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Event Notification Report for September 12, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/11/2003 - 09/12/2003

** EVENT NUMBERS **


40141 40147 40148 40150 40151

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General Information or Other Event Number: 40141
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NORTHRIDGE HOSPITAL
Region: 4
City: VAN NUYS State: CA
County:
License #: 0041
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 09/08/2003
Notification Time: 19:01 [EST]
Event Date: 09/08/2003
Event Time: 09:30 [PDT]
Last Update Date: 09/08/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
JANET SCHLUETER (NMSS)

Event Text

AGREEMENT STATE REPORT - IRIDIUM 192 SOURCE FAILED TO RETRACT

The following was received via fax from the California Radiation Control office:

"At about 9:30 a.m. on 09-08-03, an Ir-192 source (4.6 Ci [Curie]) failed to retract following a patient treatment. The source became stuck in the transfer tube. The physicist started his stopwatch, entered the room and attempted to manually retract the source. Manual retract failed. The physicist called the physician, who was waiting outside the room. The physician entered the room and disconnected the apparatus from the patient and dropped the transfer tube into a lead pig. The physicist and physician moved the patient out of the room. The physicist stopped the watch and it showed that 2 minutes had elapsed. The physicist surveyed the patient and obtained no measurement above background. The physicist re-entered the room and performed a radiation survey, and found the hot spot along the transfer tube to be in the pig. The pig measured 10 mR [millirem] /hr at 3 feet. The room was locked and posted until arrival of the manufacturer's representative, who also was unable to make the source retract. The manufacturer's representative placed the transfer tube into a shipping container and shipped it back to the manufacturer for further investigation. Doses to the patient, physicist and physician were estimated as follows: patient skin dose (10cm from source for 2 minutes) = 9 rem; physicist for 2 minutes = 45 mrem [millirem]; physician 125 mrem [millirem] whole body and 15 rem extremity."

The device used was a Nucleotron MicroSelectron HDR [High Dose Rate] model number 31324 (Serial Number D36A4476).

The malfunction of the device is under investigation.

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Power Reactor Event Number: 40147
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DON ROLAND
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/11/2003
Notification Time: 02:40 [EST]
Event Date: 09/11/2003
Event Time: 00:40 [EDT]
Last Update Date: 09/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MOHAMED SHANBAKY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 63 Power Operation

Event Text

OFFSITE NOTIFICATION MADE TO PENNSYLVANIA EMERGENCY MANAGEMENT AGENCY (PEMA)

"At 2314 EDT on 9/10/03 a fire was reported at the Unit 1B Reactor Feed Pump. The Fire Brigade was activated and the fire was extinguished at 2322 (8 minutes after identification). To support removal of the feed pump from service reactor power was reduced to 63%. Due to notifying the Pennsylvania Emergency Management Agency (PEMA) and other outside agencies, this event is being reported under 10CFR50.72(b)(2)(xi)."

The NRC Resident Inspector was notified by the Licensee.

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Other Nuclear Material Event Number: 40148
Rep Org: HUNTINGTON TESTING CO.
Licensee: HUNTINGTON TESTING CO.
Region: 2
City: KENOVA State: WV
County:
License #: 47-23076-01
Agreement: N
Docket:
NRC Notified By: PAUL YOEMAN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/11/2003
Notification Time: 12:40 [EST]
Event Date: 09/10/2003
Event Time: 11:45 [EDT]
Last Update Date: 09/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROBERT HAAG (R2)
LINDA HOWELL (R4)
TOM ESSIG (NMSS)

Event Text

RADIOGRAPHIC EXPOSURE DEVICE FAILURE

On 9/10/03 at approximately 12:45 CDT, the slide bar associated with the posi-lock interlock device on an AEA Technology Model 660B (S/N B1215) radiography camera became stuck such that the source could not be repositioned following retrieval. The camera was being used at a Steel Forgings facility in Shreveport, LA. The source (40 Curie Ir-192) was in the secured position within the camera at the time. No personnel exposures occurred. The slide bar was subsequently freed up, however a replacement control device has been sent to the job site.

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Other Nuclear Material Event Number: 40150
Rep Org: U.S. INSPECTION SERVICES
Licensee: U.S. INSPECTION SERVICES
Region: 2
City: CHARLESTON State: WV
County:
License #: 34-06943-02
Agreement: N
Docket:
NRC Notified By: DAMON LAMB
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/11/2003
Notification Time: 16:46 [EST]
Event Date: 09/09/2003
Event Time: 19:30 [EDT]
Last Update Date: 09/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
ROBERT HAAG (R2)
MONTE PHILLIPS (R3)
PATRICIA HOLAHAN (NMSS)
JOHN PELCHAT (R2)

Event Text

PERSONNEL OVEREXPOSURE

The RSO reported that on 9/9/03 an employee radiographer received a radiation exposure of 14.15 Rem whole body and 13.445 Rem shallow dose (by film badge data received 9/11/03) during pipe weld radiography for a piping fabricator's job site in Charleston, WV. A second employee received a dose of 627 millirem whole body and 613 millirem shallow dose (by film badge). No health-related symptoms have been noted by either employee.

Following a radiography shot of a pipe weld, and after the source was thought to have been retracted, the equipment was being setup for a shot of the next weld. When the source was to be exposed for the second shot, it was discovered that the source had actually been exposed (probably fully) during the estimated 7-minute setup time. Both employees were wearing dosimeters which were found off scale and were wearing rad alarm devices set at 500 millirem/hr which they stated did not alarm. Additionally, the employees stated that a radiation survey was performed during the setup with no excessive radiation levels detected. The local RSO checked the survey meter and the radiography equipment and found nothing wrong. The radiography camera is an AEA Sentinal Model 660B (20.6 Curies Ir-192).

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Fuel Cycle Facility Event Number: 40151
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 3
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: S. SKAGGS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/12/2003
Notification Time: 02:36 [EST]
Event Date: 09/11/2003
Event Time: 08:45 [CDT]
Last Update Date: 09/12/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
MONTE PHILLIPS (R3)
PATRICIA HOLAHAN (NMSS)

Event Text

DOUBLE CONTINGENCY WAS NOT MAINTAINED FOR NON-FISSILE NAMs.

NRC BULLENTIN 91-01 24 HOUR NOTIFICATION

At 0845 on 9/11/03, it was discovered that non-fissile negative air machines (NAMs) were not verified by two individuals to contain approved and properly installed filters, as specified in NCSA GEN-09, "Operation and Maintenance of Negative Air Machines". Procedure CP4-GP-BG2108, "Negative Air Machine and in-place HEPA System Internal Inspection and Filter Replacement", did not adequately flowdown requirements specified in NCSA GEN-09 was revised to make non-fissile portable negative air machines (NAMs) readily available for fissile use in emergency situations. Contrary to requirements specific in NCSA GEN-09, procedure CP4-GP-BG2108 did not include requirements for two individuals to perform independent verification that approved filters are selected and properly installed. This control prevents mass loadings of fissile material that are outside the scope of that analyzed in NCSE KY/S-249.

SAFETY SIGNIFICANCE OF EVENTS:

Double contingency was not maintained for non-fissile NAMs because the second verification was not performed. However, the non-fissile NAMs were not used for fissile material releases. The non-fissile NAMs have been subsequently verified to contain approved and properly installed filters.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR:

In order for a criticality to be possible, a non-fissile NAM would have to be used in a fissile material release and greater than a safe mass of uranium would have to accumulate within the NAM in a configuration favorable for criticality.

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

Double contingency for the accumulation of an unsafe fissile mass is maintained by implementing two controls on mass.

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

This system has a process limit of (xx) wt% U235.

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

The first leg of double contingency is based on one individual verifying and documenting that approved filters are selected and properly installed. This control prevents loadings of fissile material that are outside the scope of that analyzed in NCSE KY/S-249. This verification was performed, therefore, this control was maintained.

The second leg of double contingency is based on a different individual verifying and documenting that approved filters are selected and properly installed. This control prevents loadings of fissile material that are outside the scope of the analyzed in NCSE KY/S-249. Because this verification was not performed, this control was lost. No events have occurred to introduce fissile material into any non-fissile NAMs. Therefore, though the control was violated, the parameter was maintained.

Since double contingency is based on two controls on one parameter, and one control was violated, double contingency was not maintained.


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

1. Non-fissile Nams verified to contain the correct filters and installed in the correct orientation. Completed 9/11/2003.
2. Procedure CP4-GP-BG2108 placed on hold pending revision to include independent verification requirements specific in NCSA GEN-09. Completed 9/11/2003.


The NRC Senior Resident Inspector has been notified of this event.

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