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Event Notification Report for August 21, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/20/2003 - 08/21/2003

** EVENT NUMBERS **


40079 40085 40089 40091 40092

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General Information or Other Event Number: 40079
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WA DOT
Region: 4
City: YAKIMA State: WA
County:
License #: WN-L065-1
Agreement: Y
Docket:
NRC Notified By: SCROGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/15/2003
Notification Time: 18:09 [EST]
Event Date: 06/30/2003
Event Time: 09:45 [PDT]
Last Update Date: 08/15/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)

Event Text

TROXLER MOISTURE DENSITY GAUGE RUN OVER

"Licensee: WA State Dept. of Transportation (WA DOT), South Central Region
"City and state: Yakima, Washington
"License number: WN-L065-1
"Type of license: Portable Gauge

"Date of event: 30 June 2003
"Location of Event: near Walla Walla, Washington

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) On 30 June 2003, at about 9:45 AM, an errant motorist entered a coned-off lane and ran over a Troxler, Model 3430, moisture/density gauge, Serial Number 24671. The gauge contained two sealed sources, one of about 8 millicuries of Cesium 137 and the second of about 40 millicuries of Americium 241/Beryllium. The accident happened just north of Myra Road on State Route 125 near Walla Walla, Washington.

"An errant motorist drove past a WA DOT road flagger holding a stop sign. The motorist entered a lane that had been coned-off. The motorist proceeded to drive down the restricted lane and ran over the gauge while it was being used to test for compaction. The gauge operator saw the approaching vehicle and attempted to stop it by waving his hands and yelling as the vehicle approached. The motorist, a senior, was apparently oblivious to the lane restriction. After the gauge was hit, it wedged under the vehicle and was dragged for approximately 90 feet down the road until the motorist finally became aware of the problem and stopped. The cause was inattention or inability to understand that the road conditions had changed. It appears that age of the driver contributed to the cause of the event.

"The need to make any corrective action was deemed to be unnecessary. The gauge operator was operating per procedure and was only feet away from the gauge as it performed the test. The lane was restricted from travel by flagger and cone.

"The incident destroyed the gauge. Impact with the vehicle caused the Cesium 137 source to be drawn back into its shielded position. Although pieces of the gauge housing, electronics and mechanisms were scattered along the 90-foot section of road that the vehicle traveled after impact the gauge, the sources were still attached to their respective parts of the gauge. Subsequent leak tests were negative.

"DOH was not able to do an on site investigation due to the excessive distance to the event site and excessive time it would have taken to get staff to the site and clear the incident. The licensed RSO, a person trained to respond to events of this nature and having experience with similar events, went to the scene to give direction. The RSO performed surveys and an evaluation that allowed trained WA DOT personnel to release the area. The gauge parts were placed into the Troxler transportation box, a gravel/dirt mix was used to lower dose-rate readings to below a usual reading for an intact gauge, and the box was transported by trained WA DOT personnel to the WA DOT Headquarters facility for further evaluation, leak testing and disposition.

"WA DOH personnel performed an investigation of events and the gauge at WA DOT Headquarters after the gauge arrived. WA DOH staff inspected the gauge parts including the sources, evaluated the circumstances of the event, reviewed the report information, and consulted with WA DOT staff regarding procedure, equipment and their plan to return the gauge to Troxler. Once WA DOH staff determined that sources were not leaking and the material was safe to be returned to Troxler, it was sent to Troxler via normal method.

"There was no media attention.

"What is the notification or reporting criteria involved? 10 CFR 30.50(B)(2) and 20.2201 - After reviewing the incident file and the Handbook on Nuclear Material Event Reporting in the Agreement States , we determined that a 24 hour notification should have been sent to NRC. This did not occur; consequently we are now submitting this completed report, although late.

"Activity and Isotope(s) involved: 8 millicuries of Cesium 137 and 40 millicuries of Americium 241/Beryllium

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) No members of the public received exposure in any amount. Calculation, survey readings and previous experience with similar gauge events indicate that WA DOT radiation worker staff only received exposure that is associated with usual gauge operations. Dosimetry reports will be evaluated upon receipt from the dosimetry processor.

"Lost, Stolen or Damaged? (mfg., model, serial number) Troxler, Model 3430, Serial Number 24671 was destroyed (damaged).

"Disposition/recovery: The gauge was returned to Troxler for disposal.

"Leak test? A leak test was performed on each source. They were found to be negative.

"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) The gauge transportation vehicle was not involved in the event.

"Release of activity? There was no release of activity.

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? The licensee provided a written report, dated 7 July 2003.
"Was referring physician notified? N/A

"Consultant used? No"

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General Information or Other Event Number: 40085
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: FRED HUTCHINSON CANCER RESEARCH CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-L042-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/18/2003
Notification Time: 18:10 [EST]
Event Date: 06/19/2000
Event Time: 12:00 [PDT]
Last Update Date: 08/18/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JOHN HICKEY (NMSS)

Event Text

OVEREXPOSURE



"Exposure (intended/actual): consequences: Actual exposure received was Licensee: Fred Hutchinson Cancer "Research Center
"City and state: Seattle, Washington
"License number: WN-L042-1
"Type of license: Medium Broad License

"Date of event: Reported by licensee on 19 June 2000, (indicated overexposure for the wear period between 5 April to 4 "May 2000).

"Location of Event: Seattle, Washington
"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) On 19 June 2000, the licensed RSO reported that their dosimetry badge provider (Landauer Inc.) had notified them that one of the Fred Hutchinson employees had apparently received an exposure of 317,791 millirem of high energy gamma radiation. This employee performs animal studies involving irradiations using both a Linac and a Cobalt 60 irradiator (a J.L. Shepherd Model 285, Serial Numbers 625 & 626).

"The RSO immediately started an investigation of the reported overexposure. The RSO discovered that the individual's dosimetry badge had been lost during the second week of April 2000 for a period of about one week. An unknown person, via the inter-office mail system, returned it to the individual the next week. The employee was unable to recall any situation that would have lead to an exposure of any amount greater then the usual for the work performed over that time period.

"Several circumstantial events as well as actual occurrences seem to indicate that the exposure was probably only received by the dosimetry badge. These were: first, the employee indicated that the dosimetry badge had been lost during the second week of April 2000, for a period of about one week. Second, only the Cobalt 60 irradiator was in operation during that period; the Linac was out of service then. Third, since several groups share use of the irradiator, the badge conceivably was found, in the irradiator room, by one of those people and returned in the inter-office mail system. Lastly, the employee never experienced any radiation related illnesses. The reported exposure of 317,791 millirem was removed from the employee's exposure history and replaced with a 20 millirem exposure (average monthly exposure for previous 12 months).

"No DOH on-site investigation was made or media attention was noted.

"What is the notification or reporting criteria involved? 10 CFR 20.2202 (a)(1) significant . After reviewing our incident files and the Handbook on Nuclear Material Event Reporting in the Agreement States , we determined that an immediate notification should have been sent to NRC. This did not occur; consequently we are now submitting this completed report, although late.

"Activity and Isotope(s) involved: 518 terabecquerels (1400 curies), cobalt 60.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) The initial notification indicated that one worker (employee) had been overexposed. The event did not involve a member of the public. The Landauer report indicated that an employee had received a whole-body exposure of 317,719 millirem of high-energy gamma radiation. No consequences will be realized since the exposure was later determined to only involve the dosimetry badge. The employee's exposure history was revised to indicate a 20 millirem exposure for that period of wear.

"Lost, Stolen or Damaged? (mfg., model, serial number) The employee's dosimetry badge was lost for a period of about one week.

"Disposition/recovery: Badges were to be used by placing them into a pouch for individuals using the irradiator devices.

"Leak test? N/A

"Vehicle: N/A

"Release of activity? None

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: J.L. Shepherd Model 285 irradiator.
"Exposure (intended/actual): consequences: Actual exposure received was estimated to be the usual, average amount of 20 millirem for that wear period.
"Was patient or responsible relative notified? N/A
"Was written report provided? Yes, from licensed RSO dated 21 July 2000.
"Was referring physician notified? N/A

"Consultant used? No"

Washington State Event Report # WA-00-023.

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Fuel Cycle Facility Event Number: 40089
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 3
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: MICHAEL GINZEL
HQ OPS Officer: GERRY WAIG
Notification Date: 08/20/2003
Notification Time: 11:02 [EST]
Event Date: 08/19/2003
Event Time: 11:00 [CDT]
Last Update Date: 08/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ERIC DUNCAN (R3)
TOM ESSIG (NMSS)

Event Text

PARTIAL LOSS OF FIRE PROTECTION SYSTEM DUE TO PIPE LEAK AT HONEYWELL METROPOLIS

The fire protection system became inoperable to the Feeds Material and Fluorine Plant when an underground water leak on the fire suppression system was discovered and isolated. This caused the fire protection system water supply to be isolated to the Feeds Material and Fluorine Plant and thereby disabling a safety system. The fire system (water suppression system) to the Feeds Material and Fluorine Plant remains out of service pending repair of the failed pipe. No estimate of the time required to repair and return to service of the fire suppression system water supply is available at this time.

Licensee compensatory measures include the establishment of a fire watch and staging of fire hose to stations normally supplied by the fire suppression water system

The licensee has notified the NRC Resident Inspector and NRC Region 3 (Ken O'Brien) of this event.

The licensee has reported similar events under EN #39899 and EN #40015

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Power Reactor Event Number: 40091
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: HARRINGTON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2003
Notification Time: 12:45 [EST]
Event Date: 08/20/2003
Event Time: 10:45 [CDT]
Last Update Date: 08/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
THOMAS KOZAK (R3)
MATT HAHN (IAT)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNAUTHORIZED ACCESS

Actual individual had been granted unescorted access to a vital area. Compensatory measures immediately taken upon discovery.

NRC Senior Resident Inspector was notified of the event notification by the licensee.

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Power Reactor Event Number: 40092
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JAMES E. SCHLEIF
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2003
Notification Time: 13:19 [EST]
Event Date: 08/20/2003
Event Time: 11:20 [CDT]
Last Update Date: 08/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
THOMAS KOZAK (R3)
MATT HAHN (IAT)
TERRY REIS (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNAUTHORIZED ACCESS TO A VITAL

Actual individual had been granted unescorted access to a vital area. Compensatory measures immediately taken upon discovery.

NRC Resident Inspector will be notified of this event by the licensee.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012