U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/18/2003 - 07/21/2003
** EVENT NUMBERS **
39941 39978 39999 40000 40005
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|Hospital |Event Number: 39941 |
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| REP ORG: GUTHRIE HEALTH CARE |NOTIFICATION DATE: 06/16/2003|
|LICENSEE: GUTHRIE HEALTH CARE |NOTIFICATION TIME: 09:20[EDT]|
| CITY: SAYRE REGION: 1 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: 37-01893-01 AGREEMENT: N |LAST UPDATE DATE: 07/18/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RAYMOND LORSON R1 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: JOON PARK | |
| HQ OPS OFFICER: FANGIE JONES | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
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EVENT TEXT
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| DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE |
| |
| A patient was referred for treatment, due to reoccurring prostate cancer, to |
| the hospital where he had previously had treatment. Seeds were implanted |
| around May 2001. A scan of the previous treatment of implanted seeds |
| determined that many of the seeds were not located in the prostate, but in |
| adjacent tissue where they would have been ineffective in treatment. Also, |
| a review of the records indicated a scan was performed in early 2002, but |
| was not followed up on. The patient and referring physician have been |
| informed. The hospital is conducting an investigation into the event and |
| also developing a plan to provide appropriate treatment for the patient. |
| |
| * * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * * |
| |
| Post-op dosimetry on one patient was determined to be a misadministration. |
| The dose that covered the prostate was more than 20 percent different from |
| the prescription as well as the penile bulb dose being close to 50 percent |
| of the prescription dose. Efforts are being made to contact the affected |
| patient. The licensee will continue efforts to obtain post-op dosimetry on |
| the rest of the patients related to this incident so that evaluations for |
| misadministration can be performed. |
| |
| Notified R1DO (Della Greca) and NMSS EO (Pierson). |
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|General Information or Other |Event Number: 39978 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/07/2003|
|LICENSEE: |NOTIFICATION TIME: 11:04[EDT]|
| CITY: DENVER REGION: 4 |EVENT DATE: 07/06/2003|
| COUNTY: ARAPAHOE STATE: CO |EVENT TIME: 16:00[MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/18/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |MARISSA BAILEY NMSS |
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| NRC NOTIFIED BY: GREG STASINOS | |
| HQ OPS OFFICER: GERRY WAIG | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - STOLEN ASPHALT CONTENT OVEN |
| |
| The following is taken from a facsimile sent from the Colorado Department of |
| Health and Environment: |
| |
| On 7/6/03 at 2230 MDT Robin Koons, Colorado State Department of Health and |
| Environment, was notified by the Arapahoe County Hazmat Response Team of the |
| theft of an asphalt content oven at a construction site located on Highway |
| 36, mile marker 119 - 20 miles east of Byers, CO. Arapahoe County Hazmat |
| responded to initiate an investigation into the incident. Initial |
| information and indications pointed to a moisture density gauge being |
| stolen. The moisture density gauge has been found and accounted for. The |
| asphalt content oven contains a 100 milliCurie (plus or minus 10%) Americium |
| 241:Be source. The oven is used to test for oily content in asphalt during |
| road construction process. The area is considered a crime scene and has been |
| secured. |
| |
| Colorado Case Number: 2003-372 |
| |
| * * * UPDATE 1203 EDT ON 7/18/03 FROM TOM PENTECOST TO S. SANDIN * * * |
| |
| Colorado Dept. of Health called to confirm that a report of this incident |
| was made to the NRC. |
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|General Information or Other |Event Number: 39999 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 07/16/2003|
|LICENSEE: OHIO STATE UNIVERSITY |NOTIFICATION TIME: 10:57[EDT]|
| CITY: COLUMBUS REGION: 3 |EVENT DATE: 07/12/2003|
| COUNTY: STATE: OH |EVENT TIME: [EDT]|
|LICENSE#: OH02110250037 AGREEMENT: Y |LAST UPDATE DATE: 07/16/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KENNETH RIEMER R3 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: MR LIGHT | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| STATE OF OHIO REPORTED AN UNDERDOSE DURING A SINUS TREATMENT BY A LICENSEE. |
| |
| During treatment of a patient for a sinus tumor at the James Cancer Center, |
| an intended dose of 1,750 rads of Ir-192 was to be administered, however the |
| patient only received 750 rads. The patient and physician were notified on |
| 7/16/03. They are still investigating the root cause of this medical event. |
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|General Information or Other |Event Number: 40000 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 07/16/2003|
|LICENSEE: HALIBURTON ENERGY SERVICES |NOTIFICATION TIME: 15:18[EDT]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 07/16/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L00442-004 AGREEMENT: Y |LAST UPDATE DATE: 07/16/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LINDA SMITH R4 |
| |DOUG BROADDUS NMSS |
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| NRC NOTIFIED BY: JAMES H. OGDEN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| 4 LABORATORY SOURCES DISCOVERED MISSING AFTER AN INVENTORY CHECK OF OVER |
| 1200 SOURCES. |
| |
| |
| |
| AGREEMENT STATE REPORT FROM THE STATE OF TEXAS: TEXAS INCIDENT No. I-8037 |
| |
| |
| Licensee: Haliburton Energy Services located in Houston, Texas. Licensee |
| No. L00442-004 |
| |
| |
| "During an exhaustive inventory of over 1200 sources stored at the facility, |
| it was determined that 4 laboratory sources that had formerly belonged to |
| Sperry-Sun, were determined to be missing. The RSO thought that the report |
| required was for a 30- day written report and submitted the same to this |
| Agency. However, the activity of the missing sources are in excess of the |
| reporting requirement for 1000 time the Appendix C value, thus requiring an |
| Immediate Report. The sources from the closure of Haliburton's Fort Worth |
| site, and acquisition of Sperry-Sun sources were being combined and placed |
| in the new Houston storage facility. The four sources: 13 millicuries, |
| Cs-137, Serial No. B-404, Model VD-HP; binary source, 0.01 millicuries |
| Am-241/0.005 millicuries Cs-137, Serial No. LL-223, Model No A3201; binary |
| source, 0.001 millicuries Am-241/0.005 millicuries Cs-137, Serial No. |
| LL-224, Model No. A3201; and 0.01 millicuries, Am-241, Serial No. KK-691, |
| Model No. A3201. All sources are Licensed to Texas Licensee L00442-004, |
| Haliburton Energy Services, Houston, Texas. An exhaustive search of the |
| radioactive materials use/storage locations and non-restricted locations in |
| Building G (MTL); Building C, Manufacturing; Building E, Training; Test |
| pits, TRAC Lab, Building DD, the old Sperry source storage bunker; QC |
| CTN:Lab, Building S and Building AA, failed to locate the sources. This |
| inventory discrepancy has caused Haliburton Energy Services to incorporate |
| all sources into a central database with the capability to track movement of |
| radioactive materials globally." |
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|General Information or Other |Event Number: 40005 |
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| REP ORG: GENERAL ELECTRIC COMPANY |NOTIFICATION DATE: 07/18/2003|
|LICENSEE: GENERAL ELECTRIC COMPANY |NOTIFICATION TIME: 12:13[EDT]|
| CITY: SAN JOSE REGION: 4 |EVENT DATE: 07/18/2003|
| COUNTY: STATE: CA |EVENT TIME: [PDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/18/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JACK FOSTER NRR |
| |ANIELLO DELLA GRECA R1 |
+------------------------------------------------+JOHN MADERA R3 |
| NRC NOTIFIED BY: JASON POST |LINDA SMITH R4 |
| HQ OPS OFFICER: STEVE SANDIN | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
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EVENT TEXT
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| PART 21 REPORT INVOLVING IMPACT OF FUEL CHANNEL BOW ON CONTROL ROD BLADES |
| |
| The following is a portion of text received as a fax: |
| |
| "July 18, 2003 |
| "MFN 03-045 |
| |
| "Subject: 60 Day Interim Notification: Impact of Fuel Channel Bow on Control |
| Rod Blade Deviations |
| |
| "Reference: Letter from Jason Post (GENE) to USNRC, 'Interim Surveillance |
| Program for Fuel Channel Bow Monitoring', MFN 03-030 Revision 1, April 30, |
| 2003 |
| |
| "This communication is to inform you that GE Nuclear Energy (GENE) has been |
| evaluating a potentially reportable condition (PRC) on the impact of fuel |
| channel bow on control rod blades. The original channel bow evaluation for |
| increased fuel channel - control rod blade interference did not consider |
| previously evaluated deviations in the control rod blade. Channel bow can |
| cause increased deflection and stresses in control rod blades, which must be |
| considered in control rod blade deviation evaluations. The PRC evaluation is |
| limited to control rod blades delivered to those plants identified in the |
| referenced letter, where an interim surveillance plan for channel bow |
| monitoring is recommended, because those are the only plants where there is |
| a concern about increased fuel channel - control rod blade interference. |
| |
| "As described in the referenced letter, it was determined that BWR/6 and |
| BWR/4 & 5 C-lattice plants with Global Nuclear Fuel (GNF) thick/thin |
| channels potentially have increased channel bow that can cause fuel channel |
| control rod blade interference. An interim surveillance program was provided |
| to augment the surveillance requirements in the plant Technical |
| Specifications until other actions, which mitigate or limit the potential |
| for control rod - fuel channel interference due to channel bow can be |
| identified and implemented. This surveillance program provides early |
| indication of potentially degraded operational performance and assurance |
| that action is taken before reaching excessive levels of control rod |
| interference. This surveillance plan is limited to BWR/6 and BWR/4&5 |
| C-lattice plants with GNF thick/thin channels and GENE control rods. There |
| have been no indications of excessive interference on BWR/2, 3 and 4 |
| D-lattice plants, and as a result, they are excluded from the interim |
| surveillance program. |
| |
| "The PRC evaluation was initiated by GENE on May 19, 2003. GENE will not |
| have completed the evaluation by July 18, 2003, when the 60 day evaluation |
| period expires. Therefore, GENE is submitting this 60 Day Interim |
| Notification under 10CFR21.21(a)(2) to inform the NRC that we are working on |
| the issue, and to commit to report the results |
| of the evaluation no later than September 23, 2003." |
| |
| GE Nuclear Energy has identified the following as affected plants: Clinton, |
| Nine Mile Point 2, Fermi 2, Grand Gulf, River Bend, Limerick 1 & 2 and Perry |
| 1. |
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