Event Notification Report for March 10, 2005

CONTRACTOR SUPERVISOR FOUND POSITIVE FOR ILLEGAL DRUGS DURING A PRE-ACCESS DRUG TEST

A contractor supervisor was determined to have been under the influence of an illegal drug during a pre-access drug test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector was notified of this event by the licensee.

OFFSITE NOTIFICATION TO GOVERNMENT AGENCIES DUE TO OIL SPILL

"At approximately 15:45 a hydraulic line ruptured on a 90-ton mobile crane located outside of the Unit 2 Turbine Building. Approximately 50 gallons of hydraulic oil leaked onto the surrounding pavement. Barriers and absorption materials were positioned around the spill area and no oil was released to soil or the river.

"Required offsite notifications included the NYS Department of Environmental Conservation and the Westchester County (NY) Department of Health."

The licensee notified the NRC Resident Inspector

STOLEN TROXLER GUAGE

The licensee had a Troxler gauge model 3400 serial # 31101 with 8 millicuries Cs - 137 and 40 millicuries Am - 241:Be stolen from their storage building on their parking lot in Miami. The theft was considered a general burglary and was given a Miami Dade police report number of 7088G-D. No reward notice has yet been made.

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE DURING RADIOGRAPHY

Initial report made by licensee to the State of California at 1330 PST on 03/11/05 via voicemail:

While performing radiography at the BP Refinery located in Carson, CA, a radiography camera source was not fully retracted while disconnecting the guide tube. The camera was an INC Model IR100 Serial #4043, which contains a 90 Curie Iridium-192 source. After performing several operations of the radiography camera (approximately 10 shots) the radiographer approached the camera without his survey instruments. After disconnecting the guide tube, it became apparent to the radiographer and his assistant that there was a problem since their survey instruments were off scale, and when the radiography crew checked their pocket reading dosimeters, they were off scale also. The radiographer used pliers to force the source into the shielded position and secure the camera. The licensee estimates that the radiographer received 1800 millirem whole body, 212 Rem to the hands, and the assistant received 2766 millirem whole body. There are no reported physical manifestations from the exposure at this time. The corporate RSO is flying to the scene of the incident to reenact the events for their investigation. The personal dosimetry for both operators has been sent for processing. The camera will be sent to the manufacturer for evaluation and repair. The State of California will be conducting their own investigation into the event.

* * * UPDATE FROM CALIFORNIA (SALGADO) TO M. RIPLEY AT 1510 EST ON 03/14/05 * * *

The following information was obtained from the State via facsimile (State text in quotes):

"3/14/05, 1030 [PST]: Update, licensee is reporting that dosimetry for involved individuals has been processed with results as follow: radiographer shows 1.6 rem, whole body. Assistant shows 2.7 rem, whole body. No physical manifestations displayed at this time. Preliminary written report from licensee pending."

No further information available at this time on refinements to the extremity dose estimates. Notified R4 DO (T. Farnholtz) and NMSS EO (T. Essig).

SOURCE VIAL OF GADOLINIUM-153 REPORTED MISSING

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"This notification to the NRC Operations Center is in accordance with 10 CFR 20.2201(a)(ii) regarding the incident described below:

"On 3/10/05, we determined that 245 [microCurie] (9.1 MBq) of [Gd-153] (0.5N HCI) in a source vial was missing. The original activity was 1 [milliCurie] (37 MBq) on 4/12/2004, and the missing quantity, corrected for radioactive decay, represented the remaining activity after several labeling experiments.

"Following this discovery, the Authorized User interviewed all researchers who had access to her laboratory. None recalled disposing of the vial. In addition, a health physicist contacted a number of the researchers and performed an independent survey of this and adjacent laboratories with a photon-sensitive survey meter. The original lead pig was found in a box where other lead pigs were stored awaiting disposal. However, the source vial was not in the lead pig. In addition to searching the laboratory areas, we checked the records of both radioactive waste pick ups and other monitored waste from the building in which this laboratory is located. There was no indication of [Gd-153] in any of the records or surveys.

"At this time, the disposition of the material is unknown. Considering that the exposure rate for an unshielded point source of 245 [microCuries] of [Gd-153] is only 0.04 mR/hr, the missing material would not represent a significant external exposure risk. The approximately 69 nanograms of material missing would not represent a significant toxic hazard either.

"Corrective actions have been implemented by suspending the Authorized User's ability to order more radioactive material. With her pending departure from NIH, we do not feel any further actions will be warranted in this situation."

TRITIUM CONTAMINATION FROM A BROKEN M1A1 COLLIMATOR

The following information was provided by the licensee by fax.


"On 17 March 2005, the TACOM-RI RSO received a call from the Ft. Sill RSO informing the licensee that he discovered 3 ea broken M1A1 collimators (nsn 1240-00-332-1780 sealed source registration no. NR-155-S-102-S). Each M1A1 collimator contains a 10 curie sealed source lamp. One collimator (s/n 933) was discovered in a training area. After this collimator was discovered, the Ft Sill RSO immediately proceeded to inspect all M1A1 collimators found in the 3/30th Field Artillery, sections 2nd, 3rd, and 6th. As a result of this inspection, the RSO discovered two additional broken M1A1 collimators, (s/n's 8644, 4116). The RSO immediately took survey wipes of the collimators and areas where they were located. There was no physical damage on the exterior of the devices or cases containing the devices. Physical damage was observed of the tritium sealed source cell itself, however exterior lenses were intact on all three collimators. It could not be determined how the damage occurred. Leak tests were performed on the three collimators with the following results s/n 933 (837,000 dpm or 3.7E-4 millicuries), s/n 8644 (6,950 dpms or 3.1E-7 millicuries), and s/n 4116 (26,300 dpms or 1.2E-5 millicuries). Only Collimator s/n 933 exceeded reportable limits [110,000 DPM]. The RSO secured the purging and training areas upon discovery of the broken devices and conducted area survey in the purging area, conex trailers (where collimators are stored) and training area. None of the areas surveyed had removable tritium contamination in excess of 5,000 dpms. Tritium bioassay samples were taken on individuals (approx 10) who may have actually handled the broken M1A1 collimators. Bioassay samples will be analyzed at the US Army lab, CHPPM Aberdeen, MD. At the time of this report, the bioassay results were not available, The Ft Sill RSO has secured the three collimators in a low-level rad waste storage site for future disposal."