United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for June 26, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/25/2012 - 06/26/2012

** EVENT NUMBERS **


48033 48034 48047

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Agreement State Event Number: 48033
Rep Org: COLORADO DEPT OF HEALTH
Licensee: NUQUEST, INC.
Region: 4
City: GRAND JUNCTION State: CO
County:
License #: 1022-01
Agreement: Y
Docket:
NRC Notified By: JAMES JARVIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2012
Notification Time: 13:58 [ET]
Event Date: 06/15/2012
Event Time: 02:30 [MDT]
Last Update Date: 06/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME via E-mail ()

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

Event Text

AGREEMENT STATE REPORT - BURST VIAL OF Tc99m IN NUCLEAR PHARMACY

The following information was received via email:

"On Friday, June 15, 2012, at approximately 0230 Mountain Daylight Time (MDT), a nuclear pharmacy licensee located in Grand Junction, Colorado, had a vial containing approximately 1.9 Ci of liquid Tc99m burst and likely volatilize following placement on a heating block as part of compounding activities for preparation of cardiac imaging (Sestamibi) radiopharmaceuticals. The pharmacist, who also serves as the Radiation Safety Officer (RSO), notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer several hours later at approximately 1000 MDT on Friday, June 15.

"Following the initial notification to CDPHE, a secondary phone interview of the pharmacist was conducted. It was determined that the burst container resulted in contamination of the pharmacist, compounding area (generator room), and areas within the main pharmacy. The pharmacist was the only person in the facility at the time of the incident. Other staff - primarily courier personnel - arrived after the incident, and provided some assistance but reportedly did not enter the pharmacy lab area. As a result of the ruptured vial, radiation survey instruments in the laboratory became contaminated, which required the licensee to borrow instrumentation from a local hospital licensee. Sometime following the incident, the pharmacist initiated limited decontamination activities of himself (glove and lab coat removal/exchange) and the area. The pharmacist reportedly continued with the preparation of some radiopharmaceutical materials following the incident. Additionally, following gross decontamination activities at the pharmacy, the pharmacist left the licensee facility to shower and change clothing at his residence.

"During phone interviews with the licensee, CDPHE requested that the pharmacist obtain a urine sample, prepare for the return and processing of personal dosimeter badges and arrange for a back-up pharmacist. The pharmacist was directed to not conduct work involving radioactive material, pending further evaluation of internal and external dose.

"In response to the incident, CDPHE dispatched the on-call duty officer from the Denver office to the Grand Junction area on Friday afternoon. (NOTE - Grand Junction, Colorado is approximately 5.5 hours drive time from the Denver CDPHE office). CDPHE staff met with the licensee pharmacist/RSO on the morning of Saturday, June 16, 2012 to evaluate the situation and perform surveys of potentially impacted areas and personnel. A whole body scan of the pharmacist was conducted at a local hospital nuclear medicine department in the later morning of Saturday, June 16. Personnel surveys of the pharmacist and the scan did not indicate the presence of radioactive material. Further details and information are being gathered.

"No members of the public were believed to have been exposed above public dose limits as a result of the incident, and radioactive materials are believed to be contained within the lab area, with the exception of minor contamination discovered near the back door to the pharmacy.

"The Department continues to investigate the incident and is gathering additional information."


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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Agreement State Event Number: 48034
Rep Org: COLORADO DEPT OF HEALTH
Licensee: KUMAR AND ASSOCIATES, INC
Region: 4
City: DENVER State: CO
County:
License #: 778-01
Agreement: Y
Docket:
NRC Notified By: JAMES JARVIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/18/2012
Notification Time: 18:20 [ET]
Event Date: 06/15/2012
Event Time: 14:15 [MDT]
Last Update Date: 06/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

"On Friday, June 15, 2012, at approximately 3:15 p.m. MDT (Mountain Daylight Time), a portable gauge licensee (Kumar and Associates, Inc.; Colorado License No. 778-01, Amendment 14) based in Denver, Colorado notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer that a gauge being used on a construction site had been damaged by heavy equipment earlier in the day (~2:15 p.m. MDT). The licensee reported that heavy equipment backed up and rolled over the gauge and the gauge technician was unable to retrieve or move the gauge in time. According to the licensee, and based on visual observation, the source capsule area at the end of the rod appeared intact and not significantly damaged as a result of the incident. Neither the source nor source rod were separated from the body of the gauge. The source rod, however, could not be retracted back into the shielded position and was transported back to the licensee facility in that manner.

"The gauge involved was a Troxler model 3440 (gauge serial number 32754), currently containing approximately 6.2 mCi (decayed from 3/1/2001 assay date) of Cs-137 (serial #750-8100) and 40 mCi (5/28/99 assay date) of Am-247:Be (serial #47-28951).

"At the time of the notification by the licensee to CDPHE at approximately 3:15 pm MDT, the gauge had already been returned to the licensee's facility. CDPHE requested that a leak test be performed on the gauge sources before any further actions are taken and that the licensee consult with a licensed repair facility or manufacturer for proper shipment of the damaged gauge.

"Additional information and an incident report from the licensee is pending."

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Power Reactor Event Number: 48047
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF GROFF
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/25/2012
Notification Time: 16:38 [ET]
Event Date: 06/25/2012
Event Time: 13:30 [EDT]
Last Update Date: 06/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 26 Power Operation 0 Hot Shutdown

Event Text

REACTOR FEED PUMP TRIP RESULTS IN MANUAL REACTOR SCRAM

"At 1330 EDT on June 25, 2012, while restoring the Main Turbine Generator (MTG) to service after repairs to Main Unit Transformer 2B (MUT2B), Main Control Room (MCR) staff manually initiated a reactor scram in response to trip of both Reactor Feed Pumps (RFP). All control rods fully inserted. The lowest Reactor Water Level (RWL) reached was 154 inches and, as expected, HPCI and RCIC did not actuate. RWL was restored to normal using the Standby Feedwater (SBFW) system. RWL is currently being maintained in the normal level band with SBFW and Control Rod Drive (CRD) systems. No Safety Relief Valves (SRV) actuated. All isolations and actuations for RWL 3 occurred as expected. Investigation into the trip of RFPs continues.

"At the time of the scram, all Emergency Core Cooling Systems (ECCS) and Emergency Diesel Generators (EDG) were operable and no safety related equipment was out of service. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an event that results in actuation of the reactor protection system (RPS) when the reactor is critical."

The plant is in a normal shutdown electrical lineup with decay heat being removed via steam to the main condenser using the bypass valves.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, June 26, 2012
Tuesday, June 26, 2012