United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 14, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/13/2012 - 11/14/2012

** EVENT NUMBERS **


48480 48482 48483 48484 48504

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Agreement State Event Number: 48480
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Region: 4
City: LA JOLLA State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/05/2012
Notification Time: 12:56 [ET]
Event Date: 11/01/2012
Event Time: [PST]
Last Update Date: 11/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - DOSAGE ADMINISTERED LESS THAN PRESCRIBED

The following was received from the State of California via email:

"Patient was prescribed to receive 30.24 mCi of Y90 in Microsphere form (MDS Nordion, Model TheraSphere) through a catheter. The catheter became plugged during the procedure not allowing approximately 47% of the prescribed spheres to reach the treatment location. Patient received 16.2 mCi of the prescribed 30.24 mCi (53%)

"The dosage to the patient was not available at the time of report, therefore RHB (Radiation Health Branch) was unable to determine whether this met all requirements to be classified as a 'Medical Event.'

"The reporting requirements will be reviewed once the licensee provides RHB with the dose information.

"A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento."

California 5010 #: 110112

* * * UPDATE FROM DONALD OESTERLE TO CHARLES TEAL ON 11/5/12 AT 1428 EDT * * *

"On 11/2/2012, the dosage to the patient was not available at the time of the report, therefore RHB was unable to determine whether this met all requirements to be classified as a Medical Event. The reporting requirements will be reviewed once the licensee provides RHB with the dose information. A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento.

"At 11:00 am, 11/5/2012 RHB received additional information: The physician's written directive prescribed 130 Gy (13,000 rem) to the liver. The patient received 68.9 Gy (6,890 rem) to the intended organ. The remaining activity was contained by the microsphere delivery system.

"The NRC Operation Center was updated on 11/5/2012; 11:25AM confirming this report as meeting the necessary conditions of classifying this as a Medical Event. "

Notified R4DO (Farnholtz) and FSME Event Resource via email.

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: 48482
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CARRILLO & ASSOCIATES INC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L05804
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/06/2012
Notification Time: 12:10 [ET]
Event Date: 11/02/2012
Event Time: [CST]
Last Update Date: 11/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCES (E-MA)
ILTAB (E-MA)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT- MISSING TROXLER

The following was received from the State of Texas via email:

"On November 6, 2012, the licensee notified the Agency [State of Texas] that at approximately 0820 hrs one of its employees had discovered that a Troxler Model 3411B moisture/density gauge, containing one 8 millicurie cesium-137 source and one 40 millicurie americium-241/beryllium source, had been stolen from the company-owned vehicle while it was parked at his residence in Laredo, Texas, sometime during the preceding weekend. The licensee reported that the employee had left a temporary work site on Friday, November 2, 2012, and gone to his residence due to a family emergency and had failed to return the gauge to the licensed location. While the employee was loading the vehicle to go to a temporary work site this morning, he realized he had left the gauge in the vehicle over the weekend. When he checked the vehicle he found the chains had been cut the and gauge was gone. The license notified local law enforcement. More information will be provided as it is obtained per SA-300.

"Gauge info: Troxler, Model 3411B, SN: 13121"

Texas Incident Number: I-9007

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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Non-Agreement State Event Number: 48483
Rep Org: PINNACLE AIRLINES
Licensee: PINNACLE AIRLINES
Region: 1
City: MEMPHIS State: TN
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: RHONDA QUINT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/06/2012
Notification Time: 11:45 [ET]
Event Date: 11/06/2012
Event Time: [EST]
Last Update Date: 11/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCES (E-MA)
ILTAB (E-MA)
CHRISTINE LIPA (R3DO)

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

Event Text

AIRLINE UNDERGOING RE-ORGANIZATION UNABLE TO LOCATE VARIOUS RADIOACTIVE SOURCES

A representative for Pinnacle Airlines called to report that the company has records of various radioactive sources which cannot be located and are presumed lost. The airline is undergoing bankruptcy reorganization. The individual noted that the sources were previously registered under a company called Mesaba Airlines. Mesaba Airlines was at one time associated with Northwest Airlines. The individual believes that the devices were originally registered with the NRC as general licensed material. The material records indicate that the company was in the possession of 10 "Tritium Light Comparators" of approximately 1 curie each. The company has been able to locate 5 of these sources: In Knoxville TN; Memphis TN; Detroit MI; and Ft. Wayne IN. In addition, the company states that it had five explosive detector sources that are unaccounted for and (10 millicuries Nickel - 63 each) were last stored in Michigan (Esbaneba, Muskegon Kincheloe, and Gwinn MI). There may also be some missing Tritium Exit signs but the licensee has not been able to determine how many or where they were last located.

At this time, the licensee believes that this material is lost and that the responsible reporting agency is the NRC. The sources are registered on the generally licensed source tracking list. The licensee has discussed this information with NRC Region 3 (Reichhold).

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: 48484
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: AIR PRODUCTS & CHEMICALS INC
Region: 1
City: TAMAQUA State: PA
County:
License #: PA-1131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/06/2012
Notification Time: 13:20 [ET]
Event Date: 10/31/2012
Event Time: [EST]
Last Update Date: 11/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILURE

The following was received from the Commonwealth of Pennsylvania:

"While performing a leak test and shutter check on October 31, 2012, it was discovered that one of the level gauges had an inoperable shutter. Because the location of the gauge was on an operating tank and inaccessible to personnel, no exposure issues were plausible.

"The device is identified as:

"Manufacturer: Ohmart Corp Cincinnati OH
"Model: Minirad II
"Source Holder Model: SHF2
"Isotope: Cs-137
"Activity: 500 mCi

"The manufacturer was notified to make repairs. The licensee plans to increase shutter testing and have the manufacturer install a cover over the source holder to better protect it. DEP plans to follow up with a reactive inspection."

Event Report No: PA 120038

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Power Reactor Event Number: 48504
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRADDOCK LEWIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/13/2012
Notification Time: 07:49 [ET]
Event Date: 11/13/2012
Event Time: 09:00 [EST]
Last Update Date: 11/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTINE LIPA (R3DO)
ERDS RESOURCE (EMAI)

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

Event Text

PARTIAL LOSS OF EMERGENCY ASSESSMENT DURING PLANNED MODIFICATIONS

"Cook Nuclear Power Plant will begin a cyber security modification of Unit 1 and Unit 2 Plant Process Computers (PPCs) and associated network infrastructure on Tuesday, November 13, 2012 at 0900 EST. This includes the Emergency Response Data System (ERDS) communication with the NRC Operations Center.

"The entire PPC for each unit will be out of service and unavailable for approximately 6 hours. During that time, the PPC satellite display systems in the Control Rooms, TSC and EOF will be unavailable. After approximately 9 hours, the ERDS will be restored to service along with the satellite display systems in the Control Rooms, TSC and EOF.

"Compensatory measures exist within the DC Cook Emergency Response procedures to provide plant data in the event of an actual Emergency to the NRC Operations Center until the ERDS can be returned to service. Unavailability of the ERDS and Control Room, TSC and EOF data is being reported in accordance with 10 CFR 50.72(b)(3)(xiii) as a major loss of emergency assessment capability. The NRC Resident Inspector has been notified. A follow-up ENS communication will be made when both units ERDS are fully restored to service.

"Unit 1 and Unit 2 PPC availability is expected to be restored on Tuesday, November 13, 2012 at 1500 EST. ERDS communication with the NRC Operations Center is expected to be restored on November 13, 2012 at 1800 EST."

* * * UPDATE FROM BRADDOCK LEWIS TO HOWIE CROUCH @ 1559 EST ON 11/13/12 * * *

The licensee notified the Operations Center that the PPC work was delayed and, as a consequence, ERDS restoration will be delayed. Work on the PPC continues.

The licensee has notified the NRC Resident Inspector. Notified R3DO (Giessner) and ERDS Group (via email).

* * * UPDATE AT 1908 EST ON 11/13/12 FROM GREG KANDA TO MARK ABRAMOVITZ * * *

ERDS was declared operable at 1815 EST. The licensee notified the NRC Resident Inspector.

Notified R3DO (Giessner) and ERDS Group (via email).

Page Last Reviewed/Updated Wednesday, November 14, 2012
Wednesday, November 14, 2012