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Event Notification Report for August 14, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           08/13/2003 - 08/14/2003



                              ** EVENT NUMBERS **



40019  40055  40058  40059  



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|General Information or Other                     |Event Number:   40019       |

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| REP ORG:  CALIFORNIA RADIATION CONTROL PRGM    |NOTIFICATION DATE: 07/25/2003|

|LICENSEE:  DELLAVALLEY LABORATORIES             |NOTIFICATION TIME: 13:00[EDT]|

|    CITY:  SACRAMENTO               REGION:  4  |EVENT DATE:        07/25/2003|

|  COUNTY:                            STATE:  CA |EVENT TIME:        09:00[PDT]|

|LICENSE#:  3194-10               AGREEMENT:  Y  |LAST UPDATE DATE:  08/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |TROY PRUETT          R4      |

|                                                |FRED BROWN           NMSS    |

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

| NRC NOTIFIED BY:  KENT PREDERGAST              |                             |

|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE                      |

|                                                                              |

| "[The licensee] got in late from work, and failed to take the gauge to       |

| storage location but instead left the gauge in the back of his pickup and    |

| covered it.  The gauge was covered inside the camper shell.  Sometime        |

| between 11 PM on 7/24/03 and 1:00 AM on 7/25/03, the pickup was stolen from  |

| it's parking location.  The Sacramento Police were notified on 7/25/03 and   |

| the licensee will be placing an advertisement in the Sacramento Bee          |

| [newspaper], offering a reward for the stolen gauge.                         |

|                                                                              |

| "The Stolen gauge was a CPN 131, Model 503 DR, serial number H35126508       |

| containing 50 millicuries of Americium  241 Beryllium."                      |

|                                                                              |

| *****UPDATE 8/12/03 AT 12:46 GREGER TO LAURA*****                            |

|                                                                              |

| "The stolen nuclear gauge reported in Event # 030603 [NMED Database number]  |

| was found in a business dumpster in Sacramento, the city in which it was     |

| stolen, on August 3, 2003 by a member of the public. Both the gauge and the  |

| truck in which the gauge was stored overnight (inside a camper shell) was    |

| stolen from a private residence. The truck has not been recovered. The gauge |

| was found inside its protective transportation case. The lock on the         |

| transportation case had been removed, but the gauge remained locked          |

| (radioactive source not exposed). The individual finding the gauge stated he |

| had seen the newspaper ad offering a reward for return of the gauge. The     |

| gauge will be tested for radioactive leakage before being returned to        |

| service. Enforcement action is being taken against the gauge company for     |

| failing to properly store the gauge."                                        |

|                                                                              |

| Notified NMSS (J. Hickey) and R4DO (Phil Harrell).                           |

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|General Information or Other                     |Event Number:   40055       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 08/11/2003|

|LICENSEE:  ARIAS & KEZAR, INC.                  |NOTIFICATION TIME: 16:32[EDT]|

|    CITY:  AUSTIN                   REGION:  4  |EVENT DATE:        08/08/2003|

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

|LICENSE#:  L04964-001            AGREEMENT:  Y  |LAST UPDATE DATE:  08/11/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |PHIL HARRELL         R4      |

|                                                |M. WAYNE HODGES      NMSS    |

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

| NRC NOTIFIED BY:  JIM OGDEN                    |                             |

|  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 - TEXAS                                               |

|                                                                              |

| "On Friday, August 11, 2003, the Licensee was transporting the gauge in a    |

| Nissan Pickup truck that had a defective tailgate.  The Type 7A package was  |

| locked to the pickup with a chain but was held in place with a very small    |

| and cheap padlock.  Also in the truck were concrete samples being            |

| transported for analysis.  While transiting FM 471, the tailgate failed to   |

| the open position when the concrete samples shifted and pushed the gauge     |

| (Troxler Model 3430, Serial No. 28510, with two sealed sources - Am-241 /Be, |

| nominal 40 millicuries, Serial No. 47-25576; and Cs-137, nominal 8           |

| millicuries, Serial No. 750-2732) out of the bed and broke the lock allowing |

| the gauge to become detached from the truck.  The gauge was found by a       |

| member of the public laying in the middle of Highway FM471 being swerved     |

| around by traffic.  The member of the public stopped and picked up the       |

| package and placed in his vehicle and transported it to his residence at     |

| [address deleted], Helotes, Texas.  He opened the package which was not      |

| secured by a locking device. There is no indication that the member of the   |

| public exposed the sources.  He made notification to the Helotes Fire        |

| Department who in turn notified the Texas Department of Health's Public      |

| Health Region 8, Radiation Control Office in San Antonio.  The Public Health |

| Region responded with a Radioactive Materials Inspector who determined that  |

| the gauge was intact and appeared to have no damage.  The Licensee was       |

| notified and retrieved the gauge."                                           |

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|Power Reactor                                    |Event Number:   40058       |

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| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 08/13/2003|

|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 18:35[EDT]|

|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        08/12/2003|

+------------------------------------------------+EVENT TIME:        19:01[EDT]|

| NRC NOTIFIED BY:  MARK GREER                   |LAST UPDATE DATE:  08/13/2003|

|  HQ OPS OFFICER:  HOWIE CROUCH                 +-----------------------------+

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

|EMERGENCY CLASS:          NON EMERGENCY         |GLENN MEYER          R1      |

|10 CFR SECTION:                                 |                             |

|NONR                     OTHER UNSPEC REQMNT    |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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

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

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

|                                                   |                          |

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

|                                                   |                          |

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                                   EVENT TEXT                                   

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| 24-HOUR CONDITION OF LICENSE REPORT DUE TO INOPERABLE INVERTER               |

|                                                                              |

| "On August 11, 2003 at 1901 [EDT], annunciator was received in the Nine Mile |

| Point Unit 2 Control Room that 2VBA-UPS2B had transferred to its maintenance |

| power source.  With the inverter not powering the UPS loads, the inverter    |

| was declared inoperable as of 1901.  This required entry into Technical      |

| Specification (TS) 3.8.7, Condition A with an action of restore inverter to  |

| operable within 24 hours or enter Condition B with actions to be in Mode 3   |

| in 12 hours and Mode 4 in 36 hours.                                          |

|                                                                              |

| "On August 12 at 1958 hours, enforcement discretion was received from Region |

| 1 & NRC headquarters to extend TS 3.8.7, Condition A an additional 18 hours  |

| to complete repairs to the equipment.  Operability was restored to           |

| 2VBA-UPS2B on August 13 at 0508 hours.                                       |

|                                                                              |

| "This notification is being made in accordance with NMPNS, LLC Facility      |

| Operating License section 2.F that requires 24 hour notification, because    |

| discretionary enforcement was granted."                                      |

|                                                                              |

| The licensee has notified the NRC Resident Inspector.                        |

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|Hospital                                         |Event Number:   40059       |

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| REP ORG:  REYNOLDS ARMY COMMUNITY HOSPITAL     |NOTIFICATION DATE: 08/13/2003|

|LICENSEE:  U.S. ARMY                            |NOTIFICATION TIME: 19:11[EDT]|

|    CITY:  Ft. Sill                 REGION:  4  |EVENT DATE:        08/11/2003|

|  COUNTY:  Comanche                  STATE:  OK |EVENT TIME:             [CDT]|

|LICENSE#:  NMC-NU-1              AGREEMENT:  Y  |LAST UPDATE DATE:  08/13/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |PHIL HARRELL         R4      |

|                                                |JOHN HICKEY          NMSS    |

+------------------------------------------------+SONIA BURGESS        R3      |

| NRC NOTIFIED BY:  NELSON UZQUIANO              |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| PATIENT RECEIVES THERAPEUTIC DOSE INSTEAD OF DIAGNOSTIC DOSE OF I-131        |

|                                                                              |

| On 8/13/03,  the Chief Radiologist determined that a patient undergoing a    |

| diagnostic procedure had been given a dose of I-131 that far exceeds the     |

| customary diagnostic dose for a whole body scan.                             |

|                                                                              |

| A patient at the hospital was incorrectly prescribed 5 milliCuries of I-131  |

| and received 5.45 milliCuries of I-131 in preparation for a diagnostic scan  |

| evaluation for sub-sternal ectopic thyroid tissue.  Additionally, the        |

| patient has a history of Grave's disease (a malady affecting the thyroid).   |

| According to the Chief Radiologist, the customary dose for this type of      |

| procedure is in the 1-2 milliCuries range.                                   |

|                                                                              |

| The patient has been notified by the hospital and will undergo further       |

| diagnostic imaging.  The patient has undergone counseling at the hospital    |

| concerning the radiation effects of the I-131.  Additionally, family members |

| of the patient will be given bioassays to determine uptake, if any.  The     |

| prescribing physician will be notified. The Medical Command Radiation Safety |

| Officer has been notified.                                                   |

|                                                                              |

| The hospital has placed procedural precautions in place to minimize the      |

| chances of a future occurrence of this event.  Henceforth, all diagnostic    |

| uses of I-131 will be approved by the Chief Radiologist.  The only allowed   |

| diagnostic uses will be for whole body scans for follow-up evaluations of    |

| the efficacy of thyroid cancer treatment or for the treatment of Grave's     |

| disease.                                                                     |

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