Event Notification Report for July 28, 2011

FIRE AT RADIATION THERAPY PRACTICE

The following was received from the state via e-mail:

"N.C. Radiation Protection Section was notified on 1 August 2011 by the Regional Medical Physicist for NC Radiation Therapy Management Services, Inc. d/b/a 21st Century Oncology of a major fire on the fifth floor of the building in which the licensee operates a radiation therapy practice on the ground floor. The ground floor did not receive direct fire/smoke damage, but did realize significant water damage to portions of its facility. One fireman was killed and 10 injured while fighting the fire. The entire building has been closed and is currently under the command of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) National Response Team (NRT) along with special agents from their Charlotte Field Division. Other agencies involved in this investigation are the North Carolina State Bureau of Investigation and the Asheville Fire Department. The licensee has been permitted to enter its facility once to retrieve critical computer servers that are utilized in patient care at their clinics throughout western North Carolina. The licensee examined its HDR remote afterloader containing one Ir-192 sealed source (<12 Ci) and found the afterloader to be undamaged and securely locked in a treatment vault. The licensee also has a small number of Cs-137 brachytherapy sealed sources (<450 mCi total) in a locked lead source safe within a locked source storage room. The licensee determined that there was no damage to the source storage room and that the room is secure. The licensee is in the process of contracting Nucletron to remove and dispose of the Ir-192 sealed source and is investigating the disposal of all Cs-137 brachytherapy sealed sources.

"The Radiation Protection Section has assigned an inspector to contact the ATF to determine the earliest possible time for a site visit.

"N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued."

NC Event Report ID No. NC-11-42

* * * UPDATED AT 1515 EDT ON 08/03/11 FROM CLIFF HARRIS TO S. SANDIN * * *

The State of North Carolina is retracting this report based upon further review and discussions with NRC Region I Office staff in that the sealed sources were not impacted by the fire.

Notified R1DO (Bellamy) and FSME (McIntosh).

CONTROL ROOM TEMPERATURE RECORDER INOPERABLE

"On July 28, 2011, at 0115 hours, a main control room recorder failed. The recorder functions to remotely monitor plant area temperatures, including eight areas used in accident classification (specifically, Emergency Action Level classifications when predetermined temperature levels are exceeded).

"Troubleshooting efforts have been initiated to determine the cause of the recorder failure; the eight affected areas are being monitored locally twice per shift during operator rounds.

"Given this recorder is used for accident classification, this event is reportable under 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

DEPLETED URANIUM-238 SHIELDS ARE MISSING

Between April and June of 2010, the licensee shipped shielded Tc-99m generators to customers in Ohio and Hawaii. Each generator was shipped with a 8.1mCi depleted U-238 shield. Ohio State University (OSU) Medical Center received 2 generators and Tripler Army Medical Center in Hawaii received 1 generator. Once the generators are depleted, they are returned to Mallinckrodt in the depleted uranium shields. OSU Medical Center shipped one depleted generator in April 2010 (shield s/n 004631) and one in May 2010 (shield s/n 004042). Tripler Army Medical Center in Hawaii shipped their depleted generator in June 2010 (shield s/n 002426). Records confirm that all three shields were picked up by the carriers at the respective facilities but Mallinckrodt has no records of the shields being returned to their facility. The shields are returned to a courier contracted by Mallinckrodt who in turn delivers the shields to the Mallinckrodt facility. The carriers used for the return shipments were contacted about the missing shields and are presently investigating there whereabouts. The licensee, as well as the customers, are also searching their facilities. This matter is under investigation.

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

OFFSITE NOTIFICATION DUE TO FISH KILL EVENT

"At 2115 on 7/28/2011, Oyster Creek experienced a fish kill of greater than 100 fish caused by a loss of the thermal dilution plant power. The loss of thermal dilution plant power was based on a faulted breaker in the Oyster Creek/JCP&L substation.

"The reported failure was a relay failure inside a 34.5KV substation breaker. Oyster Creek is holding at 53% power until thermal dilution is restored for environmental limitations."

The New Jersey Department of Environmental Protection has been notified. The NRC Resident Inspector will be notified.