Event Notification Report for March 01, 2011

AGREEMENT STATE REPORT - EXTERNAL CONTAMINATION IDENTIFIED ON A PACKAGE

The following information was received from the Commonwealth of Pennsylvania via fax:

"Notifications: Licensee emailed notification to the Department's [Pennsylvania Department of Environmental Protection] South Central Regional Office on March 2, 2011. This was initially evaluated as not exceeding the limits of  71.47; however, further assessment determined it as an immediate reporting event under 20.1906(d)(1).

"Event Description: On March 1, 2011, a Nuclear Medicine Technologist from Geisinger logged in a package from Triad Isotopes radio pharmacy. Exposure on the surface of one of the containers labeled White I was measured to be 14 mR/hr. The contamination was found to be limited to the handle of the package. The inside of the container and its contents were not contaminated. The contents were removed and the empty contaminated package was double bagged and placed in decay storage.

"According to calculations provided by the licensee, the initial net wipe reading of the handle area on the suspect package was 10,670 dpm for an area of 6 [inch] x 1.5 [inch] or 15 cm x 3. 8 cm. Assuming a 10% wipe efficiency, the activity per unit area was 1,840 dpm/cm2 (0.8 mCi/cm2), which exceeded the maximum permissible limit of 220 dpm/cm2 as noted in  71.47.

"Cause Of The Event: Cross-contamination from the radio pharmacy.

"Actions: The Department called Triad Isotopes on March 2, 2011. It was stated that the driver, vehicle, and all other areas that the driver and the package came into contact with, were surveyed and no contamination was found. Triad Isotopes confirmed that the shipment met the requirements of the Radioactive White I when it left and only contained 20 mCi of Tc-99m. No further actions were taken."

PA Event Report ID No. PA110005

FAILURE TO MAINTAIN MASS CONTROL OF UO2 POWDER

"At approximately 3:00 pm [EST] on Tuesday, March 1st, it was reported that 15.3kg of UO2 powder was removed from the UO2 Sinter Test Grinding Station [High Efficiency Particulate Air] HEPA filter housing transition. This clean-out was performed as a response to routine radiological surveys that indicated the presence of uranium. It was determined that this material was present during prior filter replacement in early February in which 30.9 kg of UO2 powder was removed. The total amount of UO2 powder present in the housing was therefore approximately 46 kg, which is greater than a safe mass.

"The Sinter Test Grinding Station and associated equipment was already shut down because of the HEPA filter housing clean-out and remained down pending investigation and implementation of corrective actions.

"Failure to maintain mass control resulted in a loss of double contingency for the filter housing. The double contingency controls required include (1) mass control and (2) moderation control. Moderation control, the 2nd leg of double contingency remained in place, was effective, and was not challenged. As a result, no unsafe condition existed.

"The UO2 in the HEPA housing was transferred into [a] favorable geometry [of] 3-gallon cans per procedure. An investigation is ongoing.

"At no time did an unsafe condition exist as the moderation control was in place, was effective, and was not challenged. Immediate corrective actions [are] complete [transfer of material into 3-gallons cans]. Investigation of [the] event and implementation of long term corrective actions [are] pending.

The licensee will be notifying the NRC Region II, State, and Local Authorities.

LOST CHEMICAL DETECTION EQUIPMENT CONTAINING NI-63 SOURCES

"As part of a mass turn in of Chemical Detection Equipment (CDE) containing radioactive sources, an Air Force (AF) unit located in Fort Leonard Wood, MO. reported that it had shipped 52 CDE systems, each containing Ni-63 with 20 milli Curie sources, to the Defense Logistics Agency (DLA) Distribution Center at Red River Texas. The CDE systems were shipped in 7 separate packages and confirmation of 7 separate packages was provided which showed the receipt by DLA on 21 May 2010. An inventory, conducted on 2 February 2011, of the 7 packages at the DLA Distribution Center could only account for 40 of the 52 CDE systems. The AF Radiation Safety Office contacted the DLA Radiation Safety Office indicating that there was a discrepancy in the number of items receipted compared to the number of items identified as shipped by the unit. The AF Radiation Safety Office provided the list of serial numbers for the 52 items reportedly shipped which were compared to the current inventory on hand. It was confirmed that there were 12 serial numbers identified on the shipping list that were not in the current inventory. An initial search of the designated Radioactive Material Storage area did not locate the items.

"It has been identified that a major issue with the turn-in process was the lack of prior notification of transfer of the CDE from the AF units to the DLA Distribution Site at Red River. A global instruction was provided by the AF PM to ship the material, without the PM providing the turn-in documents. Had the AF PM directed all of the shipment, a document would have been generated and the number of items to be shipped would have been provided to the depot. In the current process, the depot could only act reactively based on available material and paperwork.

"The transfer of CDE systems to the DLA Distribution Centers has been suspended until a more accountable process can be determined. Additionally the AF will, in the future, direct all shipments directly to Wright Patterson AFB for demilitarization and disposal. A continued effort to search the hazardous material warehouses for these items will continue."


* * * RETRACTION FROM DAVID COLLINS TO JOE O'HARA AT 1642 ON 03/07/11 * * *

"DLA Distribution is retracting the initial report of potential loss (Event # 46651) as the 12 Chemical Agent Detectors have been accounted for at Pine Bluff Arsenal, another Department of Defense facility and the ultimate destruction site. The materiel was shipped from DLA Distribution Red River to Pine Bluff Arsenal on October 8, 2010, under a different NSN [National Stock Number] than the one originally sent to DLA. The Chemical Agent Detection (CDE) Equipment can be in multiple configurations, each with their own NSN. In this case they shipped from the AF unit under one NSN (entire detection system) and we subsequently shipped under a corrected NSN (detector component only)."

Notified R1DO(Hansell), R4DO(Farnholtz), FSME(Reis), Mexico, 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. 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

EMERGENCY DIESEL GENERATORS START ON A LOSS OF POWER FROM 138 KV CIRCUIT

"At 1100 EST, Indian Point Unit 2 experienced a loss of offsite power from the 138 Kv circuit. All three Emergency Diesel Generators automatically started as required. All other plant systems functioned as required. Restoration of offsite power from the 13.8 Kv offsite circuit is in progress. Investigation into the loss of the 138 Kv circuit is ongoing. Indian Point, Unit 2 continues in Mode 1 at 100 % power."

Indian Point, Unit 2 is in a 72 hour LCO due to a loss of 1 of 2 offsite circuits. Unit 3 was not affected.

The licensee has notified the NRC Resident Inspector and will be notifying the Public Service Commission of the State of New York.