United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for September 25, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/24/2012 - 09/25/2012

** EVENT NUMBERS **


48307 48308 48315 48338

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Agreement State Event Number: 48307
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA DEPARTMENT OF TRANSPORTATION
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-031
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 13:22 [ET]
Event Date: 09/13/2012
Event Time: 09:00 [MST]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENT RESOURCES (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN HUMBOLDT NUCLEAR GAUGE

The following report was received from the State of Arizona via email:

"At approximately 9:00 AM September 13, 2012, the [Arizona Radiation Regulatory] Agency was informed that the Licensee had a Humboldt Model 5001, SN 3920, portable gauge stolen from the back of a truck. The theft occurred between 9:00 PM September 12, 2012, and 6:00 AM September 13, 2012. The gauge was locked in a 16 gauge steel box bolted to the bed of the truck which was parked unattended at an employee's resident. The gauge contains 370 MBq (10 mCi) of Cesium-137 and 1.62 GBq (44 mCi) of Am:Be-241.

"El Mirage PD is investigating and has issued report number 12-09000902.

"The Agency continues to investigate this event.

"The Governor's Office, the States of CA, NV, CO, UT and NM and Mexico and U.S. NRC and U.S. FBI are being notified of this event."

Arizona Event Number: 12-020

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: 48308
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: ANDERSON REGIONAL MEDICAL CENTER
Region: 4
City: MERIDIAN State: MS
County:
License #: MS-267-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 16:57 [ET]
Event Date: 09/10/2012
Event Time: [CDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - A PATIENT RECEIVING AN INCORRECT DOSAGE OF I-131

The following report was received from the State of Mississippi via email:

"On 9-10-2012, the licensee administered 163 mCi of I-131 from an admission order dated 9-6-2012, instead of the prescribed 100 mCi of I-131 from the written directive dated 9-5-2012. The licensee's investigation revealed a misinterpretation of an admission order as a written directive by the nuclear medicine technologist due to inclusion of the authorized user's name and 150 mCi of a radionuclide activity on the admission order. The written directive was never received by the Nuclear Medicine Department. The licensee determined the root cause of the error stemmed from a new communication process by which written directives are conveyed from the authorized user to Central Scheduling and then to the Nuclear Medicine Department.

"The administered dose is described as not out of line with doses typically prescribed for patients with similar disease and the authorized user indicates an expectation of no adverse effect for the patient. The referring physician and patient were both notified on 9-10-2012 by the authorized user.

"The licensee is correcting its procedure for written directives and how they are communicated to the Hospital's Nuclear Medicine Department and will submit them for review to DRH."

Mississippi Event Report No.: MS-267-01

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.

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Agreement State Event Number: 48315
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: APPLIED INSPECTION SYSTEMS INC.
Region: 4
City: BENTON State: AR
County:
License #: ARK-576-03310
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: PETE SNYDER
Notification Date: 09/17/2012
Notification Time: 17:19 [ET]
Event Date: 09/17/2012
Event Time: 14:20 [CDT]
Last Update Date: 09/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
CHRISTOPHER CAHILL (R1DO)
BRIAN MCDERMOTT (FSME)
BARRY WRAY (ILTA)
WILLIAM GOTT (IRD)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MISSING IN TRANSIT

This report submitted by email from the Agreement State of Arkansas:

"On September 17, 2012 at 1420, the Radiation Safety Officer for Applied Inspection Systems, Inc. (ARK-576-03310) in Benton, Arkansas notified the Department that a radiography camera shipped via [a transportation company] had not been delivered to their location. The camera was shipped from a jobsite in Montoursville, Pennsylvania on September 11, 2012. The camera was scheduled for delivery on September 14, 2012 at the licensee's facility in Benton, Arkansas.

"The licensee has begun investigating the location of the camera through use of the tracking number and in conversation with customer service. The licensee has verified that the camera is not at the Pennsylvania location as of September 17, 2012.

"Camera Information: SPEC Model 150; Serial Number: 1301; Source: Iridium-192; Source Serial Number: TF0807

"The camera was shipped in an overpack cardboard container supplied by SPEC.

"The licensee and [the Arkansas Department of Health] are continuing to monitor and search for the camera. Investigation remains on-going."

Arkansas Incident Number: AR-2012-007 Additionally notified: DHS SWO, FEMA, DHS NICC, EPA, DOE, HHS, and USDA.

* * * UPDATE ON 9/18/12 AT 1240 EDT FROM JARED THOMPSON TO PETE SNYDER VIA EMAIL * * *

"The radiography camera and source have been located and has arrived at the licensee's facility on September 18, 2012 at 1040 [CDT]. The package was found in the [transportation] facility in Newark, New Jersey in the afternoon of September 17, 2012. It appears that the shipping documentation had been changed and the package was misplaced.

"The camera was surveyed and there appears to be no damage to the source or camera.

"The licensee will be preparing a report for the [Arkansas Department of Health].

"The [Arkansas Department of Health] considers this event closed."

Notified R4DO (Miller), R1DO (Cahill), FSME-Day EO (McIntosh), ILTAB (Wray), DHS SWO, FEMA, USDA, HHS, DOE, DHS, and EPA.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 48338
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/24/2012
Notification Time: 11:23 [ET]
Event Date: 09/24/2012
Event Time: 04:07 [EDT]
Last Update Date: 09/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

EMERGENCY RESPONSE DATA SYSTEM PROCESS COMPUTER DATA SERVER FAILURE

"At 04:07 EDT on September 24, 2012, Fermi 2 experienced a failure of a data server within the Process Computer system. The failure of the data server does affect data input to the server providing information to the Emergency Response Data System (ERDS). ERDS is currently not receiving updated information from Fermi data systems. This loss in capability is being reported as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

"Indications of related plant variables are available in the Main Control Room. The Visual Annunciator System (VAS) and other portions of the Process Computer system remain functional. Meteorological and process effluent radiological monitor indications are available and dose assessment capability is available. Fermi 2 personnel will use normal phone communications to update NRC Operations Center in the case of an event declaration. Information normally provided by ERDS can be transmitted via the notification system as described in the Radiological Emergency Response Preparedness Plan."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, September 25, 2012
Tuesday, September 25, 2012