Event Notification Report for March 11, 2004

LOST TRITIUM SEALED SOURCE

The US Army Tank Automotive Armaments Command reported that, during routine maintenance following live fire exercises at the National Training Center, Fort Erwin, CA, the US Army determined that the beam splitter from the muzzle reference sensor was missing from the muzzle of one of the tanks. The beam splitter contains a 10 curie tritium sealed source. The range was searched with negative results. Device number: NR-155D-120-S.

VOLUNTARY REPORT INVOLVING POTENTIAL TSC UNAVAILABILITY DURING A DBA LOCA

"Monticello Nuclear Generating plant is making a voluntary report with regard to the Technical Support Center (TSC) not meeting design criteria Subsection 8.2-1.f of Supplement 1 to NUREG-0737. This specifies that the TSC will be provided with radiological protection necessary to assure that the radiation exposure to any person working in the TSC would not exceed 5 REM whole body (or its equivalent part of the body) for the duration of the accident.

"During review of the calculations associated with an on-going Alternative Source Term project, plant staff identified the potential for a radiation shine path to exist from the reactor building to the TSC during a DBA [Design Basis Accident] - Loss of Coolant Accident [LOCA], that could result in radiation levels reaching a point dictating evacuation of the TSC under existing emergency plan procedures.

"As required by NUREG-0696 and confirmed by the plant staff, existing procedural guidance directs personnel to evacuate to the back-up TSC (located in the EOF) if the TSC cannot be occupied continuously.

"The NRC resident has been informed of this discovery."

The licensee is continuing their assessment and will determine the appropriate corrective actions.

AGREEMENT STATE REPORT FROM STATE OF NEW MEXICO

At approximately 2000 hrs MST on 3/11/04, the licensee, Baker-Hughes Oil Field Operations, was rigging a well with a well logging source (2.5 Ci of Cs-137) on a 90 foot tool string when the well started spewing natural gas. The location of the source is 4-6 feet below the rigging platform, which is approximately 15 feet tall, and around 8-10 feet above ground level. The area around the well was immediately evacuated.

Currently, a contractor team from the Cudd company is preparing to enter the well area to cap off the well. The contractor, local law enforcement and local fire department are aware of the source.

The State of New Mexico will update this report when the event has concluded.

MEDICAL EVENT INVOLVING TREATMENT TO WRONG LOCATION

"As a result of a retrospective review of HDR brachytherapy cases, a medical event was discovered. This event occurred on March 11, 2004, which involved a single esophageal HDR brachytherapy treatment. In this case, a 62 year old female patient, was treated with a Nucletron High Dose Rate (HDR) brachytherapy remote afterloader for esophageal cancer . The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a N/G tube (naso-gastric tube) for an active length of 8.0 cm using a 8.49 Curie Iridium-192 source. The treatment plan called for 17 indexer step positions at 5.0mm spacing to begin at dwell position 23 and terminating at dwell position 39. The medical physicist entered 17 indexer step positions with 5.0 mm spacing at dwell positions 1 through 17 and treatment was delivered.

"As the intended delivery site was to be delivered an intended dosage of 500 cGy for one fraction for a total of 500 cGy, the dose delivered to the unintended site was 500 cGy while the intended treatment site was not treated.

"This patient is now deceased. It is not believed this medical event was a significant contributing factor in the cause of death when consideration of the prognosis of the disease is given.

"Although this medical event occurred March 11, 2004, it was discovered 17:45 ET on September 27, 2005, as a result of a retrospective review."

The licensee has notified Region 3 (Madera and Mulay) about this event.