Event Notification Report for March 05, 2007

AGREEMENT STATE REPORT - POSSIBLE RELEASE OF TRITIUM GAS

The licensee provided the following information via email:

"Sometime between 03-05-2007 and 03-09-2007, 12 Tritium Exit signs containing approximately 6.2 Ci of Tritium each were released from Stanford University to the Newby Island Landfill in Milpitas, CA. The exit signs were reported to have been crushed on a hard surface with a possible release of the Tritium gas contained in the glass beads in the exit signs, and then covered with 60 tons of dirt. The Tritium exit signs are manufactured by the Isolite Safety Light Corporation in Bloomberg, PA. Licensee RSO will contact the Isolite Safety Light Corporation for more information concerning the Tritium exit signs and determine if the Tritium therein was released as a gas, or if any remains after crushing the glass beads that may be water soluble. The General Manager of the Newby Island Landfill was contacted by licensee RSO."

AGREEMENT STATE - MEDICAL EVENT RELATED TO DOSE LESS THAN 20% PRESCRIBED

"Upon quality review a misadministration was discovered by hospital staff on March 3, 2007; the actual medical procedure was performed on January 23, 2007. It is estimated that patient was administered a dose less than 20% of the intended dose. State was notified on 19 March 2007. This incident is referred to [the State's] radioactive materials [office] for investigation."

The misadministration involved a Gamma Knife. A quality review by the licensee confirmed that a treatment dose was prescribed as
- 40% of maximum dose equivalent equals 11Gy; but was calculated as - 50% of maximum dose equals 11Gy.

This discrepancy resulted in the administration of a dose that was 20% less than intended.

State Report FL07-046

* * * Update on 03/20/07 at 1408 EDT via e-mail from FSME (C. Flannery) to MacKinnon * * *

This event has been reviewed and determined to be a medical event. Immediate release to the public is authorized.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

POTENTIAL DEFECT IN E7000 RELAYS

"Notification of limited E7000 relay recall (CII-010).

"During our normal assembly processing of nuclear E7000 relays, Tyco Electronics experienced an issue with a component. A spring in the base assembly broke during the calibration process. An analysis of the spring revealed non-conforming heat treatment causing the spring to become brittle. Further investigation revealed that this condition was limited to one specific lot of springs."

The cause of the defect was determined to be stress corrosion cracking (SCC). Testing of other springs in this lot did not identify additional defective springs. Tyco's inspection process has been changed to better detect SCC. The defective springs have been purged from inventory and customers notified.

Plant affected by this recall are:
Braidwood
Farley
Fitzpatrick
Indian Point 3
Limerick
Millstone
North Anna
Oyster Creek
Peach Bottom
Perry
Prairie Island
San Onofre
Susquehana
Vogtle
Watts Bar

Other agencies/organizations:
Delphi Controls
Engine Systems Inc
Entergy Oswego Warehousing
Ergy Tech
GE Nuclear Energy
Progress Energy Carolinas
Trentec Inc - Curtiss-Wright Flow Control Group

AGREEMENT STATE REPORT - STOLEN CPN MOISTURE DENSITY GAUGE

"On the afternoon of March 5, 2007 at approximately 2:00 pm, the Radiation Safety Officer for Quality Assurance Testing Laboratories, Inc. of Montgomery, Alabama notified the State that a CPN model MC-3 moisture density gauge was stolen from its storage location in Montgomery, Alabama. Quality Assurance Testing Laboratories, Inc. is authorized to possess and use radioactive material under their Alabama Radioactive Material License No. 819. The gauge was last seen Thursday, March 1, 2007 when it was placed in storage. The gauge was discovered missing at 10:00 am on the morning of March 5, 2007. The Montgomery Police Department was notified and responded. The stolen gauge was identified as a CPN model MC-3, serial number M300705778, with 10 millicuries of Cs-137 and 50 millicuries of Am-241-Be. The RSO indicated that the gauge was stored in a locked shed that had no windows. The door is equipped with a regular door lock and a deadbolt. There was no sign of forced entry and only the one gauge was stolen. Other gauges containing radioactive material were in the building but not affected. The RSO indicated that the transport case was not locked and the source shutter was not locked. According to the RSO, no other equipment was stolen. The licensee is canvassing the pawn shops within the city providing them pictures for their information."

Alabama Event 07-14.


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.