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Event Notification Report for October 14, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/13/2003 - 10/14/2003

** EVENT NUMBERS **


40235 40236 40237 40242 40243 40244 40245

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General Information or Other Event Number: 40235
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: THELEN ASSOCIATES, INC.
Region: 3
City: CINCINNATI State: OH
County:
License #: 31210310005
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/09/2003
Notification Time: 13:52 [ET]
Event Date: 10/09/2003
Event Time: [EDT]
Last Update Date: 10/09/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
DOUG BROADDUS (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN MOISTURE DENSITY GAUGE

The Ohio Bureau of Radiation Protection was notified on 10/9/03 that a CPN Model MC portable moisture density gauge, S/N MD20606630, was stolen from an employee's vehicle parked overnight at his residence. The gauge contains two (2) sources; 9.7 millicuries Cs-137 and 49.8 millicuries Americium-241/Beryllium. The theft was discovered earlier this morning and reported to the State at 1259 EDT. The State is dispatching a field investigator for followup. The licensee informed the local Police Department of this incident.

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General Information or Other Event Number: 40236
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SACRED HEART MEDICAL CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: WN-M031-1
Agreement: Y
Docket:
NRC Notified By: TERRY C. FRAZEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/09/2003
Notification Time: 14:32 [ET]
Event Date: 10/08/2003
Event Time: [PDT]
Last Update Date: 10/09/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
DOUG BROADDUS (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING POTENTIAL LEAKING SOURCE

"This is notification of an event in Washington state as reported to the WA Department of Health, Division of Radiation Protection.

"STATUS:

"New (this is an preliminary notification due to the lack of required information at this point in time).

"Licensee: Sacred Heart Medical Center

"City and state: Spokane, Washington

"License number: WN-M031-1

"Type of license: Medical

"Date of event: 8 October 2003

"Location of Event: on campus (OR)

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)

"The licensee was implanting a source train of I-125 seeds for a lung cancer treatment and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped a source rather than the space between the sources.

"What is the notification or reporting criteria involved? Leaking source, possibly. If not, no notification is required, if so, then a possible overexposure to the patient (thyroid).

"Activity and Isotope(s) involved: Iodine-125 therapy seed(s).

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient.

"Lost, Stolen or Damaged? (mfg., model, serial number): This was an Iodine-125 seed, part of a source train of such seeds which was damaged when the licensee attempted to shorten the train but cut through a seed instead of the interstice desired.

"Disposition/recovery: No loss of seeds.

"Leak test? Licensee is performing one ASAP but as of this writing there are no results.

"Vehicle: (description; placards; Shipper; package type; Pkg. ID number): N/A

"Release of activity? Unknown at this time, if the seed is not leaking, then 'no'. If the seed is in fact leaking then the potential exists for release of material inside the patient.

"Activity and pharmaceutical compound intended: N/A, the proper nuclide and activity was delivered to the intended treatment site.

"Misadministered activity and/or compound received: N/A, this was not a misadministration.

Device (HDR, etc.) Mfg., Model; computer program: N/A, no device involved.

Exposure (intended/actual); consequences: No unplanned exposure, unless the source turns out to be leaking.

Was patient or responsible relative notified? Unknown at this time.

"Was written report provided? Not yet, but it will be.

"Was referring physician notified? Yes, referring MD notified by oncologist.

"Consultant used? No."

This is WA Event Report # WA-03-043.

* * * UPDATE 1830 EDT ON 10/9/03 FROM ARDEN C. SCROGGS VIA EMAIL * * *

"New (this is an updated notification).

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention)

"The licensee was implanting a source train of 31 [Iodine-125] seeds for a lung cancer treatment along the lining of the pleura and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped two source(s) rather than the space between the sources.

"The licensee administered large quantities of SSKI within one hour of breaching the seeds. The current plan is to continue administration of SSKI in amounts of at least 0.5ml daily for at least the next two weeks.

"What is the notification or reporting criteria involved? MISADMINISTRATION via leaking source.

"Activity and Isotope(s) involved: Iodine-125 therapy seed(s). A total of two seeds with an activity of 0.729mCi each according to the licensee.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient. The primary handler has received thyroid bioassay with negative results. The licensee is expecting results of the pleural fluid sample taken from the patient soon, and will attempt thyroid bioassay of the patient at the 72-hour exposure interval.

"Lost, Stolen or Damaged? (mfg., model, serial number): These are Iodine-125 seeds, part of a source train of such seeds which were damaged when the licensee attempted to shorten the train but cut through two seeds instead of the interstice desired. The manufacturer is MPI, the model is the 'Oncoseed' 'Rapid Strand'. The licensee will include an enlarged version of the product insert with their written report.

"Disposition/recovery: No loss of seeds although remains of the two leaking sources are properly stored awaiting decay/disposal.

"Leak test? Leak test results from the soak test (four hours in plain water) showed 'significant leakage' according to the licensee, and they are assuming a worst-case scenario basis of one entire seed leaking and one-half the second seed leaking.

"Release of activity? Yes, it is assumed on a worst-case basis that the entire contents of one seed and fifty percent of the second seed has or will leak.

"Misadministered activity and/or compound received: This was a misadministration by definition because the sources are determined to have leaked.

"Exposure (intended/actual); consequences: Exposure is limited to the patient only. The licensee will attempt to quantify through both calculation and bioassay the extent of patient/thyroid exposure. Physicians involved expect little or no adverse effects at this point, assuming the SSKI works as expected.

"Was patient or responsible relative notified? Yes.

"Rev 1. 1530 hrs, 9 October 2003"

Notified R4DO(Bill Johnson) and NMSS(Holonich).

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General Information or Other Event Number: 40237
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: WESTERN TECHNOLOGIES, INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ-07-080
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/09/2003
Notification Time: 18:08 [ET]
Event Date: 10/09/2003
Event Time: 15:00 [MST]
Last Update Date: 10/09/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JOHNSON (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING MOISTURE DENSITY GAUGE VEHICLE ACCIDENT

"At approximately 2:15 PM [MST] October 9, 2003 the Agency was informed by the Licensee that a truck carrying a moisture-density gauge had been involved in a single vehicle accident and the driver is dead. The reporting individual indicated that they were informed of the accident by the Department of Public Safety. The accident occurred on AZ Highway 260 between Bridgeport and Camp Verde. The moisture-density gauge is a Troxler Model 3440, SN 27494. The device contained 40 mCi Be:Am-241 and 8 mCi Cs-137 [mCi=millicuries]. The device remained in the transporting box inside a locked steel box in bed of pick up. The Licensee is trying to retrieve [it] from law enforcement for storage and leak test. [It is] Currently in an impound yard in Mayer, AZ.

"Agency continues to receive information regarding this fatality. The Agency is unaware of any press coverage regarding radioactive materials.

"The U.S. NRC is being notified of this event."

AZ First Notice: 03-19

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Power Reactor Event Number: 40242
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON BRADLEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/13/2003
Notification Time: 12:59 [ET]
Event Date: 10/13/2003
Event Time: 08:00 [EDT]
Last Update Date: 10/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
KERRY LANDIS (R2)
ANNE BOLAND (R2)
AARON DANIS (TAS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

1-HOUR SECURITY REPORT INVOLVING INADEQUATE SECURITY SEARCH

A visual inspection of the contents of three (3) food containers brought into the protected area by a food vendor was not performed due to personnel error. Compensatory measures were taken upon discovery. The licensee will inform both state/local authorities and the NRC Resident Inspector. Contact the Headquarters Operations Center for additional details.

* * * UPDATE 1500 EDT ON 10/13/03 FROM DON BRADLEY TO S. SANDIN * * *

The licensee provided additional information to include the sizes of the three (3) containers and corrective actions taken. The licensee informed the NRC Resident Inspector. Notified R2IAT (Anne Boland). Contact the Headquarters Operations Center for additional details.

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Power Reactor Event Number: 40243
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MCILNAY
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/13/2003
Notification Time: 17:53 [ET]
Event Date: 10/13/2003
Event Time: 17:00 [EDT]
Last Update Date: 10/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KERRY LANDIS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N N 0 Refueling 0 Refueling

Event Text

INJURED CROCODILE FOUND ON PLANT ACCESS ROAD

The control room was notified by Land Utilization at 1700 EDT that they had contacted the Florida Fish and Wildlife for information on where to take the injured crocodile found on the plant access road. The crocodile was taken to the Miami Zoo.


The NRC Resident Inspector was notified along with the State

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Power Reactor Event Number: 40244
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: GEORGE ROMBOLD
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/13/2003
Notification Time: 19:30 [ET]
Event Date: 10/13/2003
Event Time: 11:20 [EDT]
Last Update Date: 10/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

OFFSITE NOTIFICATION TO OSHA AT THREE MILE ISLAND REGARDING A FATALITY

"A contract delivery employee apparently suffered a heart attack while making a delivery at TMI. The contract employee was treated by the site EMTs and transported to the Hershey Medical Center by off site medical assistance. AmerGen was notified at approximately 1315 that the contract employee was declared dead at the Hershey Medical Center.

AmerGen notified OSHA as required for a fatality at the facility.

" The NRC resident was notified."

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Power Reactor Event Number: 40245
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JEFF YOUNG
HQ OPS Officer: BILL GOTT
Notification Date: 10/14/2003
Notification Time: 05:12 [ET]
Event Date: 10/14/2003
Event Time: 04:04 [EDT]
Last Update Date: 10/14/2003
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
RONALD BELLAMY (R1)
MICHAEL CASE (NRR)
TIM MCGINTY (IRO)
JEFF GLICK (DHS)
MR AUSTIN (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNUSUAL EVENT DECLARED - LOSS OF SHUTDOWN COOLING

At 0404 EDT on 10/14/03, Millstone 2 lost shutdown cooling due to the loss of power to vital power bus VA10. Power and shutdown cooling were restored at 0414. Millstone declared an Unusual Event at 0423 due to a greater than 10 degree increase in reactor coolant system temperature. Reactor coolant system temperature increased from 101 degrees to 113 degrees.

Power was lost to VA10 while attempting to swap power supplies from inverter 1 to inverter 5. Inverter 1 is now supplying power to VA10.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012