Event Notification Report for June 24, 2002

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following is taken, in-part, from a facsimile report:

"A patient received 5 fractions of brachytberapy using an lr-192 HDR unit and a tandem/ovoids applicator. During the treatment planning process, an incorrect magnification factor for the orthogonal films on which the Dosimetry was based had been used. This resulted in an underdose of approximately 50% or more depending on the part of the treatment volume used for comparison.

"The initial and corrected dosimetry has been reviewed by 3 additional physicists. The corrected Dosimetry has been verified using an independent film digitization system and TPS. A composite Dosimetry summary of the treatment as delivered has been prepared and verified. Based on that information the prescribing physician will administer an additional brachytherapy application to compensate for the lower than prescribed dose from the initial 5 fractions.

[The original prescribing physician] "contacted the patient tonight, 2 July 2002. He reported the underdose, recommended an additional brachytherapy procedure and described the misadministration report."

OFFSITE NOTIFICATION DUE TO SMALL OIL SPILL ONSITE

The control room was notified at 0730EDT that a 40T small crane had developed a hydraulic leak. Approximately one (1) pint of oil was released to the storm drain system which was subsequently collected. The licensee notified the State Nuclear Inspector, the NRC Decommissioning Office, the Maine Department of Environmental Protection and the National Response Center.

AGREEMENT STATE REPORT - SOURCE LOST IN SHIPMENT

AEA Technology QSA, Inc. (AEA) called to notify the State of the report to their office of the receipt of a package of very low activity Pu-242/Am-243 (12 Bq each) by Knolls Atomic Power Laboratory. AEA was notified by Knolls Atomic that the package, received by them on 12/6/01 or 12/7/01, was opened on or around 5/20/02, at which time the inner container appeared to have been opened, and all contents were absent.

The State Agency was informed by the licensee they received the shipment from England on 12/5/01, checked the outer cardboard container for damage, and resent the shipment to their customer, Knolls Atomic Power Laboratory in New York. The package was received 12/6/01 or 12/7/01. At Knolls, the radiation safety staff received the shipment and confirmed the outer package was undamaged and delivered it to the end user in the Chemistry Department. The user opened the package on or around 5/20/02. Knolls Atomic informed AEA they believe the seal on the inner plastic container was intact, but that the final container, a flame-sealed glass container, appeared to have been opened and the contents removed, in addition, AEA was informed that the Federal Bureau of Investigation (FBI) was notified.

* * * UPDATE FROM GALLAGHAR TO KNOKE AT 0952 ON 07/26/07 * * *

The State provided the following information via email:

"The following information is provided to close NMED Item Number 020624:

"Material was shipped to the Knolls Atomic Power Laboratory (KAPL) and received there on or around 12/6 or 12/7/2001 and not opened until Mid-May of 2002. Investigation by AEA Technology QSA, Inc. (AEA) and KAPL revealed that the shipment arrived at the laboratory intact with no apparent damage; when later opened it appeared that the materials had been used.

"Based upon the condition of the shipping containers when they arrived at KAPL it appears likely that the vials were used at the customer location, apparently without their knowledge."

Notified R1DO (Finney) and NMSS (Flannery)

MINIMUM SECURITY PERSONNEL STAFFING REQUIREMENTS NOT MET


Compensatory measures taken upon discovery.

The NRC Resident Inspector will be informed.

Refer to the HOO for additional details.


* * * UPDATE ON 6/26/02 BY ROWLAND TO GOULD * * * RETRACTION

The licensee is retracting this event and classifying it as a loggable event and not a reportable one.

The NRC resident inspector was notified.

Reg 3 RDO(Stone) was notified.

4-HOUR 91-01 NRC BULLETIN REPORT INVOLVING LOSS OF DOUBLE CONTINGENCY PROTECTION

"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: Approximately 21:00 hours, Monday, June 24, 2002.

"Reason for Notification: Moisture detected in dry ventilation system in Uranium Recycle and Recovery area.

"Summary of Process: This ventilation system draws on several processing hoods in the Uranium Recycle and Recovery area. One set of hoods process dry uranium bearing materials for dissolution and the other set of hoods typically process low uranium bearing materials for oxidation.

"As Found Condition: A summary of the as found conditions is as follows:
-Damp material was found in ventilation ductwork, filters, and filter housing.
-The ventilation system and associated processes were immediately shutdown and the Nuclear Criticality Safety (NCS) function was notified.

"Double Contingency Protection: Double contingency protection for the ventilation ductwork, filters, and filter housing is based on moderation control. Criticality in the ductwork and filters was determined to be 'not credible' based upon a bounding assumption of less than 10 weight percent water. Criticality safety limits for the filter housing were based upon the same bounding assumption. After assessing the ductwork, filters, and filter housing, it was determined that this was an unanticipated event and therefore the incident requires 4-hour notification in accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.4).

"Summary of Activity:
-Nuclear Criticality Safety (NCS) participated with engineering and operations to determine the source of moisture. This investigation is continuing.
-The ventilation ductwork was inspected near the suspected moisture source.
-The filters were removed, weighed, and inspected.
-Samples from the ductwork, filters, and filter housing were obtained for analysis.
-The ventilation and associated processes are shutdown and in a safe condition.

"Conclusions:
-There was a loss of double contingency protection.
-At no time was greater than a safe limit of moderator involved in the filters.
-At no time was there a nonfavorable geometry in the ductwork or filter housing.
-At no time was criticality possible.
-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.
-The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed."

The process will remain shutdown until the investigation is completed and the appropriate corrective actions are identified. It is not known at this time whether this shutdown will impact the overall production schedule. The licensee will inform the RII Fuel Facility Inspectors and brief the Headquarters NMSS Representative (Schwink) who is scheduled to visit the facility tomorrow.