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 December 06, 2002



                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           12/05/2002 - 12/06/2002

                              ** EVENT NUMBERS **

39415  39417  39422  39423  39424  39425  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39415       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ARKANSAS DEPARTMENT OF HEALTH        |NOTIFICATION DATE: 12/02/2002|
|LICENSEE:  CARTI-UAMS                           |NOTIFICATION TIME: 15:50[EST]|
|    CITY:  LITTLE ROCK              REGION:  4  |EVENT DATE:        11/20/2002|
|  COUNTY:                            STATE:  AR |EVENT TIME:             [CST]|
|LICENSE#:  930-BP-04-09          AGREEMENT:  Y  |LAST UPDATE DATE:  12/02/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JONES        R4      |
|                                                |THOMAS ESSIG         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JARED THOMPSON               |                             |
|  HQ OPS OFFICER:  ERIC THOMAS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION                   |
|                                                                              |
| "A medical misadministration was reported to Arkansas Department of Health   |
| Radiation Control and Emergency Management's Radioactive Materials Program   |
| by CARTI-UAMS on November 27, 2002 via a voice mail message.  Due to the     |
| Thanksgiving holiday, the message was not reviewed by the Department until   |
| December 2, 2002.                                                            |
|                                                                              |
| "According to the voice mail message and the preliminary telephone interview |
| with the licensee, the misadministration resulted from the incorrect         |
| positioning of a treatment tandem within the cervical treatment cylinder.    |
| As a result, the treatment was delivered approximately 3 cm inferior to the  |
| intended position. The incorrect positioning of the tandem that occurred     |
| during first treatment on November 20, 2002 was noted when the medical       |
| physics staff was reviewing the position verification film for the second    |
| treatment on November 27, 2002.                                              |
|                                                                              |
| "An onsite investigation will be conducted by the Department on December 2,  |
| 2002.  An updated report of the medical misadministration will be provided   |
| following this investigation."                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39417       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 12/02/2002|
|LICENSEE:  GEOSOILS                             |NOTIFICATION TIME: 17:42[EST]|
|    CITY:  VAN NUYS                 REGION:  4  |EVENT DATE:        11/29/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:        09:00[PST]|
|LICENSE#:  CA 4741-19            AGREEMENT:  Y  |LAST UPDATE DATE:  12/02/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JONES        R4      |
|                                                |THOMAS ESSIG         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BARBARA HAMRICK              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE                       |
|                                                                              |
| "This is to report a stolen moisture density gauge in the State of           |
| California (California incident number 112902).                              |
|                                                                              |
| "The licensee is Geosoils in Van Nuys, California (California license number |
| 4741-19).  The gauge was reported stolen via a voice-mail message left       |
| Friday morning, November 29, 2002.  The State offices were closed that day   |
| for the Thanksgiving holiday.                                                |
|                                                                              |
| "The gauge was stolen some time mid-morning on November 29, 2002, from the   |
| back of a pick-up truck, parked at a residence in the city of Gardena.  The  |
| chain securing the gauge package to the truck was cut.  The local police     |
| took a report.  The licensee will be running an ad offering a reward for the |
| return of the gauge for the next 10 days in the local newspaper.             |
|                                                                              |
| "This is all the information we have at the present time.  We are awaiting a |
| report from the licensee, confirming the activity and nuclide(s) in the      |
| gauge, as well as the serial number, and other information."                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39422       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CATAWBA                  REGION:  2  |NOTIFICATION DATE: 12/05/2002|
|    UNIT:  [1] [2] []                STATE:  SC |NOTIFICATION TIME: 01:52[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        12/05/2002|
+------------------------------------------------+EVENT TIME:        00:43[EST]|
| NRC NOTIFIED BY:  JIMMY BURGESS                |LAST UPDATE DATE:  12/05/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE BOLAND          R2      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF OFFSITE EMERGENCY SIRENS DUE TO ADVERSE WEATHER                      |
|                                                                              |
| "Twenty-four (24) emergency sirens out-of-service due to loss of power       |
| because of ice storm.  These sirens have been out-of-service more than one   |
| hour and preparations underway to restore to service."                       |
|                                                                              |
| The licensee will inform state/local agencies and the NRC resident           |
| inspector.                                                                   |
|                                                                              |
|                                                                              |
| * * * UPDATE ON 12/05/02 @ 1028 BY BRADLEY TO GOULD * * *                    |
|                                                                              |
| The site currently has 47 of 89 sirens out of service and has placed their   |
| backup route alerting system in service in the affected counties.  They also |
| have a reverse 911 callup system in place in the county that the site is     |
| located.                                                                     |
|                                                                              |
| Present estimates for returning power to the counties and thus to the sirens |
| is approximately one or two days.                                            |
|                                                                              |
| The Resident Inspector was notified.                                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39423       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MCGUIRE                  REGION:  2  |NOTIFICATION DATE: 12/05/2002|
|    UNIT:  [1] [2] []                STATE:  NC |NOTIFICATION TIME: 02:00[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        12/05/2002|
+------------------------------------------------+EVENT TIME:        01:45[EST]|
| NRC NOTIFIED BY:  TONY COOK                    |LAST UPDATE DATE:  12/05/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE BOLAND          R2      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF OFFSITE EMERGENCY SIRENS DUE TO ADVERSE WEATHER                      |
|                                                                              |
| "Any event that results in a major loss of emergency assessment capability,  |
| offsite response capability; or offsite communications capability.           |
| Currently greater than 16 ENS sirens are inoperable which is greater than    |
| 25% of siren capability."                                                    |
|                                                                              |
| The licensee will inform local agencies and the NRC resident inspector.      |
|                                                                              |
| * * * * UPDATE FROM LICENSEE TO MIKE RIPLEY  AT 1647 EST 12/5/02 * * * *     |
|                                                                              |
| The licensee stated that crews are continuing to restore all ENS sirens to   |
| service and that currently only 13 ENS sirens are inoperable which is less   |
| than the 25% of siren capability criteria.                                   |
|                                                                              |
| Notified R2DO (Robert Haag)                                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39424       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HARRIS                   REGION:  2  |NOTIFICATION DATE: 12/05/2002|
|    UNIT:  [1] [] []                 STATE:  NC |NOTIFICATION TIME: 08:45[EST]|
|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        12/05/2002|
+------------------------------------------------+EVENT TIME:        03:07[EST]|
| NRC NOTIFIED BY:  CHERIE L. GRIFFITH           |LAST UPDATE DATE:  12/05/2002|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRIAN BONSER         R2DO    |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF OFFSITE EMERGENCY SIRENS DUE TO ADVERSE WEATHER                      |
|                                                                              |
| "At 0307, greater than 20% of the Off Site Emergency Sirens were inoperable  |
| due to loss of power during the current Ice Storm.  Currently 59 of 81       |
| sirens are out of service.  This requires an 8 hour notification per 10CFR   |
| 50.72.  Additionally, at 0645, Lee County had gone one hour without any      |
| operable sirens.  At 0830, Harnett County had gone one hour without any      |
| operable sirens.  Transmission is aware and are prioritizing repairs."       |
|                                                                              |
| The licensee informed state/local agencies and the NRC resident inspectors.  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   39425       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  LEHEIGH VALLEY HOSPITAL              |NOTIFICATION DATE: 12/05/2002|
|LICENSEE:  LEHEIGH VALLEY HOSPITAL              |NOTIFICATION TIME: 12:10[EST]|
|    CITY:  ALLENTOWN                REGION:  1  |EVENT DATE:        12/04/2002|
|  COUNTY:                            STATE:  PA |EVENT TIME:        17:00[EST]|
|LICENSE#:  37-01548-01           AGREEMENT:  N  |LAST UPDATE DATE:  12/05/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |MICHELE EVANS        R1      |
|                                                |ROBERT PIERSON       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CYNTHIA GOODMAN              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LOTH 35.3045(a)(3)       DOSE TO OTHER SITE > SP|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL EVENT - DOSE TO SKIN OTHER THAN TREATMENT SITE                       |
|                                                                              |
| The attending physician, also the Radiation Oncologist, discovered that one  |
| of the catheters containing 3 seeds of iridium-192 was out of position.  The |
| treatment was a 48 hour dose to the lip area for a carcinoma.  The physician |
| had checked the location at 1700 EST on 12/3/02 and when checking at 1700    |
| EST on 12/4/02 discovered the one catheter under the patient under a bed     |
| pad.  The estimated dose to the skin of the back, conservatively using the   |
| entire 24 hours, is 240 rem.  The possible result is some erythmea,          |
| reddening of the skin.  The patient has been informed.  The actual treatment |
| site dose is only 4.3 % under the planned so no further treatment is         |
| necessary or reportable.                                                     |
|                                                                              |
| The Radiation Safety Officer intends to notify NRC Region 1.                 |
+------------------------------------------------------------------------------+