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Event Notification Report for February 27, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/26/2004 - 02/27/2004

** EVENT NUMBERS **


40542 40543 40544 40547 40548 40549 40550

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General Information or Other Event Number: 40542
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: JOSEPH M. KEYZERS
Region: 3
City: WISCONSIN RAPIDS State: WI
County:
License #: 97-1136-01
Agreement: Y
Docket:
NRC Notified By: JASON HUNT
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/23/2004
Notification Time: 17:23 [ET]
Event Date: 02/19/2004
Event Time: 23:45 [CST]
Last Update Date: 02/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT

"The Wisconsin Radiation Protection Section was notified of a fire involving radioactive materials on February 19, 2004 at 23:45. The item was a NDC Model 104P Portable Mass Gauge containing 25 millicuries of Am-241.

"Members from the Wisconsin Radiation Protection Section responded to the location of the fire in Wisconsin Rapids on Friday, February 20, 2004. Wisconsin Rapids Police Department controlled access to the scene and allowed no one to enter until personnel arrived from the Radiation Protection Section.

"A survey was performed at the location using sodium iodide detectors. The gauge was located under 3 to 4 inches of fire debris. The gauge was emitting 30 millirem/hour on contact with the source opening. Wipe test of the gauge and surveys of the surrounding area confirmed the source was intact. The gauge was damaged severely by the fire.

"Initial investigation into the fire by the Wisconsin Rapids Police Department indicated that the fire was set by two to three individuals to cover up an apparent robbery at the residence. These individuals have been apprehended.

"The licensee used the gauge at temporary job sites in Wisconsin to measure drainage profiles on paper lines at paper mills."

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General Information or Other Event Number: 40543
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: ALTRU HEALTH SYSTEM
Region: 4
City: GRAND FORKS State: ND
County:
License #: 33-01599-03
Agreement: Y
Docket:
NRC Notified By: JIM KILLINGBECK
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/24/2004
Notification Time: 14:10 [ET]
Event Date: 01/28/2004
Event Time: 12:00 [MST]
Last Update Date: 02/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GARY SANBORN (R4)
JOHN HICKEY (NMSS)

Event Text

AGREEMENT STATE REPORT OF MEDICAL EVENT

On 1/28/04, the patient was to receive a total dose of 50.4 Grays to the 'vaginal cuff' region using a 6 Curie Ir-192 sealed source. The dose was to be administered using a Microselectron Remote Afterloader HDR manufactured by Nucletron, serial number 31021.

The plan was to administer 3 radiation treatments using a catheter that is 1500 millimeters (mm) long. The treatment planning software system uses a default value of 995 mm for the catheter length. When preparing the treatment plan for the first of the 3 planned radiation treatments, the medical physicist did not notice that the catheter length in the treatment plan was incorrect (995 mm instead of the actual 1500 mm catheter that would be used). When the radiation oncologist and the medical physicist were doing a pretreatment review and ensuring that the important parameters of the planned treatment were correct, they did not check the catheter length in the treatment plan to ensure that it was correct.

The first radiation treatment was conducted, but instead of the radiation source traveling approximately 1500 mm in the catheter and providing radiation treatment to the 'vaginal cuff' region on the patient, it traveled only about 995 mm, and never entered the patient's body. When the medical physicist began to plan the second of the three radiation treatments, he noticed the error in the treatment plan for the first treatment. The radiation oncologist notified the patient on the same day the error was discovered.

The records of all patients previously treated by this medical physicist and radiation oncologist were reviewed to determine if a similar error had occurred during any other high dose rate remote afterloader treatments, but no other errors of this type were found. To prevent future errors, both the medical physicist and the radiation oncologist have reviewed the treatment planning software and have agreed on a program of formal cross checking of the pretreatment printout that would include verifying that the catheter length specified in the treatment plan is correct.

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General Information or Other Event Number: 40544
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SOIL TESTING AND ENGINEERING, INC.
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 612-01
Agreement: Y
Docket:
NRC Notified By: LARRY CHISMAN
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/24/2004
Notification Time: 14:51 [ET]
Event Date: 02/19/2004
Event Time: 13:00 [MST]
Last Update Date: 02/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
E. WILLIAM BRACH (NMSS)

Event Text

AGREEMENT STATE REPORT

A Campbell Pacific Nuclear (CPN) Density Gauge, Model MC2, serial number M21084026 was stolen from the backseat of a privately owned chevy suburban at approximately 1300 CST on 2/19/04. The gauge contains 10 millicuries of Cs-137, and 50 millicuries of Am-241/Be. The gauge case inside the truck was not locked, but was blocked to prevent movement. Several other items were also stolen from the truck including a cellphone, wallet, and briefcase.

The licensee reported the theft to the Colorado Springs Police Department, Case No. 04-6892, shortly after the theft was discovered. Police are investigating credit card and cellphone usage to try and track down the perpetrators.

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Power Reactor Event Number: 40547
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: BRIAN LOUIS
HQ OPS Officer: ARLON COSTA
Notification Date: 02/26/2004
Notification Time: 08:38 [ET]
Event Date: 02/26/2004
Event Time: 01:05 [EST]
Last Update Date: 02/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
MOHAMED SHANBAKY (R1)

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

Event Text

CONTROL POWER FUSE FAILURE IN HPCI SYSTEM

"The High Pressure Coolant Injection (HPCI) system had been removed from service to perform planned maintenance and testing. During post-maintenance testing, the HPCI gland seal condensate pump tripped due to a blown control power fuse. The maintenance scope did not include the pump or its power supply. The fuse was replaced and the surveillance completed satisfactorily. Investigation into the cause of the failure is ongoing. HPCI remains inoperable in support of additional pre-planned testing."

The licensee notified the State and the NRC Resident Inspector.

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Power Reactor Event Number: 40548
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [ ] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: TIM LACKEY
HQ OPS Officer: BILL GOTT
Notification Date: 02/26/2004
Notification Time: 13:59 [ET]
Event Date: 02/26/2004
Event Time: 11:51 [EST]
Last Update Date: 02/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHARLES R. OGLE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby

Event Text

RPS ACTUATION WHILE CRITICAL

While operating at power, a main turbine trip caused a reactor trip. The cause of the trip is unknown but is being investigated. All control rods inserted on the reactor trip, no primary or secondary system relief valves operated, and reactor temperature is being maintained using the turbine bypass valve to the condenser. Steam generator water levels are being maintained using main feedwater. The station electrical system is available and in a normal configuration. Current RCS pressure is 2149 psig and temperature is 552 deg F. Units 1 and 2 were not affected.

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 40549
Rep Org: ST. MARY HOSPITAL
Licensee: ST. MARY HOSPITAL
Region: 1
City: HOBOKEN State: NJ
County:
License #: 2901024-01
Agreement: N
Docket:
NRC Notified By: IRA GARELICK
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/26/2004
Notification Time: 15:43 [ET]
Event Date: 12/15/2003
Event Time: 12:00 [EST]
Last Update Date: 02/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MOHAMED SHANBAKY (R1)
CHARLIE MILLER (NMSS)

Event Text

MEDICAL EVENT

During a Health Physics audit, while reviewing seed implantation cases, the auditor was reviewing a procedure performed on a patient on 2/13/04. The procedure involved an I-125 seed implantation that delivered 5000 Rad to the patient's prostate. The auditor saw a notation in the record that a previous implantation on 12/15/03 had also delivered 5000 Rad to the same patient's prostate.

When the auditor pulled the record for the 12/15/03 implantation, he discovered that the intended dose from the procedure was 10,000 Rad. He proceeded to call Radiation Medicine Center, the licensee who performed both procedures (License # 2902023-06). Radiation Medicine Center stated that, when evaluating the patient in mid-January, they discovered, via CT scan and dosimetry, that the patient had only received 5000 Rad during the first procedure, and that is why the second procedure was performed on 2/13/04.

The auditor is reporting the implantation from 12/15/03 as a Medical Event.

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General Information or Other Event Number: 40550
Rep Org: UNIVERSITY OF VIRGINIA
Licensee: UNIVERSITY OF VIRGINIA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: RALPH ALLEN
HQ OPS Officer: BILL GOTT
Notification Date: 02/26/2004
Notification Time: 15:49 [ET]
Event Date: 02/26/2004
Event Time: [EST]
Last Update Date: 02/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MOHAMED SHANBAKY (R1)
GARY SANBORN (R4)
CHARLES MILLER (NMSS)

Event Text

LOST ELECTRON CAPTURE DETECTOR

On December 16, 2003. the University of Virginia shipped the Electron Capture Detector section of a Gas Chromatograph to Varian Chromatograph Systems in Walnut Creek, California, using FEDEX. The Electron Capture Detector has a 5 millicurie Nickel-63 source. According to FEDEX, Mr. Cordero signed for receipt of the shipment at 0909 on December 17, 2003. Today, when UVA called Varian to follow up on the status of the detector, they were told that Varian never received the detector.

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