Event Notification Report for January 23, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/20/2012 - 01/23/2012

** EVENT NUMBERS **

The following information was received from the State of Georgia:

On January 17, 2012 the State of Georgia received a fax dated January 13, 2012, from one of their licensees (PennTeck Diagnostics, Inc., license number GA 975-1) that one of their two mobile nuclear vans was broken into on Saturday, January 7, 2012, at 1030 EST, but nothing was stolen. PennTeck Diagnostics is located in Augusta, Georgia.

The State contacted the licensee this morning to see if any further details or clarification on the incident could be gathered, but no additional information was given. The licensee reiterated that all of their calibration sealed sources and flood source were accounted for; they installed new locks on the rear lift gate on the mobile van where the thief entered, and the police are looking over the surveillance tapes.

The following report was received by fax:

"On January 17, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee of a source disconnect event that occurred on January 14, 2012. The radiography crew was using a QSA 880D containing 54.9 Curies of iridium-192. The drive cables were also manufactured by QSA. The disconnect was caused by the drive cable snapping approximately four inches from the source connector. The radiographer noted the failure as he approached the camera after a shot and the dose rates indicated the source was still outside the camera. The radiographer notified his Radiation Safety Officer (RSO). The radiography crew set up new barriers and controlled access to the area. The RSO arrived at the site at 1630 hours. The RSO retrieved the source and it was returned to the fully shielded position by 1730 hours. The RSO stated that there was a section of the drive cable that looked like it may have been stretched, but he did not know when or how it could have happened. He stated that they had only had this set of drive cables for no more than eight months. No exposure limits were exceeded during this event. Additional information will be provided as it is received in accordance with SA-300."

The event occurred on County Road 289 in Gonzales County.

Texas incident: I-8922

* * * UPDATE AT 1321 EST ON 01/17/12 FROM ART TUCKER TO S. SANDIN * * *

"The licensee has stated that the drive cable will be returned to the manufacturer for inspection and a cause for the failure [investigation].

Notified R4DO (Pick) and FSME (McIntosh).

The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.

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.

The following report was received via facsimile from the PA Department of Radiation Protection.

"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business, to the central office about an event that took place on March 18, 2011. This email was received by central office on Tuesday January 17, 2012. It is reportable within 24hours under 10 CFR 30.50(b)(2).

"Event Description: On March 18, 2011, a service vendor was at Universal Well Services to perform a change of the iron piping. At that time, they noticed an improper functioning shutter mechanism and it was temporarily fixed. On December 16, 2011, Licensee was inspected by Pennsylvania DEP (Dept. of Environmental Protection). It was found that the shutter on the Berthold Technologies Detector, Serial Number 10072 was replaced on December 15, 2011 with a new shutter Serial Number 10275, permanently fixing the shutter failure.

"The device is identified as: Manufacturer: Berthold Technologies USA, LLC; Serial #: 10072 (becoming 10275); Isotope: Cs-137; Activity: 20 mCi.

"CAUSE OF THE EVENT: Excessive build-up of debris

"ACTIONS: The licensee was directed to make the required notification immediately after receiving an NOV (Notice of Violation) from Pennsylvania DEP dated January 13, 2012 about the shutter failure discovered during an inspection on December 16, 2011."

PA Report ID No.: PA110041.

The following report was received via facsimile from the PA Department of Radiation Protection.

"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business to the central office about an event that took place on approximately November 21, 2011. This email was received by central office on Tuesday, January 17,2012. It is reportable within 24 hours under 10 CFR 30.50(b)(2).

"Event Description: It was noticed during a job on approximately November 21, 2011, the shutter handle of Berthold Technologies Serial Number 10049 fell off due to constant vibration and cavitation of the iron piping on the truck. This caused the roll pin that secures the rotary shutter handle to the shutter shaft to wear and eventually fall off. The gauge was temporarily repaired in the field, and reported on November 29, 2011 to the company's safety officer. The gauge was immediately taken out of service and scheduled for repair.

"The device is identified as: Manufacturer: Berthold Technologies USA, LLC; Model: LB8010; Serial #: 10049; Isotope: Cs-137; Activity: 20 mCi.

"CAUSE OF THE EVENT: Excessive vibration of the equipment.

"ACTIONS: On December 1, 2011 repairs were made to Serial Number 10049. For preventative maintenance, the roll pin was replaced on Serial Number 10055 as well."

Event Report ID No.: PA110042

The following report was received via facsimile from the PA Department of Radiation Protection.

"Notifications: On Friday January 13, 2012, the licensee sent notification via email after close of business to the central office about an event that took place on September 29, 2011. This email was received by central office on Tuesday, January 17, 2012. It is reportable within 24 hours under 10 CFR 30.50(b)(2).

"Event Description: On September 29, 2011, a gauge with Serial Number 10153 was dropped, bending the shutter control handle, leaving the shutter stuck closed. The workers did not notify anyone of the incident and the gauge was put in storage. When the gauge was to be put back in service on November 10,2011, it was then observed to be in the damaged condition. The gauge was then put back into a secured storage until the repair could be made. The gauge was repaired by replacing the shutter with a new Serial Number 10306 on December 1, 2011.

"The device is identified as: Manufacturer: Berthold Technologies USA, LLC; Model: L88010; Serial #: 10153 (replaced by 10306); Isotope: Cs-137; Activity: 20 mCi.

"CAUSE OF THE EVENT: Human error.

"ACTIONS: On December 1, 2011 repairs were made. This was discovered on an inspection by the Department on December 16, 2011."

Event Report ID No.: PA110043.

The following report was received via facsimile from the PA Department of Radiation Protection.

"Notifications: The department's western regional office received a phone call on January 17, 2012 and then referred the matter to the central office via email and telephone on January 18, 2012. This event is reportable within 24 hours under 10 CFR 30.50(b)(2)(i)".

"Event Description: A collimator failure was discovered during a monthly routine maintenance check on January 17, 2012. The collimator had broken off of the shutter mechanism".

"The device is identified as: Manufacturer: Thermo Measure Tech; Model 5204; Isotope: Cs-137; Activity: 4 Ci".

"CAUSE OF THE EVENT: Equipment Failure"

"ACTIONS: Upon discovery, a service provider was contacted and repairs were made by replacing the collimator with a spare one. Surveys were performed to verify appropriate conditions. No employees were exposed to excess levels of radiation as a result of this failure. A 30 day licensee report is expected. The department plans to conduct a reactive inspection."

Event Report ID No.: PA120002

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

A Troxler gauge, Model 3440, was run over and the housing cracked. The source was retracted at the time. The incident is currently under investigation.

FL Incident Number: FL12-005

"On January 17, 2011 the licensee's radiation safety officer called [the state] to advise that a portion of a shipment of radiological material to be used for medical purposes had not arrived at its intended destination. A package containing two doses of Tl-201 of nominally 20 milliCi each was picked up by the Texas licensee, Pan Handle Nuclear, on January 14, 2012 in Amarillo. However, the package showed signs of repaired damage and when inspected, the third dose of Tl-201 was missing from the package. The manufacturer was alerted on the morning of January 16th and they subsequently contacted the carrier, regarding the package.

"HazMat Personnel from [the shipping company] conducted a trace of their facilities associated with the transfer which resulted in the missing vial being identified as 'found' in the Memphis 'Over goods' holding area. Apparently, the package had become damaged early in the morning on January 14th during the shipping process such that one of the three vials had escaped the packaging. The damage to the package was noted and repaired, however an accurate count of the contents was not conducted and, contrary to standing instructions from the manufacturer, the package was forwarded to the intended recipient rather than being returned to the manufacturer.

"The 'missing' vial was subsequently found on the same day later that morning, some hours after the package was processed through the Memphis hub. The vial was identified as hazardous based on the trefoil which appeared on the shielded and intact container and the manufacturer's name. It was isolated and placed into an over pack that same day. The slightly damaged, but intact shielded container was then returned to the manufacturer as of January 18, 2012 after it was determined to be the 'missing' third vial. Surveys of the returned vial conducted by the manufacturer showed that there was no external contamination on the shielded vial, there was no damaged to the vial and all the expected material remained present."

IL item number: IL 12004

A non-licensed, employee supervisor had a confirmed positive test for alcohol. The individual's unescorted access has been administratively withdrawn. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

"At 2237 EST on Friday, January 20, 2012, with the reactor at 100% core thermal power, the Pilgrim Nuclear Power Station (PNPS) determined that portions of the in-plant Safety Parameter Display System (SPDS) were not functioning as designed due to potential problems with the plant process computer. Specifically, the SPDS, which provides numerous plant parameters, some of which are credited for emergency assessment capability, are not currently available. The initial investigation has determined that the failure has not impacted the entire SPDS, but has the potential to impair the licensee's safety assessment capability at this time.

"Immediate actions are being taken to restore the system to functional status and applicable plant procedures have been entered to determine any further mitigating actions.

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

"The licensee has notified the NRC Resident Inspector.

"This notification is conservatively being made in accordance with 10 CFR 50.72 (b)(3)(xiii)."

There is no impact to plant operations. The licensee will be notifying the Commonwealth of Massachusetts.