Event Notification Report for August 09, 2006

AGREEMENT STATE REPORT - DAMAGED MOISTURE-DENSITY GAUGE

The State provided the following information via e-mail:

"At about 8:45 am, [DELETED] with California OES notified RHB that he had received a call regarding a damaged moisture-density gauge. [DELETED], Alternate RSO for Southland Geotechnical (also dba Landmark Consultants), called to report that a Troxler, Model 3430 moisture-density gauge (S/N 29144), with a nominal 8 mCi Cs-137 and a nominal 40 mCi Am-241 source was run over by a loader at a temporary job-site in Heber, CA. The guide bar was broken, but the source rod was not. They were able to fully retract the source, but could not lock it in the shielded position. They took a leak test of the source, which is being analyzed, and they used duct tape to maintain the source in the shielded position. The source is currently secured in its case at the authorized, permanent storage location. After the results of the leak test are returned, if it is negative, the gauge will be returned to Troxler for repair."

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY CAMERA

The State provided the following information via email:

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

Date of Event: Wednesday, August 9, 2006
Location of Event: Everett Washington

ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): At some time between 10:00 p.m. Tuesday, August 8 and 6:00 a.m. Wednesday August 9, 2006, a radiography truck was stolen from the parking lot of the Extended Stay America hotel on 8410 Broadway in Everett, Washington. The truck was discovered missing at 6:00 am as the radiographer was about to leave for work. The truck contained an AEA (QSA Global) model 880 radiography device, Serial Number D2720. The device contained an Iridium-192 75 curie source, serial number 28772B. The device was reported to be locked and secured in the truck. The truck was reported to be equipped with an alarm and truck disabling device but was not used. The keys to the vehicle were reported to have been left in the door of the truck. The truck is a white 2006 Chevrolet 2500HD extended cab with a dark room shell in the bed. It has a Texas license plate number [DELETED]. A report was made by the radiography company to the Everett police department upon discovery of the missing truck.

Notification Reporting Criteria: WAC 246-221-240.

Isotope and Activity involved: Iridium 192, 75 curies.

Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None.

Lost, Stolen or Damaged? (mfg., model, serial number): Stolen model AEA (QSA Global) model 880 radiography device, s/n D2720. It contained a 75 curie source, s/n 28772B.

Disposition/recovery: None.

Leak test? May 25, 2006.

Vehicle: (description; placards; Shipper; package type; Pkg. ID number)
The truck is a white 2006 Chevrolet 2500HD extended cab with a dark room shell in the bed. It has a Texas license plate number [DELETED].

Release of activity? None.

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? N/A
Was referring physician notified? N/A

Consultant used? N/A"

Washington Event Number : WA-06-051

Other agencies notified: USDA - Krisher-Clive


* * *UPDATE PROVIDED BY SCROGGS TO KOZAL VIA E-MAIL ON 8/10/06 AT 1712 EDT* * *

"The truck was found by police at 4 pm [PDT], August 9. It had been abandoned in a strip-mall parking lot near Everett. DOH staff were at the scene, making measurements and assured radiation safety for police and fire personnel during the recovery effort. It appears the dark room had not been entered. The radiography device was still in its stowed position. After the police had finished conducting their criminal investigation at the scene, the truck and device were returned to WeldSonix IR personnel.

DOH staff are continuing to investigate the incident. Corrective actions are to be determined."

Notified R4DO (Bywater), NMSS(Holahan), ILTAB(Hahn), IRD(Wilson), DHS(Craig), DOE(Watt), EPA Region X(Sibley), Canada via e-mail, HHS(Dalziel), FEMA (Bagwell), USDA(Parks)

* * * UPDATE AT 18:54 ON 1/3/2007 FROM ARDEN SCROGGS TO MARK ABRAMOVITZ * * *

"At approximately 3:40 P.M. Wednesday August 9, 2006 Snohomish County Sheriff's officers found the missing radiography truck in the parking lot of an apartment complex south of the City of Everett, Washington. A DOH Health Physicist had been dispatched to Everett that day to begin an investigation and was at the Everett police department when the vehicle was reported found. The Health Physicist went to the site of the recovered truck and performed surveys of the area. The Snohomish County Sheriff's officer was able to gain access to the truck darkroom by opening the lock and allowing the HP to perform surveys inside the vehicle's storage area. The radiography device appears to have remained in the truck and was undisturbed.

"The inspection of the stolen truck and the radiography device prompted a broader investigation resulting in the inspections of all the licensee's trucks, equipment and area operations. These inspections found several items of noncompliance that were ultimately addressed by the license.

"These items were: control licensed material at all times, assure proper key control, physically secure exposure devices inside the vehicle to prevent unauthorized removal, and block and brace the transported package to prevent movement. These items were corrected and verified by DOH follow-up, field-site inspections."

Notified the R4DO (Pruett), NMSS (Giitter), IRD (Wilson), ILTAB (English, via E-mail) and Canada (via E-mail).

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via email:

"A Moister density gauge ( Troxler 3440 - Ser # 19048) was stolen on 8/9/06 at about 1600 in El Paso Texas. The gauge was stolen from the storage area at the facility. There appears to be no signs of forced entry to the area. A Police report was filed. The EPPD was to coordinate with the jurisdictional police department to visit the prime suspect (former PSI employee) yesterday evening (8/9/06). Locks at the facility are being changed. The local scrap yards and the Texas Association of Pawnbrokers have been notified. The source information is 1 Cs-137 source serial # 50-8685 8 mCi, and AmBe serial # 4714512 40 mCi. The licensee will provide a written report as soon as all the information is gathered."

Texas incident # I - 8354

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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PROCESS UNIT 3 ALARM THRESHOLD EXCEEDED

"In accordance with 10CFR74.57(f)(2), a report to NRC is required for the following event. On August 9, 2006 the Alarm Threshold Limit was exceeded for [DELETED] Extraction (Column Based) System. This was reported to the Measurement Control Unit Manager on August 10, 2006 at approximately 07:30. The time in which the alarm was initially reported was approximately 22:30 on August 9, 2006. The initial test difference exceeded the Alarm Threshold Limit. No new feed material is being added to the process until the alarm is resolved. An internal investigation is underway.

Per E41-116 and the Fundamental Nuclear Material Control Plan (FNMCP), an Alarm Investigation Team was established since a process monitoring test exceeded its alarm threshold limit."

Licensee notified Resident Inspector and HQ NRC.

* * * UPDATE 05/11/08 BY P. SNYDER * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.

AGREEMENT STATE - MEDICAL EVENT

The State provided the following information via email:

"On August 11, 2006, RHB received notification from North Oaks Radiation Center of a potential medical event. On August 9, 2006, a patient was undergoing the third of three fractional doses from a Nucletron Model MicroSelectron-HDR Classic Afterloader, using Ir-192. The first two fractions had been delivered properly. When this fraction was delivered, the medical physicist inadvertently selected the wrong delivery tube. There are two delivery tubes available depending upon the treatment plan. In this case, the longer tube was incorrectly selected for this fraction, and the source remained outside the patient for the entire fraction. The preliminary estimate of the highest dose in this configuration was approximately 100 - 125 rads to the perineum, which was not the intended treatment site, and which would have received less than 50 rads with the intended configuration. The patient has been notified. The California Radiologic Health Branch will investigate this incident."

INVALID EECW PUMP ACTUATION DURING TESTING

"This 60-day telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of an emergency service water system component that does not normally run and which provides an ultimate heat sink.

"At 0951 hours CDT on August 9, 2006, with Unit 1 defueled and Units 2 and 3 operating at 100% power, the B3 Emergency Equipment Cooling Water (EECW) pump was tripped when an undervoltage relay was manually operated during functional testing of relaying associated with the 1B Core Spray (CS) pump breaker. While operations personnel were responding to the pump trip, but before the testing activity could be halted, performance of subsequent steps in the functional testing activity resulted in an automatic start of this same pump and then another trip when a companion undervoltage relay was manually operated. Auto-starting of associated EECW pumps upon CS pump starts is part of the equipment logic and had been anticipated, and the B3 EECW pump had been placed in service prior to beginning the relay functional testing to avoid an automatic start. The potential for tripping loads other than the 1B Core Spray pump breaker was discussed in the pre job briefing, however, the actual test instruction steps did not provide detail sufficient to ensure only specific undervoltage relay contacts were operated. Rather than operating only specific relay contacts, test personnel operated the entire relay, resulting in the unplanned trip, restart, and trip of the B3 EECW pump.

"The logic downstream from the manually operated undervoltage relays and the B3 EECW pump responded in accordance with the plant design. No other plant equipment was affected during this event, though the 2B Core Spray pump would have also tripped had it been running at the time the undervoltage relays were operated. The B3 EECW pump was secured, and the testing activity was suspended. Other operating EECW pumps were not affected and no degradation of EECW system function occurred.

"There were no safety consequences or impacts on the health and safety of the public. The event was entered into TVA's corrective action program for evaluation and resolution. Reference corrective action document PER 108425."

The licensee notified the NRC Resident Inspector.