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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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOE KLINGER                  |                             |
|  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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| 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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STEPHEN DOERFLER             |                             |
|  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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| 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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MIKE BRODERICK               |                             |
|  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 - 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      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  EDWARD GOLDSCHMIDT           |                             |
|  HQ OPS OFFICER:  RICH LAURA                   |                             |
+------------------------------------------------+                             |
|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       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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.                           |
|                                                                              |
| Licensee will notify NRC Resident Inspector.                                 |
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