Event Notification Report for January 27, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2009 - 01/27/2009

** EVENT NUMBERS **


44792 44799 44800 44801 44805

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General Information or Other Event Number: 44792
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CENTRAL TESTING LABORATORY
Region: 1
City: LEESBURG State: FL
County:
License #: 3187-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/21/2009
Notification Time: 12:40 [ET]
Event Date: 01/21/2009
Event Time: 12:00 [EST]
Last Update Date: 01/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the State of Florida via fax:

"Troxler gauge run over by dump truck at job site. Sources allegedly in shielded position. State inspector sent to investigate. Upper control rod bent, some damage to outer container. Sources in shielded position, radiation readings nominal. Gauge being transported to Troxler representative in Orlando for repair. No further action will be taken by this office."

Sources: 40 mCi Am:Be, 8 mCi Cs-137

Florida Report: FL 09-006

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General Information or Other Event Number: 44799
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: ECS CAROLINAS, LLP
Region: 1
City: GREENSBORO State: NC
County:
License #: 041-0253-4
Agreement: Y
Docket:
NRC Notified By: CLIFF HARRIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 16:06 [ET]
Event Date: 01/19/2009
Event Time: 17:15 [EST]
Last Update Date: 01/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LOST, THEN FOUND, MOISTURE DENSITY GAUGE

The following information was received from the State of North Carolina via email:

"N.C. Radiation Protection Section was notified on 19 Jan 2009 by the State EOC of the loss of a Troxler Model 3430 portable moisture density gauge (Serial No. 20385) possessed by ECS Carolinas under a specific license. The gauge contained two sealed sources: (1) Cesium-137, 8 mCi, source serial no. 75-1733 and (2) Americium-241:Beryllium, 40 mCi, source serial no. 47-15863.

"The device was lost while being transported between job sites. While in transit, the device was on the tailgate of the transport vehicle; the device was not secured in its transport box nor was it blocked and braced. The Greensboro Police and Fire Departments were notified by the company's RSO at 17:35 [hrs.] and arrived at the scene. Efforts to find the device were not successful. NC Emergency Management was notified by the company's RSO. Instrotek [a local vendor] notified the RSO that a citizen passer-by had observed the device being struck by an SUV on Merritt Drive in Greensboro, NC. The citizen stopped and placed the device in the bed of his pickup truck and transported it to his home in Burlington, NC. The citizen notified Instrotek (telephone number on calibration label on device) of his discovery. A Health Physicist from the NC Radiation Protection Section was dispatched to the citizen's residence and arrived at 19:45 [hrs.]. The device was located on the back, screened porch of the residence, well away from any occupants of the residence. The plastic housing of device was broken, but was otherwise in good condition. Radiation surveys indicated that the sources were in the shielded position, the source rod was in good condition and in the fully retracted position. The source handle/ rod assembly was not locked. The citizen reported that no one had extended the source rod while the device was in his possession. The RSO and an Authorized User from ECS Carolinas, LLP arrived at the residence, packaged the device in an appropriate transport box, blocked and braced the box in a company pickup truck, and transported the device to the authorized storage site at their home office in Greensboro, NC. There were no exposures to radiation from these sources during this event. The Health Physicist was notified on 20 January 2008 by Troxler Electronics that it took possession of the device for damage assessment and repair.

"The investigation of this event by the NC Radiation Protection Section is ongoing."

NC Event Report ID No.: NC-09-08

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General Information or Other Event Number: 44800
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PITTSBURGH MEDICAL CENTER
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 17:04 [ET]
Event Date: 12/04/2008
Event Time: [EST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO PATIENT WAS LESS THAN 50% OF PRESCRIBED DOSE

The following information was obtained from the Commonwealth of Pennsylvania via email:

"Dose administered to patient was only 44% of the prescribed amount of Y90.

"Cause: the treatment catheter became occluded and prevented further delivery of the Y-90 microspheres to the patient. It is not known what caused the occlusion. A later radiation survey of the catheter indicated a relative increased amount of radioactivity within the last 2cm from the tip. The catheter will be sent to the manufacturer for further analysis.

"Effect to the Patient: None

"Notifications : The referring physician was verbally notified of the medical event by the Authorized User. The referring physician verbally notified the patient.

"Corrective Action: Equipment returned to manufacturer for repair or disposal."

Dose given was 5.3 mCi of Y-90. Dose intended was 12.1 mCi.

PA Reference Number: PA080033

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 44801
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: APPLIED TESTING & GEOSCIENCES LLC
Region: 1
City: BRIDGEPORT State: PA
County:
License #: PA-1036
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 17:29 [ET]
Event Date: 01/07/2009
Event Time: [EST]
Last Update Date: 01/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LOST, THEN FOUND, MOISTURE DENSITY GAUGE

The following information was received from the State of Pennsylvania via email:

An Applied Testing & Geosciences employee had possession of a vehicle containing a moisture density gauge. After an evening on the town, the employee had a taxi return him to his hotel as he had forgotten where he left the vehicle. The next day, the employee called in sick and then reported the vehicle stolen to local law enforcement. Later in the day, the vehicle was recovered with the gauge intact. The licensee took possession of the gauge.

PA Reference Number: PA090005

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General Information or Other Event Number: 44805
Rep Org: AMETEK
Licensee: AMETEK
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GEORGE
HQ OPS Officer: GEROND GEORGE
Notification Date: 01/26/2009
Notification Time: 11:32 [ET]
Event Date: 01/26/2009
Event Time: [EST]
Last Update Date: 01/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
PATTY PELKE (R3)
WAYNE SCHMIDT (R1)
CHUCK CAIN (R4)
RANDY MUSSER (R2)
MJ ROSS-LEE (NRR)
THOMAS HARRITY (NRR)

Event Text

AMETEK PART 21 REPORT ON TYCO/POTTER & BRUMFIELD RELAYS

The following information was received from AMETEK via facsimile:

"COMPONENT DESCRIPTION: Electro-mechanical 14 pin relays, with AC voltages of 120 and 240, and DC voltages of 12, 24, 48 and 110. The Tyco/[Potter & Brumfield] relays were removed from the Approved Supplier Listing in 2006. The relays can be installed in Ametek Solidstate Controls equipment, or provided as a spare part.

"PROBLEM YOU COULD SEE: Nuisance alarming or erratic operation of the equipment.

"CAUSE: The problem appears to be an age related degradation of unknown cause. A failure analysis performed by First Energy Laboratory Services identified a potential cause as a crinkled appearance on the surface of the moving contact pads resulting in uneven contact with the opposing stationary contact pad. Over time, a layer of oxidation forms on the pads inhibiting electrical contact and increasing resistance.

"EFFECT ON SYSTEM PERFORMANCE: Potential unstable output voltage caused by intermittent high relay resistance. The relays are generally used for alarm functions but can be used in control circuitry as well.

"ACTION REQUIRED: Replace all Tyco/Potter & Brumfield relays listed below remaining in service with the approved Ametek Solidstate Controls equivalent.

"Component: Tyco/Potter & Brumfield Relays
SCI PIN 07-740001 - P&B PIN KHAU-17A18-120
SCI PIN 07-740002 - P&B PIN KHAU-17A18-240
SCI PIN 07-740005 - P&B PIN KHAU-17D18-12
SCI PIN 07-740006 - P&B PIN KHAU-17D18-24
SCI PIN 07-740007 - P&B PIN KHAU-17D18-48
SCI PIN 07-740008 - P&B PIN KHAU-17D18-110"

The faulty relays are a subcomponent of AMETEK battery chargers, inverters, and uninterruptible power supplies. These types of AMETEK equipment are installed at various reactor licensees. There was no information on which licensees are affected. The manufacturer received notification of the faulty relays from Beaver Valley Power Station. The problem was revealed through a malfunction of a battery charger on 12/11/2008. The manufacturer does not believe that there is an immediate safety concern.

Page Last Reviewed/Updated Thursday, March 25, 2021