Event Notification Report for November 17, 2005

LOSS AND SUBSEQUENT RECOVERY OF EMERGENCY RESPONSE DATA SYSTEM

Emergency Response Data System (ERDS) was unavailable from 00:47 until 01:51 due to an Emergency Response Data Acquisition and Display System (ERDADS) failure. The problem has been corrected and ERDADS is currently able to supply data to ERDS.

The licensee will notify the NRC Resident Inspector.

AGREEMENT STATE REPORT INVOLVING LOSS OF PALLADIUM-103 SOURCES

On the morning of 11/17/05, Deaconess Health Systems inadvertently discarded a package of twenty-four (24) TheraSeed Palladium-103 Model 200 Implants. Each implant contains a 2.01 mCi Pd-103 source used in the treatment of prostate cancer. The error occurred due to a change in packaging which was not recognized by the recipient. The discarded material was buried at the East Oak Landfill. The licensee does not intend to attempt recovery due to the relatively short half-life, i.e., 17 days, and the small of amount of material involved. The landfill utilizes a portal alarm which did not activate since the material was discarded in it's shielded shipping container.


* * * UPDATE FROM STATE (K. SAMPSON) TO M. RIPLEY 0940 EST 11/18/05 * * *

The State provided the following additional information via facsimile:

"At approximately 1:00 PM on November 17, 2005 the licensee discovered the loss of 24 Theraseed 200 brachytherapy seeds. Each seed contained 2.01 mCi of Pd-103 at the time of the loss. According to the RSO, the manufacturer of the seeds had recently changed the packaging of the material. Prior to the change, the seeds were all packaged in one lead foil tray. However, the licensee had recently received them packed in three trays stacked one atop another in a single box. In this instance when the box was opened only two trays were removed, the box was discarded with the third tray still inside it. Trash receptacles in the hospital were searched, but the missing materials were not found. The local waste hauler and landfill were contacted and it was determined that the trash had already been delivered to the landfill that morning and had been covered. In light of the short half life of Pd-103 and the low energy of the gamma it emits, and the fact that the sources were still within their shielded tray, it was decided not to attempt to locate them at the landfill."

Note also that the name of the licensee on the Oklahoma license is Deaconess Health System, LLC doing business as Deaconess Hospital. Notified R4 DO (J. Clark), NMSS EO (G. Morell) and TAS DO (A. Danis via email)

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

INITIAL PART 21 NOTIFICATION - PRIME MEASUREMENT PRODUCTS, MODELS 763 & 763A PRESSURE TRANSMITTERS AND MODEL 764 DIFFERENTIAL PRESSURE TRANSMITTERS

The following information was received via facsimile:

"On 11/2/05 SGT LLC, primary contractor for Steam Generator replacements at Callaway Plant, received notification from PRIME Measurement Products, (formerly ITT Barton) of a manufacturing defect in Model 763, 763A, and 764 pressure transmitters involving use of Zener diodes that were not in compliance with purchase specifications. Subsequently, on 11/3/05 SGT LLC notified AmerenUE Callaway Plant of the potential manufacturing defects involving the aforementioned transmitters. These transmitters provide input to steam generator level indication and control functions.

"The notification provided by PRIME stated the purchasing specifications required JANTX components, but in some cases commercial variations of the required parts were used to manufacture some transmitters. This condition was potentially reportable under 10 CFR 21, depending on the specific application at facilities using these instruments manufactured by PRIME Measurement Products. The following is a summary of the information obtained from PRIME Measurement Products:

1. This notification involves 76 specific transmitters manufactured between 2/10/04 and 9/19/05.

2. Each transmitter contains two Zener diodes which may not comply with purchase specifications.

3. The JANTX Zener diodes are different in appearance with respect to the commercial variations. Some JANTX Zener diodes used in the recent past have bodies that are solid orange or light blue in color or clear glass. The commercial Zener diodes in question have a clear glass body. The commercial Zener diode is larger (0.095" diameter X 0.275" long) than the smaller JANTX Zener diode (0.072" diameter X .155" long).

4. The existence of the commercial Zener diode can be confirmed by removal of the transmitter electronics cover and observing the Zener diodes at locations CR2 and CR3, as shown on manufacturer supplied circuit board drawings.

5. The Zener diodes are not field replaceable, as it is necessary to electronically reestablish the calibration zero which will likely necessitate replacement of a calibration resistor. This calibration resistor is located in a temperature sensitive portion of the electronic circuit and requires thermal performance validation.

6. PRIME believes that transmitters with commercial Zener diodes that are currently installed in a plant can be relied upon to continue to operate and perform their safety-related function in the event of an accident. This belief is based on the facts that the commercial Zener diodes installed in any transmitter have been shown to be functional at the accident maximum sustained temperature and because the radiation effects on commercial Zener diodes are known to be within the margin of the original Barton qualification.

"SGT LLC purchased 22 of the suspect transmitters for use in the Callaway Plant Steam Generator replacement project. Additionally, 6 suspect transmitters had been supplied directly to Callaway Plant. Physical inspections by SGT LLC and Callaway Plant staff determined 21 of the transmitters had the commercial Zener diodes installed. These transmitters were returned to PRIME where the commercial Zener diodes were replaced with qualified Zener diodes and proper transmitter operation was verified. The affected transmitters have since been returned to Callaway as fully qualified for safety related use in nuclear applications.

"On 11 /16/05, Callaway Plant personnel completed evaluations and determined the use of commercial Zener diodes constituted a defect per 10 CPR 21, requiring initial notification to the NRC within two days. Per the information provided by PRIME, all other affected customers have been notified.

"The concern was identified while Callaway Plant was shutdown for a refueling outage when the transmitters were installed, and prior to being returned to service. Therefore, no other reporting criteria apply.

"The NRC Resident Inspectors have been notified of this issue."

BOTH TRAINS OF SHIELD BUILDING VENTILATION DECLARED INOPERABLE DUE TO MISSING CLAMPS

"At 1651 on 11/17/2005 both trains of Shield Building Ventilation were declared out-of-service because it was identified that Shield Building penetrations 31 and 36NW flexible boot seals were not clamped per the design drawing. Since there is no documentation to show that Shield Building Ventilation would be able to perform its function during a design basis event with no clamps installed, Shield Building Vent was declared inoperable. Clamps have been installed and the penetrations were returned to the design configuration. At 1810 CST Shield Building Ventilation was declared Operable."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM MALONEY TO HUFFMAN AT 1105 EST ON 1/13/06 * * *

The licensee has performed an engineering review and determined that the boot seals would have been capable of performing their design basis function without the clamps installed. Consequently, this event is no longer considered reportable and is being retracted.

The NRC Resident Inspector has been notified by the licensee. R3DO (O'Brien) has also been notified.

LOSS AND RECOVERY OF COMMUNICATIONS

The Emergency Notification System (ENS) was lost due to the loss of offsite telephone communications. Troubleshooting to determine the cause is in progress. Offsite telephone communications were restored at 0040 EST on 11/18/05.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via email:

"Event Report # WA-05-062

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"STATUS: new

"Licensee: USKH, Inc.
"City and state: Spokane, Washington
"License number: WN-I0409-1
"Type of license: Portable Gauge

"Date of event: 17 November 2005, Called in 5:45 PM.
"Location of Event: Spokane, Washington
"ABSTRACT: The license's Radiation Safety Officer reported that sometime between 2 and 5 PM a Troxler, Model 3411B, moisture density gauge, Serial Number 5541, was stolen out of the operator's transport vehicle parked in a Diamond Parking lot adjacent to the 'Flour Mill' where the company's offices are located at 621 W. Mallon Avenue, Suite 309, Spokane, Washington. A police report was filed on 17 November 2005 but Spokane police declined to investigate the scene.

"Bolt cutters were used to liberate the gauge/transport box from 2 separate chains with a padlock on each attaching the box to the rear of the operator's pick-up truck. The parking lot (of over 75 vehicles) has an attendant who did not observe the theft.

"The operator appears to have violated at least one DOH requirement that may have contributed to the theft to the device. Department of Health Order, dated 2 December 2002, requires that when the licensee's portable gauge is not physically under the control of the operator that the device must be covered or carried in such a way that the passer-by cannot see the device.

"Another potential contributing factor to the theft, is that the operator was planning on transporting the gauge to his residence to recharge and take it to the work site the next morning because the work site was halfway between the operator's residence and the primary storage location. Preliminary information indicates that the work site is within 50 miles of the primary storage location. This is still under investigation. The licensee will be cited for at least one violation as a result of the event, and corrective actions will be discussed with the licensee.

"The event is currently under investigation. This report will be updated to include any new findings. No media attention noted at present.

"What is the notification or reporting criteria involved? WAC 246-221-240 Reports of stolen, lost or missing radiation sources

"Activity and Isotope(s) involved: 296 megaBq (8 millicuries) Cesium-137 and 1480 megaBq (40 millicuries) Americium 241/Beryllium.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) N/A

"Lost, Stolen or Damaged? STOLEN (mfg., model, serial number) noted above

"Disposition/recovery: pending

"Leak test? Unknown

"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) pick-up truck with no cap

"Release of activity? N/A

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A

"Consultant used? N/A"

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.