Event Notification Report for October 09, 2008

24-HOURS BULLETIN 91-01 REPORT INVOLVING FAILURE TO VISUALLY INSPECT STORAGE CYLINDERS

The following information is provided without quotation for readability:

DESCRIPTION: On 10/09/08 at 1537 hours it was determined that procedure CP4-CU-CH6430, "In Storage Fissile Cylinder Inspection", does not fully meet the periodic inspection requirements of NCSA GEN-003. GEN-003 requires inspection every four years of all thick wall cylinders that contained fissile material since they were last washed on the inside of the cylinder. Only cylinders that were filled with fissile material on their last fill have been identified for inspection. Cylinders filled with fissile material, emptied and subsequently filled with non-fissile material and emptied, have not been inspected as required. Approximately 73 Cylinders that have contained fissile material since their last washing have not been inspected in violation of the requirement of NCSA GEN-003, these cylinders could contain residual nonvolatile material referred to as heel. Potentially the residual heel could contain fissile material.

Double contingency is maintained by implementing two independent controls on one parameter (moderation). The first leg of double contingency relies on the design of the cylinder to ensure moderation control. Cylinders are designed to the requirements of ANSI N14.1 and ensure that it is unlikely for the cylinder wall to breach and allow water intrusion. This control on moderation was not violated.

The second leg of double contingency relied on inspections every 4 years of the cylinder wall, valve, and plug for abnormal corrosion. This control ensures that in the event of a cylinder breach, it is unlikely that sufficient moderation to cause a criticality will enter the cylinder before it is identified and mitigated. Since the cylinders were not inspected within the 4 year time frame as required, this control on moderation was violated.

The NRC Resident Inspector has been notified of this event. PGDP Problem Report No. ATRC-08-2918; PGDP Event Report No. PAD-2008-31; NRC Worksheet No. 44558.

SAFETY SIGNIFICANCE OF EVENTS: Although a control requiring inspection of the cylinders every 4 years was violated, no cylinder breaches occurred. Later inspections identified no cylinder integrity issues, moderation control was lost and double contingency was not maintained.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR): In order for a criticality to be possible, more than 10kgs of water would have to enter a breach in a cylinder which contains more than a critical mass of material enriched to greater than 1.0 wt% 235U.

CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): Moderation.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS) : There were 73 cylinders which were not inspected as required. These cylinders had at one time held fissile material. The cylinders were emptied except for a small residual heel and then filled with non-fissile material. The non-fissile material was then emptied leaving only the residual heel in the cylinder. Cylinder heels are typically less than 50 pounds. Assay is always less than 5.5% enrichment.

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: NCSA GEN-003 requires cylinders containing material enriched to greater than or equal to 1.0 wt % 235U to be inspected every 4 years to identify significant signs of degraded cylinder wall, valve and plug. These cylinders were filled with fissile material, emptied and then subsequently filled with non-fissile material and then emptied again, but were not inspected within the four year requirement.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED : Cylinders have been inspected per the CP4-CU-CH6430 and the identified cylinders were found to comply with NCSA GEN-003.

* * * UPDATE AT 1750 EDT ON 10/10/08 FROM BILLY WALLACE TO STEVE SANDIN VIA FAX * * *

On 10/10/08 at 1500 CDT, an additional 8 cylinders were discovered which had not been properly inspected. The additional cylinders were of a different size than the initial cylinders found, but fall under the same requirement. The additional cylinders have been inspected and all met the NCSA requirements.

Notified R2DO (Shaeffer) and NMSS (McCartin).

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was provided by the state via e-mail:

"Wal-Mart Corporate Office reported a total of 8 tritium exit signs missing from various stores in Ohio. These signs were removed from service and were being held pending return to the manufacturer for disposal. The signs were discovered missing on or about October 8, 2008 at each store. Store management and maintenance personnel have conducted a search at each store and have determined that the signs are not on the premises. Wal-Mart is declaring these signs to be missing.

"Wal-Mart Corporate office notified the Ohio department of health by phone at approximately 1:45 PM on October 9, 2008, and followed with a written description of the signs on October 10, 2008."

The device information is as follows:

1. Location: Store number 01495 Huber Heights, Manufacturer - Isolite, Serial number - 272778, Curie content - 11.5.

2. Location: Store number 01724 Millersburg, Manufacturer - Isolite, Serial number - 260634, Curie content - 20.

3. Location: Store number 02441 Hamilton, Manufacturer - Isolite, Serial number - Unknown, Curie content - 11.5.

4. Location: Store number 02441 Hamilton, Manufacturer - Isolite, Serial number - 338664, Curie content - 11.5.

5. Location: Store number 02441 Hamilton, Manufacturer - Isolite, Serial number - 365140, Curie content - 11.5.

6. Location: Store number 03656 Cincinnati, Manufacturer - Isolite, Serial number - Unknown, Curie content - 11.5.

7. Location: Store number 03656 Cincinnati, Manufacturer - Isolite, Serial number - 362582, Curie content - 11.5.

8. Location: Store number 6327 Warren, Manufacturer - Isolite, Serial number - Unknown, Curie content - 11.5.

Ohio report number - OH080007

* * * UPDATE ON 11/7/2008 AT 1205 FROM MICHAEL SNEE TO MARK ABRAMOVITZ * * *

Received from the state of Ohio via e-mail:

A tritium exit sign was reported missing from the Wal-Mart store in Centerville, OH. The Isolite sign (S/N 318793) contained 11.5 Curies of tritium and was reported to Ohio at 1000 on 11/7/2008.

Ohio Report Number: OH080009

Notified R3DO (Cameron) and FSME (Suber).

* * * UPDATE ON 11/12/2008 AT 1205 FROM MICHAEL SNEE TO JOHN KNOKE * * *

Received from the state of Ohio via e-mail:

Two Tritium exit signs were reported missing from the Wal-Mart store in Middletown, OH. The SRB Technologies signs (S/N 280511) & (S/N 280548) contained unknown activity, and was reported to Ohio at 1230 on 11/12/2008.

Ohio Report Number: OH0800011

Notified R3DO (Hills) and FSME (Suber), ILTAB email

* * * UPDATE ON 11/12/2008 AT 1205 FROM MICHAEL SNEE TO JOHN KNOKE * * *

Received from the state of Ohio via e-mail:

A Tritium exit sign was reported missing from the Wal-Mart store in Newark, OH. The SRB Technologies sign (S/N 268804) contained 20 Ci of Tritium, and was reported to Ohio at 1230 on 11/12/2008.

Ohio Report Number: OH0800013

Notified R3DO (Hills) and FSME (Suber). ILTAB email

* * * UPDATE ON 11/12/2008 AT 1205 FROM MICHAEL SNEE TO JOHN KNOKE * * *

Received from the state of Ohio via e-mail:

A Tritium exit sign was reported missing from the Wal-Mart store in Mount Vernon, OH. The Isolite sign (S/N 293419) contained 11.5 Ci of Tritium, and was reported to Ohio at 1230 on 11/12/2008.

Ohio Report Number: OH0800012

Notified R3DO (Hills) and FSME (Suber). ILTAB email

* * * UPDATE ON 11/14/2008 AT 1329 FROM MICHAEL SNEE TO MARK ABRAMOVITZ * * *

The following information was received from the state of Ohio via e-mail:

Two additional lost Tritium exit signs were reported missing at store #5104 in Moraine, OH. The signs were manufactured by SRB with serial numbers 300242 and 300243. Each sign contained 20 Ci of Tritium.

Notified the R1DO (Krohn), FSME (Flannery) and ILTAB (via e-mail).


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.

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

AGREEMENT STATE REPORT - SOURCE CARRIER DETACHED FROM SOURCE HOLDER

"The SC Department of Health and Environment Control was notified on Thursday, October 9, 2008, at 1105 hrs, that a source carrier from Ohmart/Vega Model SHLM-B2, s/n 66590, containing 500 mCi of Cs-137, had been inadvertently detached from the source holder at 1030 hrs on October 9, 2008. The Facility RSO stated that personnel were attempting to lock out the source when the source carrier was detached from the source holder. The state responded to the scene and arrived at 1326 hrs. The area around the gauge had been properly roped off and the source carrier had been placed on a gear box platform below the source holder. The inspector surveyed the barricaded areas and all readings were 2 mR/hr or less. The facility RSO stated that he had contacted Ohmart/Vega and the Field Service Representative was enroute to secure the source carrier. The inspector advised Facility RSO to maintain physical control of the barricaded areas until the source carrier had been secured. The facility RSO stated that the barricaded areas would be controlled to prevent unauthorized access. The inspector was contacted by the Field Service Representative at 1830 hrs on October 9, 2008, and he stated that he had secured the source carrier in the source holder and the source holder had been secured in a locked storage area. The Field Service Representative stated that he would return to the facility within the next week to package and ship the source holder back to Ohmart/Vega for further evaluation to determine why the source carrier detached from the source holder.

"The facility RSO was advised by the state to submit a written report detailing this event to the Department within 30 days. The event is open and pending the licensee's investigation and report to the Department, updates will be made through the national NMED system."

EMERGENCY DIESEL GENERATOR AND AUXILLARY FEEDWATER ACTUATION DUE TO BUS UNDERVOLTAGE

"On October 9, 2008, during scheduled monthly testing per surveillance procedure 3-PT-M62C, '480 volt Undervoltage Degraded Grid Protection System Bus 6A Functional,' the normal supply power to 480 volt safeguards Bus 6A de-energized resulting in the start and load of Bus 6A by the 32 Emergency Diesel Generator (EDG), and the actuation of the '33' motor driven Auxiliary Feedwater Pump (AFWP), and the '32' steam driven AFWP. All equipment performed as designed. Auxiliary feedwater (AFW) was injected into the Steam Generators (SG). Core reactivity changes as a result of AFW injection resulted in an 0.1% increase in reactor power. SG level change from normal of approximately 1-2% with no actuation of SG alarms, no challenge to automatic control, and no rod movement. No significant change to the Nuclear Instrumentation was observed. Normal supply power was restored to bus 6A and the EDG-32 returned to Auto. Investigation into the cause of the event is in progress. Unit 2 was unaffected and is at 100% power."

The licensee notified the NRC Resident inspector.

AGREEMENT STATE REPORT - 50 PERCENT UNDERADMINISTRATION OF YTTRIUM-90

The state provided in the following information via e-mail:

"On 10/10/08, licensee's RSO notified DRH [Division of Radiological Health] of a Yttrium-90 SIR-Spheres medical event. The reportable event involved the administration of 54 mCi of SIR-Spheres for one patient with approximately 27 mCi instilled into both the right and left hepatic arteries. After instilling approximately 27 mCi of Yttrium-90 SIR Spheres based on radiation readings into the right hepatic artery, a smaller catheter for the left hepatic artery was used due to anatomy and to get to the segment feeding the tumor. While attempting to instill the Yttrium-90 SIR Spheres into the left hepatic artery over-pressurization caused the three (3) way valve in the containment box to give way and resulted in the release of a therapeutic dose of Yttrium-90 SIR Spheres into the delivery system containment box as per design. Due to the release of the second part of the dose into the containment box only approximately 50% of the dose was able to be administered. The procedure was terminated and the delivery box was bagged and held for decay-in-storage. Personnel in the room were monitored for contamination and the room was surveyed and released. The patient was released with no harmful effects foreseeable by the Radiation Oncologist. The patient and referring physician were notified of additional future treatment.

"Licensee suggested the incident may have been caused by the size of the catheter, a kink in the catheter, or a smaller syringe being used by the interventional radiologist putting increased pressure on the 3 way valve. As a result of the medical event the licensee's treatment team will review the delivery system setup before pressure is applied to ensure the flow of the SIR-Spheres will not be impeded within the catheter."

License No.: MS-MBL-01

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.