Event Notification Report for June 14, 2000

AGREEMENT STATE REPORT

The State of Florida Bureau of Radiation Control reported that a Troxler soil moisture/density gauge (Model 3430, Serial #30059), containing 8 mCi of Cs-137 and 40 mCi of Am-241/Be, had been stolen from a state licensee. The licensee reported that the gauge was stolen from a temporary job site between the hours of 6 p.m. on 6/13/00 and 9 a.m. on 6/14/00. The chain link fence surrounding the site was not damaged, but the door to the shed had been pried open. The lock on the storage locker containing the container and gauge had been cut. The gauge and container were the only items taken. The Hillsborough Sheriff's Office and the Florida Bureau of Radiation Control are investigating. The Sheriff's Office is planning to issue a press release.

* * * UPDATE 1544 EST 10/30/2000 FROM ADAMS TAKEN BY STRANSKY * * *

"Licensee reported that a gauge was stolen on June 14th. The gauge was found on October 30 at Veterans Memorial Park in Tampa. Item was found along a bike path. The gauge was slightly damaged, but the sources were intact locked in the gauge. Swipes showed no contamination. Item has been returned to owner."

Notified R2DO (Boland).

LOSS OF ACTIVATION CAPABILITY OF ALL OFFSITE SIRENS

Citrus County notified the licensee that the offsite sirens were not able to be activated. Subsequent tests indicated that all offsite sirens were inoperable. The vendor has been notified and is on the way to make repairs.

The licensee notified the local counties, Citrus and Levy, and intends to notify the State Warning Point and the NRC Resident Inspector.

********** UPDATE AT 1525 ON 06/14/00 FROM SHAWN SIMON TO LEIGH TROCINE **********

At 1510 on 06/14/00, the licensee was notified that the sirens were fully operable.

The licensee plans to notify the NRC resident inspector and plans to make a courtesy notification to the state. The NRC operations officer notified the R2DO (Bernhard).

OFFSITE NOTIFICATION REGARDING A 2-GALLON OIL SPILL INSIDE THE PROTECTED AREA

At 1430 on 06/14/00, the licensee notified the National Response Center of an oil spill onsite. Approximately 5 to 10 gallons of hydraulic oil spilled onto the ground near the shoreline of the Back River, and approximately 2 gallons of this hydraulic oil subsequently entered the Back River (a body of water located off of the Sheepscot River).

The oil leaked from a hydraulic fitting on a tractor trailer (a heavy hauler) located near the shore line inside the protected area. At the time of the event, the tractor trailer was being utilized to load a pressurizer onto a barge. The initial spill was reported to the control room at 1315, and it was discovered that some of the oil entered the water at 1335.

The leak has been stopped, booms have been placed into the water to contain the oil, and clean up efforts are currently in progress. Oil pads have been placed both on the surface of the water and on the ground to contain and soak up the oil. The licensee has also called a local hazardous waste response organization (Clean Harbors) and their estimated time of arrival is approximately 1630.

The unit is currently shutdown, and decommissioning is in progress. There is no NRC resident inspector assigned to this site at this time.

NRC BULLETIN 91-01 RESPONSE - FAILURE TO MAINTAIN THE ESTABLISHED DOUBLE CONTINGENCY INVOLVING THE LOSS OF ONE OF TWO CONTROLS (24-HOUR REPORT)

The following text is a portion of a facsimile received from Paducah personnel:

"The plant water hose containing valve W-10 on the C-400 cylinder wash stand was long enough to allow a physical connection to the cylinder wash solution tanks in violation of a safety-related item contained in NCSE.006.03. Safety-related item 5.5.7 states that the hose shall not be long enough to connect the plant water system to the cylinder wash tanks. This is to prevent the potential for backflow of fissile solution into the plant water system, which is not analyzed for fissile solution."

"SAFETY SIGNIFICANCE OF EVENTS:"

"The plant water hose was never connected to the cylinder wash tanks. The normal plant water system pressure is well above the maximum pressure in the cylinder wash tanks and would preclude backflow even if connected. In addition, the connecting fittings on the plant water hose and on the cylinder wash tanks were incompatible."

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIOS) OF HOW CRITICALITY COULD OCCUR:"

"In order for a criticality to be possible, the hose would have to be connected to the solution storage tanks, fissile solution would have to backflow into the plant water system, and it would have to accumulate a critical mass in an unsafe geometry."

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY CONCENTRATION, ETC):"

"[The] double contingency for this scenario is established by implementing two controls on mass."

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):"

"None. The C-400 cylinder wash was out of service at the time of discovery. The plant water hose was never connected to the cylinder wash tanks when the cylinder wash was in operation."

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:"

"[The] double contingency for this scenario is established by implementing two controls on mass."

"The first leg of double contingency is an administrative control, which prohibits connecting the plant water hose directly to the cylinder wash tanks. This control was not violated, and the first leg of double contingency was maintained."

"The second leg of [the] double contingency is a physical control on the length of the plant water hose to prevent connection to the cylinder wash tanks. The hose containing valve W-10 was physically long enough to connect to the cylinder wash tank at air sparge valve A-22. This control was violated, and [the] double contingency was not maintained."

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:"

"This area is being controlled to ensure that the hose is not moved without NCS approval. The corrective action will be to reduce the length of the hose such that it is compliant with the safety-related item."

Paducah personnel notified the NRC resident inspector.

GEORGE WASHINGTON UNIVERSITY HOSPITAL REPORTED AN UNDERTREATMENT DURING BRACHYTHERAPY.

THE HOSPITAL REPORTED THAT A FEMALE PATIENT WAS BEING TREATED WITH CESIUM 137 SEEDS IN THE FIRST OF A TWO PHASE TREATMENT SEQUENCE WITH EACH DELIVERING APPROXIMATELY 1,680 RADS. DURING THIS TREATMENT THE DEVICE THAT CONTAINED THE SEEDS SLIPPED OUT OF THE AREA BEING TREATED. IT IS NOT KNOWN WHEN THIS ACTUALLY OCCURRED, BUT THE UNDERTREATMENT COULD HAVE LASTED BETWEEN 3.25 - 6 HOURS. THEY ARE ESTIMATING THAT THE PATIENT MAY HAVE ONLY RECEIVED 1,478.5 RADS. A CORRECTION FOR THIS UNDERTREATMENT CAN BE DONE DURING THE SECOND PHASE. THERE ALSO MAY HAVE BEEN OTHER AREAS NOT DESTINED FOR TREATMENT THAT WERE EXPOSED TO THE RADIATION WHEN THE DEVICE SLIPPED. THE PATIENT HAS BEEN REEXAMINED A WEEK FOLLOWING THIS MISADMINISTRATION AND NO ADVERSE AFFECTS WERE DETERMINED. A SECOND FOLLOWUP EXAMINATION WILL BE DONE WITHIN A WEEK. THE PATIENT WAS INFORMED AND THE ATTENDING PHYSICIAN WAS NOTIFIED.