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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  



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|Hospital                                         |Event Number:   39941       |

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| 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|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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).                           |

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|General Information or Other                     |Event Number:   39978       |

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| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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.                                                         |

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|General Information or Other                     |Event Number:   39999       |

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| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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. |

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|General Information or Other                     |Event Number:   40000       |

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| 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        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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."                                             |

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|General Information or Other                     |Event Number:   40005       |

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| 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  |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| 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.                                                                           |

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