
| the gauge. Meanwhile, an Ameritech employee in a truck was behind the SCI    |
| truck and watched the gauge fly out the back. He then stopped to get the     |
| device. Nearby was a friend of his that worked for a construction company    |
| and was familiar with nuclear gauging devices. He noted the type of the      |
| device and the serial number and called SCI to report the find. SCI had, in  |
| the interim, already sent two technicians to help look for the device after  |
| hearing of the loss from the SCI truck driver. This all occurred in          |
| approximately 10 minutes according to SCI.                                   |
|                                                                              |
| "The State expressed concern to the licensee in the timeliness of the        |
| notification and the fact that a gauge was allowed to 'fly' out the back of  |
| one of their trucks. The licensee agreed and stated that a report would be   |
| filed with the department as soon as possible. The department will take      |
| appropriate measures to ensure that there will be no recurrence of this type |
| of an event by this licensee."                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39204       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 09/20/2002|
|LICENSEE:  CEDARS-SINAI MEDICAL CENTER          |NOTIFICATION TIME: 15:29[EDT]|
|    CITY:  LA                       REGION:  4  |EVENT DATE:        05/29/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:             [PDT]|
|LICENSE#:  0404-19               AGREEMENT:  Y  |LAST UPDATE DATE:  09/20/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVE LOVELESS        R4      |
|                                                |FRED BROWN           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STEPHEN DOERFLER             |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A MEDICAL DIAGNOSTIC MISADMINISTRATION      |
|                                                                              |
| "Background:  On June 12, 2002 the licensee Radiation Safety Officer         |
| reported a diagnostic misadministration which occurred on May 29, 2002. An   |
| elderly patient had been scheduled for an iodine-123 uptake and scan. When   |
| she arrived, the nuclear medicine technologist noticed a scar on her neck    |
| from a thyroidectomy. Based on this observation, and interview with the      |
| patient, the nuclear medicine technologist presumed that the patient needed  |
| a neck and head scan with iodine-131. She was given 3.0 mCi of iodine-131    |
| without discussing it with the physician. It turned out that she only had a  |
| partial thyroidectomy, and her partial right lobe had approximately a 22%    |
| uptake. There was a delay in notifying this Department because the physician |
| felt it wasn't a misadministration, as the primary care physician had        |
| ordered the wrong exam to begin with. Dose with iodine-123 would have been   |
| 7.0 rads, dose with 3.0 millicuries of iodine-131 was 3087 rads to the       |
| thyroid.                                                                     |
|                                                                              |
| "Regulatory Issues: This incident was reported within 15 days as required by |
| the California Code of Regulations, title 17, section 30322. The RSO sent a  |
| June 18, 2002 letter describing the root cause of the event and corrective   |
| actions to prevent the likelihood of a recurrence. This letter was received  |
| in this office on July 10, 2002. During a September 11, 2002 telephone       |
| conversation, I was told that the Nuclear Medicine Department procedures     |
| were changed so that scheduling for these type of procedures are now         |
| performed by nuclear medicine technologists and not clerical personnel.      |
|                                                                              |
| "This was reportable to the NRC because it involved over 39 millicuries of   |
| I-131. Cedars-Sinai Medical Center will be cited for violation of the        |
| California Code of Regulations, title 17, sections 30521, which requires     |
| nuclear medicine technologists to be under General Supervision when          |
| performing nuclear medicine technology procedures, and 30502 which defines   |
| General Supervision as meaning that the supervisor is responsible for, and   |
| has control of all of the following:                                         |
| 1. Quality, technical and medical aspects of all nuclear medicine technology |
| procedures;                                                                  |
| 2. Radiation health and safety of patients, ancillary personnel and other    |
| persons;                                                                     |
| 3. Ascertaining that nuclear medicine technologists maintain their           |
| competency by participation in management sponsored or formal continuing     |
| education or training offered by professional organizations or societies, or |
| institutions of higher learning.                                             |
|                                                                              |
| "Contrary to the above, the nuclear medicine technologist who administered   |
| the 3 millicuries of I-131, and under the General Supervision of the         |
| authorized user, made decisions regarding the procedure and dose to be       |
| administered without consultation with the authorized user.                  |
|                                                                              |
| "Health and Safety Concerns: The patient received an unnecessary dose. Her   |
| thyroid should have received only about 7 rads had she received 200          |
| microcuries of I-23, but instead she received 3,087 rads. The information    |
| needed was obtained, and an additional dose was not given. Because there is  |
| a possibility of reduction in thyroid function, Cedars-Sinai Medical Center  |
| has said the patient will be followed by her physician.                      |
|                                                                              |
| "Conclusion: The referring physician's written order on file at the hospital |
| was not examined during the investigation because neither the document, or a |
| copy of this document, could be released to this office due to a new patient |
| privacy law, according to the RSO."                                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39212       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 09/23/2002|
|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 23:58[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        09/23/2002|
+------------------------------------------------+EVENT TIME:        23:35[EDT]|
| NRC NOTIFIED BY:  ROBERT MALONEY               |LAST UPDATE DATE:  09/24/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |PETE ESELGROTH       R1      |
|10 CFR SECTION:                                 |                             |
|AMED 50.72(b)(3)(xii)    OFFSITE MEDICAL        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     N          N       0        Refueling        |0        Refueling        |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| CONTAMINATED WORKER TRANSPORTED OFFSITE FOR MEDICAL ASSISTANCE               |
|                                                                              |
| At 2335EDT on 9/23/02 a worker involved in decontamination activities inside |
| the Unit 3 containment was transported offsite to Lawrence and Memorial      |
| Hospital in New London, CT for medical assistance.  EMTs administered oxygen |
| to the worker who they believed was suffering from heat stress and           |
| hypertension.  A rad survey conducted onsite showed contamination levels of  |
| 1000 ccpm on his right thigh.  An HP technician and supervisor accompanied   |
| the worker to the hospital where he was decontaminated.                      |
|                                                                              |
| * * * UPDATE 0035EDT ON 9/24/02 FROM MALONEY TO S. SANDIN * * *              |
|                                                                              |
| The HP supervisor who accompanied the contaminated worker to the hospital    |
| notified the site that rad surveys completed at 0015EDT confirmed that the   |
| ambulance, the ambulance travel path and the hospital treatment room were    |
| free of contamination and free released.                                     |
|                                                                              |
| The licensee will inform state/local agencies and the NRC Resident           |
| Inspector.                                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   39214       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WESTINGHOUSE ELECTRIC CORPORATION    |NOTIFICATION DATE: 09/24/2002|
|   RXTYPE: URANIUM FUEL FABRICATION             |NOTIFICATION TIME: 13:55[EDT]|
| COMMENTS: LEU CONVERSION (UF6 to UO2)          |EVENT DATE:        09/23/2002|
|           COMMERCIAL LWR FUEL                  |EVENT TIME:        18:10[EDT]|
|                                                |LAST UPDATE DATE:  09/24/2002|
|    CITY:  COLUMBIA                 REGION:  2  +-----------------------------+
|  COUNTY:  RICHLAND                  STATE:  SC |PERSON          ORGANIZATION |
|LICENSE#:  SNM-1107              AGREEMENT:  Y  |WALTER RODGERS       R2      |
|  DOCKET:  07001151                             |RICHARD WESSMAN      IRO     |
+------------------------------------------------+JOHN HICKEY          NMSS    |
| NRC NOTIFIED BY:  EDWARD STECK                 |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01 24 HOUR REPORT                                            |
|                                                                              |
| "Facility: Westinghouse Electric Company, Commercial Fuel Fabrication        |
| Facility, Columbia SC,  PWR fuel fabricator for commercial light water       |
| reactors. License: SNM-1107.                                                 |
|                                                                              |
| "Time and Date of Event: Approximately 18:10 hours, Monday, September 23,    |
| 2002.                                                                        |
|                                                                              |
| "Reason for Notification: Scrubber ventilation ductwork containing gross     |
| contamination was stacked without proper spacing.                            |
|                                                                              |
| "Summary of Process: The scrubber ventilation system ductwork is             |
| non-operational and was being removed.                                       |
|                                                                              |
| "As Found Condition: A summary of the as found conditions is as follows:     |
| -Scrubber ventilation ductwork was found stacked in the Conversion           |
| Decontamination Room.                                                        |
| -Gross contamination was evident in several sections of ductwork.            |
|                                                                              |
| "Criticality Safety Protection: Criticality safety protection for floor      |
| storage of material with 'gross contamination' consists of a 12-inch or      |
| greater spacing requirement. Gross contamination is defined as visually      |
| observable uranium-bearing material. A criticality would only be possible if |
| an excessive accumulation of uranium occurs, it becomes moderated, and it is |
| not detected before a critical configuration is formed. After assessing the  |
| situation, it was determined that this was a nuclear criticality safety      |
| event, in an analyzed system, for which less than previously documented . .  |
| .  protection remains. . . Therefore, the event requires 24-hour             |
| notification in accordance with Westinghouse Operating License (SNM-1 107),  |
| paragraph 3.7.3 (c.5).                                                       |
|                                                                              |
| "Summary of Activity:                                                        |
| -Nuclear Criticality Safety (NCS) was notified by operations.                |
| -Removal of the ventilation ductwork was ceased.                             |
| -NCS visually inspected the ventilation ductwork.                            |
| -NCS required the ductwork be unstacked and placed in an authorized          |
| configuration.                                                               |
|                                                                              |
| "Conclusions                                                                 |
| -There was a violation of spacing requirements.                              |
| -At no time was there any risk to the health or safety of any employee or    |
| member of the public. No exposure to hazardous material was involved.        |
| -The Incident Review Committee (IRC) determined that this is a safety        |
| significant incident in accordance with governing procedures. A formal       |
| causal analysis will be performed."                                          |
+------------------------------------------------------------------------------+