Event Notification Report for February 26, 2002

AGREEMENT STATE REPORT REGARDING THE LOSS OF CONTROL AND RECOVERY OF AN ACS ENGINEERING GROUP, CONSTRUCTION, MOISTURE/DENSITY GAUGE IN TEMPE, ARIZONA

The following text is a portion of Preliminary Notification PNO-IV-02-013 received from NRC Region 4:

"On February 26, 2002, the Arizona Radiation Regulatory Agency (ARRA) notified NRC Region IV by facsimile of the loss of control and recovery of a portable gauge. The ARRA was informed by the Gilbert, Arizona fire department on February 26, 2002, that a Troxler moisture/density gauge, Model 2401 (Serial No. MD91 005368) containing a 370 megabecquerel (10 millicurie) source of americium-241/beryllium and a 1.48 gigabecquerel (40 millicurie) cesium-137 source had been recovered by a motorist that saw the device fall off of a truck. The motorist picked up the gauge and turned it into the local police department. ARRA determined that the truck was operated by two employees of ACS Engineering Group, Construction, an Arizona licensee. The gauge was not damaged. The licensee reclaimed the device on February 26, 2002. ARRA will be investigating the event. Media interest included reports by three local television stations."

"Region IV received notification of this occurrence by facsimile from ARRA at 2:35 p.m. (CT) on February 26, 2002. Region IV has informed OEDO, NMSS, STP, and OPA."

NRC BULLETIN 91-01 RESPONSE INVOLVING A C4 DISSOLVER ACID WASH PUMPOUT (24-Hour Report)

The following text is a portion of a facsimile received from the licensee:

"Facility -- Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched (<=5.0 wt. % U-235) PWR fuel fabricator for commercial light water reactors. License: SNM-1107."

"Time and Date of Event -- Approx. 15:00 hours, Tuesday, February 26, 2002."

"Reason for Notification -- During an internal procedure review by Operations, it was discovered that a current Process Information Form (PIF) for flushing and pumping out the lines of the C4 dissolvers did not contain all the required criticality controls. The operating procedure for pumpout of UN product to non-favorable geometry bulk storage requires sampling for grams U-235 per liter, pH, and % free acid. The PIF required only % free acid."

"Summary of Process -- During normal processing, uranium is recovered from scrap materials in the favorable geometry C4 dissolvers system. The resulting uranyl nitrate (UN) is sampled and released. It is then pumped through gamma monitors, an active engineered control, to the non-favorable geometry UN bulk storage tanks."

"When needed for uranium accountability purposes, the C4 dissolver system tanks are filled with water to the 40% level and then with water and acid to the 43% level (approximately 102.3 gallons total) to flush the system."

"As-Found Condition -- A summary of the as found conditions is as follows:
* The condition was found during an internal procedure review - not during acid wash pumpout.
* The PIF was approved for use on February 14, 2002.
* The PIF required only sampling for free acid.
* The gamma monitors were functioning properly."

"Double Contingency Protection -- Double contingency protection for this situation is based on concentration control, that is (1) preventing solutions with >10 grams U-235 per liter from being transferred into the UN bulk storage tanks, and (2) detecting any increasing concentration of U-235 in the tanks and taking corrective actions. It was determined, however, that documented double contingency protection was lost because sampling for pH was not required on the PIF. Double contingency protection was immediately restored by withdrawing the PIF. Therefore, the incident requires notification in accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3(c.5), in which less than previously documented double contingency protection remains in an analyzed system, but less than safe mass is involved."

"Summary of Activity --
* The PIF was immediately withdrawn.
* Immediate instructions were given to Operations to ensure that all required sampling was performed.
* A causal analysis will be performed to determine corrective actions needed to prevent recurrence."

"Conclusions --
* Loss of documented double contingency protection did occur, but was immediately restored.
* At no time was criticality possible because the gamma monitors ensure that the concentration remains <5 grams U-235 per liter.
* At no time was there any risk to the health or safety of any employee or member of the public. No exposure to hazardous material was involved.
* It has been determined that this is a safety significant incident in accordance with governing procedures. A root cause analysis will be performed."

The licensee notified the NRC Region 2 office (David Ayres) and NMSS (Dennis Morey).

(Call the NRC operations officer for a licensee contact telephone number.)

ST BERNARD'S REGIONAL MEDICAL CENTER MEDICAL MISADMINISTRATION

The following event description is taken from a faxed report.

"Description of Event:

Following initial source send, the proximal gold marker could not be discerned under fluoroscopy due to wire suture in the patients sternum. Twenty-four seconds elapsed between the arrival of the distal marker at the treatment site to source return to the delivery device. Two additional source sends were attempted with immediate return of the sources due to the inability to discern the proximal marker. Upon return of the sources to the delivery device, all sources were visible in the source chamber but the distal marker was not visualized. The treatment catheter was removed from the patient while still attached to the delivery device. The catheter and delivery device were placed into the bail-out box. The sources and distal cold marker were successfully returned to the delivery device following conclusion of the case."

***EVENT UPDATED 3/25/02 1135 EST BY FAX TO MIKE NORRIS***

The following was taken from a facsimile received from the Arkansas Department of Health, Radiation Control and Emergency Management on 3/25/02:

"The Department received the licensee's written report via facsimile on March 19, 2002, with the original mailed hardcopy received on March 21, 2002.

"The Department arranged for two qualified medical experts, a Radiation Oncologist and an Interventional Cardiologist, both approved for the Novoste Beta-Cath Devise, to review hardcopy cine images as well as a CD copy of the cine film. Neither expert could visualize the proximal marker on the images. In addition, one expert stated that they were unable to locate the source beads on the images and therefore could not determine their location in the body. In the final report, however, the licensee maintains that although the proximal marker could not be visualized they believe that the entire source train was delivered to the treatment site.

"The licensee also submitted a dose calculation based on a 24-second dwell time. This dwell time equated to a dose of 2.4 Gy delivered at a distance of 2 mm from the centerline of the sources. The license's final report indicated that the written directive had been revised to note a delivered dose of 2.4 Gy to the target. The Department requested this revised written directive, however, it was not provided.

"Based on the information provided to the Department by the two qualified experts, the Department does not agree with the licensee's determination that the dose was delivered to the target area. Therefore, the Department is classifying the event as a misadministration based on a 2.4 Gy dose delivered to an unintended and undetermined area of the body.

"The licensee's report indicated that the suggested cause of the device failure was an inadequate connection of the treatment catheter or the fluid management system. This conclusion was supported by the amount of fluid accumulated in the sterile bag as well as the lack of pressure experienced by the radiation oncologist during the case. In order to prevent further occurrence, the licensee will perform an additional test run using the active source. This test run will be conducted outside the patient on a table located away from the cath lab staff.

"In accordance with Department regulations, both the patient and the referring physician were notified of the misadministration. A copy of the licensee's final report was sent to the referring physician.

"The Department considers this event closed."

The NRC operations officer notified the R4DO (Chuck Cane) and NMSS EO (Janet Schlueter).

SECURITY REPORT INVOLVING UNESCORTED ACCESS GRANTED INAPPROPRIATELY

Contract employee granted unescorted access inappropriately. Contact the Headquarters Operations Officer for additional details. The licensee will inform the NRC Resident Inspector.

INVALID SPECIFIED SYSTEM ACTUATION WHILE TESTING

"Title: Invalid Safety Injection actuation during testing.

"This is a verbal report being made in accordance with 10 CFR 50.73(a)(2)(iv)(A). It is NOT considered a Licensee Event Report (LER)

"Description:

"On February 26, 2002, at 1438 CST, an inadvertent actuation of Unit 2; Train B; Safety Injection occurred. Unit 2 was in Mode 4, during start-up from the Refueling Outage. During performance of the 'Test of Reactor Trip and Bypass Breakers Auxiliary Contacts' procedure, electricians were installing volt meter test probes on terminals to obtain voltage readings during the test. While installing the test probe, the electrician inadvertently made contact with an adjacent terminal. This contact shorted two terminals causing a complete actuation of Safety Injection -Train B. Following the actuation, operators promptly identified that the signal was not valid and took action to realign equipment as necessary to stabilize the plant.

"All Unit 2, Train B safeguards equipment started and functioned as required. D6 Diesel Generator started as required but did not load because normal power remained available.

"The reactor was not critical at the time of the event. The Reactor Protection System did not actuate as all control rods were fully inserted with the Reactor Trip Breakers open prior to the event."

The NRC Resident Inspector has been notified.