Event Notification Report for September 25, 2001

INCORRECT ACTIVITY SOURCE PROVIDED BY VENDOR

The licensee called to report that a sealed source installed in their irradiator facility does not have the source activity specified. The source is supposed to contain 200 Ci, but the licensee estimates the actual activity at approximately 100 Ci. The source was installed by GE Vallecito within the past several weeks. The licensee has contacted GE regarding the apparent discrepancy.

4-HOUR 91-01 BULLETIN RESPONSE

The following text is a portion of a facsimile received from Portsmouth personnel:

"At 0930, uranium bearing material was observed in the interior spaces of a block wall in the X-705 recovery area the openings leading to the interior spaces of the block wall is a violation of administrative control #3 of NCSA 0705_076.A03 because the exact geometry or volume of the potential collection area is unknown. This is a loss of one leg of double contingency as defined in NCSE 0705_076.E03. The presence of an unknown (at this time) amount of uranium bearing material that was spilled (at some time in the facility's past) is a potential violation of passive design feature one of NCSA 0705_076.A03 which credits the physical integrity of X-705 system piping this would represent a loss of the second leg as defined in NCSE 0705_076.E03."

"Measurements are being conducted and are ongoing to determine amount of material, which may affect this report."

"SAFETY SIGNIFICANCE OF EVENTS: The safety significance of this event is potentially high (at this time) because the exact amount of Uranium bearing material that could have entered the opening in the block wall is unknown. Measurements to quantify the material are in progress. The apparent block wall construction (as evidenced by visual inspection of wall openings in the other areas of Recovery) indicates the potential for the presence of unfavorable geometry voids within and between the blocks compromising the exterior building wall."

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR): If 1) a significant amount of uranium bearing material entered the void spaces of the block wall, 2) the material has collected in the multiple voids resulting in a single unfavorable geometry configuration, 3) the material has a high enrichment and uranium concentration, and 4) the material would become sufficiently moderated, then a potentially critical configuration could result. Note that no spills or leaks of uranium bearing material from present X-705 systems has occurred at this time. The material in question has apparently been there for some time."

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): Double contingency for inadvertent containers relies upon the physical integrity of X-705 piping to prevent a spill of an unsafe amount of material. An unsafe amount is defined by the concentration and enrichment of the material. Double contingency also relies upon administrative controls limiting the presence of unfavorable geometry or unsafe volume containers that could collect a spill or leak."

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE OF CRITICAL MASS): Unknown at this time. Enrichment could be greater than 90% based upon historical operations. The form is most likely uranyl nitrate or UO2F2. Measurements for determination of mass and assay are currently in progress."

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The openings leading to the interior spaces of the block wall is a violation of administrative control #3 of NCSA.705_076.A03 because the exact geometry or volume of the potential collection area is unknown. This is a loss of one leg of double contingency as defined in NCSE-0705_076.E03. The presence of an unknown (at this time) amount of uranium bearing material that has spilled (at some time in the facility's past) is a potential violation of passive design feature 1 of NCSA-0705_076.A03 which credits the physical integrity of X-705 system piping. This would represent a loss of the second leg of double contingency as defined in NCSE-0705_076.E03."

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: Samples of the material have been taken and DNA measurements will be taken to determine amounts of material and assay."

The NRC Resident Inspector was notified and the DOE Representative will be notified.

***** UPDATE FROM JIM McCLEERY TO LEIGH TROCINE AT 1942 ON 09/27/01 *****

The following text is a portion of a facsimile received from Portsmouth personnel:

"Update #1 - Conservative NDA analysis of the area near column A-16 indicates a total maximum mass of 225+/-113 grams 235U with an enrichment of 8.2% is present (preliminary NDA analysis reported less conservative values), which is less than the safe mass limit for uranium. Investigations to determine the extent of condition have identified three additional areas of potential concern in X-705 Recovery. These areas are: the wall near the A-loop overflow column, the wall adjacent to the Calciner system, and the wall near the top of the B-38 storage columns. Each of these areas has received preliminary scans via NDA analysis to determine the potential for uranium material holdup in the block walls. Preliminary results indicate that the amount of material, if any, in the wall near the A-loop overflow and near the Calciner are bounded by the amount quantified near column A-6. More detailed [quantitative] NDA scans for these two locations (to differentiate between surface contamination, uranium holdup, and background) are currently in progress and will be reported when available. Preliminary results indicate that no material is suspect in the wall near the B-38 storage column (near background readings). Additional NDA scans are currently in progress to locate any other potential areas of concern in the Recovery Area.

"SAFETY SIGNIFICANCE OF EVENTS: The safety significance of this event is now low because the amount of uranium bearing material that entered the openings in the block wall is known to be less that 338 grams 235U which is less than the safe mass limit for uranium."

Portsmouth personnel plan to notify the NRC resident inspector. The NRC operations officer notified the R3DO (Phillips) and NMSS EO (Holahan).

***** UPDATE FROM MIKE RITCHIE TO LEIGH TROCINE AT 1626 ON 10/01/01 *****

The following text is a portion of a facsimile received from Portsmouth personnel:

"Update #2 - More detailed quantitative NDA scans for the wall near the A-loop overflow column indicate a total maximum mass of 92+/-46 grams 235U with an enrichment of 86% is present (less than a safe mass). Quantitative NDA scans for the wall adjacent to the Calciner system indicate a total maximum mass of 201+/-101 grams 235U with an enrichment of 5.3% (also less than a safe mass). It should be noted that these results incorporate conservative assumptions about the distribution of uranium bearing material in the wall matrix, and total amount of uranium present may be found to be much less upon final disposition."

"Preliminary results indicate that no material is suspected in the wall near the B-38 storage column (near background readings): therefore, quantification was not performed in this area."

"[...]"

Portsmouth personnel plan to notify the NRC resident inspector. The NRC operations officer notified the R3DO (Hills) and NMSS EO (Brown).

(Call the NRC operations officer for additional details.)

***** UPDATE FROM CURT SISLER TO LEIGH TROCINE AT 0408 ON 02/05/02 *****

The following text is a portion of a facsimile received from Portsmouth personnel:

"Update #3 - To reestablish compliance, an approximately 24" X 80" section of block wall was removed in accordance with NCSA-0705_135. Following removal of the primary area, five locations around the perimeter were then subjected to additional NDA analysis. Conservative NDA analysis indicated less than 306 grams U235 total spread over the five additional locations. In a second removal operation, additional blocks were removed at four locations adjacent to the primary area where greater than 15 grams U235 was indicated. When combining all NDA estimates which make conservative assumptions about the distribution of uranium-bearing material in the wall matrix, up to 705 [grams] U235 may have been distributed in this area. If the mass were concentrated in one location, it would still be less than the maximum subcritical mass [...] given in ANSI/ANS-8.1-1983."

Portsmouth personnel plan to notify the NRC resident inspector. The NRC operations officer notified the R3DO (Tom Kozak) and NMSS EO (John Hickey).

(Call the NRC operations officer for additional details.)

AGREEMENT STATE REPORT INVOLVING POTENTIAL DAMAGE TO A PORTABLE GAUGE DURING TRANSPORT

"A portable gauge fell off the bed of the transporting pickup and was slightly damaged. The gauge was not carried in it's shipping container at the time of the incident. The guide rod (as opposed to the source rod) broke near the base of the gauge. The source was in the safe, shielded position at the time of the incident. The gauge has been surveyed and leak tested and has been shipped to an authorized repair facility. The gauge was a Humboldt 5001, s/n 400 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be.

"Cause of the incident was lack of attention to detail. Event Report ID No. NV-01-005."

AGREEMENT STATE REPORT REGARDING A RADIOGRAPHY CAMERA THAT WAS LOST AND FOUND IN LONGVIEW, TEXAS (Texas Incident #7806)

A logging source was found at the intersection of Eastman Road and Cotton Street in Longview, Texas. The Longview Fire Department responded to the scene, and the licensee, Hi-Tech Testing Service, Inc., was contacted. A licensee representative also responded to the site and performed a complete survey of the exposure device using a calibrated survey meter. There were no abnormally high readings observed during this survey. The IR100 exposure device was also visually examined for any damage to the body, locking mechanism, and outlet port. There was no physical damage seen during this examination.

The exposure device was returned to the licensee's shop, thoroughly inspected, and locked inside a radioactive storage area. This subsequent detailed inspection revealed that all mechanical components were functioning properly, and there was no apparent damage to the exposure device body. One transport label was replaced because some of the information was illegible. It was later determined that the exposure device had unknowingly fallen onto the highway from the bumper of a pickup truck.

NOTE: Exposure Device S/N 4573, Source S/N 00564B, Type and Activity of Source Material - Not Reported

MEDICAL MISADMINISTRATION DUE TO IMPROPER POSITIONING OF IMPLANT DEVICE

"Abstract - Female patient undergoing vaginal implant therapy on September 25, 2001. 'T-bomb' applicator loaded with 3 Cs-137 sources, each 19.73 mg RaEq [milligram Radium Equivalent] (49.92 mCi each, total activity 149.75 mCi). Implant performed 8:30 AM on 9/25/01. Status of implant placement made by nurse at 10:42 AM, and again at 2:10 PM. When physician checked patient at 5:00 PM on 9/25/01, implant was found outside of patient adjacent to her vaginal area. Physician did not report incident to Radiation Safety Officer, thus Licensee did not report incident to State. Estimate of total absorbed dose to the surface of the affected area was 7.55 Gy [Gray], this includes a dose of 0.74 Gy that comes from the normal implant itself.

"Consequence of exposure - Tissue necrosis in affected area."

The cause of the misadministration is still under investigation. A contributing factor was the failure to periodically check the implant placement. The patient was informed.