Event Notification Report for April 21, 2016

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN

The following report was received from the State of Georgia via email:

"On Tuesday, April 26, 2016 our department [Georgia Department of Natural Resources, Radioactive Materials Program] received a report from GA Pacific, Cedar Springs, Georgia, that the shutters were stuck in the open position on a Kay Ray fixed gauge with 2000 mCi of Cs-137 and a Berthold fixed gauge with 30 mCi of Cs-137. Georgia Pacific maintenance personnel were doing a 6 month service check and realized that the shutters would not close. The incident occurred on 4/21/16. On 4/22/16, [the licensee RSO] received the report and was trying to determine reporting requirements. On 4/25/16, [the RSO determined] that they needed to do a notification report but our office was closed. Our department was notified on 4/26/16. Tag devices are being used but work cannot be performed around the area near the tank/pipeline. Berthold has been contacted but Kay Ray is out of business. A complaint has been opened in CTS [Complaint Tracking System] and our office has an ongoing investigation."

FITNESS FOR DUTY - CONTRACTOR SUPERVISOR ATTEMPTS TO SUBVERT FITNESS FOR DUTY TEST

"A non-licensed supervisory contractor admitted to attempting to subvert a Fitness for Duty test. The contractor's site access has been terminated. The NRC Resident Inspector was notified."

AGREEMENT STATE REPORT - RADIATION LEVEL ON PACKAGE GREATER THAN LIMITS

The following information was obtained from the State of Texas via email:

"On April 21, 2016, the Agency [Texas Department of State Health Services] was contacted by the Environmental Protection Agency in response to a notice it had received regarding excessive dose rates coming from a package in shipment. The package was being carried by [a common carrier] and was located at one of its facility in Houston, Texas. The Agency contacted the radiation safety officer (RSO) for [the common carrier]. He stated they had been informed by Customs and Border Patrol that one of their packages was reading higher than expected and they had responded. The RSO stated their surveys indicated dose rates at three feet were 41 mrem per hour and 7 rem per hour on contact with the package. The RSO stated their surveys were not consistent with the dose rates reported by Customs. The RSO stated the package contained a 2.79 (11.84 original activity) curie iridium 192 source being returned to the manufacturer. The source was from a high dose rate after loader being returning from outside the United States. The shipping container was opened and the source was found sitting on top of the shield. The source was placed in a different shield and returned to a safe storage location.

"While the shipper was investigating the event, a person inside the facility called 911. When the hazmat team arrived they performed a radiation survey and decided the dose rates warranted evacuating all the workers from the building. The building was evacuated for more than an hour, but less than two hours.

"[The common carrier] is investigating the event and any possible exposures to their workers. The RSO stated he did not believe any individual of the general public would have exceeded any limits. The RSO and this Agency has scheduled a call on April 22, 2016, to exchange additional information. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9391

* * * UPDATE AT 0907 EDT ON 04/25/16 FROM ART TUCKER TO S. SANDIN VIA EMAIL * * *

"The Agency contacted the Houston Texas Hazmat Team leader (HTL). They stated their surveys at 200 feet indicated the radiation readings were background. The HTL stated when they arrived the bucket containing the source was on a pallet held in place with plastic wrap and a cinch strap. The HML stated the bucket containing the source was the only item on the pallet. The Hazmat Team (HMT) removed the plastic wrap from the bucket and removed the bucket from the pallet. The bucket (containing the source) was then placed in a 30 gallon container. The container was filled with a dry material containing clay. That container was sealed and placed in a 55 gallon drum. The 55 gallon drum was filled with water and the top placed on the drum. The manufacturer's representative who retrieved the source was contacted. They stated dose rate on the side of the 55 gallon drum was 7 rem/hr (this dose rate was reported as on the side of the package in the initial report.) The dose rate on the top of the source container (package) was 15 rem/hr. He stated he noted the end of the drive cable near and past the source had been damaged. He found that the source was not inside the shield and both security seals were missing from the shipping container."

Notified R4DO (Groom) and NMSS Events Notification via email.

MISSING FIRE BARRIERS

"Missing fire barrier between Fire Area (FA) 59 and 85.

"During a walk down of fire barriers for the NFPA 805 project, it was determined that the fire barrier between Fire Area 59 (Unit 1) and 85 (common) is not a rated barrier due to unsealed penetrations in the barrier. Evaluation FPEE 12-006 evaluated the acceptability of the barrier being unrated based on separation of safe shutdown equipment however a review of equipment credited for Appendix R safe shutdown identified that the redundant credited Appendix R equipment is on either side of the fire barrier which is not 3 hour rated. The conclusion of the FPEE is therefore no longer valid.

"Fire Hazard Analysis Drawings Do Not Match Boundary Description.

"The plant layout in F5 Appendix F, Rev. 28, Fire Hazard Analysis (FHA), does not agree with the boundary description in the FHA for the Unit 1 and 2 Containment Annulus fire areas, Fire Area (FA) 68 and 72. The layout should but does not show the fire area boundary between the annulus and adjacent fire areas, FA 60 and 75 on 735 [foot] and 61A on 755 [foot], as an Appendix R boundary. The annulus airlock doors are 3-hour fire rated and the airlock is constructed of concrete thick enough to qualify as a 3 hour fire barrier however, there are penetrations in the barrier that are not sealed with fire rated materials or inspected as required by the Fire Protection Program.

"Therefore, this is an unanalyzed condition reportable under 10 CFR 50.72(b)(3)(ii)(B). This condition does not affect the health and safety of the public or station employees. The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received by the State of Ohio via email:

"On 4/21/2016 in OR [Operating Room] 11, during seed loading, the dosimetrist noticed that one seed was missing from the transferring stylet as he was transferring the seeds to the loading needle. He immediately notified the physicist in the room. The physicist then checked the sterile area around the cartridge with a survey meter and picked up radiation reading by the luer - lock hub of the cartridge. The physicist assumed that the source had fallen in the sterile towel under the cartridge and determined loading should continue, and they will retrieve the dislodged seed after all needles have been loaded. After all needles were loaded and while implantation was still in progress the physicist and the dosimetrist went to retrieve the dislodged seed but they were not able to locate it. They resurveyed the spot where it was and there was no radiation detected. The physicist emptied the cartridge to verify the number of seeds remaining in the cartridge and the count was as stated in the loading summary. The dislodged seed was missing.

"To prevent a recurrence, surgical drapes will be used to cover the area under and around the cartridge/loading area instead of sterile hand towels. This would make it easier to identify any seed that may have fallen out during loading. Loose/broken seed(s) will be placed in the lead pig immediately. If there is a dislodged/loose seed that could not be recovered immediately, the physicist will ensure that everyone leaving the room is surveyed.

"Licensee has previously observed that I-125 seeds are prone to static buildup and have the tendency to cling to plastic, glass walls, and other surfaces. Most likely, the lost seed was swept up and discarded with normal trash.

"Based on the relatively low activity and low energy of the I-125 seed and measured background readings in the operating room, there was no radiation exposure to personnel or members of the public due to this loss."

Source/Radioactive Material: Sealed source brachytherapy
Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125, 0.000382 Ci

Ohio Item Number: OH160006

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