Event Notification Report for March 2, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/27/2009 - 03/02/2009

** EVENT NUMBERS **


44873 44876 44881 44882

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General Information or Other Event Number: 44873
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALIFORNIA INSTITUTE OF TECHNOLOGY
Region: 4
City: PASADENA State: CA
County:
License #: 0314
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: JASON KOZAL
Notification Date: 02/24/2009
Notification Time: 20:58 [ET]
Event Date: 02/23/2009
Event Time: [PST]
Last Update Date: 02/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
PATRICE BUBAR (FSME)
ILTAB (VIA EMAIL) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - PARTIALLY LOST AM-241 SOURCE

The following was provided by the state via email:

The licensee discovered a damaged Am-241 alpha source during a routine sealed source inventory and leak test on Monday February 23, 2009. A pinhole leak was discovered through the source active area. After further assessment on February 24, 2009, it was determined that more than half of the source activity cannot be located.

The Am-241 source was manufactured by North American Scientific (model # CAL2702, source #67250) with an activity of 845.8 nCi (nanocuries) as of October 1, 2005. Currently there is 160 nCi remaining on the Am-241 source and 160 nCi of contamination on the sponge insert in the source container. 521 nCi of the activity cannot be accounted for.

The licensee has performed preliminary contamination surveys of the source storage area, source use area, and the common lab area. The survey were performed using GM survey meters with pancake detectors and wipes counted with a liquid scintillation counter. No significant contamination was found.

The licensee will perform additional surveys and continue to investigate the cause of this incident.

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.

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General Information or Other Event Number: 44876
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NDE, INCORPORATED
Region: 1
City: TAMPA State: FL
County:
License #: 3404-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/25/2009
Notification Time: 11:18 [ET]
Event Date: 02/25/2009
Event Time: [EST]
Last Update Date: 02/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
ANGELA McINTOSH (FSME)
PATRICE BUBAR (FSME)

Event Text

POSSIBLE OVER EXPOSURE DURING RADIOGRAPHY

"Employee's TLD recorded an overexposure of 6.381 rem whole body deep dose; shallow was 6.061 rem. Date [exposure occurred] was between 10 Jan 2009 to 9 Feb 2009. [The] affected employee claims he left his shirt with TLD in area where radiography was being performed. Pocket dosimeter reading was no more than 20 mr. Other employees who worked with him during [the] same time period 10 Jan 2009 to 9 Feb 2009 have no excessive exposures. RSO calculates dose should be approximately 205 mr during month as per records. RSO believes [this is] not an occupational overexposure. Employee's TLD report received today 25 Feb 2009."

Isotope(s): Ir-192 from two (2) separate radiography cameras with activities of 24 Ci and 77 Ci.

State radiation personnel plan to investigate the event.

Florida incident number FL09-020.

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Power Reactor Event Number: 44881
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KEN RUSSELL
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/27/2009
Notification Time: 04:37 [ET]
Event Date: 02/27/2009
Event Time: 05:00 [EST]
Last Update Date: 02/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HIRONORI PETERSON (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT OF SERVICE

"The Perry Nuclear Power Plant will be taking the Plant Computer out of service for scheduled maintenance which will take ERDS out of service. From 0500 hours EST on February 27, 2009 for approximately 15 hours, personnel will be performing inspection and cleaning activities on the Plant Computer power center panel. During the planned maintenance, the Safety Parameter Display System (SPDS) and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) will be unavailable.

"In the event of an emergency, plant parameter data will be orally transmitted to the facilities through the Status Board Ring Down circuit with back-up by the Private Branch Exchange, the Off Premise Exchange, and various redundant intra-facility circuits throughout the emergency facilities. The dose assessment function will be maintained during the out of service time period by manual input of data into CADAP and, if required, by manual calculation. The ability to open and maintain an 'open line' using the Emergency Notification System will not be affected and will be the primary means of transferring plant data to the NRC as a contingency until the ERDS can be returned to service during the period of unavailability.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii), as a condition that results in a major loss of offsite communications capability. A follow-up notification will be made when the maintenance activities are completed and the equipment is restored.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM TOM MORSE TO JOE O'HARA AT 1910 EST ON 2/27/09 * * *

The Perry Plant computer and the ERDS have been restored to service as of 1845 EST this evening.

The licensee will notify the NRC Resident Inspector.

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Other Nuclear Material Event Number: 44882
Rep Org: USAF
Licensee: USAF
Region: 1
City: ANDREWS AFB State: MD
County:
License #: 42-23539-01
Agreement: Y
Docket:
NRC Notified By: LT COL CRAIG ADAMS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/27/2009
Notification Time: 12:52 [ET]
Event Date: 02/04/2009
Event Time: [EST]
Last Update Date: 02/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTOPHER CAHILL (R1)
VINCENT GADDY (R4)
ANGELA MCINTOSH (FSME)
ILTAB VIA E-MAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST NICKEL-63 SOURCE

"Description of the material involved, including kind, quantity, and chemical and physical form: GE Vapor Tracer 2 detection system (SN 07024933861). Approx. 8 mCi Nickel-63 (#09-3896).

"Description of the circumstances under which the loss occurred: On 29 Jan 09, during a routine semi-annual audit, the Andrews Air Force Base (AAFB) Radiation Safety Officer (RSO) identified the missing device used by the Aerial Port Squadron (APS). The device was used to screen luggage for explosives/narcotics. A review of records indicated the device was sent to the Defense Reutilization and Marketing Service (DRMS) through base supply by the user on 1 Jul 08. On 4 Feb 09, the RSO contacted the USAF Radioisotope Committee (RIC) to report the event. NOTE: The RSO is a member of the Bioenvironmental Engineering (BE) office.

"An investigation shows the APS (user) contacted the BE office on 24 Jan 08 and received instructions for disposing of the device via the DRMS. A technician from the BE office certified the device did not contain any hazardous material and would be suitable for turn-in to the DRMS. On 25 Jan 08, an officer from the BE office (not the RSO) sent a letter to the user affirming the technician's assessment. The technician and officer had no knowledge the device contained radioactive material (RAM). No RAM warning labels were visible on the exterior surface of the device.

"During the investigation of the loss of material, the RSO found the RAM warning label was located under the battery pack and not visible. Being unfamiliar with the device, the technician evaluated it for chemical hazards (and found none) but didn't consider radiological aspects.

"After review of all transfer/receipt and inventory documents over a span of three years, the RSO found no evidence that another event of this type had occurred at AAFB. This is an isolated event. Air Force Instruction 40-201, Managing Radioactive Material in the U.S. Air Force, expressly prohibits GLDs from being sent to the DRMS.

"A statement of disposition, or probable disposition, of the material involved: The investigation by the RSO revealed the device left AAFB and traveled to DRMS at FT Meade, MD and then to the DRMS at Mechanicsburg, PA. It was sold to a de-manufacturing contractor, Global Investment Recovery, where it was shredded for scrap. The scrap was sold through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further.

"Exposures of individuals to radiation, circumstances under which the exposures occurred, and the possible total effective dose equivalent to persons in unrestricted areas: Nickel-63 is a pure beta emitter with a 100 year half life. The ingestion annual limit on intake (ALI) is 9 millicuries (mCi). Ingestion of the source would not exceed the ALI and the committed effective dose equivalent (CEDE) would be less than 5 rem. The (Class D) inhalation ALI is 2 mCi. Using the EPA's inhalation dose conversion factor of 3.1 millirem/microCuries, the CEDE for 8 mCi of Ni-63 (Class D) is 25 rem. The size of the source is approximately that of a pencil eraser. It is unlikely an industrial shredder could have pulverized it to such an extent so as to present an inhalation hazard. The possible total effective dose equivalent to persons in unrestricted areas is presumed to be less than 1% of the ALI.

"Actions that have been taken, or will be taken, to recover the material: The RSO tracked the device from AAFB (1 Jul 08) to the DRMS at Fort Meade, MD and to the DRMS at Mechanicsburg, PA (7 Aug 08). It was shredded by Global Investment Recovery, the DRMS de-manufacturing contractor and sold as scrap through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further.

"Procedures or measures that have been, or will be, adopted to ensure against a recurrence of the loss of material: The RSO has determined the root cause of the event to be inadequate training. The users of the device and the BE office did not, collectively, possess information about GL material. The RSO had not shared his knowledge about the material with the BE office.

"The following corrective measures have been taken: Photographs of GLDs will be taken and provided to the BE staff, the users, base supply and DRMS. If warning labels are considered to be inadequate, new labels will be affixed to GLDs to alert individuals that RAM is present. The RSO, working with BE staff, has initiated awareness training for users of GLDs. Such will be conducted annually. Users will be required to possess binders in which to maintain information about their devices (e.g., safety data sheets, owner's manuals, policy, pictures, inventory, leak test results, contact numbers, etc.).

"The RSO has informed management of the event. Lessons learned will be passed down to targeted audiences. Andrews AFB instructions will be evaluated for gaps in policy and strengthened as necessary. The means for purchasing and transferring GLDs back to the manufacturer will be addressed in detail.

"The RIC Secretariat has contacted the GE Radiation Safety Officer regarding the placement of the radiation warning label. The RIC Secretariat informed Ms. Rachel Browder, NRC Region-IV, about the loss of a GLD on 10 Feb 09."


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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