U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
06/03/2003 - 06/04/2003
** EVENT NUMBERS **
39892 39901 39902
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 39892 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 05/29/2003|
|LICENSEE: Phoenix Baptist Hospital & Medical Ce|NOTIFICATION TIME: 17:19[EDT]|
| CITY: PHOENIX REGION: 4 |EVENT DATE: 05/27/2003|
| COUNTY: STATE: AZ |EVENT TIME: [MST]|
|LICENSE#: 070-146 AGREEMENT: Y |LAST UPDATE DATE: 05/30/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KRISS KENNEDY R4 |
| |MELVYN LEACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: WILLIAM A. WRIGHT | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - ARIZONA |
| |
| The following information was obtained from the Arizona Radiation Regulatory |
| Agency via facsimile: |
| |
| "On May 27, 2003, a patient was administered 27 mCi of Iodine-131 (Iodide) |
| instead of the prescribed dose of 5 mCi. Initial investigation indicates |
| that Medi-Physics Inc. had mistakenly sent a 27 mCi dose designated for AMI |
| to Phoenix Baptist Hospital and the 5 mCi dose for Phoenix Baptist Hospital |
| to AMI. It appears that the 27 mCi dose had been accurately assayed by the |
| Technician, had been noted to differ from the requested 5 mCi, but had been |
| administered to the patient anyway. It should also be noted that the |
| patient had a thyroid ablation procedure conducted previously. Medi-Physics |
| Inc. and Phoenix Baptist Hospital are investigating the situation and a |
| report from each will be forthcoming. |
| |
| "The Agency and licensees will continue to investigate this occurrence and |
| report further." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 39901 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 06/03/2003|
| UNIT: [2] [3] [] STATE: NY |NOTIFICATION TIME: 13:44[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 06/01/2003|
+------------------------------------------------+EVENT TIME: 06:14[EDT]|
| NRC NOTIFIED BY: SEAN EAGLETON |LAST UPDATE DATE: 06/03/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAMES LINVILLE R1 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| STATE OF NEW YORK AND ORANGE COUNTY NOTIFIED |
| |
| On June 3, 2003 at approximately 1006 hours, a review of siren data from |
| June 1, 2003 revealed that four (4) of a total of 16 sirens in Orange County |
| experienced a power failure. The power failure lasted from approximately |
| 0614 until restoration at 0819 hours. The two (2) hour power failure was |
| caused by damage sustained to a power pole in Orange and Rockland utility |
| system. Route alerting was available during the loss of sirens. |
| |
| The NRC Resident Inspectors, State and Orange county were notified of this |
| event. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 39902 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. BARNABAS MEDICAL CENTER |NOTIFICATION DATE: 06/03/2003|
|LICENSEE: ST. BARNABAS MEDICAL CENTER |NOTIFICATION TIME: 15:13[EDT]|
| CITY: LIVINGSTON REGION: 1 |EVENT DATE: 06/03/2003|
| COUNTY: STATE: NJ |EVENT TIME: 09:30[EDT]|
|LICENSE#: 29-01608-03 AGREEMENT: N |LAST UPDATE DATE: 06/03/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES LINVILLE R1 |
| |TOM ESSIG NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID STEIDLEY | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SOURCES IN PATIENT FOUND TO HAVE MIGRATED DURING TREATMENT |
| |
| After 17 hours of irradiation with a cesium-137 source, it was discovered |
| that the source was capable of migrating along a tube that was 16 |
| centimeters long. While the Doctors thought the sources (left and right |
| tubes) were at the 0 centimeter position in the tube they were probably at |
| various locations in the tube during the patient's treatment. Spacers were |
| not placed in the tubes to prevent the cesium-137 sources from moving. |
| During the 17 hours the sources were in the patient the patient laid flat on |
| his/her back but the patient was allowed to move his/her legs and move back |
| and forth. The movements of the patient caused the sources (one cesium-137 |
| source in each tube) to move up and down the tubes. At the end of 17 hours |
| it was found that one of the sources was at the far end of the tube instead |
| of being at the other end of the tube (0 centimeter position). Doctor of |
| the patient was informed of this incident. Patient was not harmed by this |
| error. |
+------------------------------------------------------------------------------+
