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Event Notification Report for August 26, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2003 - 08/26/2003

** EVENT NUMBERS **


40090 40093 40099 40100 40101

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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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General Information or Other Event Number: 40093
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA TESTING LABS
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-10577-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/21/2003
Notification Time: 11:11 [EST]
Event Date: 08/09/2003
Event Time: [CDT]
Last Update Date: 08/21/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was reported to the Operations Center by Oklahoma Department of Environmental Quality:

"On August 19, 2003, the licensee RSO [Radiation Safety Officer] conducted a biweekly inventory of his gauges and discovered that one of them was missing. Upon investigation he discovered that the gauge, a Troxler 3411B, S/N 6322, was last used on August 8, 2003. The next day, the technician who used the gauge took the gauge out to his truck and, preparing to go to a jobsite, loaded the gauge into the toolbox bolted to [the] bed of the truck. He left the tool box unlocked while he helped another worker unload, then discovered the gauge was missing when he returned. He had since decided not to work that day. He did not report this to anyone because he assumed that the other worker had taken the gauge out on the job with him. The licensee has contacted the police and has prepared a press release offering a reward for return of the gauge. According to the licensee, the gauge contained 281.2 Mega Becquerels of activity [7.6 milliCuries] as of 5/15/83. The gauge was not in its transport case and the gauge plunger was apparently unlocked when stolen."

The Troxler contained an Am: Be source, S/N CAA-2493 and a CS-137 source, S/N CC-3452. Oklahoma Department of Environmental Quality is considering issuing a press release to its border states. The licensee will be offering a reward for the return of the gauge.

The Oklahoma Department of Environmental Quality has notified NRC Region 4 (Linda McLean).

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Other Nuclear Material Event Number: 40099
Rep Org: MALLINCKRODT INC
Licensee: MALLINCKRODT INC
Region: 3
City: Bridgeton State: MO
County:
License #: 2404206
Agreement: N
Docket:
NRC Notified By: REX AYERS
HQ OPS Officer: RICH LAURA
Notification Date: 08/25/2003
Notification Time: 08:18 [EST]
Event Date: 08/25/2003
Event Time: 06:30 [CDT]
Last Update Date: 08/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
THOMAS KOZAK (R3)
TOM ESSIG (NMSS)

Event Text

LOST NUCLEAR MATERIAL DURING DELIVERY

The licensee reported five I-123 capsules that were lost when they fell out of the back doors of a panel van during shipment by Associates Couriers International (ACI). This occurred in Bridgeton, MO at Lindberg Boulevard at Blake. The I-123 capsules each contained 600 microcuries during precalibration and were calibrated for noon at 8/26/03 for 100 microcuries. The capsules are used for diagnostic thyroid disorders. The licensee indicated there was no significant health aspect of this event due to the short half life (i.e., 13 hours) of I-123 and the relatively low activity level.

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Power Reactor Event Number: 40100
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN RODEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/25/2003
Notification Time: 13:03 [EST]
Event Date: 08/25/2003
Event Time: 09:45 [EDT]
Last Update Date: 08/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MIKE ERNSTES (R2)

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

Event Text

AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO A SUDDEN PRESSURE RELAY SIGNAL FROM MAIN TRANSFORMER BANK "1C"


"On August 25, 2003, Watts Bar (WBN) Unit 1 was operating at 100 percent power when there was an operation of a "Sudden Pressure Relay" for Main Transformer Bank 1C. The actuation of the relay resulted in a turbine trip and a subsequent reactor trip at approximately 0945 EDT. The cause of the relay actuation is under investigation at this time. All control rods inserted as required and the safety systems actuated as designed including the motor and turbine driven pumps for the Auxiliary Feedwater (AFW) System. AFW pump 1B-B was inoperable at the time of the trip due to work on an area cooler. However, the pump was available for service and started as required. Unit 1 is currently stable in Mode 3 and will remain in this mode until the completion of the investigation into the cause of the trip."

At the time of the Sudden Pressure Relay for Main Transformer Bank 1C, an oil sample was being taken of the Transformer. Fire Brigade was sent but there was no fire and no explosion to the Transformer. The electrical grid is stable, and Emergency Core Cooling systems and the Emergency Diesel Generators are fully operable if needed. At this time only the 1B-B Motor Driven Auxiliary Feedwater pump is still operating.

The NRC Resident Inspector was notified of this event by the licensee.

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Hospital Event Number: 40101
Rep Org: COMMUNITY HOSPITAL OF ANDERSON
Licensee: COMMUNITY HOSPITAL OF ANDERSON
Region: 3
City: ANDERSON State: IN
County: MADISON
License #: 13-10205-01
Agreement: N
Docket:
NRC Notified By: JOE RASTETTER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/25/2003
Notification Time: 16:20 [EST]
Event Date: 08/08/2003
Event Time: 08:30 [CST]
Last Update Date: 08/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
CHRIS MILLER (R3)
TOM ESSIG (NMSS)

Event Text

FEMALE NOT KNOWING THAT SHE WAS PREGNANT WAS ADMINISTERED IODINE-131

A female doctor not knowing that she was pregnant was administered 29.8 millicuries of iodine-131 for a hyper thyroid condition. She was asked if she was pregnant and she stated that she was not pregnant and she chose not to take a pregnancy test before being administered the iodine-131.

Today, Community Hospital of Anderson, IN was notified that the female patient was 15 weeks pregnant when she received the 29.8 millicuries of iodine-131. The patient has been informed by her doctor. Calculated total body dose to the fetus is 11.69 rads and the calculated dose to the fetal thyroid is 27,840 rads.

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