Event Notification Report for November 09, 2007

ILLINOIS AGREEMENT STATE REPORT - HIGH EXTERNAL RADIATION LEVELS ON I-125 MEDICAL SEED SHIPMENT

"This afternoon [at 1330 CST, the State of Illinois] received a call from the [Deleted], the Radiation Safety Officer [RSO] for Bard Brachytherapy located in Carol Stream, IL. The RSO advised that a package of fifty one, I-125 seeds with a total activity of 38 milliCuries, had been returned to them from a client that had abnormal radiation levels associated with the package. Surface readings showed 600 mr/hr and readings at 1 meter showed 1.4 mr/hr. Their investigation quickly showed that all sources identified in the shipping papers were accounted for. However, the lid to the pig which shielded the contents had become askew during transit due to failure to secure it properly resulting in the elevated readings. The vial within the leaded container was intact with no signs of external radioactive contamination or loss of integrity. The RSO promptly notified the shipper, Virginia Mason Medical Center of Seattle, Washington as well as the courier's (Federal Express) radiation safety officer. There is no reason to suspect that there were any overexposures to transportation personnel as a result of the event considering the low level gamma radiation associated with I-125. This event has no media attention associated with it at this time, nor are there any security concerns associated with it. Given the improper preparation of the package by the shipper, no further action is expected from Bard Brachytherapy at this time save for filing the appropriate written report."

IL Event No: IL070058

See also EN #43778, Washington State Agreement State report.

PART 21 NOTIFICATION - CONVAL VALVES WELD QUALIFICATIONS

The manufacturer provided the following information via facsimile:

"This letter serves to notify the Commission of two (2) potential safety-related, non-compliances as defined in 10CFR-Part 21. These non-compliances involve Electron Beam (EB) weld qualifications for welds performed on pressure boundary and safety related components of Conval valves; and Electron Beam (EB) welding of cobalt alloy types 6 and 21 to pressure boundary parts of Conval valves.

"Possibly as high as 2,000 forged-body, globe valves generally for use on high temperature steam and hot water in sizes ranging from, 1/2" to 4", possibly involving one or more of these non-compliances, have been supplied by Conval to approximately 25 nuclear power plants over an estimated time period extending from the 1980's to the present. Probably over half of the valves suspected of nonconformances were procured as Commercial Grade valves."

Potentially affected plants are:
Region 1: Fitzpatrick, Indian Point, Pilgrim, Vermont Yankee, Nine Mile Point
Region 2: North Anna, Surry, Oconee, Brunswick, Crystal River, Harris
Region 3: Cook, Palisades, Quad Cities, Point Beach
Region 4: Arkansas Nuclear One, Fort Calhoun, Palo Verde, Grand Gulf, Waterford, Cooper, South Texas
Foreign Plants: Laguna Verde (Mexico), Keoberg (South Africa)

AGREEMENT STATE REPORT - TRUCK TRANSPORTING A RADIOGRAPHY CAMERA OVERTURNED

The State provided the following information via facsimile:

"At approximately 1530 hours the left rear tire of the pickup truck transporting the camera blew out. Truck rolled on its side [just West of I-4/I-95 intersection on I-4]. There were no injuries and no damage to the camera. Company personnel have custody of camera and a truck is being dispatched to retrieve it. Camera will be tested for leakage and functionality before being placed back into service. No further action will be taken in this incident."

Camera: Sential Model 424-9 S/N 3688
Source: 29 Curies Ir-192

Florida Incident: FL07-174

AGREEMENT STATE REPORT - HIGH EXTERNAL RADIATION LEVELS ON I-125 MEDICAL SEED SHIPMENT

The State provided the following information via email:

"Bard Brachytherapy, a vendor of I-125 prostate seeds based in Carol Stream Illinois, notified the Illinois Radiation Control Program that they had received a shipment of seeds from a state of Washington licensee, Virginia Mason Medical Center, which had excessive external radiation levels. The Illinois, Division of Nuclear Safety promptly notified the state of Washington, Department of Health via phone and email.

"At the surface the package was reported to be reading 600 mR/hr while readings at a meter were 1.4 mR/hr. It was determined the lid of the pig which contained the returned seeds (51 seeds total from an original shipment of 90, with an activity of 1406 MBq [38 mCi]) had shifted during transport allowing a beam of radiation to penetrate the external surface of the transport package.

"Immediately upon notification from Illinois, the shipper (Virginia Mason Medical Center) was contacted. Washington DOH staff spoke with the Authorized Medical Physicist who provided this information: This was the remainder of a shipment originally received by the licensee on 5 November 2007. It arrived with a total of 90, I-125 seeds with an average activity of 0.4 mCi/seed. Thirty-nine of the original 90 seeds were implanted and the remaining 51 were repackaged according to the manufacturer's (Bard's) instructions.

"At the time of shipment, licensee records show a dose rate at the surface of the package of 0.14 mR/hr, and a reading at one meter of 15 microR/hr.

"The licensee, upon questioning, acknowledged this shipment differed from all prior shipments from this vendor because it was a sterile shipment (all prior shipments had been non-sterile) and thus came in new/different packaging with different packaging instructions.

"The licensee firmly believes the lid of the pig was dislodged due to abuse during shipment.

"The licensee stated they had been in contact with Bard concerning this incident. Bard has agreed that on all future such shipments for clients in the state of Washington (it was unclear if corrective action would be extended to clients in other states as well) Bard will include more tape, for sealing the 'lid' of the pig, and that repackaging shipping instructions would also include steps for taping the pig closed prior to shipment."

See also EN #43775, Illinois Agreement State report.

AGREEMENT STATE REPORT - P-32 SOURCE LOST

The following information was received via fax:

"351 microcuries of P-32 was lost (on 11/9/07). The isotope was checked in, delivered and signed for at the research lab on 11/9/07. When lab personnel went to use the isotope, they could not locate it. Radiation safety staff searched dumpsters, garbage cans, and the lab, but could not locate the vial of P-32. It is possible it was put out as garbage by mistake. The RSO contacted the garbage removal contractor.

"Written report received on 11/16/07. Although the licensee could not determine the precise circumstances that caused the source to be lost, the corrective action appears to be adequate. No press release was issued. No reward offered. The incident will be reviewed during the next routine inspection. Incident closed."

New York Event: NY-11-17
New York Incident: 575

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source