Event Notification Report for September 11, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/10/2012 - 09/11/2012
EVENT NUMBERS
4830248303482964829748299483004840948326
Agreement State
Event Number: 48302
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: FLINT HILLS RESOURCES CHEMICAL INTERMEDIATES
Region: 3
City: JOLIET State: IL
County:
License #: IL-01337-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Licensee: FLINT HILLS RESOURCES CHEMICAL INTERMEDIATES
Region: 3
City: JOLIET State: IL
County:
License #: IL-01337-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/12/2012
Notification Time: 16:26 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [CDT]
Last Update Date: 09/12/2012
Notification Time: 16:26 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [CDT]
Last Update Date: 09/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE FOUND WITH STUCK SHUTTER
The following information was received from the State of Illinois via email:
"On Tuesday afternoon, the Agency [Illinois Emergency Management Agency] received a call from the RSO for Flint Hills Resources Chemical Intermediates, LLC (IL-01337-01). He called to report a shutter failure of a fixed gauge which he cannot close. The device manufacturer, Ronan Engineering, has been contacted and arrangements are pending for repair of the device. The RSO has isolated the area, posted warning signs and instituted a lock out/tag out procedure for the manway entrance to the vessel in order to prevent exposures which might occur from someone attempting to perform work within the tank that the gauge is located. Area surveys performed show no variations above normal (i.e., less than 1 milliR/h at 1 foot) for when the shutter is open and the unit is in operation. The shutter had last been tested in March with no abnormalities noted. The gauge has not been subjected to any corrosives or solvents or other conditions which exceed the gauge's prototype test conditions.
"The RSO was reminded of the requirement to provide a written report within 30 days of the event and to contact the Agency when the manufacturer was able to perform the site visit to evaluate/repair the device. The Agency considers this matter open pending those additional actions."
The Ronan gauge is model X90-SA1, S/N M7389, contains 24.5 mCi Cs-137.
The following information was received from the State of Illinois via email:
"On Tuesday afternoon, the Agency [Illinois Emergency Management Agency] received a call from the RSO for Flint Hills Resources Chemical Intermediates, LLC (IL-01337-01). He called to report a shutter failure of a fixed gauge which he cannot close. The device manufacturer, Ronan Engineering, has been contacted and arrangements are pending for repair of the device. The RSO has isolated the area, posted warning signs and instituted a lock out/tag out procedure for the manway entrance to the vessel in order to prevent exposures which might occur from someone attempting to perform work within the tank that the gauge is located. Area surveys performed show no variations above normal (i.e., less than 1 milliR/h at 1 foot) for when the shutter is open and the unit is in operation. The shutter had last been tested in March with no abnormalities noted. The gauge has not been subjected to any corrosives or solvents or other conditions which exceed the gauge's prototype test conditions.
"The RSO was reminded of the requirement to provide a written report within 30 days of the event and to contact the Agency when the manufacturer was able to perform the site visit to evaluate/repair the device. The Agency considers this matter open pending those additional actions."
The Ronan gauge is model X90-SA1, S/N M7389, contains 24.5 mCi Cs-137.
Agreement State
Event Number: 48303
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: DONG HWA PARK
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/13/2012
Notification Time: 12:05 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2012
Notification Time: 12:05 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - PATIENT UNDEREXPOSURE USING YTTRIUM-90 SIR-SPHERES TREATMENT
The following event was received from the Commonwealth of Pennsylvania via facsimile:
"Event type: A medical event (ME) involving the administration of yttrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).
"Notifications: On September 12, 2012, an inspector was performing a reactive inspection for a recent event (PA120026) that occurred on August 23, 2012. During the inspection the licensee reported another similar Sir-Sphere event.
"Event Description: A patient was being treated for disease of the liver with 33.04 millicuries (mCi) of Y-90 and received 25.6 mCi resulting in 77.5% of the intended dose. The treating physician, who also is the referring physician, notified the patient.
"Cause of the Event: Currently under investigation and unknown at this time.
"Actions: No harm to the patient is expected. The Department's reactive inspection occurring on September 11, 2012 incorporated this new event and therefore no new inspection is planned."
PA Report Number: 120030
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.
The following event was received from the Commonwealth of Pennsylvania via facsimile:
"Event type: A medical event (ME) involving the administration of yttrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).
"Notifications: On September 12, 2012, an inspector was performing a reactive inspection for a recent event (PA120026) that occurred on August 23, 2012. During the inspection the licensee reported another similar Sir-Sphere event.
"Event Description: A patient was being treated for disease of the liver with 33.04 millicuries (mCi) of Y-90 and received 25.6 mCi resulting in 77.5% of the intended dose. The treating physician, who also is the referring physician, notified the patient.
"Cause of the Event: Currently under investigation and unknown at this time.
"Actions: No harm to the patient is expected. The Department's reactive inspection occurring on September 11, 2012 incorporated this new event and therefore no new inspection is planned."
PA Report Number: 120030
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.
Power Reactor
Event Number: 48296
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: HANS OLSON
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: HANS OLSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/11/2012
Notification Time: 04:08 [ET]
Event Date: 09/11/2012
Event Time: 03:08 [CDT]
Last Update Date: 09/12/2012
Notification Time: 04:08 [ET]
Event Date: 09/11/2012
Event Time: 03:08 [CDT]
Last Update Date: 09/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)
JOHN GIESSNER (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 94 | Power Operation | 94 | Power Operation |
TECHNICAL SUPPORT CENTER NON-FUNCTIONAL DUE TO PLANNED MAINTENANCE
"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the TSC [Technical Support Center] ventilation system from service. The TSC would be rendered non-functional with the loss of ventilation. The repair to the TSC ventilation is expected to last 3 days.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore ventilation to the TSC.
"This notification is being made in accordance with 10CR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC ventilation system has been restored to normal operation."
The licensee notified the NRC Resident Inspector
* * * UPDATE FROM MIKE STROPE TO CHARLES TEAL ON 9/12/12 AT 1157 EDT * * *
The TSC maintenance has been completed. The TSC has been restored to service.
The NRC Resident Inspector has been informed.
Notified R3DO (Kunowski).
"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the TSC [Technical Support Center] ventilation system from service. The TSC would be rendered non-functional with the loss of ventilation. The repair to the TSC ventilation is expected to last 3 days.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore ventilation to the TSC.
"This notification is being made in accordance with 10CR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC ventilation system has been restored to normal operation."
The licensee notified the NRC Resident Inspector
* * * UPDATE FROM MIKE STROPE TO CHARLES TEAL ON 9/12/12 AT 1157 EDT * * *
The TSC maintenance has been completed. The TSC has been restored to service.
The NRC Resident Inspector has been informed.
Notified R3DO (Kunowski).
Power Reactor
Event Number: 48297
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: MIKE WEAVER
HQ OPS Officer: JOHN SHOEMAKER
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: MIKE WEAVER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2012
Notification Time: 11:11 [ET]
Event Date: 09/11/2012
Event Time: 07:33 [EDT]
Last Update Date: 09/11/2012
Notification Time: 11:11 [ET]
Event Date: 09/11/2012
Event Time: 07:33 [EDT]
Last Update Date: 09/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
MARK KING (NRR)
JANE MARSHALL (IRD)
CHRISTOPHER NEWPORT (R1DO)
MARK KING (NRR)
JANE MARSHALL (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
VOLUNTARY OFFSITE NOTIFICATION WITH POTENTIAL MEDIA INTEREST
"This ENS [report] is being voluntarily issued to notify the NRC that voluntary communications were made to offsite agencies this morning between 0700 and 0830 [EDT] due to an event of potential public interest.
"At approximately 1 a.m. on September 11, 2012, Peach Bottom outage workers on the Unit 2 refuel floor were disassembling the reactor head vent when steam discharged from the flange, causing a small but detectable amount of airborne contamination that was contained in the building. All workers were wearing the proper protective equipment and no significant personal [personnel] exposure has been reported. As a precaution, employees were asked to temporarily leave the area for onsite evaluation while radiation protection technicians investigated. Approximately 50 workers were impacted by the radiological airborne event at Peach Bottom and had to stay over shift for radiological monitoring. In accordance with station Radiological procedures, affected personnel are being monitored and as required bioassay is being conducted. Radiation monitors in the reactor building initially detected the airborne contamination, but all have returned to normal levels. This event resulted in no significant impact to the health and safety of our workers or the public. The station made voluntary notifications to the NRC Senior Resident, the State Bureau of Radiation Protection and state and local stakeholders.
"This issue has been entered into the site Corrective Action Program for evaluation and implementation of further corrective actions."
"This ENS [report] is being voluntarily issued to notify the NRC that voluntary communications were made to offsite agencies this morning between 0700 and 0830 [EDT] due to an event of potential public interest.
"At approximately 1 a.m. on September 11, 2012, Peach Bottom outage workers on the Unit 2 refuel floor were disassembling the reactor head vent when steam discharged from the flange, causing a small but detectable amount of airborne contamination that was contained in the building. All workers were wearing the proper protective equipment and no significant personal [personnel] exposure has been reported. As a precaution, employees were asked to temporarily leave the area for onsite evaluation while radiation protection technicians investigated. Approximately 50 workers were impacted by the radiological airborne event at Peach Bottom and had to stay over shift for radiological monitoring. In accordance with station Radiological procedures, affected personnel are being monitored and as required bioassay is being conducted. Radiation monitors in the reactor building initially detected the airborne contamination, but all have returned to normal levels. This event resulted in no significant impact to the health and safety of our workers or the public. The station made voluntary notifications to the NRC Senior Resident, the State Bureau of Radiation Protection and state and local stakeholders.
"This issue has been entered into the site Corrective Action Program for evaluation and implementation of further corrective actions."
Agreement State
Event Number: 48299
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: WOOD'S HOLE OCEANOGRAPHIC INSTITUTION
Region: 1
City: WOOD'S HOLE State: MA
County:
License #: 00-0643
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: STEVE SANDIN
Licensee: WOOD'S HOLE OCEANOGRAPHIC INSTITUTION
Region: 1
City: WOOD'S HOLE State: MA
County:
License #: 00-0643
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/11/2012
Notification Time: 14:28 [ET]
Event Date: 09/11/2012
Event Time: 12:05 [EDT]
Last Update Date: 09/11/2012
Notification Time: 14:28 [ET]
Event Date: 09/11/2012
Event Time: 12:05 [EDT]
Last Update Date: 09/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - LEAK TEST RESULTS FOR NI-63 SOURCE > .005 MICROCURIES
The following information was received from the Commonwealth of Massachusetts via fax:
"[The licensee] called the Agency [Massachusetts Radiation Control] to report that [the licensee] received leak test results that were above 0.005 microCurie for their 'Shimadzu' [Manufacturer] Ni-63 gas chromatograph instruments, each containing approximately 10 milliCurie foil sources. [The licensee] reported that the leak test results were 0.0053 and 0.0069 microCurie. [The licensee] stated that wipe surveys for Ni-63 were taken of the lab areas where these instruments were used. [The licensee] did not yet have the LSC [liquid scintillation counter] results of the wipe surveys. [The licensee] also disassembled the electron capture detectors (ECD) from the GC [Gas Chromatograph] instruments and placed them inside a scaled poly bag to store the ECD's until [the licensee] can return the ECD's to 'Shimadzu'."
The following information was received from the Commonwealth of Massachusetts via fax:
"[The licensee] called the Agency [Massachusetts Radiation Control] to report that [the licensee] received leak test results that were above 0.005 microCurie for their 'Shimadzu' [Manufacturer] Ni-63 gas chromatograph instruments, each containing approximately 10 milliCurie foil sources. [The licensee] reported that the leak test results were 0.0053 and 0.0069 microCurie. [The licensee] stated that wipe surveys for Ni-63 were taken of the lab areas where these instruments were used. [The licensee] did not yet have the LSC [liquid scintillation counter] results of the wipe surveys. [The licensee] also disassembled the electron capture detectors (ECD) from the GC [Gas Chromatograph] instruments and placed them inside a scaled poly bag to store the ECD's until [the licensee] can return the ECD's to 'Shimadzu'."
Agreement State
Event Number: 48300
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HALLIBURTON
Region: 4
City: HOUSTON State: TX
County:
License #: 02113
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Licensee: HALLIBURTON
Region: 4
City: HOUSTON State: TX
County:
License #: 02113
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/12/2012
Notification Time: 08:37 [ET]
Event Date: 09/11/2012
Event Time: 21:00 [CDT]
Last Update Date: 10/05/2012
Notification Time: 08:37 [ET]
Event Date: 09/11/2012
Event Time: 21:00 [CDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RYAN LANTZ (R4DO)
BRIAN MCDERMOTT (FSME)
JANE MARSHALL (IRD)
MEXICO (E-MA)
JIM WHITNEY (ILTA)
RYAN LANTZ (R4DO)
BRIAN MCDERMOTT (FSME)
JANE MARSHALL (IRD)
MEXICO (E-MA)
JIM WHITNEY (ILTA)
AGREEMENT STATE REPORT - LOST AM-241/BE WELL LOGGING SOURCE
The following information was obtained from the Texas Department of State Health Services Radiation Branch via e-mail:
"On September 11, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that an Americium-241/ Beryllium [well logging] source could not be located. The source had been used earlier that day at a well site near Pecos, Texas. The well logging crew left the Pecos site and went about 130 miles to a well site south of Odessa, Texas. When the crew went to remove the Am-241 source they discovered the source transport container lock and plug were not in place and that the source was missing. The crew returned to the well site near Pecos and searched for the source, but did not find it. The Radiation Safety Officer (RSO) stated that the lock was found in the storage compartment in the back of the truck. The transport container plug was not in the container. The RSO stated they were putting together a group to look for the source along the roadway between the two locations.
"The RSO stated that the crew stated that they did not stop anywhere along the route between the two locations. The RSO stated they were verifying that using the vehicles black box. The RSO agreed to contact the appropriate local law enforcement. The RSO stated he would send a copy of the latest dose rate readings for the source to the Agency.
"The Agency has notified their local inspectors of the event. Additional information will be provided as it is received in accordance with SA-300 [Reporting Material Events]."
The source was described as approximately 7 inches long by 1 inch in diameter stainless steel cylinder. The State has not requested any assistance in locating the source at this time.
Texas Report I-8988
* * * UPDATE AT 1744 EDT ON 09/12/12 FROM ART TUCKER TO S. SANDIN * * *
The following update was received from the State of Texas via fax:
"[At] 1430 hours [CDT] the Agency [Texas Department of State Health Services] was contacted by the licensee and provided the following information.
"The licensee has completed a press release which provides a description of the source, actions to take if found, and stated that they would offer a reward. The press release will be issued by their Public Information Group. The licensee has completed logging of the well near Pecos and the source was not located.
"The licensee stated that the well site had been searched and surveyed twice. The licensee stated that the road between Pecos and Odessa had been surveyed using well logging tools extended from pickup trucks and driven between 5 and 10 miles per hour and the source was not found. The licensee stated they have had people on the ground searching, but did not know how much area away from the well site in Pecos had been searched.
"The licensee has sent a Radiation Safety Officer and a second supervisor to the Pecos well site. The RSO is bringing scintillation survey instruments to the well site for additional surveys. An Agency inspector will meet the RSO at the well site.
"The licensee has reviewed the well logging data and confirmed that the source was installed on the tool during logging operations. The licensee has performed preliminary interviews with the operator involved. The licensee indicated that additional interviews are required. They have not been able to determine how the source could have been lost during transport. The licensee stated that they completed a review of the truck's black box and confirmed that the truck did not stop while traveling between the two well sites.
"The license stated that the local sheriff has responded to the Pecos location and was interviewing the tool operators. The licensee stated they believe that the group supervisor involved had been evaluated under the IC's [Increased Controls] as trust worthy and reliable.
"The licensee stated that other entities at the well site as well as the lease holder have been notified of the event. The licensee stated that they will continue to search for the source until it can be located. The Agency has offered their assistance to the licensee. Additional information will be provided as it is received in accordance with SA - 300 [Reporting Material Events]."
Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email/fax.
* * * UPDATE ON 9/13/12 AT 1015 EDT FROM ART TUCKER TO HUFFMAN * * *
The following update was received from the State of Texas via e-mail:
"A third search of the well site was completed on September 12, 2012 at 2030 hours. The source was not found. The licensee will resume the search early today. The licensee stated that surveys will be conducted on the road between Odessa and Pecos today. The licensee stated that a mud pit at the Pecos site will be logged today. The logging truck is at their shop in Odessa now and they are literally stripping it down, removing every piece of equipment looking for the source. The licensee stated that the three individuals who were conducting the well logging operations when the source was lost were interviewed by individuals from the Federal Bureau of Investigation working with the Department of Transportation. The licensee stated that the FBI would only say that they believed there was no criminal activity involved with the missing source. Additional information will be provided as it is received in accordance with SA - 300."
Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email.
* * * UPDATE ON 10/05/12 AT 0915 EDT FROM ART TUCKER TO DONG PARK * * *
The following update was received from the State of Texas via e-mail:
"On October 5, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that the missing Americium - 241/Beryllium source had been recovered. No additional information was available at the time of the report. Additional information will be provided as it is received in accordance with SA-300.
Notified R4DO (Powers). ILTAB (Hahn), FSME Events Resource and Mexico informed via email.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was obtained from the Texas Department of State Health Services Radiation Branch via e-mail:
"On September 11, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that an Americium-241/ Beryllium [well logging] source could not be located. The source had been used earlier that day at a well site near Pecos, Texas. The well logging crew left the Pecos site and went about 130 miles to a well site south of Odessa, Texas. When the crew went to remove the Am-241 source they discovered the source transport container lock and plug were not in place and that the source was missing. The crew returned to the well site near Pecos and searched for the source, but did not find it. The Radiation Safety Officer (RSO) stated that the lock was found in the storage compartment in the back of the truck. The transport container plug was not in the container. The RSO stated they were putting together a group to look for the source along the roadway between the two locations.
"The RSO stated that the crew stated that they did not stop anywhere along the route between the two locations. The RSO stated they were verifying that using the vehicles black box. The RSO agreed to contact the appropriate local law enforcement. The RSO stated he would send a copy of the latest dose rate readings for the source to the Agency.
"The Agency has notified their local inspectors of the event. Additional information will be provided as it is received in accordance with SA-300 [Reporting Material Events]."
The source was described as approximately 7 inches long by 1 inch in diameter stainless steel cylinder. The State has not requested any assistance in locating the source at this time.
Texas Report I-8988
* * * UPDATE AT 1744 EDT ON 09/12/12 FROM ART TUCKER TO S. SANDIN * * *
The following update was received from the State of Texas via fax:
"[At] 1430 hours [CDT] the Agency [Texas Department of State Health Services] was contacted by the licensee and provided the following information.
"The licensee has completed a press release which provides a description of the source, actions to take if found, and stated that they would offer a reward. The press release will be issued by their Public Information Group. The licensee has completed logging of the well near Pecos and the source was not located.
"The licensee stated that the well site had been searched and surveyed twice. The licensee stated that the road between Pecos and Odessa had been surveyed using well logging tools extended from pickup trucks and driven between 5 and 10 miles per hour and the source was not found. The licensee stated they have had people on the ground searching, but did not know how much area away from the well site in Pecos had been searched.
"The licensee has sent a Radiation Safety Officer and a second supervisor to the Pecos well site. The RSO is bringing scintillation survey instruments to the well site for additional surveys. An Agency inspector will meet the RSO at the well site.
"The licensee has reviewed the well logging data and confirmed that the source was installed on the tool during logging operations. The licensee has performed preliminary interviews with the operator involved. The licensee indicated that additional interviews are required. They have not been able to determine how the source could have been lost during transport. The licensee stated that they completed a review of the truck's black box and confirmed that the truck did not stop while traveling between the two well sites.
"The license stated that the local sheriff has responded to the Pecos location and was interviewing the tool operators. The licensee stated they believe that the group supervisor involved had been evaluated under the IC's [Increased Controls] as trust worthy and reliable.
"The licensee stated that other entities at the well site as well as the lease holder have been notified of the event. The licensee stated that they will continue to search for the source until it can be located. The Agency has offered their assistance to the licensee. Additional information will be provided as it is received in accordance with SA - 300 [Reporting Material Events]."
Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email/fax.
* * * UPDATE ON 9/13/12 AT 1015 EDT FROM ART TUCKER TO HUFFMAN * * *
The following update was received from the State of Texas via e-mail:
"A third search of the well site was completed on September 12, 2012 at 2030 hours. The source was not found. The licensee will resume the search early today. The licensee stated that surveys will be conducted on the road between Odessa and Pecos today. The licensee stated that a mud pit at the Pecos site will be logged today. The logging truck is at their shop in Odessa now and they are literally stripping it down, removing every piece of equipment looking for the source. The licensee stated that the three individuals who were conducting the well logging operations when the source was lost were interviewed by individuals from the Federal Bureau of Investigation working with the Department of Transportation. The licensee stated that the FBI would only say that they believed there was no criminal activity involved with the missing source. Additional information will be provided as it is received in accordance with SA - 300."
Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email.
* * * UPDATE ON 10/05/12 AT 0915 EDT FROM ART TUCKER TO DONG PARK * * *
The following update was received from the State of Texas via e-mail:
"On October 5, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that the missing Americium - 241/Beryllium source had been recovered. No additional information was available at the time of the report. Additional information will be provided as it is received in accordance with SA-300.
Notified R4DO (Powers). ILTAB (Hahn), FSME Events Resource and Mexico informed via email.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 48409
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: WATCH CITY MUSEUM
Region: 1
City: WALTHAM State: MA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Licensee: WATCH CITY MUSEUM
Region: 1
City: WALTHAM State: MA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 11:31 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2012
Notification Time: 11:31 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (E-MA)
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (E-MA)
AGREEMENT STATE- DAMAGED WATCH WITH REMOVABLE RADIUM CONTAMINATION
The following report was received from the Commonwealth of Massachusetts via facsimile:
"During a decommissioning survey of the Watch City Museum, the museum's consultant 'Babcock Services, Inc.' (BSI), discovered an antique radium watch with potential damage. The subject watch, marked '8-Day Watch' was missing the glass face. BSI obtained the following radiological survey results:
- Maximum radiation reading on contact [was] 0.38 mR/hr and
- Alpha plus beta removable contamination smear of 52,767 dpm/100 cm2.
- The estimated Ra-226 activity is less than 1 microCuries
"The 8-Day Watch was removed from the museum, securely wrapped, and placed in a secure container.
"The owner of the 8-Day Watch, 'Charles River Museum of Industry and Innovation', was notified about the condition of the 8-Day Watch. The timepiece owner and the Watch City Museum agreed that the damaged timepiece should be properly disposed as radioactive waste. The 'Watch City Museum' arranged for the disposal of the timepiece with their decommissioning consultant, BSI. The Agency agreed with the disposition of the damaged timepiece.
"The Agency conducted a confirmatory radiological survey of the timepiece display case and the adjacent museum floor. The survey included the display case glass cover (outside and inside surfaces), the display case base, the adjacent floor within 2 feet of the display case, the secured container of the 8-Day Watch, [and] the viewing surface where the timepiece was displayed. [The] inspector observed no readings above background of 10 cpm using an alpha probe. Maximum radiation level at the surface of the time piece container was 0.2 mR/hr using a gamma probe.
"The Agency considers this event to be closed."
The following report was received from the Commonwealth of Massachusetts via facsimile:
"During a decommissioning survey of the Watch City Museum, the museum's consultant 'Babcock Services, Inc.' (BSI), discovered an antique radium watch with potential damage. The subject watch, marked '8-Day Watch' was missing the glass face. BSI obtained the following radiological survey results:
- Maximum radiation reading on contact [was] 0.38 mR/hr and
- Alpha plus beta removable contamination smear of 52,767 dpm/100 cm2.
- The estimated Ra-226 activity is less than 1 microCuries
"The 8-Day Watch was removed from the museum, securely wrapped, and placed in a secure container.
"The owner of the 8-Day Watch, 'Charles River Museum of Industry and Innovation', was notified about the condition of the 8-Day Watch. The timepiece owner and the Watch City Museum agreed that the damaged timepiece should be properly disposed as radioactive waste. The 'Watch City Museum' arranged for the disposal of the timepiece with their decommissioning consultant, BSI. The Agency agreed with the disposition of the damaged timepiece.
"The Agency conducted a confirmatory radiological survey of the timepiece display case and the adjacent museum floor. The survey included the display case glass cover (outside and inside surfaces), the display case base, the adjacent floor within 2 feet of the display case, the secured container of the 8-Day Watch, [and] the viewing surface where the timepiece was displayed. [The] inspector observed no readings above background of 10 cpm using an alpha probe. Maximum radiation level at the surface of the time piece container was 0.2 mR/hr using a gamma probe.
"The Agency considers this event to be closed."
Agreement State
Event Number: 48326
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: UNIVERSITY OF TENNESSEE MEDICAL CENTER
Region: 1
City: KNOXVILLE State: TN
County:
License #: R-47011
Agreement: Y
Docket:
NRC Notified By: JERRY BINGAMAN
HQ OPS Officer: JOHN KNOKE
Licensee: UNIVERSITY OF TENNESSEE MEDICAL CENTER
Region: 1
City: KNOXVILLE State: TN
County:
License #: R-47011
Agreement: Y
Docket:
NRC Notified By: JERRY BINGAMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/20/2012
Notification Time: 16:38 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2012
Notification Time: 16:38 [ET]
Event Date: 09/11/2012
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
FSME EVENT RESOURCE (EMAI)
CHRISTOPHER CAHILL (R1DO)
FSME EVENT RESOURCE (EMAI)
AGREEMENT STATE REPORT - PATIENT RECEIVED UNDERDOSE OF Y-90 MICROSPHERES
The following information was provided by the State of Tennessee via facsimile:
"On September 11, 2012, the Division of Radiological Health received a report from the University of Tennessee Medical Center regarding a misadministration that occurred September 11, 2012. A patient was prescribed a dose of 20.0 mCi of Y-90 SirSphere microspheres, and only 15.32 mCi was administered. The administered dosage was 23% less than prescribed and will result in an absorbed dose of 40.1 Gy less than the calculated 171.3 Gy. The reason why this event occurred is not known.
"The residual activity was detectable in the SirSpheres waste container which contained the V-vial; tubing, catheters, and protective radioactive waste cloths. The administered dosage is still considered to be within therapeutic range, but less than that prescribed by the physician. The patient and the referring physician were both notified on September 11, 2012. Inspectors from the Knoxville Field Office will follow-up on this incident."
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.
The following information was provided by the State of Tennessee via facsimile:
"On September 11, 2012, the Division of Radiological Health received a report from the University of Tennessee Medical Center regarding a misadministration that occurred September 11, 2012. A patient was prescribed a dose of 20.0 mCi of Y-90 SirSphere microspheres, and only 15.32 mCi was administered. The administered dosage was 23% less than prescribed and will result in an absorbed dose of 40.1 Gy less than the calculated 171.3 Gy. The reason why this event occurred is not known.
"The residual activity was detectable in the SirSpheres waste container which contained the V-vial; tubing, catheters, and protective radioactive waste cloths. The administered dosage is still considered to be within therapeutic range, but less than that prescribed by the physician. The patient and the referring physician were both notified on September 11, 2012. Inspectors from the Knoxville Field Office will follow-up on this incident."
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.