United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for July 21, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/20/2010 - 07/21/2010

** EVENT NUMBERS **


46082 46083 46095 46098 46100 46102 46110 46111

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General Information or Other Event Number: 46082
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MARSHFIELD CLINIC
Region: 3
City: MARSHFIELD State: WI
County:
License #: 141-1162-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/09/2010
Notification Time: 12:50 [ET]
Event Date: 07/09/2010
Event Time: [CDT]
Last Update Date: 07/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - BRACHYTHERAPY TREATMENT DOSE DELIVERED DIFFERS FROM PRESCRIBED

The following was received via fax from the State of Wisconsin:

"On July 8, 2010, the licensee's Radiation Safety Officer (RSO) reported the preliminary identification of six medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During recent routine inspection, DHS [Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee is currently evaluating all 269 prostate implants performed since August 2003. This review is ongoing and will include an assessment of whether any implants involved doses to an organ or tissue above 0.50 Sv and 50% more than the expected dose. The licensee is in the process of notifying the affected patients and referring physicians.

"The reported medical events involve two locations of use. One facility identified three under doses (74.8%, 75.2%, and 76.5%) and one overdose (121.4%). The second facility identified one under dose (78.2%) and one overdose (121.0%). DHS inspectors are investigating these medical events and will send a special inspection team following completion of the licensee's review"

Event Report No.: WI100012

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

* * * UPDATE FROM MEGAN SHOBER TO HOWIE CROUCH VIA FACSIMILE ON 7/20/10 @ 1709 EDT * * *

"This is an update to Event Notification 46082. On July 20, 2010, the licensee's Radiation Safety Officer reported the identification of three additional medical events involving permanent implants of I-125 for prostate brachytherapy where the doses to all organ or tissue is above 0.50 Sv and 50% more than the expected dose. The licensee increased the cases reviewed to 275 prostate brachytherapy cases against the medical event criteria. The licensee is in the process of notifying the affected patients and referring physicians.

"The three additional medical events were overdoses to the urethra (159.7%, 161.3% and 151.6%). DHS inspectors are investigating these medical events and will send a special inspection team."

Notified R3DO (Stone) and FSME (Ries).

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Power Reactor Event Number: 46083
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOHN WHALLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/09/2010
Notification Time: 15:55 [ET]
Event Date: 07/09/2010
Event Time: [EDT]
Last Update Date: 07/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ELEVATED LEVELS OF TRITIUM FOUND IN A WELL SAMPLE

"Entergy Pilgrim Station has twelve groundwater monitoring wells used to sample for tritium and other radioactive nuclides in accordance with the Nuclear Energy Institute's (NEI) voluntary Groundwater Protection Initiative (GPI). One of the wells, MW-205, located in the vicinity of the Condensate Storage Tanks (CST) indicated an elevated level of tritium, however well below the limits established by the NEI Groundwater Protection Initiative, the Nuclear Regulatory Commission's (NRC) limits for liquid effluent release and the Environmental Protection Agency's (EPA) limits for tritium in drinking or non-drinking water wells. The latest sample taken on June 21, 2010, returned a test result of 11,072 picocuries per liter of tritium. To date, tritium is the only isotope detected in the samples collected at the site. This information has been communicated to federal, state and local stakeholders and a press advisory is expected to be issued by the Massachusetts Department of Public Health (MDPH). On that basis and the anticipated interest to the general public this notification is being made.

"This event has no impact on the health and/or safety of the public.

"The NRC Resident Inspector is on-site and has been notified."

* * * UPDATE FROM MERT PROBASCO TO HOWIE CROUCH @ 1808 EDT ON 7/20/10 * * *

"Entergy Pilgrim Station has received the results of its most recent weekly tritium sample taken on July 7, 2010 for groundwater monitoring well, MW-205. The sample results have shown an increase in the tritium concentration to 25,552 picocuries per liter (pCi/L) from the previous sample taken on June 30, 2010 which had a test result of 8,477 pCi/L. The latest results remain below any regulatory reporting requirements and the Environmental Protection Agency's (EPA) limits for tritium in non-drinking water wells. This information has been communicated to federal, state and local stakeholders. There remains no threat to drinking water sources and no impact on the health and/or safety of the public.

"The NRC Resident Inspector is on-site and has been notified of this update.

"This is an update to the 4-hour non-emergency notification made in accordance with 50.72(b)(2)(xi) on July 9, 2010 at 1555 hours."

Notified R1DO (Doerflein).

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General Information or Other Event Number: 46095
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: SAINT-GOBAIN PERFORMANCE PLASTICS
Region: 1
City: MERRIMACK State: NH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: TWILA KENNA
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2010
Notification Time: 10:28 [ET]
Event Date: 07/14/2010
Event Time: [EDT]
Last Update Date: 07/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)
ILTAB via email ()

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

Event Text

POTENTIALLY MISSING GENERAL LICENSED GAUGES

The following information was received by facsimile:

On July 14, 2010, Saint-Gobain Performance Plastics contacted the New Hampshire Department of Health and Human Services and provided notification that an inventory had been completed and three thickness gauges were discovered missing. Saint-Gobain is still trying to locate the gauges.

Saint-Gobain is located at 701 Daniel Webster Highway, Merrimack, New Hampshire and possesses the radioactive gauges under a general license. The company is not a specific licensee.

The following missing Beta gauges were supplied by NDC: Sensor serial number 3195, equipment number 103 (7441 LX), source assembly date of 11/27/1992, 150 mCi of AM-241; sensor serial number 3108, equipment number 103 (4414 LX), source assembly date of 11/6/1991, 150 mCi of Am-241; sensor serial number 2271, equipment number 102 (1473 LX), source assembly date of 2/26/1990, 150 mCi of Am-241.

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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General Information or Other Event Number: 46098
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RIVERSIDE MEDICAL CENTER
Region: 3
City: KANKAKEE State: IL
County:
License #: IL-01242-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/15/2010
Notification Time: 18:29 [ET]
Event Date: 07/13/2010
Event Time: [CDT]
Last Update Date: 07/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
KEVIN HSUEH (FSME)
DARYL JOHNSON email (ILTA)

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

Event Text

AGREEMENT STATE REPORT - MISSING BRACHYTHERAPY SOURCES

"On July 15, 2010 the Director of Radiological Services at Riverside Medical Center (IL-01242-01), Kankakee, IL called the Agency [Illinois Emergency Management Agency] to advise that they were missing several sealed sources associated with their inactive brachytherapy program. She had been contacted by her radiation safety officer, who made the initial discovery on Tuesday, July 13, 2010. The staff began a visual search the same day.

"The Riverside Medical Center Administration was notified the following day and directed that additional searches be conducted of more potential locations as the old storage area had since been demolished as part of a facility remodeling project and the safe could have been relocated to another area of the Medical Center. Housekeeping, Maintenance, Facility Management, Radiology and Security Departments at the Medical Center were directed to take part in the search as well.

"Prior to the remodeling, 14 sources of Cs-137 were stored in a lead lined 'safe' which had been locked and secured in a basement storage room of the facility. The new RSO had been in the process of conducting a routine inventory/leak test of the sources when the discovery was made. The key to the safe was still in the possession of the RSO. The 'safe' is approximately 1.5'x1.5'x2.0'. Its weight precludes one or two individuals from removing the safe without additional mechanical assistance. It was marked and labeled with appropriate warning signs.

"The specific inventory of sources is as follows with activities corrected as of today's date; 2 sources of 46 milliCi, 4 sources of 31 milliCi, 4 sources of 23 milliCi and 4 sources of 16 milliCi. The manufacturer's safety sheets infers that these sources have a dose rate of 3.6 milliR/h at a distance of 1 foot for each milliCi of activity (46 milliCi; 167 milliR/h). The sources are nickel plated and appear metallic. The radioactivity is doubly encapsulated within stainless steel. Individually the sources are less than a tenth of an inch (3 millimeters) in diameter and less than an inch (20 millimeters) in length. The sources were last used for a medical treatment in October of 2003 but were included in routine inventories and leak tests. The licensee has no information to suggest any nefarious activity associated with the missing storage safe/sources and currently suspects it may have been removed from the site as part of the construction debris associated with last year's remodeling. A consultant has been contracted to perform additional monitoring at their facility with more sensitive radiation instruments in hopes of locating the storage safe.

"The Agency [Illinois Emergency Management Agency] is monitoring the licensee's search efforts. Sources of this nature are likely to set off radiation monitor alarms which are established at scrap metal facilities and some landfills however, an intact storage safe with the sources still inside is less likely to set off such alarms, due to its inherent shielding to protect medical staff. Maximum surface readings from the safe as measured previously by Agency personnel during site inspections are approximately 35 milliR/h with readings falling to 0.5 to 2 milliR/h at one foot. All sources were physically confirmed as being present by the Agency during a 2005 inspection."

Illinois Report Number: IL10049

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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General Information or Other Event Number: 46100
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: TECUMSEH POULTRY LLC
Region: 4
City: TECUMSEH State: NE
County:
License #: GL0103
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/16/2010
Notification Time: 14:16 [ET]
Event Date: 07/16/2010
Event Time: [CDT]
Last Update Date: 07/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
GLENDA VILLAMAR (FSME)
DARYL JOHNSON email (ILTA)

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

Event Text

AGREEMENT STATE REORT - THIRTEEN TRITIUM EXIT SIGNS LOST

The following was received via fax from the NE Division of Radioactive Materials:

"Six Isolite model 2040-01-12 Tritium exit signs were shipped to Campbell Soup Company at 333 South 3rd Street in Tecumseh, NE in 1993 with 10 Curies of tritium per sign. Six Evenlite model 201 Tritium exit signs were shipped in 1995 with 12.5 Curies of Tritium per sign. One additional sign from Brandhurst, Inc was shipped in 1986. Isolite, Evenlite and Brandhurst did not provide Nebraska with the serial numbers. MBA Poultry bought the facility from Campbell Soup Company in 1998. MBA Poultry sold it to Tecumseh Poultry in 2000. Tecumseh Poultry does not know where the 13 tritium exit signs went."

Manufacturer Activity Model Manufacturer Activity Model
1) Isolite 10.0 Ci 2040 7) Evenlite 12.5 Ci 201
2) Isolite 10.0 Ci 2040 8) Evenlite 13.5 Ci 201
3) Isolite 10.0 Ci 2040 9) Evenlite 12.5 Ci 201
4) Isolite 10.0 Ci 2040 10) Evenlite 12.5 Ci 201
5) Isolite 10.0 Ci 2040 11) Evenlite 12.5 Ci 201
6) Isolite 10.0 Ci 2040 12) Evenlite 12.5 Ci 201
13) Brandhurst unknown 201
Nebraska Report No: NE100001


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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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General Information or Other Event Number: 46102
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: AMC HOFFMAN CENTER 22
Region: 1
City: ALEXANDRIA State: VA
County: FAIRFAX
License #: GL-1722
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/16/2010
Notification Time: 15:53 [ET]
Event Date: 07/02/2010
Event Time: [EDT]
Last Update Date: 07/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
KEVIN HSUEH (FSME)
ILTAB (E-MAIL) (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

"On July 2, 2010 it was discovered during the morning walk-through that one exit sign containing 7.5 curies of H-3 [tritium] was stolen. The licensee searched the trash cans and talked with janitorial staff. The sign was not found. A police report was filed with the Alexandria Police Department."

Virginia Event Number: VA-10-06

The sign was manufactured by Isolite, model 2040-50B. The sign contained 7.5 Ci at the time of manufacture however, the date of manufacture and thus the current sign activity is not known.

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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Other Nuclear Material Event Number: 46110
Rep Org: GLOBAL X-RAY AND TESTING
Licensee: GLOBAL X-RAY AND TESTING
Region: 4
City:  State: LA
County:
License #: 17-29308-01
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/20/2010
Notification Time: 15:09 [ET]
Event Date: 06/24/2010
Event Time: 23:59 [CDT]
Last Update Date: 07/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GREG WERNER (R4DO)
MICHELE BURGESS (FSME)

Event Text

FAILURE TO RETRACT RADIOGRAPHY SOURCE TO SHIELDED POSITION

The licensee was performing radiography at the South Timbalier 55 site in the Gulf of Mexico, under an NRC license, when the source failed to retract to the shielded position. They were using a SPEC-150 camera (serial #860) with a 58 Ci Ir-192 source (serial #RC1106).

The RSO went to the site and retrieved the source. During the retrieval, there were no overexposures to personnel. The camera was returned to the manufacturer who determined that the pig tail connector failed. The device was repaired by the manufacturer and returned to service.

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Power Reactor Event Number: 46111
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: MATT GROHOL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/20/2010
Notification Time: 23:37 [ET]
Event Date: 07/20/2010
Event Time: 20:20 [EDT]
Last Update Date: 07/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOCAL 911 ACTIVATION OF EMERGENCY SIRENS DUE TO POTENTIAL TORNADO IN THE AREA

"Exelon Nuclear Peach Bottom Atomic Power Station received notification from the Harford and Cecil County 911 centers that Harford County emergency sirens were intentionally activated due to a potential tornado in the area. The siren activation was due to the tornado and is in no way related to the operation of Exelon Nuclear Peach Bottom Atomic Power Station."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012