Event Notification Report for June 02, 2008

POTENTIAL MISADMINISTRATION GREATER THAN 20% OF PRESCRIBED DOSE

The RSO performed a quarterly audit on 9/2/08 and discovered that a misadministration greater than 20% of prescribed dose and greater than 50 Rem to the lung tissue occurred on 6/2/08. The prescribed dose was 1.0 ml of P-32 chromic phosphate into two separate syringe applications.

The technician prepared the first P-32 dose into syringe "A" and recorded into the written record after calibrated assay as 1.3 ml and performed the same procedure for the second dose which was recorded into the written record as 1.0 ml into syringe "B". The first dose in syringe "A" exceeded the allowable dose. Both syringe applications were given to the patient into separate lung tube injections.

The prescribing physician and authorized user have been notified. It is not known if the patient has been notified.

* * * RETRACTION AT 1545 EDT ON 9/5/08 FROM OYTOMARI TO SANDIN * * *

Based on further review of this event by the licensee, it was determined that the total dose to the lung was less than 50 Rem. As a result, the event does not meet reportability criteria under 10CFR35.3045. The licensee has reviewed its conclusion with NRC Region 4 inspectors (Whitten and Munoz).

R4DO (Jones) and FSME (Turtil) have been notified.

MASSACHUSETTS AGREEMENT STATE REPORT - NI-63 SOURCE LEAKAGE

The following information was obtained from the State of Massachusetts via facsimile:

The licensee reported that two Electron Capture Device (ECD) leak tests were positive for leakage. ECD serial number U0504 had a reading of 0.1 microCuries. ECD serial number U2861 had a reading of 0.06 microCuries. Both units are Agilent model G2397A and contain 15 mCi of Ni-63. The licensee has taken both units out of service and has contacted Agilent for the return of both devices.

FLORIDA AGREEMENT STATE REPORT - LOSS OF CONTROL OF REFERENCE SOURCES

State of Florida Bureau of Radiation Control reported that the licensee, Indian River Radiology, sold two gamma cameras to another entity. By mistake, the purchaser of the cameras also took the reference sources that are used for calibrations. The sources will be returned to the licensee (seller) by Wednesday, June 4, 2008. This is considered a loss of control of radioactive material.

The sources each contained 20 mCi of Cs-137 and 250 mCi of Gd-153.

Florida Incident Number: FL08-083

* * * UPDATE FROM STEVE FURNACE TO HOWIE CROUCH @1651 HRS. ON 6/3/08 * * *

The State of Florida amended the report to state that the Cs-137 source was 30 mCi in strength as of 1 MAY 1999 and is used as a PET scan source, not a reference source. The Gd-153 source was 250 mCi on 1 DEC 2004. They are encouraging the expedited return of the sources to the licensee.

Notified R1DO (Henderson) and FSME EO (Chang).

SHIPPING CASK ARRIVES WITH A LOOSE BOLT

"The following is a 4 Hr Non-Emergency notification in accordance with 10 CFR 50.72(b)(2)(xi), Offsite Notification.

"At 1440, June 2, 2008, Susquehanna LLC was notified by the Barnwell South Carolina waste disposal facility, of an issue with a shipping cask containing irradiated hardware shipped from Susquehanna LLC. The cask was received at the facility on 5/31/08 and the incoming radiological survey was completed with no out of specification values. On June 2, 2008, the cask had the impact limiter removed and was in the process of being offloaded when it was discovered that one of the twelve bolts that secure the cask base plate to the cask body was found hand tight. The remaining eleven bolts were not loose, There was no radiological safety concern associated with the bolting condition as survey results confirmed that no radioactivity leaked from the cask. The waste facility will issue a condition report for Susquehanna's response.

"The site South Carolina Department of Health and Environmental Controls (SC DHEC) Inspector was notified by Barnwell facility personnel of the issue."

The licensee's QC inspector is required to verify bolt torque before the cask leaves the site. This will be confirmed by the licensee. The licensee will be notifying PEMA (Pennsylvania Emergency Management Agency).

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT INVOLVING A DAMAGED TROXLER MOISTURE DENSITY GAUGE

On June 2, 2008 at approximately 2:15 pm a Troxler Moisture Density Gauge, Model 3430, was run over by a skid steer at a construction site in the Denver Metro area . The licensee notified the Colorado Radiation Management Unit at approximately 4:00 pm that the gauge had been transported back to the main office in Golden, Colorado. Subsequent preliminary testing indicated that the sources were intact and not leaking. Results of the formal leak test are pending.

INVALID SYSTEM ACTUATION OF DIVISION 1 CONTAINMENT ISOLATION VALVES

"On June 2, 2008 at 6:24 a.m. CDT power was lost on the reactor protection system (RPS) bus 'A'. The plant was operating at 100 percent power at the time. The loss of RPS bus 'A' interrupted power to containment isolation actuation circuitry. This caused the Division 1 containment isolation valves in various balance of plant systems to automatically close, as designed. Plant operators implemented recovery procedures to shift RPS 'A' to its alternate power supply, and restore the systems affected by the isolation. The containment isolation valves were confirmed to have actuated as required. Plant capacity was not interrupted by the containment isolation signal.

"As their primary power source, each RPS bus is supplied by its own motor generator set. The investigation of this event found that two resistors on a circuit card in the voltage regulator on the 'A' RPS motor-generator set failed. This had the effect of causing the generator voltage to fluctuate significantly, resulting in a automatic trip of the generator output breaker and a loss of power on the bus.

"This event is being reported in accordance with 10CFR50.73(a)(2)(iv)(A) as an invalid actuation of the Division I containment isolation actuation system."

The licensee informed the NRC Resident Inspector.