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Event Notification Report for June 4, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/03/2003 - 06/04/2003



                              ** EVENT NUMBERS **



39892  39901  39902  





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|General Information or Other                     |Event Number:   39892       |

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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 05/29/2003|

|LICENSEE:  Phoenix Baptist Hospital & Medical Ce|NOTIFICATION TIME: 17:19[EDT]|

|    CITY:  PHOENIX                  REGION:  4  |EVENT DATE:        05/27/2003|

|  COUNTY:                            STATE:  AZ |EVENT TIME:             [MST]|

|LICENSE#:  070-146               AGREEMENT:  Y  |LAST UPDATE DATE:  05/30/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |KRISS KENNEDY        R4      |

|                                                |MELVYN LEACH         NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  WILLIAM A. WRIGHT            |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - ARIZONA                                             |

|                                                                              |

| The following information was obtained from the Arizona Radiation Regulatory |

| Agency via facsimile:                                                        |

|                                                                              |

| "On May 27, 2003, a patient was administered 27 mCi of Iodine-131 (Iodide)   |

| instead of the prescribed dose of 5 mCi. Initial investigation indicates     |

| that Medi-Physics Inc. had mistakenly sent a 27 mCi dose designated for AMI  |

| to Phoenix Baptist Hospital and the 5 mCi dose for Phoenix Baptist Hospital  |

| to AMI.  It appears that the 27 mCi dose had been accurately assayed by the  |

| Technician, had been noted to differ from the requested 5 mCi, but had been  |

| administered to the patient anyway.  It should also be noted that the        |

| patient had a thyroid ablation procedure conducted previously.  Medi-Physics |

| Inc. and Phoenix Baptist Hospital are investigating the situation and a      |

| report from each will be forthcoming.                                        |

|                                                                              |

| "The Agency and licensees will continue to investigate this occurrence and   |

| report further."                                                             |

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|Power Reactor                                    |Event Number:   39901       |

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| FACILITY: INDIAN POINT             REGION:  1  |NOTIFICATION DATE: 06/03/2003|

|    UNIT:  [2] [3] []                STATE:  NY |NOTIFICATION TIME: 13:44[EDT]|

|   RXTYPE: [2] W-4-LP,[3] W-4-LP                |EVENT DATE:        06/01/2003|

+------------------------------------------------+EVENT TIME:        06:14[EDT]|

| NRC NOTIFIED BY:  SEAN EAGLETON                |LAST UPDATE DATE:  06/03/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |JAMES LINVILLE       R1      |

|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   |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|2     N          Y       100      Power Operation  |100      Power Operation  |

|3     N          Y       100      Power Operation  |100      Power Operation  |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| STATE OF NEW YORK AND ORANGE COUNTY NOTIFIED                                 |

|                                                                              |

| On June 3, 2003 at approximately 1006 hours, a review of siren data from     |

| June 1, 2003 revealed that four (4) of a total of 16 sirens in Orange County |

| experienced a power failure.  The power failure lasted from approximately    |

| 0614 until restoration at 0819 hours.  The two (2) hour power failure was    |

| caused by damage sustained to a power pole in Orange and Rockland utility    |

| system.  Route alerting was available during the loss of sirens.             |

|                                                                              |

| The NRC Resident Inspectors, State and Orange county were notified of this   |

| event.                                                                       |

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|Hospital                                         |Event Number:   39902       |

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| REP ORG:  ST. BARNABAS MEDICAL CENTER          |NOTIFICATION DATE: 06/03/2003|

|LICENSEE:  ST. BARNABAS MEDICAL CENTER          |NOTIFICATION TIME: 15:13[EDT]|

|    CITY:  LIVINGSTON               REGION:  1  |EVENT DATE:        06/03/2003|

|  COUNTY:                            STATE:  NJ |EVENT TIME:        09:30[EDT]|

|LICENSE#:  29-01608-03           AGREEMENT:  N  |LAST UPDATE DATE:  06/03/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |JAMES LINVILLE       R1      |

|                                                |TOM ESSIG            NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  DAVID STEIDLEY               |                             |

|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |

+------------------------------------------------+                             |

|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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| SOURCES IN PATIENT FOUND TO HAVE MIGRATED DURING TREATMENT                   |

|                                                                              |

| After 17 hours of irradiation with a cesium-137 source, it was discovered    |

| that the source was capable of migrating along a tube that was 16            |

| centimeters long. While the Doctors thought the sources (left and right      |

| tubes) were at the 0 centimeter position in the tube they were probably at   |

| various locations in the tube during the patient's treatment.  Spacers were  |

| not placed in the tubes to prevent the cesium-137 sources from moving.       |

| During the 17 hours the sources were in the patient the patient laid flat on |

| his/her back but the patient was allowed to move his/her legs and move back  |

| and forth. The movements of the patient caused the sources (one cesium-137   |

| source in each tube) to move up and down the tubes.  At the end of 17 hours  |

| it was found that one of the sources was at the far end of the tube instead  |

| of being at the other end of the tube (0 centimeter position).  Doctor of    |

| the patient was informed of this incident. Patient was not harmed by this    |

| error.                                                                       |

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