Event Notification Report for July 27, 2009

AGREEMENT STATE REPORT - LOST (THEN RECOVERED) I-123 CAPSULES

"On July 29, 2009, The [Illinois Emergency Management] Agency received preliminary notification from the licensee's radiation safety officer that a package of radioactive material destined for a radiopharmacy in Arizona had not arrived as scheduled, but was subsequently located and forwarded after a day's delay. Subsequent conversations indicated that for a period of approximately 12 hours the package was secured in the possession of a member of the public until it was retrieved by the courier and forwarded to the licensed recipient. The package contained a total of 3 vials with 30 capsules of I-123 which are intended for medical diagnostic studies. Those capsules were 100 to 200 microCi of I-123 each for a total activity in the package of 20.5 milliCi at the time the package was prepared for shipment on July 26, 2009. The measured dose rate 3 feet from the package at the time of shipment was less than 0.1 milliR/h. Due to limited time spent handling and being near the package for the period in question, the dose to the member of the public was well below regulatory limits. When finally received by the pharmacy, the package was found to be intact, with no signs of damage, leakage or the contents having been previously opened or removed. The licensee is investigating corrective actions to take with regards to actions by the courier top prevent a recurrence. A formal report from the licensee concerning this matter is pending. Until that time, this item remains open and under investigation by the [Illinois Emergency Management] Agency."

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

TECHNICAL SUPPORT CENTER REMOVED FROM SERVICE FOR UPGRADES

"On Monday, July 27, 2009, at 0752, Seabrook Station is temporarily relocating its Technical Support Center (TSC) from the permanent location on the 75 foot level of the Control Building (CB) to an alternate location in the Online/Outage Control Center (OCC). This relocation is necessary to allow for installation of new equipment and upgrading of existing equipment in the TSC.

"The site Emergency Response Organization (ERO) has been notified of the modifications and has been instructed on the planned compensatory measure to be implemented during the temporary relocation.

"The NRC Resident Inspector has been notified of the relocation activities.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to loss of the emergency response facility.

"Seabrook Station will provide updates as necessary and will advise the NRC of the restoration of the permanent TSC."

The State of New Hampshire has been notified.

* * * UPDATE FROM MARK HANSEN TO JOE O'HARA AT 1635 ON 7/30/09 * * *

"On Thursday. July 30. 2009. Seabrook Station completed modifications of its Technical Support Center (TSC) and has restored the TSC permanent location on the 75 foot level of the Control Building (CB) to service. The permanent TSC was declared operable at 1456 on Thursday July 30, 2009.

"The site Emergency Response Organization (ERO) has been notified that the modifications to the permanent TSC have been completed, that compensatory measures are no longer necessary and that TSC personnel are to report to the permanent TSC in the case of a plant emergency.

"The NRC Resident Inspector has been notified that the permanent TSC has been restored to service."

The State of New Hampshire and the Commonwealth of Massachusetts have been notified. Notified R1DO (A. Dimitriadis).

TECHNICAL SUPPORT CENTER TEMPORARILY UNAVAILABLE FOR USE

"On July 27, 2009, Fermi 2 is removing the Technical Support Center (TSC) from operation to facilitate maintenance activities for furniture and facility upgrade. During this work the facility will not be available for use. Fermi 2 is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event TSC activation is necessary the Emergency Operations Facility (EOF) will be utilized. Activation and use of the EOF as a back up for the TSC is included in Fermi 2's Radiological Emergency Response Preparedness Plan. The Emergency Call Out System (ECOS) is designed to facilitate contacting TSC personnel to respond directly to the EOF in the event of an emergency. Fermi 2 will notify the NRC upon completion of this work which is expected to be July 31, 2009."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM JEFF GROFF TO JOE O'HARA AT 1414 EDT ON 7/31/09 * * *

"Update to Event #45230 regarding unavailability of the Technical Support Center (TSC) for planned furniture and facility upgrade. The work to upgrade the facility has been completed satisfactorily. The TSC has been restored as an Emergency Response facility. The facility had been removed from operation on July 27, 2009 at 0935 EDT. The TSC was restored to operation at 1330 EDT on July 31, 2009."

The NRC Resident Inspector has been notified.

Notified R3DO(Daley).

TECHNICAL SUPPORT CENTER (TSC) HVAC FOUND DEGRADED DUE TO WATER INTRUSION

"At about 10:00, on July 27, 2009, the Technical Support Center (TSC) HVAC was found to be degraded. The fan motor was running but there was no air flow and the TSC rooms were not being maintained with a positive pressure. Upon investigation, the fan housing was found partially filled with water, submerging the motor and preventing air flow through the system. Repair of the motor will take more than one day and is being immediately pursued. This affects the ability of the TSC ventilation to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. All other capabilities of the TSC are unaffected by this emergent repair. Existing procedures provide direction to relocate TSC personnel in the event of a TSC habitability concern; however, the backup facility does not have standby electrical power or a filtered ventilation system. Therefore, this condition is considered a major loss of emergency assessment capability and is reportable under 10CFR50.72(b)(3)(xiii)."

The TSC HVAC was last functionally tested satisfactorily on 06/29/09. The licensee believes the water found in the HVAV fan housing may be a result of a clogged drain line.

The licensee will inform the NRC Resident Inspector.

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The following information was received from the Arizona Radiation Regulatory Agency via email:

"At approximately 9:45 am, July 28, 2009, the Agency [Arizona Radiation Regulatory Agency] was notified that a Troxler Model 3411 had fallen out of the transporting vehicle on the way to the construction site. The operator had placed the device in the pickup truck at approximately 6:30 am on July 27, 2009, became distracted and failed to secure the device or to close the tailgate. The device, serial number 10308, apparently fell off the truck on the way to the construction site at Broadway and Jessica St. A search was instituted, but the device was not located and the Tucson Police were called at approximately 8:00 am July 27. Tucson Police report number 09 07270185 was prepared. As of the time cited above, the device has not been recovered. Press interest is expected. The Agency [Arizona Radiation Regulatory Agency] continues to investigate this event.

"The U.S. NRC, the State of CA, NV, UT, NM, CO and TX and Mexico are being notified of this event. "

Arizona Report Number 09-003

* * * UPDATE FROM AUBREY GODWIN TO VINCE KLCO ON 11/30/12 AT 1154 EST * * *

The following information was received by email:

"On 11/29/2012 [at 0915 MST], the Tucson Police were called after a couple found a yellow container with radiation stickers on it outside of a City of Tucson Recyclables Dumpster located at Park and East Fair Street, Tucson, AZ. The Tucson Police department notified the Tucson Fire Hazardous Material team who then notified the Tucson Bomb Squad who then notified the FBI. X-Rays by the Bomb Squad found nothing suspicious. During this time (10:40 AM) the Agency was then called and responded to the scene.

"The Agency response team surveyed the device and made wipe smears. The survey indicated a source was in the device and the smears were negative for contamination. A review of the x-ray made by the Bomb Squad indicated the sources were in the device as designed. The case was undamaged but not locked. The device is being held by the Agency pending return to licensee.

"There was minor media interest in the recovery.

"The USNRC, FBI, the States of Ca, NV, UT, NM, CO and TX and Mexico are being notified of this event."

The recently found Troxler serial number match with the originally reported lost Troxler.

Notified R4DO (Whitten), ILTAB(Langlie) and FSME via email.

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.

AGREEMENT STATE REPORT - LOST IODINE 125 SEEDS

The following information was received from the State of California Radiologic Health Branch via email:

"Pomona Valley Hospital Medical Center discovered an Iodine-125 seed shortage of 10 seeds (.449 mCi/seed) all in one cartridge on Monday July 27, 2009 at approximately 1800 hours during a permanent prostate seed implant. The physician performing the implant discovered the cartridge missing when he opened the sterilized package. These I-125 sources are used for permanent implant into the prostate for therapy.

"The physicist last saw the 7 cartridges and 100 seeds in the Hot Lab, located in the basement of the hospital on Friday July 24, 2009 at approximately 1050. Of the 100 seeds in the order, he assayed the cartridge with 9 seeds plus 1 for a total of 10 seeds. Once he completed the assay he re-loaded the cartridge with all 10 seeds, and placed the cartridge back in the storage block with the other 6 cartridges (containing 15 seeds each), and returned the storage block to the lunch box (used for carrying the cartridges to surgery). He placed the lunch box behind the loading shield and secured the Hot Lab, anti-room and exterior door before leaving the area.

"On Monday at approximately 1510 the lunch box was retrieved form the locked Hot Lab and taken, with the seeds inside, to the Operating Room (OR). Possession of the lunch box was transferred to an RN, who called Sterile Processing to retrieve the seeds from her desk for sterilization. A staff member from Sterile Processing retrieved the lunch box from RN's desk (located in the surgery suite area) to prepare for sterilization. The Sterile Processing staff member had to be directed on how to wrap the seeds as he had never prepared the seeds for sterilization before. The wrapped seeds were taken back up to Surgery and placed in Sterilizer #34. Once the sterilization process was complete, the seed package was delivered to OR #2 where the implant procedure was being performed.

"Once the physician discovered the missing cartridge during the procedure, the Medical Physicist and RSO, was notified and immediately went to the Hot Lab in attempt to locate the missing cartridge. The RSO contacted the physicist by phone who confirmed all 100 seeds in 7 cartridges were accounted for on Friday morning when he assayed them. The RSO also interviewed the staff member who prepared the seeds for Sterile processing to ask him if he dropped the lunch box and perhaps lost a cartridge, which the staff member denied. The RSO then took the spill meter (TBM survey meter) and surveyed Sterile Processing and both elevators. The Hot Lab was taken apart and thoroughly surveyed, as well as the anti-room and packaging materials. No evidence of radioactive materials was found.

"The implant procedure concluded without incident. The dosimetry plan for the patient called for 90 seeds which they had available. At the completion of the implant we had no seeds left over. All 90 seeds were implanted into the patient and the patient is doing well. In no way was the patient's care compromised by this set of missing I-125 seeds.

"Bard [Brachytherapy, Inc], the manufacturer of the sources was called to verify the shipment was in fact complete, but at 2100 hours their time July 27, 2009, no one was available. The hospital was able to contact Bard, located in Carol Stream, Illinois the following day concerning a preliminary investigation of the order. According to Bard's records the assembler of the order pulled 100 seeds off the line and 7 cartridges from inventory. None of their other customers reported receiving 10 seeds not ordered. Bard will not provide a formal report of our order until it has passed their legal department.

"Last night (July 27, 2009) Security was notified and started a formal investigation of the incident. The Hospital Administration, the Chief of Security, and the Manager of Sterile Processing were notified and explained the seriousness of the situation. Today (July 28, 2009) Pomona Valley Hospital Medical Center is continuing to search for the seeds and taking statements from all the involved associates.

"The Lot Number for the sources is: BBTG0030."

Note that this report was edited to remove reference to the names of the employees involved.

California Report number 072809.

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.