Event Notification Report for October 29, 2007

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE UNATTENDED FOR SIX HOURS

The State provided the following information via facsimile:

"This is the initial notification for an incident that was reported to this Department on this date. Conam Inspection & Engineering Services, Inc., 6900 East 47th Ave. Unit 200 Denver, CO 80216, a Radiography Licensee (Colorado License # 963-01) provided the Department with the attached Preliminary Incident Investigation report (two pages). Initial details indicate that a radiography source was left unattended and improperly secured on a jobsite for approximately six hours. A member of the job site staff identified the problem and notified the licensee. It appears that this was a result of an ill employee leaving the job site without properly securing the source. An investigation has been initiated by the Colorado Department of Public Health and Environment. No other details are available at this time."

The Conam Preliminary Incident Investigation Report follows:

"Date and time of incident: October 29, 2007 at 11:00 p.m.
Location of the incident: Suncor USA in Commerce City, CO.
Date and time investigation began: October 30, 2007 at approximately 4:30 a.m.

"Description of the Incident/Chronology of Verifiable Events: Conam I&ES performed radiography services at Suncor Refinery in Commerce City, CO on October 29, 2007. These services were being performed on a 24 hour basis. An exposure device was maintained on site and transferred from day shift personnel to night shift personnel. On October 29, 2007 the exposure device was not stored properly in the transport vehicle by the day shift radiographer. The day shift radiographer neglected to lock the outer door to the darkroom and the tailgate on the transport vehicle prior to leaving visual surveillance of the transport vehicle. The vehicle was parked on Suncor property approximately 40 feet from the Conam office. The day shift radiographer departed the job site at approximately 6:45 p.m. The night shift radiographer was on site prior to the departure of the day shift radiographer. The night shift radiographer became ill, and left the lob site at approximately 11:30 p.m. The night shift radiographer left the exposure device on site unattended by any approved Conam I&ES personnel. The night shift radiographer did not access the darkroom at any time on site prior to his departure since the radiography assistant was not present that evening. A Suncor representative noticed the darkroom on site without any Conam representation at approximately 4:30 a.m. The Suncor representative locked the darkroom and removed the keys to the vehicle then notified Conam management. Conam management responded at approximately 5:15 a.m. and representation was on site to properly secure the exposure device at 6:15 a.m. There were no exposures to the Public during this time period.

"List of Contributing Factors: Radiographers failed to follow proper security procedures for securing radioactive materials with IC orders.

"Proposed Corrective Actions: Conam management had a safety stand down for all radiographic personnel at Suncor. All additional radiographic personnel will have a safety stand down this week. The staff will be reinstructed as to the proper protocol for securing radioactive materials with the IC order. The two radiographers have been suspended from radiographic services at this time.

"Corrective Action Plan Complete? No

"If Not, Reason: Corrective action will be completed upon the final outcome of the investigation and the completion of reinstruction to radiographic personnel."

TRANSPORTATION ACCIDENT INVOLVING Tc-99m

"A nuclear pharmacy delivery vehicle has been in an accident. The accident took place on the Chickasaw Turnpike, south of Ada, in Pontotoc County. It is at Mile Marker 14, two miles south of highway 1 and the turnpike junction.

"The vehicle was a nuclear pharmacy delivery vehicle from Nutech, a nuclear pharmacy, in Wichita Falls, TX. He was returning to Wichita Falls (Nutech headquarters is in Tyler, TX, but they have a pharmacy in Wichita Falls). He was returning from making deliveries, and is believed to have had only empty containers of radioactive materials. The radioisotope involved is believed to be Technicium-99m, used in diagnostic nuclear medicine. The doses are believed to have been administered last Friday, which would mean only a slight residue would be in the containers. If the doses involved were in fact from last Friday, the radioactive component should have decayed away by now, and be non-radioactive. The pharmacy reports that the driver had new doses with him for delivery this morning, but he is believed to have delivered those before the accident.

"The delivery vehicle is reported to have swerved across the median of the turnpike and struck an oncoming semi head-on. The driver was killed. Emergency responders removed the driver's body from the vehicle, but no other contact with the vehicle has been made. OHP reports that the ammunition cans used for transport of these doses are outside the vehicles, and at least one has ruptured. There is no evidence of radioactive material on the road, and OHP has left the highway open. This should be safe, even if there is full-strength Tc-99m present.

"OHP and the Ada Fire Department have requested DEQ assistance in verifying the presence or absence of contamination, and a team is on their way there now. If contamination is found, it is likely that DEQ will recommend that the accident area be cordoned off until the material has decayed.

"It is possible there is no hazard at all remaining here, and in any case, there is no hazard except to people in intimate contact with the wreck debris. Keep in mind that these isotopes are intended to be administered to patients, so there is nothing 'lethal' here. DEQ takes any prospect of significant radiation contamination seriously, of course. I am about to inform the NRC of the incident.

"The above is based entirely on reports from OHP, Ada Fire Dept., and NUTECH. It is preliminary and may change as we get more information. There is no known media interest yet, but media interest is likely."

Both the licensee RSO and Oklahoma DEQ are sending teams to investigate possible radiation at the site. It is suspected that the ammo cans are empty since the accident occurred after making deliveries.

* * * UPDATE AT 10:28 ON 10/29/2007 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *

The State provided the following information via email:

"DEQ inspectors [DELETED] have been to the accident scene and done surveys. The driver's body and all people who handled the driver's body were surveyed and showed no signs of radiation. They found no evidence of loose radiation contamination, but did find some intact pigs that showed some evidence of still containing radioactivity inside. They worked with the pharmacy owner to confirm that all pigs had been recovered. All syringes except two empty ones have been recovered. They were unable to find the two empty syringes despite repeated surveys of the crash area, which is covered in tall grass. The pharmacy is taking custody of all pigs and syringes, and packaging them to return them to the licensee facility. Vehicles and the body of the pharmacy driver have been removed from the accident scene. The inspectors are returning to the office.

"The above is a preliminary notification based on a telephonic report from the inspectors in the field.

"The pharmacy license number is Texas license L04274."

Notified R4DO (Powers) and FSME EO (Kokajko).

PLANNED OUTAGE OF ERDADS

"This notification is being made due to a planned loss of [Emergency Response Data Acquisition Display System] (ERDADS). Maintenance will be replacing a bad disc drive for the 'B' Plant Environmental Data System (PEDS) and utilizing the 'A' PEDS for restoration of software. Estimated [time for] return to service is by the end of the business day (1700) [10/29/07]."

The licensee notified the NRC Resident Inspector.

STOLEN TROXLER GAUGE

An authorized user (AU) of the licensee called the RSO at 12:45 on 10/29/07 indicating a 3401 Troxler gauge (s/n 12664) in his possession was stolen. "The gauge was last seen at the authorized user's (AU) residence in Livonia, MI between 4:00 and 5:00 p.m. on 10/28/07. The gauge was secured to the truck bed with two cables that were threaded through the gauge case handle to prevent the gauge case from being opened. Each cable had its own lock. The gauge case lid was also locked. The source rod was locked in the shielded position.

On 10/29/07, the AU drove to a secured temporary job site in Detroit, MI and stayed in or near the open bed pickup truck containing the gauge at all times. The AU identified that the gauge as missing at about noon on 10/29/07. All other equipment in the truck bed remained. The cables were not cut. All of the locks were taken. The licensee suspects that the thief cut the cable locks to steal the gauge.

The licensee searched the area near the AU's residence and did not find the gauge. In addition, the licensee filed a report with its LLEA. The licensee is contemplating whether or not to notify the local media as a means of finding the gauge.

The licensee is in the process of deciding what actions to take to prevent a similar event, with a focus on enhancing security, including making the gauges less visible when they are in open bed trucks."

The activity of the sources are: Am-241/Be (40 millicuries) and Cs-137 (8 millicuries).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

LOSS OF POWER TO TECHNICAL SUPPORT CENTER (TSC)

"On 10/29/07 at 1930 hours, it was determined that the Hope Creek TSC has been unavailable for greater than 8 hours as a result of a scheduled electrical bus outage. Although SPDS, the radiation monitoring system, and communications capabilities remain unaffected, and adequate contingency measures are in place to utilize the Salem Generating Station TSC if required, the loss of normal lighting, computers, CRIDS [Control Room Integrated Display System] and dose assessment capabilities have impaired the effective and efficient use of the Hope Creek TSC. A causal investigation to determine why the impact of the electrical bus outage was not pre-identified has been directed. The plant is currently stable in Operational Condition 5. This report is being made pursuant to 10CFR50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector and the Lower Alloways Creek Township government.

LOSS OF CONTROL OF AM-241 SOURCES IN STATIC ELIMINATOR BARS

The State provided the following information via facsimile:

"On October 29, 2007, the Agency received notification from a metal recycling facility that unexpected radioactive material had been detected in an incoming load of scrap. Agency representatives responded to the site and determined, by using a radioisotope identifier, the presence of Americium-241. The load was returned to its originator under DOT SP 10656, MA-MA-07-01, where an investigation into the type, quantity and form of Am-241 could be performed under controlled conditions. Telephone interviews with the scrap recycler indicated the scrap had originally come from two facilities, one that had already been contacted by him, and had acknowledged possession and use of process gauges at their facility. The Agency contacted the responsible individual and requested an inventory of their sources be performed to determine whether any were lost or missing.

"On October 30, the general licensee reported none of their sources were unaccounted for. Consequently, an agency responder met with the scrap recycler later that day, and on separating the device from other materials, identified the source was a static eliminator bar. The licensee representative was contacted again, and he and another individual responded to the site, where on visual inspection they promptly took responsibility for disposing of the bar from their facility.

"The Agency's investigation to date indicates the initial bar found was one of 12 that had been transferred to the North Andover facility from another of the company's facilities located in Somerville, MA. An additional five bars were discovered the following day in a pile of aluminum scrap at the recycler's yard, where they have been temporarily secured. Six bars were found installed in process equipment at the North Andover facility. The static eliminator bars are not registered with the Agency, and current facility management claims no knowledge that these bars, originally distributed to Sweetheart Cup between 1993 and 1995 by NRD, Grand Island, NY, are required to be registered and controlled under equivalent general license regulations to other devices currently registered with the Agency.

"Sweetheart Cup was purchased by the Solo Cup Company approximately four years ago, and further investigation is necessary before determinations may be made on where, and how, the breakdown in communication regarding these devices occurred, and on the scope of the problem in Massachusetts, or in other jurisdiction where Solo Cup has had, or maintains, manufacturing facilities. The static eliminator bars are NRD Model No. A-2003 and contain up to 20.25 mCi Am-241 each. The licensee has committed to hiring a qualified consultant to assist them with fully characterizing the scope of this event, establishing a plan of correction, and implementing corrective actions if needed."

AGREEMENT STATE REPORT - RADIUM-226 FOUND IN DEMOLITION DEBRIS

The following information was received via fax:

"On 10/29/07, the portal monitor at Nucor Steel alarmed from a load originating at Eastman Kodak. The load contained structural demolition debris. An Exploranium GR-135 identified the source as Radium-226 with a max reading of 210 uR/hr. Eastman Kodak has been notified for follow-up."

New York Event: NY-11-16
New York Incident: 571