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Event Notification Report for December 2, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/01/2004 - 12/02/2004

** EVENT NUMBERS **


41230 41234 41235

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General Information or Other Event Number: 41230
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: NORTH SHORE MEDICAL CENTER
Region: 1
City: SALEM State: MA
County:
License #: 44-0161
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/29/2004
Notification Time: 14:07 [ET]
Event Date: 09/25/2001
Event Time: 17:00 [EST]
Last Update Date: 11/29/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
LINDA GERSEY (NMSS)

Event Text

MEDICAL MISADMINISTRATION DUE TO IMPROPER POSITIONING OF IMPLANT DEVICE

"Abstract - Female patient undergoing vaginal implant therapy on September 25, 2001. 'T-bomb' applicator loaded with 3 Cs-137 sources, each 19.73 mg RaEq [milligram Radium Equivalent] (49.92 mCi each, total activity 149.75 mCi). Implant performed 8:30 AM on 9/25/01. Status of implant placement made by nurse at 10:42 AM, and again at 2:10 PM. When physician checked patient at 5:00 PM on 9/25/01, implant was found outside of patient adjacent to her vaginal area. Physician did not report incident to Radiation Safety Officer, thus Licensee did not report incident to State. Estimate of total absorbed dose to the surface of the affected area was 7.55 Gy [Gray], this includes a dose of 0.74 Gy that comes from the normal implant itself.

"Consequence of exposure - Tissue necrosis in affected area."

The cause of the misadministration is still under investigation. A contributing factor was the failure to periodically check the implant placement. The patient was informed.

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Other Nuclear Material Event Number: 41234
Rep Org: US NAVY
Licensee: US NAVY
Region: 4
City: EVERETT State: WA
County:
License #: 45-23645-01NA
Agreement: Y
Docket:
NRC Notified By: CDR LINO FRAGOSO
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/01/2004
Notification Time: 11:55 [ET]
Event Date: 11/29/2004
Event Time: [PST]
Last Update Date: 12/01/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DAVID GRAVES (R4)
JAMES TRAPP (R1)
JOHN HICKEY ()

Event Text

LOST RADIOACTIVE MATERIAL GREATER THAN 10 TIMES THE LIMIT

On 12/22/03, six hand held vapor tracer explosive detectors were sent from the Naval Surface Warfare Center (NSWC) in Crane, IN and received by the Fleet Industrial Supply Center (FISC) in Everett, WA in the beginning of Jan 04. The vapor tracers were then sent to the Todds Pacific Shipyard for delivery to the USS Shoup and the USS Ingraham. Todds Pacific Shipyard denies ever receiving the vapor tracers from FISC. The USS Shoup did receive 5 vapor tracers in Jan 04 and transferred 2 to Todds Pacific Shipyard since only 3 were needed. The remaining 2 vapor tracers were delivered to the USS Ingraham.

The licensee is reporting the loss of one vapor tracer between FISC and Todds Pacific Shipyard. The vapor tracer contains a 8 millicurie Ni 63 source. A search for the lost vapor tracer was conducted at the NSWC, FISC, Todds Pacific Shipyard. Wanted posters were also posted to alert personnel of the missing device. On 11/22/04, NSWC exhausted all likely possibilities for finding the lost devise and declared the vapor tracer lost.

Licensee contacted NRC Region 2 representative.

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Power Reactor Event Number: 41235
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GLENN HORNE
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/01/2004
Notification Time: 15:27 [ET]
Event Date: 12/01/2004
Event Time: 13:30 [EST]
Last Update Date: 12/01/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAUL FREDRICKSON (R2)

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

OFFSITE NOTIFICATION DUE TO LUBE OIL SPILL ONSITE

"At 1330 12/1/04, Catawba determined that the SC Department of Health and Environmental Control (SCDHEC) will be notified of a leak of used oil from the Used Lube Oil Storage Tank. This is an underground storage tank and the leak is not currently active because the system has been secured. An unknown quantity of oil has leaked into the immediately surrounding ground and is currently contained in the soil. Visual observations have not identified any oil leakage into the environment. The used oil is not classified as a hazardous material."

The licensee will inform the States of North Carolina, South Carolina, the counties of York, Gaston and Mecklenburg and has informed the NRC resident inspector.

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Friday, March 30, 2012