Event Notification Report for January 3, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/02/2008 - 01/03/2008

** EVENT NUMBERS **


39201 43734 43872 43879

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General Information or Other Event Number: 39201
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BUILDING AND EARTH SCIENCES
Region: 2
City:  State: AL
County:
License #: 1266
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/19/2002
Notification Time: 16:28 [ET]
Event Date: 09/18/2002
Event Time: [CDT]
Last Update Date: 01/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL FREDRICKSON (R2)
FRED BROWN (NMSS)

Event Text

MOISTURE DENSITY GAUGE STOLEN FROM THE BACK OF A PICKUP TRUCK

"The writer received a call from [an employee] of Building and Earth Sciences at approximately 9:00 AM on September 19, 2002. The employee reported that a Troxler Model 3430 gauge (S/N 30199) had been stolen sometime during the night of September 18, 2002, from their truck working under reciprocity in Memphis, Tennessee.

"The gauge had been left chained in the back of the truck overnight at [ . . . . . ]. The chain had been cut, and the gauge taken. The licensee's employee had contacted both the State of Tennessee and had filed a report with the local police.

"The licensee is continuing their investigation, and considering additional methods to expedite recovery of the gauge."

Contact the Headquarters Operations Officer for additional information.

* * * UPDATE ON 1/2/2008 AT1215 FROM BOBBY SMITH TO MARK ABRAMOVITZ * * *

The State provided the following information via email:

"[Mississippi] DRH [Division of Radiological Health] received a phone call from Desoto County [MS] EMA [Emergency Management Agency] on 12-20-07 about a Troxler Model 3430 moisture/density gauge ( Serial # 30199 ) that was found by a member of the public in the woods. The moisture/density gauge had been stolen on September 19, 2002, (NRC Event No. 39201) in Memphis, Tennessee, while Building & Earth Sciences was working under reciprocity of their Alabama Radioactive Material License AL-1266. The theft was originally reported to Alabama Radiation Control, Tennessee Division of Radiological Health, and the Memphis Police Department. The gauge was picked up by Mississippi Division of Radiological Health on 12-21-07 and returned to our office where it was leak tested and stored. Building & Earth Sciences was contacted and is going to pick the gauge up on 1-3-08. No leakage was detected."

Notified the R1DO (Conte) and FSME EO (Flannery).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43734
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA HOSPITAL
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: JOE O'HARA
Notification Date: 10/19/2007
Notification Time: 18:43 [ET]
Event Date: 10/19/2007
Event Time: 04:00 [CDT]
Last Update Date: 01/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3)
MICHAEL TSCHILTZ (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE GREATER THAN 50 REM

A patient intervened during a vaginal iridium seed implant treatment by removing one of the needles from her body. The needle was found by a nurse approximately 30 minutes after it had been removed by the patient. The needle was located at the foot of the bed near the patients right foot and ankle. The doctor directed the nurse to place the source back into the pig. There were six sources in the needle. Total activity is 7 milliCuries of Ir-192. The estimated dose to the nurses hand was 13 milliRem, and she was wearing a whole body dosimeter, which is being examined. The estimated dose to the patients right ankle is 4.6 to 165 Rem. The patient will be monitored for acute radiation signs. The patient is in the process of receiving the planned dose.

* * * UPDATE PROVIDED BY MELANIE RASMUSSON TO JEFF ROTTON AT 1123 EST ON 01/02/08 * * *

The State of Iowa received a recent update stating that the licensee concluded that the patient's intended dose with IMRT (external beam Intensity Modulated Radiation Therapy) and the dose to the exposed areas of the patients' legs and ankles from the removed source showed no signs of skin reaction as of December 5, 2007 and was due to patient intervention. They are going to continue to follow the patient and said that they would keep the State of Iowa informed.

Notified R3DO (Louden) and FSME (Flannery)

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 43872
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SOUTHWEST VOLUSIA HEALTHCARE CORP
Region: 1
City: ORANGE CITY State: FL
County:
License #: 2467-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/28/2007
Notification Time: 11:34 [ET]
Event Date: 12/28/2007
Event Time: [EST]
Last Update Date: 12/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
SANDRA WASTLER (FSME)

Event Text

MEDICAL EVENT - INCORRECT ISOTOPE ADMINISTERED

"Doctor ordered iodine (didn't specify isotope) thyroid uptake & scan for a patient. This licensee uses I-123 for this purpose. Patient was incorrectly scheduled for a I-131 (2.2mCi) whole body scan and that was done on 12/17/07. Error was discovered 12/25. Patient & doctor have been notified and no adverse health effects are expected. Licensee will submit a written report. Scheduling personnel will be re-educated to verify an order before scheduling patients for a procedure. The tech will be re-educated to read the script before dosing a patient. Any further action on this incident is referred to Radioactive Materials."

Incident Number FL07-205


A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 43879
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GLENN SAXON
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/02/2008
Notification Time: 10:45 [ET]
Event Date: 01/02/2008
Event Time: 03:31 [EST]
Last Update Date: 01/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN VIAS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N Y 98 Power Operation 98 Power Operation

Event Text

LOSS OF TSC RADIO SYSTEM DUE TO BATTERY BACKUP DEPLETION DURING POWER SUPPLY CHANGEOUT

"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Required Action B.2. The functionality of the TSC was lost due to inadvertent removal of electrical power from the radio system that provides the communication function between the TSC and Field Monitoring Teams. Normal power supply was authorized to be removed at 0331 on 01/02/2008 and condition was discovered when battery power depleted. Electrical power has been restored as of 0956 on 01/02/2008 and operability of communication capability has been verified.

" NRC Resident Inspector has been notified."

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