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Event Notification Report for June 19, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           06/18/2003 - 06/19/2003



                              ** EVENT NUMBERS **



39933  39934  39935  39936  39948  



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|General Information or Other                     |Event Number:   39933       |

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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  QUALITY TESTING                      |NOTIFICATION TIME: 13:00[EDT]|

|    CITY:  TEMPE                    REGION:  4  |EVENT DATE:        06/10/2003|

|  COUNTY:                            STATE:  AZ |EVENT TIME:        08:00[MST]|

|LICENSE#:  AZ07-491              AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  GODWIN                       |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| ARIZONA LICENSEE, QUALITY TESTING, REPORTED A MISSING TROXLER MOISTURE       |

| DENSITY GAUGE                                                                |

|                                                                              |

| "At approximately 8:00 AM MST June 10, 2003,  Arizona was informed by the    |

| Licensee Radiation Safety Officer that they believe a Troxler Model 3411 B   |

| SN 4647 moisture-density gauge was missing and had been since 5:00 AM.  At   |

| approximately 8:30 MST the Agency was informed that gauge fell off of the    |

| truck and had been recovered by JSW Concrete Contractor.  The gauge was      |

| recovered from Price Road under the Fry Road Overpass.  The Department of    |

| Public Safety and the Chandler Police were notified prior to recovery.  The  |

| Licensee took possession of the gauge at approximately 9:00AM. There were no |

| indications the gauge had been opened.  Inspection by the State Agency       |

| revealed several possible violations."                                       |

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|General Information or Other                     |Event Number:   39934       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  CHRISTUS SANTA ROSA                  |NOTIFICATION TIME: 14:47[EDT]|

|    CITY:  SAN ANTONIO              REGION:  4  |EVENT DATE:        06/13/2003|

|  COUNTY:                            STATE:  TX |EVENT TIME:             [CDT]|

|LICENSE#:  L02237-001            AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  WATKINS                      |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| WRONG DOSAGE ADMINISTERED TO A PATIENT DUE TO HUMAN ERROR                    |

|                                                                              |

| Discovery of right patient/ right radiopharmaceutical but wrong dosage.      |

| Patient returned after 48 hours for a scan. Doctor asked the tech for the    |

| prescription that was issued.  The tech had ordered the wrong dose for the   |

| prescribed procedure.  A thyroid scan was conducted with 2.3 millicuries of  |

| Iodine -131 vs. the required 300 microcuries of I-131.  As corrective action |

| any I-131 dose will require concurrence of the physician prior to ordering   |

| the dose.  The cause was due to human error since the radiopharmacy sent the |

| dose as ordered by the Tech.                                                 |

|                                                                              |

| Both the referring physician and the patient have been informed of the       |

| error. The physician has stated that the dose error has caused no injury to  |

| the patient.                                                                 |

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|General Information or Other                     |Event Number:   39935       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  COLLEGE STATION HOSPITAL             |NOTIFICATION TIME: 15:14[EDT]|

|    CITY:  COLLEGE STATION          REGION:  4  |EVENT DATE:        06/11/2003|

|  COUNTY:                            STATE:  TX |EVENT TIME:             [CDT]|

|LICENSE#:  L02559                AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  WATKINS                      |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| SIX VIOLATIONS FOUND DURING RECENT INSPECTION AT A TEXAS LICENSED FACILITY   |

|                                                                              |

| On June 11, 2003 the Texas Department of Health, Bureau of Radiation Control |

| conducted a follow up inspection of licensed activities at the Humana        |

| Hospital Day Surgery Center DBA The Surgical Center (TSC), Bryan, Texas. The |

| inspection findings were discussed with Dr. Alikhan, Radiation Safety        |

| Officer and his staff In a preliminary exit briefing at close of             |

| inspection.                                                                  |

|                                                                              |

| Based on the results of his inspection., the Inspector has determined that   |

| at least 6 violations of the Agency requirements occurred. In addition, the  |

| violations were identified by this Agency rather than through the Licensee   |

| conducting Radiation Protection Program (RPP) audits.                        |

|                                                                              |

| The Inspector reviewed five (5) total patients affected, since the last      |

| inspection by this Agency conducted on January 18, 2001.  Utilization logs   |

| indicate that this number could increase given a review of the patients      |

| treated prior to January 18, 2001, with the use of the stroutium-90 eye      |

| applicator.  Therefore, as discussed with the RSO during the exit briefing,  |

| additional information may be required of TSC before the Agency can make a   |

| determination to conclude this issue. The Inspector informed the Licensee    |

| that the number and characterization of apparent violations could change as  |

| a review Is conducted.                                                       |

|                                                                              |

| Inspection Findings: Items of Noncompliance                                  |

|                                                                              |

| 1.  Violation of 25 TAC §289.256(ee)(1)(a)(i):                               |

| The Licensee failed to report and notify this Agency of a dose that differs  |

| from the prescribed dose by more than 5 rem (0.05 Sv) effective dose         |

| equivalent, 50 rem (0.5 Sv) to an organ or tissue, or 50 rem (0.5 Sv)        |

| shallow dose equivalent to the skin and either:                              |

|                                                                              |

| a. the total dose delivered differs from the prescribed dose by 20% or       |

| more.                                                                        |

|                                                                              |

| 2.  Violation of 25 TAC §289.202(e)(1):                                      |

|                                                                              |

| The Licensee failed to conduct a Radiation Protection Program (RPP),         |

| sufficient to ensure compliance with the provisions of §289.202. The RPP was |

| not developed, documented, and implemented.                                  |

|                                                                              |

| 3.  Violation of 25 TAC §289.201(g)(1)(b):                                   |

|                                                                              |

| The Licensee exceeded the six-month leak test interval for a sealed source   |

| of radioactive material for a 100mCi Sr-90 source, S/N 0214, during the time |

| period from January 18, 2001 until June 4, 2003.                             |

|                                                                              |

| 4.  Violation of 25 TAC §289.256(p)(1)&(2):                                  |

|                                                                              |

| At the time of the inspection, the Licensee had failed to generate written   |

| directives signed and dated by an authorized user prior to administration of |

| Sr-90 Brachytherapy.                                                         |

|                                                                              |

| (i)   prior to implantation: the treatment site, the radionuclide, number of |

| sealed sources and dose; and                                                 |

| (ii)  after implantation but prior to completion of the procedure: the       |

| radionuclide, treatment site, number of sealed sources, total sealed source  |

| strength and exposure time or, equivalently, the total dose.                 |

|                                                                              |

| 5.  Violation of 25 TAC§289.256(bb)(6)(A)(B)(C)&(D):                         |

|                                                                              |

| The Licensee failed to determine the calibration measurements of             |

| Brachytherapy sealed sources.                                                |

|                                                                              |

| 6. Violation of 25 T,AC §289.256(i)(2)(A)&(B):                               |

|                                                                              |

| The Licensee's Radiation Safety Committee has not been composed of the       |

| required personnel. By evidence of the January 30, 2003 Radiation Safety     |

| Committee minutes that identifies representatives to attendance, the         |

| Radiation Safety Officer and an authorized user of type of use permitted     |

| (surgery) by the license, were not present.                                  |

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|General Information or Other                     |Event Number:   39936       |

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| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 06/13/2003|

|LICENSEE:  UNITED DAIRYMAN OF AZ                |NOTIFICATION TIME: 15:55[EDT]|

|    CITY:  TEMPE                    REGION:  4  |EVENT DATE:        06/12/2003|

|  COUNTY:                            STATE:  AZ |EVENT TIME:        16:20[MST]|

|LICENSE#:  AZ-GL                 AGREEMENT:  Y  |LAST UPDATE DATE:  06/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |DAVID GRAVES         R4      |

|                                                |TOM ESSIG            NMSS    |

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

| NRC NOTIFIED BY:  GODWIN                       |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| ARIZONA LICENSEE, UNITED DAIRYMEN OF AZ, DISCOVERED A DAMAGED HYDROGEN 3     |

| EXIT SIGN                                                                    |

|                                                                              |

| At approximately 4:20 PM MST June 12, 2003, the Agency was informed by the   |

| General Licensee that they had discovered an EXIT sign containing Tritium    |

| was damaged. The sign contained 11.5 Curies of Tritium when installed.  The  |

| General Licensee had no idea when the sign was damaged, in fact, he was      |

| surprised to learn that it contained radioactive material.  The sign was a   |

| Safety Light Model XT.  When the Agency arrived on scene, it was determined  |

| that the light tubes were all missing for this sign.  One individual had     |

| used a ladder to attempt to replace the "light" bulbs since they were        |

| "burned" out.  Wet wipes taken of the remains of the sign did not detect     |

| hydrogen 3.   No one could tell the Agency of the condition of the glow      |

| tubes or where they are now located.  The sign was located in a 30,000       |

| square foot warehouse storing powdered milk. Evaporative coolers circulate   |

| cool air into the warehouse.                                                 |

|                                                                              |

| The Agency continues to investigate this incident.                           |

|                                                                              |

| The NRC and FBI will be notified of this event                               |

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|Power Reactor                                    |Event Number:   39948       |

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| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 06/18/2003|

|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 13:27[EDT]|

|   RXTYPE: [1] GE-4                             |EVENT DATE:        06/18/2003|

+------------------------------------------------+EVENT TIME:        11:44[EDT]|

| NRC NOTIFIED BY:  STEVEN NEVELOS               |LAST UPDATE DATE:  06/18/2003|

|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |RAYMOND LORSON       R1      |

|10 CFR SECTION:                                 |                             |

|ASHU 50.72(b)(2)(i)      PLANT S/D REQD BY TS   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |

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

|1     N          Y       100      Power Operation  |99       Power Operation  |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| UNIT COMMENCED A TS REQUIRED SHUTDOWN DUE TO AN INOPERABLE EDG               |

|                                                                              |

| "This 4-hour report is being made pursuant to 10CFR50.72(b)(2)(i). A unit    |

| shutdown was commenced at 11:44 on June 18, 2003 to comply with Hope Creek   |

| Generating Station Technical Specification (TS) 3.8.1.1 due to the           |

| inoperability of the 'A' Emergency Diesel Generator (EDG).                   |

|                                                                              |

| "On June 15, 2003 at 04:35am, an excessive seal leak from the engine driven  |

| jacket water intercooler pump was identified, rendering the 'A' EDG          |

| inoperable and warranting entry into ACTION b of TS 3.8.1.1. That action     |

| requires the inoperable 'A' EDG to be returned to an operable condition by   |

| June 18, 2003 at 04:35. Corrective actions attempted thus far have been      |

| unsuccessful at eliminating leakage from the 'A' EDG jacket water            |

| intercooler pump seal. Engineering is continuing to evaluate the             |

| acceptability of the leakage from the seal.                                  |

|                                                                              |

| "All other safety related equipment is operable."                            |

|                                                                              |

| The Unit is currently at 65% power and anticipates a full shutdown by        |

| 1600EDT. The licensee will inform both local agencies and the NRC resident   |

| inspector.                                                                   |

|                                                                              |

| * * * UPDATE 1725 EDT on 6/18/03 from Steven Nevelos to Bill Gott * * *      |

|                                                                              |

| "UPDATED:  As of June 18, 2003 at 16:17, with reactor power at 42%, the unit |

| shutdown to comply with TS 3.8.1.1 was terminated. The 'A' EDG has been      |

| declared operable but degraded with compensatory actions in place to         |

| maintain EDG operability. Corrective maintenance to repair the machine and   |

| eliminate the need for compensatory measures will be planned and performed   |

| in a timely manner."                                                         |

|                                                                              |

| The licensee will inform both local agencies and the NRC resident inspector. |

| Notified R1DO (Raymond Lorson).                                              |

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