Event Notification Report for September 26, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
09/25/2002 - 09/26/2002
** EVENT NUMBERS **
39203 39204 39210 39215 39216
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|General Information or Other |Event Number: 39203 |
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| 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 |
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| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: RICH LAURA | |
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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 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." |
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|General Information or Other |Event Number: 39204 |
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| 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 |
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| NRC NOTIFIED BY: STEPHEN DOERFLER | |
| HQ OPS OFFICER: RICH LAURA | |
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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 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." |
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|General Information or Other |Event Number: 39210 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 09/23/2002|
|LICENSEE: APAC |NOTIFICATION TIME: 10:47[EDT]|
| CITY: OKLAHOMA CITY REGION: 4 |EVENT DATE: 09/21/2002|
| COUNTY: STATE: OK |EVENT TIME: 02:30[CDT]|
|LICENSE#: OK26937-01 AGREEMENT: Y |LAST UPDATE DATE: 09/24/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN PELLET R4 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: MIKE BRODERICK | |
| 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 - DAMAGED TROXLER GAUGE |
| |
| The licensee reported to the State of Oklahoma that on Friday night that one |
| of their trucks was proceeding south on I-35 near 4th St. in Moore, OK when |
| a Troxler gauge was bounced out of the bed of the truck. The gauge was |
| struck by another vehicle and damaged severely. The gauge was recovered and |
| taken to the shop where a survey indicated 8 millirem around the outside of |
| the case. A leak test is being conducted, results are not yet available. |
| The company has contacted Troxler concerning the gauge. More information |
| will be available later. |
| |
| * * * UPDATE AT 1316 EDT ON 9/24/02 FROM PAM BISHOP TO GERRY WAIG * * * |
| |
| The Oklahoma Dept. of Environmental Quality called to report that the |
| damaged Troxler gauge, model #4640, serial #750143, is licensed to APAC |
| Oklahoma Inc, P. O. Box 580670, 3605 North 129th East Ave, Tulsa, OK |
| 74158-0670. The source is a Cs-137, 7.1 millicurie source. The gauge has |
| been disassembled and no external contamination was detected. Wipes and |
| pictures of the damaged gauge have been sent to Troxler for evaluation. The |
| damaged gauge is being held by the licensee in it's Shawnee, OK office. The |
| APAC Radiation Safety Officer is Mr. John Ringwald (918) 438-2020. |
| |
| Notified R4DO (John Pellet) and NMSS (Doug Broaddus) |
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|Hospital |Event Number: 39215 |
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| REP ORG: KENNEDY MEMORIAL HOSPITAL |NOTIFICATION DATE: 09/25/2002|
|LICENSEE: KENNEDY MEMORIAL HOSPITAL |NOTIFICATION TIME: 16:26[EDT]|
| CITY: CHERRY HILL REGION: 1 |EVENT DATE: 09/24/2002|
| COUNTY: STATE: NJ |EVENT TIME: 17:30[EDT]|
|LICENSE#: 29-17925-01 AGREEMENT: N |LAST UPDATE DATE: 09/25/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TOM ESSIG NMSS |
| |ANIELLO DELLA GRECA R1 |
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| NRC NOTIFIED BY: EDWARD GOLDSCHMIDT | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BLO2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
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EVENT TEXT
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| LOST CS-137 CALIBRATION SOURCE AT HOSPITAL |
| |
| The licensee reported a missing/lost Cs-137 sealed source of 4.9 millicuries |
| which was used for diagnostic medical purposes. The licensee performed an |
| extensive search that did not locate the missing source. The licensee |
| speculated that the source may have been inadvertently disposed of in the |
| waste stream for incineration. |
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|Power Reactor |Event Number: 39216 |
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| FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 09/25/2002|
| UNIT: [1] [2] [] STATE: AL |NOTIFICATION TIME: 17:34[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 09/25/2002|
+------------------------------------------------+EVENT TIME: 08:30[CDT]|
| NRC NOTIFIED BY: WAYNE VAN LANDINGHAM |LAST UPDATE DATE: 09/25/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WALTER RODGERS R2 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N N 0 Refueling |0 Refueling |
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EVENT TEXT
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| CONTRACT SUPERVISOR TESTED POSITIVE FOR ALCOHOL DURING INITIAL IN-PROCESS |
| SCREENING |
| |
| Licensee has denied individual access to the site. |
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| Licensee will notify NRC Resident Inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021