Event Notification Report for July 31, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/30/2003 - 07/31/2003
EVENT NUMBERS
400394004040041400484009040094
Power Reactor
Event Number: 40039
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: ALAN HALL
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: ALAN HALL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/31/2003
Notification Time: 05:59 [ET]
Event Date: 07/31/2003
Event Time: 01:10 [EDT]
Last Update Date: 07/31/2003
Notification Time: 05:59 [ET]
Event Date: 07/31/2003
Event Time: 01:10 [EDT]
Last Update Date: 07/31/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES MOORMAN (R2)
JAMES MOORMAN (R2)
| 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 |
EMERGENCY RESPONSE DATA ACQUISTION AND DISPLAY SYSTEM (ERDADS) INOPERABLE FOR GREATER THAN ONE HOUR
"Emergency Response Data Acquisition and Display (ERDADS) computer failed at 0110 on 7/31/03. It was successfully restored to service at 0235. This resulted in the loss of the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) for greater than one hour. This event is reportable as a eight hour non-emergency notification per 10CFR50.72(b)(3)(xiii) in that the failure constituted a major loss of emergency assessment capability, offsite response capability, or offsite communications capability."
The NRC Resident Inspector will be notified of this event by the licensee.
"Emergency Response Data Acquisition and Display (ERDADS) computer failed at 0110 on 7/31/03. It was successfully restored to service at 0235. This resulted in the loss of the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) for greater than one hour. This event is reportable as a eight hour non-emergency notification per 10CFR50.72(b)(3)(xiii) in that the failure constituted a major loss of emergency assessment capability, offsite response capability, or offsite communications capability."
The NRC Resident Inspector will be notified of this event by the licensee.
Other Nuclear Material
Event Number: 40040
Rep Org: VIRGINIA DEPT. OF HEALTH
Licensee: N/A
Region: 2
City: RICHMOND State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: JAMES DeKRAFFT
HQ OPS Officer: HOWIE CROUCH
Licensee: N/A
Region: 2
City: RICHMOND State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: JAMES DeKRAFFT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/31/2003
Notification Time: 14:00 [ET]
Event Date: 07/31/2003
Event Time: 00:00 [EDT]
Last Update Date: 07/31/2003
Notification Time: 14:00 [ET]
Event Date: 07/31/2003
Event Time: 00:00 [EDT]
Last Update Date: 07/31/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES MOORMAN (R2)
TOM ESSIG (NMSS)
MRS. RAWLS (EPA)
JAMES MOORMAN (R2)
TOM ESSIG (NMSS)
MRS. RAWLS (EPA)
CESIUM-137 PIPE SOURCE DISCOVERED IN SCRAP METAL
NRC Region 2 personnel were notified by the Commonwealth of Virginia, Department of Health, Bureau of Radiological Health that a metal dealer, Smith Iron & Metal Company, located in Richmond, VA had discovered a Cs-137 pipe source in some scrap material. The pipe measured approximately 24 inches long with a 6 inch diameter. The pipe was sheared in two and sent to Chaparral Virginia Steel Recycling, located in Petersburg, VA, where is set off portal monitors. Chaparral isolated the material and returned it to Smith Iron & Metal. Smith contacted the Commonwealth of Virginia who dispatched a response team.
The response team determined that there was no external contamination on the pipe. Contact readings are at 120 mR/hr with <2.6 mR/hr readings at three feet. There were no identifying marks on the source. The source is currently isolated on a trailer at Smith Iron & Metal. Region 2 NRC with be sending a team of personnel to investigate. The Environmental Protection Agency has been notified.
NRC Region 2 personnel were notified by the Commonwealth of Virginia, Department of Health, Bureau of Radiological Health that a metal dealer, Smith Iron & Metal Company, located in Richmond, VA had discovered a Cs-137 pipe source in some scrap material. The pipe measured approximately 24 inches long with a 6 inch diameter. The pipe was sheared in two and sent to Chaparral Virginia Steel Recycling, located in Petersburg, VA, where is set off portal monitors. Chaparral isolated the material and returned it to Smith Iron & Metal. Smith contacted the Commonwealth of Virginia who dispatched a response team.
The response team determined that there was no external contamination on the pipe. Contact readings are at 120 mR/hr with <2.6 mR/hr readings at three feet. There were no identifying marks on the source. The source is currently isolated on a trailer at Smith Iron & Metal. Region 2 NRC with be sending a team of personnel to investigate. The Environmental Protection Agency has been notified.
Power Reactor
Event Number: 40041
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK GORLEY
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK GORLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/31/2003
Notification Time: 17:02 [ET]
Event Date: 07/31/2003
Event Time: 15:20 [EDT]
Last Update Date: 07/31/2003
Notification Time: 17:02 [ET]
Event Date: 07/31/2003
Event Time: 15:20 [EDT]
Last Update Date: 07/31/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES MOORMAN (R2)
JAMES MOORMAN (R2)
| 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 |
TEMPORARY LOSS OF EMERGENCY ASSESSMENT CAPABILITIES
The following information was obtained from the licensee via facsimile:
"NOAA Weather Radio Prompt Notification System was found not working. This results in a major loss of the offsite notification system. The State of Georgia (GEMA) [Georgia Emergency Management Agency] and the four EPZ [Emergency Planning Zone] counties were notified of the NOAA Weather Radio Prompt Notification System outage.
"NOAA Weather Radio Prompt Notification System was returned to service at 1642 EDT. The State of Georgia (GEMA) and the four EPZ counties were notified of the NOAA Weather Radio Prompt Notification System being returned to service."
The four counties notified were: Tattnall, Jeff Davis, Toombs and Appling counties.
The licensee notified the NRC Resident Inspector.
The following information was obtained from the licensee via facsimile:
"NOAA Weather Radio Prompt Notification System was found not working. This results in a major loss of the offsite notification system. The State of Georgia (GEMA) [Georgia Emergency Management Agency] and the four EPZ [Emergency Planning Zone] counties were notified of the NOAA Weather Radio Prompt Notification System outage.
"NOAA Weather Radio Prompt Notification System was returned to service at 1642 EDT. The State of Georgia (GEMA) and the four EPZ counties were notified of the NOAA Weather Radio Prompt Notification System being returned to service."
The four counties notified were: Tattnall, Jeff Davis, Toombs and Appling counties.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 40048
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: Medical University of South Carolina
Region: 2
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Melinda Bradshaw
HQ OPS Officer: ERIC THOMAS
Licensee: Medical University of South Carolina
Region: 2
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Melinda Bradshaw
HQ OPS Officer: ERIC THOMAS
Notification Date: 08/06/2003
Notification Time: 15:53 [ET]
Event Date: 07/31/2003
Event Time: 16:00 [EDT]
Last Update Date: 08/06/2003
Notification Time: 15:53 [ET]
Event Date: 07/31/2003
Event Time: 16:00 [EDT]
Last Update Date: 08/06/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEPHEN CAHILL (R2)
M. WAYNE HODGES (NMSS)
STEPHEN CAHILL (R2)
M. WAYNE HODGES (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
On 7/31/03, at approximately 1600 EDT, an Iotrex I-125 sealed source was administered to a brachytherapy patient to treat a brain tumor. The sealed source contained 325 millicuries of I-125. On 8/5/03 at 1148 EDT, upon removal of the sealed source from the patient, the hospital staff noted that the amount of I-125 withdrawn from the patient was only 31.5 millicuries.
The source is a liquid that is inserted into a balloon inside the patient's skull, then removed after a designated amount of time. On 8/6/03, a manufacturer's representative from Proxima accompanied hospital staff to inspect the catheter and balloon that were used during this administration. The catheter and balloon were visually inspected and tested with a dye for leaks. No leaks were apparent during either test.
The licensee did not report any immediate adverse affects on the patient. The referring physician was informed of this event.
On 7/31/03, at approximately 1600 EDT, an Iotrex I-125 sealed source was administered to a brachytherapy patient to treat a brain tumor. The sealed source contained 325 millicuries of I-125. On 8/5/03 at 1148 EDT, upon removal of the sealed source from the patient, the hospital staff noted that the amount of I-125 withdrawn from the patient was only 31.5 millicuries.
The source is a liquid that is inserted into a balloon inside the patient's skull, then removed after a designated amount of time. On 8/6/03, a manufacturer's representative from Proxima accompanied hospital staff to inspect the catheter and balloon that were used during this administration. The catheter and balloon were visually inspected and tested with a dye for leaks. No leaks were apparent during either test.
The licensee did not report any immediate adverse affects on the patient. The referring physician was informed of this event.
General Information or Other
Event Number: 40090
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: STL SEATTLE
Region: 4
City: TACOMA State: WA
County:
License #: R-0158
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOHN MacKINNON
Licensee: STL SEATTLE
Region: 4
City: TACOMA State: WA
County:
License #: R-0158
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2003
Notification Time: 12:05 [ET]
Event Date: 07/31/2003
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2003
Notification Time: 12:05 [ET]
Event Date: 07/31/2003
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4)
TOM ESSIG (NMSS)
BLAIR SPITZBERG (R4)
TOM ESSIG (NMSS)
MISSING FOIL SOURCE
"STATUS: new & closed
"Licensee: STL Seattle (STL)
"City and state: Tacoma, Washington
"License number: R-0158 (a General Licensee)
"Type of license: N/A - receipt of generally licensed gas chromatography cells from manufacturer or equivalent.
"Date of event: July 31, 2003 - date of licensee notification letter to DOH (date of actual event is unknown).
"Location of Event: Severn Trent Laboratories Inc., dba STL Seattle.
"5755 8th Street East, Tacoma, Washington 98424
"ABSTRACT: STL Seattle sent DOH notification dated July 31, 2003 of a lost GC detector cell, foil source. The letter was received August 4, 2003. In the letter STL Seattle reported a missing 555 megabecquerel (15 millicurie), Nickel 63, foil source, Serial Number A5447 that was assumed to have been in a Varian ECD cell. The cell had been sent to a DOH specific licensee that is licensed for GC repair work. A technician at the GC-repair licensee discovered the missing foil source. The GC-repair licensee notified STL of the missing source. STL performed a thorough search of the lab but could not find the missing foil.
"DOH contacted both STL and our GC-repair licensee after receipt of the letter. The Operations Manager at STL, [DELETED], who was the event reporter, could not initially be contacted. DOH did reach him for discussion two weeks later. DOH contacted our GC-repair licensee shortly after receipt of the notification. The GC-repair RSO mentioned that the ECD cell received from STL was an older cell that looked like it had never been used. The cell showed severe corrosion, which indicated that this cell had been in storage for a long time. The cell came in a box and was broken. The GC-repair RSO stated that the foil in these cells could fall out or removed easily, if the cell had been opened or if the ceramic portion of the cell was broken. This cell had a broken connector when received by the GC-repair licensee. The GE-repair RSO said that the cells can become loose in the Varian device and can break at the ceramic connector, which may have happened when someone attempted to remove it from the GC device. A tool is needed to remove the source from a cell in normal condition. The GC-repair RSO said that the cell didn't look like it had been tampered with in a purposeful manner. The GC-Repair RSO contacted [DELETED] when it was determined that the source was missing. They discussed the event in detail and [DELETED] was reminded, per the terms of GL device receipt requirements that they were not allowed to perform activities involving removal of sources. [DELETED] had recently taken over the program at STL Seattle. [DELETED] was further reminded of his record keeping responsibilities and the other limitations of receipt of GL GC detector cells.
"When DOH talked with [DELETED] he confirmed that he had spoken with the GC-repair RSO and had been made aware that the source was missing after the cell had been received. The cell had not been used for a few years. A person, no longer employed by STL Seattle, was thought to have worked on the cell. He had not worked for the company in over a year. [DELETED] thought that any work done on the cell would have been a year or two previous to this individual leaving. He did not know if this work had included removing the foil from the cell. [DELETED] stated that when he had been informed of the missing radioactive source, staff at STL performed a search of the lab. He stated that they have a Geiger counter, but were not able to find the source. DOH re-informed [DELETED] that they are not licensed to perform source work on cells, [DELETED] agreed. He stated that this won't happen again . [DELETED] stated that STL management oversight of lab activities had recently been improved.
"DOH issued an item of noncompliance to STL that was categorized as a Violation, for their failure to keep licensed radioactive material secure. DOH did not perform an on site investigation and no media attention was noted.
"What is the notification or reporting criteria involved? 10 CFR 20.2201(a)(1)(ii) 30 days.
"Activity and Isotope(s) involved: 555 megabecquerel (15 millicurie), Nickel 63.
"Overexposures? Likely N/A but was unable to be determined.
"This is a lost source: Manufacturer Varian Associates Inc., Model- 02-001972-0, Serial Number 5447.
"Disposition/recovery? STL was several times reminded of their responsibilities and limitations.
"Leak test? N/A
"Vehicle: N/A
"Release of activity? Loss of 555 megabecquerel (15 millicurie), Nickel 63, foil source.
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Exposure (intended/actual); consequences: exposure, if any, is unknown; consequences are unlikely.
"Was patient or responsible relative notified: N/A
"Was written report provided? Yes
"Was referring physician notified? N/A
"Consultant used? No"
"STATUS: new & closed
"Licensee: STL Seattle (STL)
"City and state: Tacoma, Washington
"License number: R-0158 (a General Licensee)
"Type of license: N/A - receipt of generally licensed gas chromatography cells from manufacturer or equivalent.
"Date of event: July 31, 2003 - date of licensee notification letter to DOH (date of actual event is unknown).
"Location of Event: Severn Trent Laboratories Inc., dba STL Seattle.
"5755 8th Street East, Tacoma, Washington 98424
"ABSTRACT: STL Seattle sent DOH notification dated July 31, 2003 of a lost GC detector cell, foil source. The letter was received August 4, 2003. In the letter STL Seattle reported a missing 555 megabecquerel (15 millicurie), Nickel 63, foil source, Serial Number A5447 that was assumed to have been in a Varian ECD cell. The cell had been sent to a DOH specific licensee that is licensed for GC repair work. A technician at the GC-repair licensee discovered the missing foil source. The GC-repair licensee notified STL of the missing source. STL performed a thorough search of the lab but could not find the missing foil.
"DOH contacted both STL and our GC-repair licensee after receipt of the letter. The Operations Manager at STL, [DELETED], who was the event reporter, could not initially be contacted. DOH did reach him for discussion two weeks later. DOH contacted our GC-repair licensee shortly after receipt of the notification. The GC-repair RSO mentioned that the ECD cell received from STL was an older cell that looked like it had never been used. The cell showed severe corrosion, which indicated that this cell had been in storage for a long time. The cell came in a box and was broken. The GC-repair RSO stated that the foil in these cells could fall out or removed easily, if the cell had been opened or if the ceramic portion of the cell was broken. This cell had a broken connector when received by the GC-repair licensee. The GE-repair RSO said that the cells can become loose in the Varian device and can break at the ceramic connector, which may have happened when someone attempted to remove it from the GC device. A tool is needed to remove the source from a cell in normal condition. The GC-repair RSO said that the cell didn't look like it had been tampered with in a purposeful manner. The GC-Repair RSO contacted [DELETED] when it was determined that the source was missing. They discussed the event in detail and [DELETED] was reminded, per the terms of GL device receipt requirements that they were not allowed to perform activities involving removal of sources. [DELETED] had recently taken over the program at STL Seattle. [DELETED] was further reminded of his record keeping responsibilities and the other limitations of receipt of GL GC detector cells.
"When DOH talked with [DELETED] he confirmed that he had spoken with the GC-repair RSO and had been made aware that the source was missing after the cell had been received. The cell had not been used for a few years. A person, no longer employed by STL Seattle, was thought to have worked on the cell. He had not worked for the company in over a year. [DELETED] thought that any work done on the cell would have been a year or two previous to this individual leaving. He did not know if this work had included removing the foil from the cell. [DELETED] stated that when he had been informed of the missing radioactive source, staff at STL performed a search of the lab. He stated that they have a Geiger counter, but were not able to find the source. DOH re-informed [DELETED] that they are not licensed to perform source work on cells, [DELETED] agreed. He stated that this won't happen again . [DELETED] stated that STL management oversight of lab activities had recently been improved.
"DOH issued an item of noncompliance to STL that was categorized as a Violation, for their failure to keep licensed radioactive material secure. DOH did not perform an on site investigation and no media attention was noted.
"What is the notification or reporting criteria involved? 10 CFR 20.2201(a)(1)(ii) 30 days.
"Activity and Isotope(s) involved: 555 megabecquerel (15 millicurie), Nickel 63.
"Overexposures? Likely N/A but was unable to be determined.
"This is a lost source: Manufacturer Varian Associates Inc., Model- 02-001972-0, Serial Number 5447.
"Disposition/recovery? STL was several times reminded of their responsibilities and limitations.
"Leak test? N/A
"Vehicle: N/A
"Release of activity? Loss of 555 megabecquerel (15 millicurie), Nickel 63, foil source.
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Exposure (intended/actual); consequences: exposure, if any, is unknown; consequences are unlikely.
"Was patient or responsible relative notified: N/A
"Was written report provided? Yes
"Was referring physician notified? N/A
"Consultant used? No"
Other Nuclear Material
Event Number: 40094
Rep Org: RADIATION SAFETY ASSOCIATES, INC.
Licensee: P&G - CLAIROL, INC.
Region: 1
City: Stamford State: CT
County:
License #: 0611703-02
Agreement: N
Docket:
NRC Notified By: K. PAUL STEINMEYER
HQ OPS Officer: MIKE RIPLEY
Licensee: P&G - CLAIROL, INC.
Region: 1
City: Stamford State: CT
County:
License #: 0611703-02
Agreement: N
Docket:
NRC Notified By: K. PAUL STEINMEYER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/21/2003
Notification Time: 13:06 [ET]
Event Date: 07/31/2003
Event Time: 00:00 [EDT]
Last Update Date: 08/21/2003
Notification Time: 13:06 [ET]
Event Date: 07/31/2003
Event Time: 00:00 [EDT]
Last Update Date: 08/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JOHN KINNEMAN (R1)
WILLIAM BRACH
JOHN KINNEMAN (R1)
WILLIAM BRACH
TWO NICKEL-63 SOURCES LOST
Radiation Safety Associates, a consultant for the licensee, reported that two detector cells for gas chromatography units containing 15 millicuries of nickel-63 were determined to be missing. The two sources are a Perkin Elmer Model # 6000204 (Serial # 1140) and an HP/Agilant Technologies Model # G2379A (Serial U0169). Radiation Safety Associates, Inc. was performing decommissioning activities for the licensee at its Stamford, CT, facilities. In performing an inventory of material in one area of the facility, they were unable to locate a cardboard box which supposedly contained the sources. The box had been set aside and marked "save" for disposal as radioactive waste. The consultant believes that the box was inadvertently disposed of as normal trash. Trash is picked up by Waste Management, Inc. at P&G-Clairol on a daily basis. Trash is then taken to the Bridgeport, CT incinerator where it is incinerated daily.
Radiation Safety Associates, a consultant for the licensee, reported that two detector cells for gas chromatography units containing 15 millicuries of nickel-63 were determined to be missing. The two sources are a Perkin Elmer Model # 6000204 (Serial # 1140) and an HP/Agilant Technologies Model # G2379A (Serial U0169). Radiation Safety Associates, Inc. was performing decommissioning activities for the licensee at its Stamford, CT, facilities. In performing an inventory of material in one area of the facility, they were unable to locate a cardboard box which supposedly contained the sources. The box had been set aside and marked "save" for disposal as radioactive waste. The consultant believes that the box was inadvertently disposed of as normal trash. Trash is picked up by Waste Management, Inc. at P&G-Clairol on a daily basis. Trash is then taken to the Bridgeport, CT incinerator where it is incinerated daily.