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 +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39334 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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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Page Last Reviewed/Updated Thursday, March 25, 2021