Event Notification Report for April 13, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/12/2001 - 04/13/2001
** EVENT NUMBERS **
37904 37914 37915
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|General Information or Other |Event Number: 37904 |
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| REP ORG: MARYLAND DEPT OF THE ENVIRONMENT |NOTIFICATION DATE: 04/10/2001|
|LICENSEE: CAMPBELL & NOLAN ASSOCIATES |NOTIFICATION TIME: 08:38[EDT]|
| CITY: FALLSTON REGION: 1 |EVENT DATE: 04/09/2001|
| COUNTY: HARFORD STATE: MD |EVENT TIME: [EDT]|
|LICENSE#: MD-25-030-01 AGREEMENT: Y |LAST UPDATE DATE: 04/12/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES LINVILLE R1 |
| |DON COOL NMSS |
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| NRC NOTIFIED BY: ALAN JACOBSON | |
| HQ OPS OFFICER: STEVE SANDIN | |
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|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A LOST TROXLER MOISTURE DENSITY GAUGE |
| |
| "Baltimore, MD (April 9,2001)-The Maryland Department of the Environment |
| (MDE) has received a report that a moisture density gauge containing nuclear |
| material is missing from a contractor in Fallston, Harford County, Maryland. |
| Engineering consultants Campbell and Nolan Associates, Inc. reported that |
| the device apparently fell from the back of a pick-up truck as it was |
| leaving a construction site in Harford County on the morning of April 9, |
| 2001. |
| |
| "The gauge is believed to have been lost between Monmouth Meadows on Singer |
| Road and the offices of Campbell and Nolan Associates located at 2813 Bel |
| Air Road in Fallston, Maryland. |
| |
| "The portable device is used to measure the moisture and density of soil. |
| The gauge, a Troxler, model 3430 [S/N 26218], is yellow in color and |
| approximately 3' X 2' X 2'. The device contains radioactive material |
| identified as Cesium-137 on an extendable rod and Americium-241 encased in |
| the device. Campbell and Nolan personnel reported that the device was |
| secured with a padlock to prevent inadvertent exposure of the radioactive |
| source. The radioactive material is not a threat to public health and safety |
| as long as it remains intact within the device's shielded enclosure." |
| |
| Call the Operations Center for contact information. |
| |
| * * * UPDATED AT 1000 EDT ON 4/12/01 BY ALAN JACOBSON TO FANGIE JONES * * * |
| |
| MDE reported that the gauge has been recovered undamaged. |
| |
| Notified the R1DO (William Ruland) and NMSS (Don Cool). |
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|Fuel Cycle Facility |Event Number: 37914 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/12/2001|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 13:23[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/11/2001|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:15[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/12/2001|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |GEOFFREY WRIGHT R3 |
| DOCKET: 0707001 |BRIAN SMITH NMSS |
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| NRC NOTIFIED BY: E. G. WALKER | |
| HQ OPS OFFICER: JOHN MacKINNON | |
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|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
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EVENT TEXT
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| NRC BULLETIN 91-01 24 HOUR NOTIFICATION |
| |
| AN NCS ADMINISTRATIVE REQUIREMENT NOT MET. |
| |
| On 04/11/01, it was discovered that C-333 Unit 2 Cell 1 freon systems were |
| at zero freon level without current independent verification documentation |
| that the cell was less than 1.0 wt% U235 in violation of NCSA CAS.011. An |
| independent assay verification was performed in May of 2000, however the |
| cell was subsequently placed onstream and taken back offstream and shutdown |
| in October of 2000. Since shutdown, independent assay verification had not |
| been performed when the freon was drained and prior to implementation of |
| NCSA CAS.011. Due to independent assay verification not being performed |
| prior to implementation of NCSA CAS.011, and NCS administrative requirement |
| was not met. Upon discovery, independent assay verification was immediately |
| performed and cell assay was determined to be less than 1.0 wt% U235. |
| |
| SAFETY SIGNIFICANCE OF EVENT: |
| |
| Double contingency was not maintained. Although the required documentation |
| was not verified at the tome the R-114 level was removed from the cell, the |
| assay of the cell was well known through historical process knowledge. Upon |
| discovery, the historical cascade gradient was reviewed and it was |
| determined that the cell was less than 1.0 wt% U235. |
| |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S)) OF HOW |
| CRITICALITY COULD OCCUR: |
| |
| In order for criticality to be possible, the shutdown cell would need to |
| have an unsafe mass of moderated uranium with an enrichment greater than 1.0 |
| wt% U235. |
| |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| |
| Double contingency for this scenario is established by implementing two |
| controls on assay. |
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| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE CRITICAL MASS): |
| |
| 0.7183 wt% U235. |
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| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: |
| |
| The first leg of double contingency is based on verification that the |
| equipment contains uranium enriched to less than 1.0 wt% U235. The |
| verification of assay was not performed. Therefore, the control was |
| violated and the first leg of double contingency was lost. |
| |
| The second leg of double contingency is based on independent verification |
| that the equipment contains uranium enriched to less than 1.0 wt% U235. |
| This independent verification was not performed. Therefore, the control was |
| violated and the second leg of double contingency was lost. |
| |
| Since double contingency is based on two controls on assay, double |
| contingency was not maintained. |
| |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: |
| |
| An independent assay verification was performed and documented, which |
| indicated that the assay was less than 1.0 wt% U235. |
| |
| The NRC Resident Inspector was notified of this event by the Certificate |
| Holder. |
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|General Information or Other |Event Number: 37915 |
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| REP ORG: ARKANSAS DEPT OF HEALTH |NOTIFICATION DATE: 04/12/2001|
|LICENSEE: ST. JOSEPH REGIONAL HEALTH CENTER |NOTIFICATION TIME: 16:55[EDT]|
| CITY: HOT SPRINGS REGION: 4 |EVENT DATE: 04/12/2001|
| COUNTY: GARLAND STATE: AR |EVENT TIME: 15:32[CDT]|
|LICENSE#: ARK342BP0402 AGREEMENT: Y |LAST UPDATE DATE: 04/12/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |BRIAN SMITH NMSS |
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| NRC NOTIFIED BY: CATHEY BRADLEY | |
| HQ OPS OFFICER: JOHN MacKINNON | |
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|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION |
| |
| At 1532 CT on 04/12/01, Saint Joseph Regional Health Center located in Hot |
| Springs, Arkansas, notified the Arkansas Department of Health of the |
| following Medical Misadministration: |
| |
| Since March 7, 2001, a patient at Saint Joseph Regional Health Center |
| received a total of 24 treatments, 2 grays each, for a total dose of 48 |
| grays to the back of his left hand instead of to his left knuckle. The |
| applicator needles were 5 centimeters shorter than the applicator (stopping |
| shorter than where they were supposed to stop). The source used for the |
| radiation treatments was Iridium-192. State of Arkansas licensee number for |
| the licensee is ARK-342-BP-04-02. State of Arkansas will send personnel out |
| to investigate this incident. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021