Event Notification Report for December 02, 2010

SOURCE FAILED TO RETRACT DUE TO ICE BUILD-UP

A radiography crew working on the Prudhoe Bay North Slope experienced a malfunction of the source retraction portion of their Sentinel Delta 880 radiography device due to ice intrusion. The device source is Ir-192 with a 99 Curie activity.

The radiography crew was able to retract the source into the shielded position using the device crank.

Based on pocket dosimetry readings, there were no personnel over-exposures during this incident.

AGREEMENT STATE REPORT - EMPLOYEE CONTAMINATIONS DURING CYCLOTRON OPERATION

The following information was received by e-mail:

The state reported that three employees of Cardinal Health were contaminated by Fluorine 18 (F-18) from operation of a cyclotron. Initial contamination of the employees was 1600 cpm. Soap and water was used to decontaminate the personnel and at 1130 PST the contamination was reported to be 1300 dpm.

The licensee believes the cause of the contamination to be faulty delivery lines. The cyclotron device is a General Electric Accelerator PETrace.

Nevada Incident Number: NV100022

* * * RETRACTION FROM SNEHA RAVIKUMAR TO ERIC SIMPSON AT 1507 EST ON 12/3/10 * * *

The following information was received by email from the State of Nevada:

The State of Nevada is retracting the Event Report sent on December 2, 2010, regarding Cardinal Health.

This event does not need to be reported based on the fact that a contamination events must restrict access to the area for more than 24 hours or cause doses to workers that exceed regulatory limits in order to be reportable. Due to the short half life of the material involved and the fact that it was limited to the transfer tube, it is unlikely that anyone received a dose >1 ALI (24 hr notification) or >5 ALI (immediate notification).

Notified R4DO (Powers) and FSME (McIntosh).

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

The following was received via email from the State of Arkansas:

"The Arkansas Department of Health, Radioactive Materials Program, was notified at 1315 CST on December 2, 2010 by licensee Grubbs, Hoskyn, Barton, and Wyatt, Inc. (ARK-0456-03121) of a missing Troxler moisture/density gauge. The gauge was being transported between their office in Little Rock, Arkansas and a job-site in Bryant, Arkansas. The authorized user observed the gauge was missing at approximately 1230 CST. The gauge had apparently fallen from the transport vehicle.

"The Troxler gauge is a Model 3430 (SN 63492) containing 40 mCi Am-241:Be and 8 mCi Cs-137.

"It appears that the gauge was not properly secured in the vehicle. The Arkansas Department of Health is investigating the circumstances surrounding this event.

"The Arkansas Department of Health prepared a press release concerning this event. Arkansas Department of Health also notified the Police Departments of Little Rock and Bryant, the Sheriff's Offices of Saline and Pulaski Counties, the Arkansas State Police, and the Arkansas Department of Emergency Management.

"Arkansas has assigned event report ID number AR-12-10-02."

* * * UPDATE AT 1147 EDT ON 9/6/11 FROM PEMBERTON TO HUFFMAN VIA E-MAIL * * *

"On August 30, 2011, the Arkansas Department of Health, Radioactive Material Division was informed by [the] Radiation Safety Officer for Grubbs, Hoskyn, Barton and Wyatt, that the Troxler 3430 Moisture/Density Gauge, SN#63492, lost on December 2, 2010, had been recovered.

"A Departmental investigation confirmed that the gauge recovered on August 30, 2011, was in fact the device lost on December 2, 2010. The Department considers this incident to be closed."

The State Department of Health Representative indicated that the gauge was returned to the licensee by a private citizen who wished to remain anonymous.

R4DO (Drake) and FSME (McIntosh) notified. ILTAB notified 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - DELIVERED DOSE GREATER THAN PRESCRIBED DOSE

The following information was received via email from the State of Colorado:

"At approximately 1600 MST, 12/2/10, the Colorado Department of Public Health and Environment received a report of a possible misadministration at the Prostate Seed Center, a Colorado radioactive materials licensee.

"Additional information was received on 12/3/10 that there was indeed a misadministration of I-125 in seed form. An excess dose of 27 to 32% was administered above the prescribed dose.

"There was an apparent miscommunication between the supplier and the Prostate Seed Center about the units of dose the seeds were to contain. Apparently, Air Kerma units were ordered and milliCuries were delivered.

"An investigation as to the cause of the misadministration is being performed. A written report on the incident is required by the Department within 30 days."

The excess dose was delivered to the patient's prostate.

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.

THEFT OF TROXLER MOISTURE DENSITY GAUGE

A Troxler moisture density gauge being used at Fort Meade (Maryland) was found to be stolen along with other industrial equipment at 1400 on 12/2/10. The Troxler gauge was last seen on Monday afternoon, 11/29/10, when it was secured in a temporary storage location inside a lock-box and chained to a sea container. Other items stolen included crane mats, a generator and miscellaneous tools.

The nuclear gauge is a Troxler Model 3430, S/N 37672, which contains two radioactive sources. One source is 44 mCi of Am-241/Be (S/N 78-2430). The other source is 9 mCi of Cs-137 (S/N 77-4907).

The licensee will notify base police to begin an investigation into the theft.

The licensee has notified the State of Maryland of the theft.

* * * UPDATE FROM DREW THOMAS TO JOE O'HARA AT 0948 ON 12/14/10 * * *

On 12/10/10, FT. Meade U.S. Army base police officers informed the licensee that the stolen container had been "dumped" back onto the jobsite. The licensee responded to the site and discovered the missing gauge inside the container. The source was in the locked and shielded position inside the gauge and the gauge doesn't appear to have been damaged. The gauge has been recovered and is now in the custody of the licensee. A leak test of the gauge is scheduled to be performed.

Notified R1DO(Holody), FSME(Reis) and ILTAB.

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

URANIUM CONCENTRATION GREATER THAN EXPECTED IN GAS STRIPPER SYSTEM FOLLOWING AN ACID WASH

"Background:
The purpose of the Ammonia Recovery Facility (ARF) facility is to recover ammonia from the ammonium diuranante (ADU) process effluent by use of a stripper column. The feed of effluent to ARF has a uranium concentration is typically less than 1 ppm. Two uranium analyzers provide assurance that the effluent uranium concentration is less than 100 ppm prior to discharge to the Ammonia Recovery process feed tank V-621.

"The ISA Summary for this process states that only minute quantities of radioactive material are present in the feed to the ARF and that there are no credible accident sequences that result in intermediate or high consequences.

"Event Description:
On 12/02/2010 at 0715, a Process Engineer informed Nuclear Criticality Safety (NCS) that he had confirmed that an acid wash of ARF stripper column had recovered 8 kg of Uranium (U). The acid wash is expected to have removed all significant amounts of Uranium from the system. This resulted in a review of the adequacy of the ISA treatment for the ARF stripper column.

"Safety Significance of Event:
The safety significance is low. The amount of Uranium recovered, approximately 8 kg, is less than 25% of a minimum critical mass in spherical geometry. The concentration of the liquid is about 1 g U/liter. The 8 kg constitutes an approximate ten year accumulation since the last column acid wash in 2001. Based on the accumulation rate over the past 10-years, another 40 years of accumulation would be required without any removal during maintenance before achieving a critical mass.

"The system was down for maintenance at the time of discovery. Maintenance activities were suspended and will remain suspended until an appropriate processing path is identified to process this material and appropriate controls are established. The system will not be restarted until the system has been reanalyzed and appropriate controls are verified to be in place to meet 10CFR70.62 performance criteria.

"Potential Criticality Pathways Involved (Brief Scenarios of how criticality could occur):
Criticality is possible if material in the ARF equipment exceeds a minimum critical concentration and a minimum critical mass for a given geometry.

"Controlled Parameters:
The controlled parameters are upstream of the ARF process and are based on concentration of the feed material. The uranium concentration in ARF feed is typically less than 1 ppm. Two uranium analyzers provide assurance that the ADU effluent uranium concentration is less than 100 ppm prior to discharge to the Ammonia Recovery process.

"Estimated Amount, Enrichment, Form of Licensed Material and % of worst case Critical Mass:
The facility is only licensed to 5 wt.% U-235. The material present in the stripper column prior to being dissolved was likely ammonium diuranate. Once dissolved, the material is uranyl nitrate. The mass in the system is expected to have been less than 25% of a minimum critical mass in spherical geometry.

"When equipment geometry is taken into account, much higher masses are required to obtain a critical condition. For example, the ARF feed tank with a uniform slab of U02-H20 would require an areal density exceeding 10 kg U/ft2 (more than 500 kg U).

"Nuclear Criticality Controls) or Control System(s)) and Description of the Failure Deficiencies:
The upstream controls on concentration performed as required. The material plate-out within the stripper column was greater than anticipated.

"Corrective Actions to Restore Safety Systems and When Each Was Implemented:
The system was down for maintenance at the time of discovery. Maintenance activities were suspended and will remain suspended until an appropriate processing path is identified to process this material and appropriate controls are established. The system will not be restarted until the system has been reanalyzed and appropriate controls are verified to be in place."

The licensee initiated the acid wash of the gas stripper as a result of concerns over the differences in the inlet and outlet pressures of the system, which indicated that the system was becoming less efficient. The licensee briefed Region 2 management and Region 2 fuel cycle facility inspectors about this event.

OFFSITE NOTIFICATION DUE TO AN INDIVIDUAL CONTAMINATION

"TVA notified TN Dept of Environment and Conservation [TDEC] of an incident at Watts Bar as follows:

"On December 2, 2010, a contractor employee of PAR-Westinghouse was processing in through Watts Bar Nuclear Plant Radiological Protection Program for his first day of work. He was discovered to have been previously contaminated with radioactive material from another worksite. It is clear that the radioactive contamination did not come from any TVA source and was found before he entered the rad control area.

"The contamination was discovered during required in-processing activities for workers by TVA's radiation monitoring and detection equipment. The contamination was found to be a particle on the individual's shoe.

"The individual's clothing was also found to contain measurable contamination and was confiscated. The radioactive contamination found on the individual has been safely contained.

"TDEC Division of Radiological Health was notified of this event as of 1610 Eastern Time and this notification under 10 CFR 50.72(b)(2)(xi) is for that Government Agency notification. TVA has notified the NRC Resident Inspector and Regional Administrator of this incident."

FIXED NUCLEAR GAUGE RECOVERED IN LOAD OF SCRAP STEEL

A 50mCi Cs-137 Kay-Ray Model 7062B (S/N 17573) Gauge was recovered in a pile of scrap steel at the Pacific Steel & Recycling Company in Bozeman, MT. The U.S. NRC Region IV contacted the device manufacturer to identify the owner of the general licensed source and dispatched an NRC Inspector on 12/3/10 to initiate a reactive inspection (PNO-RIV-2010-006).

The owner, Cyprus Industrial Minerals in Ennis, Montana, had purchased the gauge in June 1984 for use in their Yellowstone mine. The company was subsequently sold to Rio Tinto Minerals located in Three Forks, MT.

The representative from Rio Tinto Minerals is currently arranging for removal and disposal of the gauge in safe storage at the Pacific Steel & Recycling Company.

A conference call was held on 12/2/10 at 1800 EST with R4 (Vivian Campbell, Tony Gaines) and FSME (James Danna).

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