U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/13/2003 - 08/14/2003
** EVENT NUMBERS **
40019 40055 40058 40059
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|General Information or Other |Event Number: 40019 |
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| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 07/25/2003|
|LICENSEE: DELLAVALLEY LABORATORIES |NOTIFICATION TIME: 13:00[EDT]|
| CITY: SACRAMENTO REGION: 4 |EVENT DATE: 07/25/2003|
| COUNTY: STATE: CA |EVENT TIME: 09:00[PDT]|
|LICENSE#: 3194-10 AGREEMENT: Y |LAST UPDATE DATE: 08/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TROY PRUETT R4 |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: KENT PREDERGAST | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER GAUGE |
| |
| "[The licensee] got in late from work, and failed to take the gauge to |
| storage location but instead left the gauge in the back of his pickup and |
| covered it. The gauge was covered inside the camper shell. Sometime |
| between 11 PM on 7/24/03 and 1:00 AM on 7/25/03, the pickup was stolen from |
| it's parking location. The Sacramento Police were notified on 7/25/03 and |
| the licensee will be placing an advertisement in the Sacramento Bee |
| [newspaper], offering a reward for the stolen gauge. |
| |
| "The Stolen gauge was a CPN 131, Model 503 DR, serial number H35126508 |
| containing 50 millicuries of Americium 241 Beryllium." |
| |
| *****UPDATE 8/12/03 AT 12:46 GREGER TO LAURA***** |
| |
| "The stolen nuclear gauge reported in Event # 030603 [NMED Database number] |
| was found in a business dumpster in Sacramento, the city in which it was |
| stolen, on August 3, 2003 by a member of the public. Both the gauge and the |
| truck in which the gauge was stored overnight (inside a camper shell) was |
| stolen from a private residence. The truck has not been recovered. The gauge |
| was found inside its protective transportation case. The lock on the |
| transportation case had been removed, but the gauge remained locked |
| (radioactive source not exposed). The individual finding the gauge stated he |
| had seen the newspaper ad offering a reward for return of the gauge. The |
| gauge will be tested for radioactive leakage before being returned to |
| service. Enforcement action is being taken against the gauge company for |
| failing to properly store the gauge." |
| |
| Notified NMSS (J. Hickey) and R4DO (Phil Harrell). |
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|General Information or Other |Event Number: 40055 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 08/11/2003|
|LICENSEE: ARIAS & KEZAR, INC. |NOTIFICATION TIME: 16:32[EDT]|
| CITY: AUSTIN REGION: 4 |EVENT DATE: 08/08/2003|
| COUNTY: STATE: TX |EVENT TIME: [CDT]|
|LICENSE#: L04964-001 AGREEMENT: Y |LAST UPDATE DATE: 08/11/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PHIL HARRELL R4 |
| |M. WAYNE HODGES NMSS |
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| NRC NOTIFIED BY: JIM OGDEN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - TEXAS |
| |
| "On Friday, August 11, 2003, the Licensee was transporting the gauge in a |
| Nissan Pickup truck that had a defective tailgate. The Type 7A package was |
| locked to the pickup with a chain but was held in place with a very small |
| and cheap padlock. Also in the truck were concrete samples being |
| transported for analysis. While transiting FM 471, the tailgate failed to |
| the open position when the concrete samples shifted and pushed the gauge |
| (Troxler Model 3430, Serial No. 28510, with two sealed sources - Am-241 /Be, |
| nominal 40 millicuries, Serial No. 47-25576; and Cs-137, nominal 8 |
| millicuries, Serial No. 750-2732) out of the bed and broke the lock allowing |
| the gauge to become detached from the truck. The gauge was found by a |
| member of the public laying in the middle of Highway FM471 being swerved |
| around by traffic. The member of the public stopped and picked up the |
| package and placed in his vehicle and transported it to his residence at |
| [address deleted], Helotes, Texas. He opened the package which was not |
| secured by a locking device. There is no indication that the member of the |
| public exposed the sources. He made notification to the Helotes Fire |
| Department who in turn notified the Texas Department of Health's Public |
| Health Region 8, Radiation Control Office in San Antonio. The Public Health |
| Region responded with a Radioactive Materials Inspector who determined that |
| the gauge was intact and appeared to have no damage. The Licensee was |
| notified and retrieved the gauge." |
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|Power Reactor |Event Number: 40058 |
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| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 08/13/2003|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 18:35[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 08/12/2003|
+------------------------------------------------+EVENT TIME: 19:01[EDT]|
| NRC NOTIFIED BY: MARK GREER |LAST UPDATE DATE: 08/13/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |GLENN MEYER R1 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| 24-HOUR CONDITION OF LICENSE REPORT DUE TO INOPERABLE INVERTER |
| |
| "On August 11, 2003 at 1901 [EDT], annunciator was received in the Nine Mile |
| Point Unit 2 Control Room that 2VBA-UPS2B had transferred to its maintenance |
| power source. With the inverter not powering the UPS loads, the inverter |
| was declared inoperable as of 1901. This required entry into Technical |
| Specification (TS) 3.8.7, Condition A with an action of restore inverter to |
| operable within 24 hours or enter Condition B with actions to be in Mode 3 |
| in 12 hours and Mode 4 in 36 hours. |
| |
| "On August 12 at 1958 hours, enforcement discretion was received from Region |
| 1 & NRC headquarters to extend TS 3.8.7, Condition A an additional 18 hours |
| to complete repairs to the equipment. Operability was restored to |
| 2VBA-UPS2B on August 13 at 0508 hours. |
| |
| "This notification is being made in accordance with NMPNS, LLC Facility |
| Operating License section 2.F that requires 24 hour notification, because |
| discretionary enforcement was granted." |
| |
| The licensee has notified the NRC Resident Inspector. |
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|Hospital |Event Number: 40059 |
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| REP ORG: REYNOLDS ARMY COMMUNITY HOSPITAL |NOTIFICATION DATE: 08/13/2003|
|LICENSEE: U.S. ARMY |NOTIFICATION TIME: 19:11[EDT]|
| CITY: Ft. Sill REGION: 4 |EVENT DATE: 08/11/2003|
| COUNTY: Comanche STATE: OK |EVENT TIME: [CDT]|
|LICENSE#: NMC-NU-1 AGREEMENT: Y |LAST UPDATE DATE: 08/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PHIL HARRELL R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+SONIA BURGESS R3 |
| NRC NOTIFIED BY: NELSON UZQUIANO | |
| HQ OPS OFFICER: HOWIE CROUCH | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
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EVENT TEXT
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| PATIENT RECEIVES THERAPEUTIC DOSE INSTEAD OF DIAGNOSTIC DOSE OF I-131 |
| |
| On 8/13/03, the Chief Radiologist determined that a patient undergoing a |
| diagnostic procedure had been given a dose of I-131 that far exceeds the |
| customary diagnostic dose for a whole body scan. |
| |
| A patient at the hospital was incorrectly prescribed 5 milliCuries of I-131 |
| and received 5.45 milliCuries of I-131 in preparation for a diagnostic scan |
| evaluation for sub-sternal ectopic thyroid tissue. Additionally, the |
| patient has a history of Grave's disease (a malady affecting the thyroid). |
| According to the Chief Radiologist, the customary dose for this type of |
| procedure is in the 1-2 milliCuries range. |
| |
| The patient has been notified by the hospital and will undergo further |
| diagnostic imaging. The patient has undergone counseling at the hospital |
| concerning the radiation effects of the I-131. Additionally, family members |
| of the patient will be given bioassays to determine uptake, if any. The |
| prescribing physician will be notified. The Medical Command Radiation Safety |
| Officer has been notified. |
| |
| The hospital has placed procedural precautions in place to minimize the |
| chances of a future occurrence of this event. Henceforth, all diagnostic |
| uses of I-131 will be approved by the Chief Radiologist. The only allowed |
| diagnostic uses will be for whole body scans for follow-up evaluations of |
| the efficacy of thyroid cancer treatment or for the treatment of Grave's |
| disease. |
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