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Event Notification Report for November 6, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/05/2002 - 11/06/2002

                              ** EVENT NUMBERS **

39334  39335  39336  39341  39344  39345  

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|General Information or Other                     |Event Number:   39334       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 10/31/2002|
|LICENSEE:  KUMAR AND ASSOCIATES, INC            |NOTIFICATION TIME: 12:10[EST]|
|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        10/30/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MST]|
|LICENSE#:  778-01                AGREEMENT:  Y  |LAST UPDATE DATE:  11/04/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ED STROUD                    |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE                      |
|                                                                              |
| Licensee reported that a Troxler gauge, was stolen from the open bed of a    |
| pickup truck parked in front of a private residence, sometime during the     |
| night of 10/30/02. The gauge, model #3440 serial #16911, contained           |
| approximately 44 millicuries of Am-241:Be, and approximately 9 millicuries   |
| of Cs-137.  The gauge was locked and the chain was cut. The licensee will be |
| notifying the Denver police department of the theft.                         |
|                                                                              |
| * * * * * UPDATE 1800 EST 11/4/2002 TO MIKE RIPLEY FROM COLORADO DEPARTMENT  |
| OF PUBLIC HEALTH AND ENVIRONMENT (received via fax)   * * * *                |
|                                                                              |
| "The police recovered a Troxler moisture-density gauge that was reported     |
| stolen last week.  Kumar and Associates, a Colorado licensee, reported the   |
| gauge stolen on 10/31/02 (sec preliminary report 39334). Later that same     |
| night, police were called to a Denver location because of a suspicious       |
| package that was left by a dumpster. The package was labeled with, a         |
| radioactive sticker. The Denver Fire Department's Haz-mat team checked the   |
| package and removed it to a safe storage location. Today, 11/4/02, the       |
| package was positively identified as the stolen gauge, and returned to the   |
| licensee. The licensee reported that the gauge was intact and that the       |
| sources appeared undisturbed."                                               |
|                                                                              |
| Notified R4 DO (C. Marschall) and NMSS EO (P. Holahan)                       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39335       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FLORIDA BUREAU OF RADIATION CONTROL  |NOTIFICATION DATE: 10/31/2002|
|LICENSEE:  BAYFRONT MEDICAL CENTER              |NOTIFICATION TIME: 16:45[EST]|
|    CITY:  ST. PETERSBURG           REGION:  2  |EVENT DATE:        10/31/2002|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EST]|
|LICENSE#:  0023-2                AGREEMENT:  Y  |LAST UPDATE DATE:  11/05/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |KERRY LANDIS         R2      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CHARLES ADAMS(email)         |                             |
|  HQ OPS OFFICER:  ARLON COSTA                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT                             |
|                                                                              |
| "Manufacturer's employee changed the Gamma Knife's printer on 2 Aug 02 and   |
| during the process the calibration parameters for the Gamma Knife instrument |
| were reset from 3.52 c/gray (on 6-02) to 3.5 c/gray (on 1-99). Licensee was  |
| not aware of the change. Ten patients were treated with this instrument from |
| 26 Aug-30 Oct 02. The area treated was the brain and the overexposure was as |
| much as 60% above the prescribed dose of 12-24 grays. The physicians and     |
| patients involved are being notified. The error was discovered during a      |
| recalibration on 10-30-02. The instrument has been removed from service.     |
| Florida is investigating."                                                   |
|                                                                              |
| The isotope used by the Gamma Knife Model C S/N 4189C is Co-60 (Activity     |
| 5.72 Ci).                                                                    |
|                                                                              |
| *** UPDATE AT 0800 11/5/2002 FROM CHARLIE ADAMS TO ERIC THOMAS ***           |
|                                                                              |
| The above Co-60 activity was listed incorrectly in the original report.  The |
| correct value is 5720 Ci.                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39336       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UTAH DIVISION OF RADIATION CONTROL   |NOTIFICATION DATE: 11/01/2002|
|LICENSEE:  AMERICAN TESTING SERVICES, INC       |NOTIFICATION TIME: 16:11[EST]|
|    CITY:  WEST VALLEY CITY         REGION:  4  |EVENT DATE:        11/01/2002|
|  COUNTY:                            STATE:  UT |EVENT TIME:        11:00[MST]|
|LICENSE#:  UT 1800062            AGREEMENT:  Y  |LAST UPDATE DATE:  11/01/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |TOM ESSIG            NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JULIE R. FELICE (e-mail)     |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE                      |
|                                                                              |
| "A Troxler Electronic Laboratories, Inc. Model 3411B, portable gauging       |
| device [serial number 7940, containing approximately 8.0 millicuries of      |
| Cs-137 (source serial number CC-571), and approximately 40 millicuries of    |
| Am-241/Be (source serial number CAA-4262)] was stolen from the bed of a      |
| pickup truck while the licensee's employee went into [ ] Food & Drug to      |
| purchase some batteries. The gauging device's source rod was locked in the   |
| safe shielded position, the gauging device's transport case was locked, and  |
| the transportation case was chained to the licensee's pickup truck. Bolt     |
| cutters were used to remove the gauging device from the pickup truck."       |
|                                                                              |
| The Licensee notified the West Valley City Police.                           |
|                                                                              |
| The state of Utah has issued a press release.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39341       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 11/02/2002|
|LICENSEE:  AMGEN, INC                           |NOTIFICATION TIME: 12:10[EST]|
|    CITY:  THOUSAND OAKS            REGION:  4  |EVENT DATE:        11/01/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:        14:45[PST]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  11/02/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CLAUDE JOHNSON       R4      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT GREGOR                |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING UNACCOUNTED FOR Po-210 SOURCE               |
|                                                                              |
| Licensee reported that a 1.5 millicurie Po-210 source is unaccounted for.    |
| The source is believed to be at the facility and a search is being           |
| performed.                                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   39344       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GRAND VIEW HOSPITAL                  |NOTIFICATION DATE: 11/05/2002|
|LICENSEE:  GRAND VIEW HOSPITAL                  |NOTIFICATION TIME: 10:33[EST]|
|    CITY:  SELLERSVILLE             REGION:  1  |EVENT DATE:        11/04/2002|
|  COUNTY:                            STATE:  PA |EVENT TIME:        11:00[EST]|
|LICENSE#:  37-13187-02           AGREEMENT:  N  |LAST UPDATE DATE:  11/05/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LAWRENCE DOERFLEIN   R1      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DAVID LIGHTFOOT              |                             |
|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|BLO2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| REPORTED LOSS OF I-125 SEED FOLLOWING IMPLANTATION                           |
|                                                                              |
| On 11/4/2002 at approximately 1100 hours, following a procedure to implant   |
| I-125 seeds into the prostate of a patient, the licensee counted only 57 of  |
| planned 58 seeds implanted.  Survey of area, surrounding materials, and      |
| counting room did not turn up any indications of the lost seed.  The         |
| unaccounted for seed contains 382 microcuries.  Licensee contacted Region I. |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39345       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 11/05/2002|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 15:19[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        11/05/2002|
+------------------------------------------------+EVENT TIME:        11:10[CST]|
| NRC NOTIFIED BY:  E. HENSON                    |LAST UPDATE DATE:  11/05/2002|
|  HQ OPS OFFICER:  MIKE RIPLEY                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|ADEG 50.72(b)(3)(ii)(A)  DEGRADED CONDITION     |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DEFECTIVE STEAM GENERATOR TUBES DISCOVERED DURING INSPECTION                 |
|                                                                              |
| "During refueling outage RF12, interim results of "A" Steam Generator tube   |
| inspections indicate 62 tubes out of 5431 tubes (i.e.,> 1%) have been found  |
| to be defective. This steam generator tube inspection result for the "A"     |
| Steam Generator is classified as category C-3 in accordance with Technical   |
| Specification 5.5.9, Table 5.5.9-2.  All defective tubes will be plugged     |
| before the steam generator is returned to service.  There were no adverse    |
| safety consequences or implications as a result of this event.  This event   |
| did not adversely affect the safe operation of the plant or the health and   |
| safety of the public."                                                       |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
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