Event Notification Report for June 30, 2011

IONIZING AIR NOZZLES LOST DURING TRANSPORTATION ACCIDENT

On May 26, 2011 a transportation truck was involved in an accident in Ashland, NE. The truck was carrying 62 Ionizing Air Nozzles to NRD LLC in Grand Island, NY. The nozzles contained 10 mCi/each of Po-210 at the time of manufacture. At the time of shipment, a total activity of 74.9 mCi aggregate remained.

After the accident, a contractor separated out the debris to damaged and undamaged packages. The damaged packages were sent to the landfill in Lancaster County, NE. After the remaining undamaged shipping containers were resorted, however, the shipping company could not locate the static eliminators. The licensee believes that the package containing the air nozzles were sent to the landfill.


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 - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following information was received from the State of Wisconsin via fax:

"Wisconsin Department of Health Service (DHS) received notification by voicemail from the licensee on July 5, 2011 about an incident that occurred on June 30, 2011. A patient was to receive 25.6 mCi of Samarium-153 (Sm-153) for bone pain; but the patient received 14.8 mCi (58%) of the planned dose. During administration of the Sm-153 to the patient, the staff used a three-way stopcock connected to the IV line. The syringe containing the radioactive material was connected to the stopcock. During the procedure the syringe was mistakenly removed from the stopcock and a few drops of the radioactive materials dripped on the absorbent pad before a member of the staff reconnected the syringe. The event was reported to the RSO within minutes, and a voicemail was left with DHS the following day (July 1, 2011). The patient was notified the same day.

"On July 6, 2011, DHS inspectors conducted a reactive inspection. The licensee is instituting corrective actions. The corrective actions are as follows: 1) Conduct a dry run before administration of doses. 2) Use syringe shields previously used by the hospital, which fits syringes better. 3) Inform the nuclear pharmacy to add saline to the radioactive materials, which serves two purposes; first, decrease the radioactive material per volume of total material in the syringe so that administrations to the patient contain small amounts of radioactive materials, and second, if there is a spill, there will be only a small quantity of radioactive material in the spill. The licensee will send DHS an official report of the incident within 15 working days."

WI Event #: WI110008

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.

STOLEN NUCLEAR GAUGE CONTAINING 40 MILLICURIES CADMIUM 109

The gauge was stolen from a locked company truck along with other tools parked at the place of business sometime between 1800 on 6/29/11 and 0755 on 6/30/11. The device is a Niton machine built by Thermo-Fisher Scientific XRF Model 300 S/N U2349 used for measuring the quantity of lead in lead based paint. The source serial number is NR-1176 and contains 40 milliCuries of Cd-109. This is generally licensed material.

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

POWER RANGE MONITOR CHANNELS OUT OF ALIGNMENT

"At 0516 [CDT] on 6/30/11 after control rod movements to support rod pattern adjustment, 3 of 4 APRMs were out of required Technical Specification deviations of +/-2% power in relation to calculated Core Thermal Power. APRM #1 was at -3.6% deviation, APRM #3 was at +2.5% and APRM #4 was at +3.1 %. APRMs 1, 3, and 4 were declared inoperable. With 3 of the 4 APRM channels affected, the functions of the APRM were inoperable and that RPS trip capability had not been maintained. Technical Specification Conditions 3.3.1.1.A and 3.3.1.1.C were entered at 0516. All three (3) APRM gains were adjusted and the Tech Spec Conditions were exited at 0540 [CDT].

"Thermal Limits were evaluated and no limits were challenged.

"This event is reportable under 10CFR50.72 (b)(3)(v) as an event that could have prevented the fulfillment of the safety function of a system needed to: 50.72(b)(3)(A) shutdown the reactor and 50.72(b)(3)(D) mitigate the consequences of an accident."

The licensee notified the NRC Resident Inspector.

TROXLER MODEL 3400 MOISTURE DENSITY GAUGE WAS DAMAGED AT A CONSTRUCTION SITE

The following was provided by the State of North Carolina via e-mail:

"A Troxler portable nuclear gauge belonging to Kam Engineering Services was run over by a smooth drum roller and has been damaged.

"The event occurred near the intersection of Normandy Street and Half Street in Fort Bragg, NC. Fort Bragg is under a NRC license and the licensee should be working under reciprocity.

"The licensee does not possess any survey instruments but they have an agreement to borrow one from Troxler (RTP, NC.) Someone has been dispatched to Troxler to get a meter and to take it back to the accident site.

"The RSO is on-site and has cordoned off a 20 foot circle around the gauge."

The licensee will notify the State of North Carolina when additional survey results are available. The gauge contained 9 milliCuries Cs-137 and 44 milliCuries of Am-241.

** * * UPDATE FROM HENRY BARNES TO JOE O'HARA VIA E-MAIL AT 1703 ON 6/30/11 * * *

"The RSO called [the state]. The area was surveyed and the dose rate at the 20 ft boundary was 0.02 - 0.04 mR/hr. The RSO worked his way toward the damaged gauge and the readings remained constant. At 1 meter, the reading was still 0.2 mR/hr (Transport Index) On contact, the gauge was about 7 mR/hr. The RSO repositioned the gauge and sent pictures to Troxler. Troxler said it appeared that the tungsten blocks were still in place and there was no damage to the source shielding. The RSO (per Troxler instructions) then placed the gauge in the transport box and locked it.

"The damaged gauge is being transported to the company office tonight and will be transported to Troxler tomorrow."

Notified R1DO(Welling) and FSME(Jackson)

Incident NC 11-35.

OFFSITE NOTIFICATION DUE TO PERSON BEING EVACUATED

"At 1423 CDT, the Control Room was notified of a fire inside the protected area isolated to a portable water evacuation pump. At 1425 CDT, the Control Room was notified the fire was extinguished and the presence of an injured person; the Control Room immediately notified Washington County 911 to request emergency medical assistance. At 1511 CDT, injured person was transferred off-site by medical helicopter.

"This four-hour notification is being made pursuant to 10 CFR 50.72(b)(2)(xi), event or situation related to health and safety of on-site personnel for which notification to other government agencies has been made. NRC Resident informed.

"Due to this event, 1/2 gallon of gasoline was discharged to the Missouri River. The spill was reported to the State of Nebraska on 6/30/2011.

"This condition is also being reported pursuant to 10 CFR 50.72(b)(2)(xi) for News Release or Notification of Other Government Agency. Applicable state agencies have been notified per plant procedures."

The injured person is a plant employee and was injured while refueling a portable generator. The injured person suffered burns to the forearms and neck. The licensee intends to issue a press release.

The NRC Resident Inspector has been notified.

OFFSITE NOTIFICATION DUE TO INADVERTENT SIREN ACTUATION

"On June 30th, 2011 at 1425 PDT, a public evacuation siren was inadvertently activated for ~ 40 seconds. Preventative maintenance was being performed on the siren at the time of actuation.

"The licensee has notified Benton County, Franklin County, and the Department of Energy. The NRC Resident Inspector has been notified."