Event Notification Report for November 02, 2011

AGREEMENT STATE REPORT - LOSS OF 13 Ni-63 SOURCES

Groundwater Analytical Company, Massachusetts radioactive materials licensee G0046, underwent bankruptcy proceedings. Their assets were subsequently seized in a bank action and auctioned off by The Branford Group. Among the items auctioned were 13 Ni-63 sources associated with gas chromatograph devices. This auction took place on 11/2/2011. The Massachusetts Radiation Control Program (Agency) discovered this event on 2/15/2012 and has opened an investigation to find the missing radioactive sources.

The auction house which handled the transfer of the gas chromatographs has indicated that they have records of the individuals who purchased the items and will be providing that information to the Agency by the end of the week.

The Agency continues the investigation into this matter and this item remains open.

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

MEDICAL DOSE LESS THAN INTENDED DUE TO A LEAKING CONNECTOR

The patient had a written directive to receive 81 mCi of Sm-153 (Quadramet) as a whole body exposure for bone metastases. The administered dose was 29 mCi with the rest leaking out of a connector onto the tubing and absorbent pads. Any residual contamination was cleaned up. Both the doctor and patient were notified of the underdose and a follow-on treatment has been scheduled for next week.

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.

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER STUCK OPEN

The following was received via email:

"On November 3, 2011, the Agency [Texas Department of Health] was notified by the licensee that the shutter on an Ohmart Vega model SH-F1A containing 50 milliCuries of cesium - 137 failed to close during the required maintenance check done on November 2, 2011. The gauge shutter is stuck in the open position, which is the normal operating position for the gauge and does not pose an increased exposure risk to any individual. The licensee stated that the pin attaching the operating handle to the shutter operating arm was found broken. They had not determined when the pin was broken. On November 3, 2011, the license determined that they could not repair the gauge. The vessel the gauge is attached to is not accessed during system operation. The licensee stated that they were in the process of contacting the manufacturer for repairs or replacement of the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-8897

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER STUCK OPEN

The following was received via email:

"On November 3, 2011, the agency [Texas Department of Health] was notified by the licensee that the shutter on an Ohmart Vega model SH-F2 containing 500 milliCurie of cesium-137 failed to close during the required maintenance check done on November 2, 2011. The gauge shutter is stuck in the open position, which is the normal operating position for the gauge and does not pose an increased exposure risk to any individual. The licensee stated that the pin attaching the operating handle to the shutter operating arm was found broken. They had not determined when the pin was broken. On November 3, 2011, the licensee determined that they could not repair the gauge. The reactor vessel the gauge is attached to is not accessed during system operation. The licensee stated that they were in the process of contacting the manufacturer for repairs or replacement of the gauge. Additional information will be provided as it is received in accordance with SA-300"

Texas Report: I-8898

UNANALYZED CONDITION CAUSED BY NON-CONFORMING FIRE BARRIERS

"Ongoing field inspections as a result of Industry Operating Experience have identified certain fire barriers that are not in conformance with required tested configurations. Specifically, some of the flexible conduit that penetrates these barriers has a coating that does not exhibit flame retardant characteristics and therefore does not meet the requirements for fire barriers at Beaver Valley Power Station, Unit 1.

"In the event of a postulated fire, this non-conformance has the potential to affect fire barriers separating the two independent trains required for post fire Safe Shutdown equipment. This issue is being reported per 10CFR 50.72(b)(3)(ii)(B).

"Compensatory actions have been established in accordance with the approved Fire Protection Program.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - UNDERDOSAGE OF Y-90 THERASPHERES

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

"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 63%, which is reportable under 10CFR35.3045(a)(1)(ii).

"Notifications: On November 2, 2011, at 1550, the Department's Southeast Regional Office received notification via phone message about the ME.

"Event Description: A patient who was being treated with MDS Nordion Y-90 TheraSpheres, received only 37% of the intended dose based on the before and after survey readings of the TheraSphere accoutrements (5.8mR/hr vs. 3.8mR/hr). The licensee is in the process of notifying the patient. No more information is available at this time.

"Cause of the Event: The licensee suspects that procedural changes led to the problem. Nordion recently changed the procedure to clamp the priming line with a hemostat because the original clamp is hard to manipulate. This was their first procedure using the hemostat.

"Actions: Nordion has been contacted. The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection."

Event Report ID No. PA 110033

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.

AGREEMENT STATE REPORT - THICKNESS GAUGE WARNING LIGHTS LOST POWER

The following was received from the Commonwealth of Pennsylvania via facsimile:

"A licensee's thickness gauge warning lights lost power. The problem was found to be in the wiring circuitry to the gauge. Repairs were made to wiring with the shutter remaining closed throughout the event. No radiation exposure to personnel ensued. The device is identified as: Manufacturer (AccuRay), Model (U-3), Serial # (771353031), isotope (Americium-241, Activity (1000 mCi).

"Repairs were made to the wiring. A 30-day licensee report is expected. The department plans to do a reactive inspection."

PA Event #: PA110034

AGREEMENT STATE REPORT - NUCLEAR GAUGE DISLODGED FROM MOUNTING

The following report was received via e-mail:

"Curwood, Inc. reported an incident involving a NDC Infrared Engineering, Inc. thickness gauge, model 103, serial number 13457, containing 150 mCi's of Americium-241 that occurred on November 2, 2011. A sample of film was cut from the web on a production line and as the sample passed the device, the tail snagged the gauge and dislodged it from the mounting bracket. The gauge fell approximately 40 inches to the treater deck platform. The fall caused the shutter to become dislodged from the device and the crystal lens was cracked. Curwood contacted NDC and was instructed to perform a survey and wipe test of the device. The survey and wipe test indicated that the source was intact and no removable contamination was present. The device is currently packaged and in storage awaiting shipment to NDC for repair. The cause of this incident was the fact that the sample was taken prior to the device and that one of the two screws mounting the device was missing. Corrective actions include now taking the samples at a location on the production line after the device, replacing and securing the missing screw, [performing] a daily spot check of the mounting screws, and a weekly check of the screws to ensure that they are secure."

Iowa Event: IA110006