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Event Notification Report for August 25, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/22/2003 - 08/25/2003

** EVENT NUMBERS **


40087 40088 40090 40095 40096 40098

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General Information or Other Event Number: 40087
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOURCE PRODUCTION AND EQUIPMENT CO.
Region: 4
City: SAINT ROSE State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/19/2003
Notification Time: 14:23 [EST]
Event Date: 08/05/2003
Event Time: 12:00 [CDT]
Last Update Date: 08/19/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JOHN HICKEY (NMSS)

Event Text

OVEREXPOSURE

Louisiana Radiation Protection Division received the following information on August 6, 2003 from Source Production and Equipment Co., located in Saint Rose.

On August 5, 2003 a Hot Cell operator discovered material on the floor that was reading a high radiation level. He believed the source was a form of contamination which he attempted to clean up with his hand and a swipe. It was later discovered the same day that the source was a iridium-192 wafer that had inadvertently been released from the Hot Cell (the caller said that it took them fours hours to find out how the wafer got out of the Hot Cell). The persons radiation badge was sent in for a reading on August 6, 2003. Whole Body dose to the person from the badge was 157 millirems. Hand exposure calculation is still being investigated but the exposure to his hand ranges from 20 Rem to 700 Rems. Two weeks after the incident the person hand does not show any clinical indication to exposure to a high dose of radiation (no reddening). This event is under investigation.

The size of the iridium-192 wafer is approx. 0.1 inches in diameter, 0.01 inches in thickness with a total activity of 7.6 curies.

NRC Region 4 was notified of this event by Louisiana Radiation Protection Division.

Called did not have the licensee's license number or the State of Louisiana event number.

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General Information or Other Event Number: 40088
Rep Org: ILLINOIS DEPT OF NUCLEAR SAFETY
Licensee: RUSH NORTH MEDICAL CENTER
Region: 3
City: SKOKIE State: IL
County:
License #: IL-01578-01
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/19/2003
Notification Time: 18:44 [EST]
Event Date: 08/18/2003
Event Time: 11:00 [CDT]
Last Update Date: 08/19/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS KOZAK (R3)
E. WILLIAM BRACH (NMSS)

Event Text

PATIENT EXCEEDED PRESCRIBED DOSE.

A patient was undergoing an intravascular brachytherapy procedure using a Novoste 40 mm. Sr-90 system with a prescribed dose of 23 gray. Due to difficulties retracting the source train to its shielded position, the exposure time was 5.09 minutes (one minute longer than the planned 4.09 minutes). Preliminary estimates indicate that the delivered dose exceeded the prescribed dose by approximately 25 percent. Novoste was notified and a Novoste representative went to the medical facility to investigate. The Novoste system will be sent to Novoste in Georgia for analysis. The licensee continues to investigate and refine the dose calculations and will submit the required written report as soon as possible.

Illinois assigned event number: IL030064.

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General Information or Other Event Number: 40090
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: STL SEATTLE
Region: 4
City: TACOMA State: WA
County:
License #: R-0158
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2003
Notification Time: 12:05 [EST]
Event Date: 07/31/2003
Event Time: 12:00 [PDT]
Last Update Date: 08/20/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
TOM ESSIG (NMSS)

Event Text

MISSING FOIL SOURCE

"STATUS: new & closed

"Licensee: STL Seattle (STL)
"City and state: Tacoma, Washington
"License number: R-0158 (a General Licensee)
"Type of license: N/A - receipt of generally licensed gas chromatography cells from manufacturer or equivalent.

"Date of event: July 31, 2003 - date of licensee notification letter to DOH (date of actual event is unknown).

"Location of Event: Severn Trent Laboratories Inc., dba STL Seattle.
"5755 8th Street East, Tacoma, Washington 98424

"ABSTRACT: STL Seattle sent DOH notification dated July 31, 2003 of a lost GC detector cell, foil source. The letter was received August 4, 2003. In the letter STL Seattle reported a missing 555 megabecquerel (15 millicurie), Nickel 63, foil source, Serial Number A5447 that was assumed to have been in a Varian ECD cell. The cell had been sent to a DOH specific licensee that is licensed for GC repair work. A technician at the GC-repair licensee discovered the missing foil source. The GC-repair licensee notified STL of the missing source. STL performed a thorough search of the lab but could not find the missing foil.

"DOH contacted both STL and our GC-repair licensee after receipt of the letter. The Operations Manager at STL, [DELETED], who was the event reporter, could not initially be contacted. DOH did reach him for discussion two weeks later. DOH contacted our GC-repair licensee shortly after receipt of the notification. The GC-repair RSO mentioned that the ECD cell received from STL was an older cell that looked like it had never been used. The cell showed severe corrosion, which indicated that this cell had been in storage for a long time. The cell came in a box and was broken. The GC-repair RSO stated that the foil in these cells could fall out or removed easily, if the cell had been opened or if the ceramic portion of the cell was broken. This cell had a broken connector when received by the GC-repair licensee. The GE-repair RSO said that the cells can become loose in the Varian device and can break at the ceramic connector, which may have happened when someone attempted to remove it from the GC device. A tool is needed to remove the source from a cell in normal condition. The GC-repair RSO said that the cell didn't look like it had been tampered with in a purposeful manner. The GC-Repair RSO contacted [DELETED] when it was determined that the source was missing. They discussed the event in detail and [DELETED] was reminded, per the terms of GL device receipt requirements that they were not allowed to perform activities involving removal of sources. [DELETED] had recently taken over the program at STL Seattle. [DELETED] was further reminded of his record keeping responsibilities and the other limitations of receipt of GL GC detector cells.

"When DOH talked with [DELETED] he confirmed that he had spoken with the GC-repair RSO and had been made aware that the source was missing after the cell had been received. The cell had not been used for a few years. A person, no longer employed by STL Seattle, was thought to have worked on the cell. He had not worked for the company in over a year. [DELETED] thought that any work done on the cell would have been a year or two previous to this individual leaving. He did not know if this work had included removing the foil from the cell. [DELETED] stated that when he had been informed of the missing radioactive source, staff at STL performed a search of the lab. He stated that they have a Geiger counter, but were not able to find the source. DOH re-informed [DELETED] that they are not licensed to perform source work on cells, [DELETED] agreed. He stated that this won't happen again . [DELETED] stated that STL management oversight of lab activities had recently been improved.

"DOH issued an item of noncompliance to STL that was categorized as a Violation, for their failure to keep licensed radioactive material secure. DOH did not perform an on site investigation and no media attention was noted.

"What is the notification or reporting criteria involved? 10 CFR 20.2201(a)(1)(ii) 30 days.

"Activity and Isotope(s) involved: 555 megabecquerel (15 millicurie), Nickel 63.
"Overexposures? Likely N/A but was unable to be determined.
"This is a lost source: Manufacturer Varian Associates Inc., Model- 02-001972-0, Serial Number 5447.

"Disposition/recovery? STL was several times reminded of their responsibilities and limitations.

"Leak test? N/A
"Vehicle: N/A

"Release of activity? Loss of 555 megabecquerel (15 millicurie), Nickel 63, foil source.

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Exposure (intended/actual); consequences: exposure, if any, is unknown; consequences are unlikely.
"Was patient or responsible relative notified: N/A
"Was written report provided? Yes
"Was referring physician notified? N/A

"Consultant used? No"

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Power Reactor Event Number: 40095
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: RICH LAURA
Notification Date: 08/22/2003
Notification Time: 04:05 [EST]
Event Date: 08/22/2003
Event Time: 02:59 [EDT]
Last Update Date: 08/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JOHN KINNEMAN (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

TURBINE TRIP CAUSES AUTOMATIC REACTOR SCRAM AT OYSTER CREEK

The licensee reported that an automatic reactor scram occurred at 0259 due to a turbine generator trip from a hi-hi moisture separator water level. One control rod indicated position 02; however, the remainder of the control rods indicated full in. All other systems and components functioned as designed. The licensee is cooling the plant down to cold shutdown.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 40096
Rep Org: U.S. AIR FORCE
Licensee: U.S. AIR FORCE
Region: 2
City: TAMPA State: FL
County: HILLSBOROUGH
License #: 4223539-01AF
Agreement: Y
Docket: 03000318
NRC Notified By: DAVID PUGH
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 08/22/2003
Notification Time: 10:33 [EST]
Event Date: 08/07/2003
Event Time: 08:30 [EDT]
Last Update Date: 08/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MIKE ERNSTES (R2)
BLAIR SPITZBERG (R4)
DOUG BROADDUS (NMSS)

Event Text

SIX CHEMICAL AGENT MONITORS CONTAINING NI-63 REPORTED MISSING

During a recent inventory check at MacDill Air Force Base in Florida, six Chemical Agent Monitors (15 milliCuries each) containing Ni-63 were found to be missing. In February 2002, these devices were scheduled to be shipped to Kimhae, Korea. The monitors were submitted to the shipping department at that time. During an inventory check in May 2003, it was determined that these sources could not be found in either Korea or MacDill AFB. The U.S. Air Force is unsure whether the materials were lost after the shipment commenced or whether the materials were even shipped at all.

Searches at a MacDill AFB warehouse are scheduled for next week in an attempt to locate these devices.

The licensee notified NRC Region IV.

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Power Reactor Event Number: 40098
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: JEFF GARDINER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/22/2003
Notification Time: 13:23 [EST]
Event Date: 08/22/2003
Event Time: 02:34 [PDT]
Last Update Date: 08/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BLAIR SPITZBERG (R4)

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

Event Text

REACTOR CORE ISOLATION COOLING SYSTEM INOPERABLE

"This ENS notification is made to report that on August 22, 2003 at 02:34 PDT Reactor Core Isolation Cooling was isolated due to the discovery of a degraded pilot cell in the Division 1 250 VDC battery. Operators isolated the steam inlet valve to the RCIC turbine (RCIC-V-1) because the minimum flow bypass valve, RCIC-V-19, (a primary containment isolation valve) was declared inoperable and isolated to comply with the plant TS. Isolation of RCIC-V-1 effectively removed RCIC from service since it is the containment isolation valve.

"The event is considered reportable to the NRC under 10 CFR 50.72(b)(3)(v)(D) based on guidance contained in NUREG 1022, "Event Reporting Guidelines," and NRC Regulatory Issue Summary (RIS) 2001-14, "Position on Reportability Requirements for Reactor Core Isolation Cooling System Failure." A follow-up LER will be issued under 10 CFR 50.73(a)(2)(v)(D)."

The licensee will be notifying the NRC Resident Inspector.

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