Home
> NRC Library
> Document Collections
> Reports Associated With Events
> Event Notification Reports > 2003 > July 21
Event Notification Report for July 21, 2003
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/18/2003 - 07/21/2003 ** EVENT NUMBERS ** 39941 39978 39999 40000 40005 +------------------------------------------------------------------------------+ |Hospital |Event Number: 39941 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: GUTHRIE HEALTH CARE |NOTIFICATION DATE: 06/16/2003| |LICENSEE: GUTHRIE HEALTH CARE |NOTIFICATION TIME: 09:20[EDT]| | CITY: SAYRE REGION: 1 |EVENT DATE: 06/12/2003| | COUNTY: STATE: PA |EVENT TIME: [EDT]| |LICENSE#: 37-01893-01 AGREEMENT: N |LAST UPDATE DATE: 07/18/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |RAYMOND LORSON R1 | | |DOUG BROADDUS NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JOON PARK | | | HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| | |LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE | | | | A patient was referred for treatment, due to reoccurring prostate cancer, to | | the hospital where he had previously had treatment. Seeds were implanted | | around May 2001. A scan of the previous treatment of implanted seeds | | determined that many of the seeds were not located in the prostate, but in | | adjacent tissue where they would have been ineffective in treatment. Also, | | a review of the records indicated a scan was performed in early 2002, but | | was not followed up on. The patient and referring physician have been | | informed. The hospital is conducting an investigation into the event and | | also developing a plan to provide appropriate treatment for the patient. | | | | * * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * * | | | | Post-op dosimetry on one patient was determined to be a misadministration. | | The dose that covered the prostate was more than 20 percent different from | | the prescription as well as the penile bulb dose being close to 50 percent | | of the prescription dose. Efforts are being made to contact the affected | | patient. The licensee will continue efforts to obtain post-op dosimetry on | | the rest of the patients related to this incident so that evaluations for | | misadministration can be performed. | | | | Notified R1DO (Della Greca) and NMSS EO (Pierson). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39978 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/07/2003| |LICENSEE: |NOTIFICATION TIME: 11:04[EDT]| | CITY: DENVER REGION: 4 |EVENT DATE: 07/06/2003| | COUNTY: ARAPAHOE STATE: CO |EVENT TIME: 16:00[MDT]| |LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/18/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KRISS KENNEDY R4 | | |MARISSA BAILEY NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: GREG STASINOS | | | HQ OPS OFFICER: GERRY WAIG | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - STOLEN ASPHALT CONTENT OVEN | | | | The following is taken from a facsimile sent from the Colorado Department of | | Health and Environment: | | | | On 7/6/03 at 2230 MDT Robin Koons, Colorado State Department of Health and | | Environment, was notified by the Arapahoe County Hazmat Response Team of the | | theft of an asphalt content oven at a construction site located on Highway | | 36, mile marker 119 - 20 miles east of Byers, CO. Arapahoe County Hazmat | | responded to initiate an investigation into the incident. Initial | | information and indications pointed to a moisture density gauge being | | stolen. The moisture density gauge has been found and accounted for. The | | asphalt content oven contains a 100 milliCurie (plus or minus 10%) Americium | | 241:Be source. The oven is used to test for oily content in asphalt during | | road construction process. The area is considered a crime scene and has been | | secured. | | | | Colorado Case Number: 2003-372 | | | | * * * UPDATE 1203 EDT ON 7/18/03 FROM TOM PENTECOST TO S. SANDIN * * * | | | | Colorado Dept. of Health called to confirm that a report of this incident | | was made to the NRC. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39999 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 07/16/2003| |LICENSEE: OHIO STATE UNIVERSITY |NOTIFICATION TIME: 10:57[EDT]| | CITY: COLUMBUS REGION: 3 |EVENT DATE: 07/12/2003| | COUNTY: STATE: OH |EVENT TIME: [EDT]| |LICENSE#: OH02110250037 AGREEMENT: Y |LAST UPDATE DATE: 07/16/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |KENNETH RIEMER R3 | | |FRED BROWN NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: MR LIGHT | | | HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STATE OF OHIO REPORTED AN UNDERDOSE DURING A SINUS TREATMENT BY A LICENSEE. | | | | During treatment of a patient for a sinus tumor at the James Cancer Center, | | an intended dose of 1,750 rads of Ir-192 was to be administered, however the | | patient only received 750 rads. The patient and physician were notified on | | 7/16/03. They are still investigating the root cause of this medical event. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 40000 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 07/16/2003| |LICENSEE: HALIBURTON ENERGY SERVICES |NOTIFICATION TIME: 15:18[EDT]| | CITY: HOUSTON REGION: 4 |EVENT DATE: 07/16/2003| | COUNTY: STATE: TX |EVENT TIME: [CDT]| |LICENSE#: L00442-004 AGREEMENT: Y |LAST UPDATE DATE: 07/16/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |LINDA SMITH R4 | | |DOUG BROADDUS NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: JAMES H. OGDEN | | | HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 4 LABORATORY SOURCES DISCOVERED MISSING AFTER AN INVENTORY CHECK OF OVER | | 1200 SOURCES. | | | | | | | | AGREEMENT STATE REPORT FROM THE STATE OF TEXAS: TEXAS INCIDENT No. I-8037 | | | | | | Licensee: Haliburton Energy Services located in Houston, Texas. Licensee | | No. L00442-004 | | | | | | "During an exhaustive inventory of over 1200 sources stored at the facility, | | it was determined that 4 laboratory sources that had formerly belonged to | | Sperry-Sun, were determined to be missing. The RSO thought that the report | | required was for a 30- day written report and submitted the same to this | | Agency. However, the activity of the missing sources are in excess of the | | reporting requirement for 1000 time the Appendix C value, thus requiring an | | Immediate Report. The sources from the closure of Haliburton's Fort Worth | | site, and acquisition of Sperry-Sun sources were being combined and placed | | in the new Houston storage facility. The four sources: 13 millicuries, | | Cs-137, Serial No. B-404, Model VD-HP; binary source, 0.01 millicuries | | Am-241/0.005 millicuries Cs-137, Serial No. LL-223, Model No A3201; binary | | source, 0.001 millicuries Am-241/0.005 millicuries Cs-137, Serial No. | | LL-224, Model No. A3201; and 0.01 millicuries, Am-241, Serial No. KK-691, | | Model No. A3201. All sources are Licensed to Texas Licensee L00442-004, | | Haliburton Energy Services, Houston, Texas. An exhaustive search of the | | radioactive materials use/storage locations and non-restricted locations in | | Building G (MTL); Building C, Manufacturing; Building E, Training; Test | | pits, TRAC Lab, Building DD, the old Sperry source storage bunker; QC | | CTN:Lab, Building S and Building AA, failed to locate the sources. This | | inventory discrepancy has caused Haliburton Energy Services to incorporate | | all sources into a central database with the capability to track movement of | | radioactive materials globally." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 40005 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: GENERAL ELECTRIC COMPANY |NOTIFICATION DATE: 07/18/2003| |LICENSEE: GENERAL ELECTRIC COMPANY |NOTIFICATION TIME: 12:13[EDT]| | CITY: SAN JOSE REGION: 4 |EVENT DATE: 07/18/2003| | COUNTY: STATE: CA |EVENT TIME: [PDT]| |LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/18/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |JACK FOSTER NRR | | |ANIELLO DELLA GRECA R1 | +------------------------------------------------+JOHN MADERA R3 | | NRC NOTIFIED BY: JASON POST |LINDA SMITH R4 | | HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PART 21 REPORT INVOLVING IMPACT OF FUEL CHANNEL BOW ON CONTROL ROD BLADES | | | | The following is a portion of text received as a fax: | | | | "July 18, 2003 | | "MFN 03-045 | | | | "Subject: 60 Day Interim Notification: Impact of Fuel Channel Bow on Control | | Rod Blade Deviations | | | | "Reference: Letter from Jason Post (GENE) to USNRC, 'Interim Surveillance | | Program for Fuel Channel Bow Monitoring', MFN 03-030 Revision 1, April 30, | | 2003 | | | | "This communication is to inform you that GE Nuclear Energy (GENE) has been | | evaluating a potentially reportable condition (PRC) on the impact of fuel | | channel bow on control rod blades. The original channel bow evaluation for | | increased fuel channel - control rod blade interference did not consider | | previously evaluated deviations in the control rod blade. Channel bow can | | cause increased deflection and stresses in control rod blades, which must be | | considered in control rod blade deviation evaluations. The PRC evaluation is | | limited to control rod blades delivered to those plants identified in the | | referenced letter, where an interim surveillance plan for channel bow | | monitoring is recommended, because those are the only plants where there is | | a concern about increased fuel channel - control rod blade interference. | | | | "As described in the referenced letter, it was determined that BWR/6 and | | BWR/4 & 5 C-lattice plants with Global Nuclear Fuel (GNF) thick/thin | | channels potentially have increased channel bow that can cause fuel channel | | control rod blade interference. An interim surveillance program was provided | | to augment the surveillance requirements in the plant Technical | | Specifications until other actions, which mitigate or limit the potential | | for control rod - fuel channel interference due to channel bow can be | | identified and implemented. This surveillance program provides early | | indication of potentially degraded operational performance and assurance | | that action is taken before reaching excessive levels of control rod | | interference. This surveillance plan is limited to BWR/6 and BWR/4&5 | | C-lattice plants with GNF thick/thin channels and GENE control rods. There | | have been no indications of excessive interference on BWR/2, 3 and 4 | | D-lattice plants, and as a result, they are excluded from the interim | | surveillance program. | | | | "The PRC evaluation was initiated by GENE on May 19, 2003. GENE will not | | have completed the evaluation by July 18, 2003, when the 60 day evaluation | | period expires. Therefore, GENE is submitting this 60 Day Interim | | Notification under 10CFR21.21(a)(2) to inform the NRC that we are working on | | the issue, and to commit to report the results | | of the evaluation no later than September 23, 2003." | | | | GE Nuclear Energy has identified the following as affected plants: Clinton, | | Nine Mile Point 2, Fermi 2, Grand Gulf, River Bend, Limerick 1 & 2 and Perry | | 1. | +------------------------------------------------------------------------------+