Event Notification Report for November 9, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/08/2000 - 11/09/2000
** EVENT NUMBERS **
37503 37504 37505 37506
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|Power Reactor |Event Number: 37503 |
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| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/08/2000|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 12:10[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 11/08/2000|
+------------------------------------------------+EVENT TIME: 11:37[EST]|
| NRC NOTIFIED BY: CALVIN WARD |LAST UPDATE DATE: 11/08/2000|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |KERRY LANDIS R2 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
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EVENT TEXT
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| OFFSITE NOTIFICATION REGARDING THE CAPTURE OF AN INJURED GREEN SEA TURTLE |
| IN THE PLANT'S INTAKE NET |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "At 1137 on 11/08/00, a notification was made to the Florida Fish and |
| Wildlife Conservation Commission regarding a live green sea turtle found in |
| the plant's intake net. The turtle will be sent to an offsite |
| rehabilitation facility. [...] The notification to a State Government |
| Agency requires a notification to the NRC per 10CFR50.72(b)(2)(vi)." |
| |
| The licensee stated that the turtle was apparently injured by a boat |
| propeller before entering the plant's intake. |
| |
| The licensee notified the NRC resident inspector. |
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|General Information or Other |Event Number: 37504 |
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| REP ORG: OHIO BUREAU OF RADIATION PROTECTION |NOTIFICATION DATE: 11/08/2000|
|LICENSEE: AULTMAN HOSPITAL |NOTIFICATION TIME: 14:10[EST]|
| CITY: CANTON REGION: 3 |EVENT DATE: 11/04/2000|
| COUNTY: STATE: OH |EVENT TIME: 13:00[EST]|
|LICENSE#: 02120770003 AGREEMENT: Y |LAST UPDATE DATE: 11/08/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GEOFFREY WRIGHT R3 |
| |BRIAN SMITH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARK LIGHT | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
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EVENT TEXT
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| TWO PATIENTS GIVEN INCORRECT DELIVERED DOSE |
| |
| The Radiation Safety Officer from Aultman Hospital, on November 4, 2000 at |
| 1300 hours, notified the Ohio Department of Health, that two patients |
| received brachytherapy doses involving Ir-192 temporary implants in excess |
| of 20% of the prescribed dose. The misadministration were discovered during |
| an internal audit of the licensee's Quality Management Program on November |
| 3, 2000, by the Radiation Safety Officer and Radiation Protection Staff. |
| |
| One patient received two courses of brachytherapy treatments with Ir-192 |
| temporary implants. On September 18, 2000, the delivered dose was 3330 cGy, |
| while the prescribed dose was 2000 cGy. This represents a delivered dose |
| discrepancy of 67%. On October 9, 2000, the prescribed dose was 2250 cGy, |
| while the delivered dose was 3500 cGy. This represents a delivered dose |
| discrepancy of 56%. The patient also had external beam therapy treatment |
| from a linear accelerator that was not considered in this |
| misadministration. |
| |
| Another patient received two courses of brachytherapy treatments, with only |
| one brachytherapy treatment qualifying as a misadministration. On August |
| 22, 2000, the delivered dose from Ir-192 was 3500 cGy, while the prescribed |
| dose was 1980 cGy. This represents a delivered dose discrepancy of 78%. |
| The patient also had external beam therapy treatment from a linear |
| accelerator that was not considered in this misadministration. |
| |
| The primary notification from the licensee indicates that the |
| misadministration are due to operator error in data entry of the source |
| strength in the treatment computer. The facility has recently acquired a |
| new computer, and the operator mistakenly entered the source strengths into |
| the computer as milligram-Radium equivalent (mg-Ra-eq) strengths instead of |
| units of millicuries. |
| |
| The licensee does not anticipate any adverse effects to the patients as a |
| result of the additional doses. One patient was notified of the |
| misadministration on November 3, 2000. The other patient will be notified |
| later this week by the radiation oncologist, as the referring physician was |
| not immediately available. |
| |
| The Licensee shall submit a written report to the Ohio Department of Health, |
| Bureau of Radiation Protection, within 15 days after discovery of the |
| misadministration, as delineated in 10 CFR 35.33(2). |
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|General Information or Other |Event Number: 37505 |
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 11/08/2000|
|LICENSEE: DESIGN FUELS CORPORATION |NOTIFICATION TIME: 15:34[EST]|
| CITY: HUEYTOWN REGION: 2 |EVENT DATE: 11/07/2000|
| COUNTY: STATE: AL |EVENT TIME: [CST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 11/08/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KERRY LANDIS R2 |
| |MICHELE EVANS R1 |
+------------------------------------------------+JOHN HICKEY NMSS |
| NRC NOTIFIED BY: DONALD C. WILLIAMSON |CHARLES MILLER IRO |
| HQ OPS OFFICER: LEIGH TROCINE |PAUL LOHAUS OSP |
+------------------------------------------------+FRED COMBS OSP |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| PRELIMINARY INCIDENT NOTIFICATION OF THE DISCOVERY OF A TN TECHNOLOGIES |
| SOURCE HOLDER (WITH A 1-CURIE CESIUM-137 SOURCE AND THE SHUTTER LOCKED OPEN) |
| NEAR HUEYTOWN, AL, AND POSSIBLE ILLEGAL TRANSPORT OF THE DEVICE FROM DESIGN |
| FUELS CORPORATION IN McMURRY, PA, DURING THE EARLY 1990s |
| |
| The following text is a portion of a facsimile received from the State of |
| Alabama Department of Public Health, Alabama Office of Radiation Control: |
| |
| "Subject: Preliminary Notification of a Found Source" |
| |
| "Members of the staff of the Alabama Office of Radiation Control (the |
| Agency) traveled to Hueytown, AL, on November 7, 2000, to investigate the |
| finding of a TN Technologies Model-5191 source holder containing 1,000 |
| millicuries of Cs-137 (as of 1985)." |
| |
| "Circumstances of the Event" |
| |
| "Based on initial information, it appears that the general licensed device |
| was illegally transported by Design Fuels Corporation from their facility in |
| McMurry, PA, to Alabama in the early 1990s. During this transport, and |
| until the time it was discovered, the device shutter was locked in the open |
| position. The device was discovered in a wooded area away from personnel, |
| on private property not accessible to the general public. It is believed |
| the device had been in that location since early 1992." |
| |
| "The device shutter has subsequently been locked in the closed position, and |
| the device [has been] moved to a secure storage location near Hueytown, AL, |
| pending determination of final disposition. Maximum exposure readings with |
| the shutter open were 2.6 rem/hr at near contact with the pipe opposite the |
| source holder. After closing the shutter, maximum readings are 1.8 mrem/hr |
| at contact with the pipe opposite the source holder, 0.5 mrem/hr at 30 cm, |
| and 7.0 mrem/hr at contact with the source holder. The source was tested |
| for leakage. Leak test results were negative." |
| |
| The Alabama Office of Radiation Control notified the NRC Region II office |
| (Richard Woodruff). At this time, the NRC Region II office plans to clarify |
| this information with the State, notify the Environmental Protection Agency, |
| and issue a Preliminary Notification of Event or Unusual Occurrence. |
| |
| (Call the NRC operations officer for contact information.) |
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|General Information or Other |Event Number: 37506 |
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| REP ORG: ALABAMA RADIATION CONTROL |NOTIFICATION DATE: 11/08/2000|
|LICENSEE: QORE, INC. |NOTIFICATION TIME: 18:16[EST]|
| CITY: HUNTSVILLE REGION: 2 |EVENT DATE: 11/08/2000|
| COUNTY: STATE: AL |EVENT TIME: [CST]|
|LICENSE#: 1022 AGREEMENT: Y |LAST UPDATE DATE: 11/08/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KERRY LANDIS R2 |
| |E. WILLIAM BRACH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID TURBERVILLE | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| MOISTURE DENSITY GAUGE MISSING FROM QORE, INC., IN HUNTSVILLE, ALABAMA. |
| |
| The following text is a portion of a facsimile received from the Alabama |
| Office of Radiation Control: |
| |
| "FROM: David Turberville, Radiation Physicist II" |
| |
| "SUBJECT: Alabama Incident File #00-30 - Lost Moisture Density Gauge." |
| |
| "On the morning of November 8, 2000, Shane Kirby, Radiation Safety Officer |
| for Qore, Inc., of Huntsville, Alabama, notified the Alabama Office of |
| Radiation Control stating that it appears that they have lost a CPN model |
| MC-1 moisture density gauge, serial number M1310598? or M13105089? |
| containing 10 millicuries of Cs-137 and 50 millicuries of Am-241/Be. Qore, |
| Inc. is authorized to possess and use the device under Alabama Radioactive |
| Material License No. 1022. The missing device is one of sixteen devices on |
| the licensee's inventory." |
| |
| "Mr. Kirby stated that his records indicate that the device was last used in |
| May of 1999 and was last leak tested on May 16, 1999. Mr. Kirby explained |
| the reason the gauge had not been leak tested or inventoried since May of |
| 1999 was because the file for this device was lost since that time and it |
| did not come to his attention until the file was recently found. Mr. Kirby |
| has no records of transfer since August of 1998." |
| |
| "The Agency last inspected this licensee on January 26, 2000 [...]." |
| |
| "The licensee continues to search the facilities, notify other branches and |
| licensees, and review records of accountability in an effort to locate the |
| device." |
| |
| (Call the NRC operations officer for contact information.) |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021