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
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|General Information or Other |Event Number: 39415 |
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| 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 | |
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| | |
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| | |
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EVENT TEXT
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| 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." |
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|General Information or Other |Event Number: 39417 |
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| 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 | |
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EVENT TEXT
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| 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." |
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|Power Reactor |Event Number: 39422 |
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| 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| |
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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 Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 39423 |
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| 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| |
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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 Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| 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) |
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|Power Reactor |Event Number: 39424 |
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| 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| |
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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 |
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EVENT TEXT
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| 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. |
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|Hospital |Event Number: 39425 |
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| 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| |
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EVENT TEXT
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| 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. |
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