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Event Notification Report for November 24, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/23/2004 - 11/24/2004

** EVENT NUMBERS **


41206 41208 41210 41216 41217 41219 41220

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General Information or Other Event Number: 41206
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: NC ENVIRONMENTAL HEALTH SERVICES
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0456-17
Agreement: Y
Docket:
NRC Notified By: LARRY MICHAELS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/18/2004
Notification Time: 18:15 [ET]
Event Date: 11/18/2004
Event Time: 15:52 [EST]
Last Update Date: 11/18/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
DANIEL GILLEN (NMSS)

Event Text

AGREEMENT STATE REPORT - LEAD PAINT ANALYZER MISSING AND THEN RECOVERED

An employee of the North Carolina Department of Environmental Health [NCDEH], Environmental Health Services reported to his supervisor on 11/18/04 that his Niton XRF lead paint analyzer device was missing or stolen from the trunk of his car. After retracing his travels going back to the last time he used the device on 11/09/04, it was discovered that he had inadvertently left the device in the parking lot of the Union County Health Department where he had earlier performed a lead investigation. An Union County Health Department employee had found the locked device on 11/09/04 in the parking lot and secured it in their building.

The device will be retrieved by a NCDEH employee on 11/19/04. The device contains 14 milliCuries of Cadmium-109. The device serial number is U1399. The sealed source serial number is NR4649.

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General Information or Other Event Number: 41208
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: H&H X-RAY SERVICES INCORPORATED
Region: 1
City: EAST POINT State: KY
County:
License #: 201-34205
Agreement: Y
Docket:
NRC Notified By: MATT MacKINLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/19/2004
Notification Time: 11:37 [ET]
Event Date: 11/19/2004
Event Time: 10:03 [CST]
Last Update Date: 11/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)
JIM WHITNEY (TAS)
RICHARD WESSMAN (IRD)
JANNIE EVERETTE (DHS)
THOMAS YATES (DOE)
EUGENE LEE (EPA)
SUZANNE RIGBY (USDA)
JOHN ALDAHONDO (HHS)
JIM DUNKER (FEMA)

Event Text

AGREEMENT STATE REPORT OF A STOLEN RADIOGRAPHY CAMERA

The State of Kentucky Radiation Control Branch reported a stolen radiography camera AEA Model 880D with a 40 Curie Ir-192 source (Camera Serial#D1121; Source Model 424-9; Source Serial #16663-B). The Camera is owned and licensed to H&H X-Ray Services that has an office located in East Point, Kentucky. The camera was located in the radiographer's truck which was in the town of Corbin, Kentucky in preparation for a job. The radiographer lent the truck to the assistant radiographer on Wednesday night (11/17/04). The assistant radiographer did not return with the truck all day Thursday. Without any contact with the assistant radiographer since Wednesday night, the radiographer reported the truck and camera stolen this morning (11/19/04). The local police believe they saw the truck parked at a home in the Corbin area. The camera was locked in the truck but the assistant radiographer has a key to the camera so the current status is unknown.

The State has notified NRC Region 1 (Sheri Minnick). In addition to the other Federal agencies notified above, contacted the National Response Center (Ms. Jones).


* * * UPDATE 1420 EST ON 11/21/04 FROM CLYDE SLAUGHTER (RSO - H&H X-RAY SERVICES, INC.) TO S.SANDIN * * *

The abandoned vehicle containing the radiography camera was recovered in Wise, VA after the assistant radiographer contacted another company employee providing information as to its location. Mr. Slaughter inspected the camera and found no indication of tampering. The camera is enroute to the East Point, KY office and will later be returned to the West Monroe, LA main facility. The licensee informed the KY Department of Homeland Security (Lt. Joe England).

Notified R1DO(Dimitriadas), NMSS(Gillen), IRD(Wessman), TAS Duty Officer(Whitney), NSIR(Weber, Zimmerman), Chairman Diaz(Fragoyannis), EDO(Hsia), DHS(Evans), DOE(Smith), EPA(Baumgartner), USDA(Comeau), HHS(Miller), FEMA(Caldwell) and FBI.

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General Information or Other Event Number: 41210
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI
Region: 1
City:  State: MS
County:
License #: MS-232-02
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/19/2004
Notification Time: 12:36 [ET]
Event Date: 11/18/2004
Event Time: [CST]
Last Update Date: 11/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A THERAPY MISADMINISTRATION

The following information was provided via email from the Radioactive Materials Branch Director, Division of Radiological Health, MS State Dept. of Health:

"On November 18, 2004, licensee's RSO notified Division of Radiological Health/MS State Dept. of Health, of a Iodine-125 therapy misadministration. The prescribed treatment was for 145 gray to the prostate gland; however, due to an error concerning the coordinates, the treatment area was partially missed and resulted in a greater than 10 gray treatment to the rectum. The isotope was Iodine -125, 88 seeds with average activity of .300 millicuries, total activity of 26.8 millicuries. The patient was notified of the error and agreed to have the treatment performed again with no problems occurring. The RSO notified DRH after discussing the error with the authorized user and agreeing on corrective actions to prevent reoccurrence. At the present time, this is all the information we have received. I will update as soon as possible."

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Power Reactor Event Number: 41216
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: DAN JORDHEIM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/23/2004
Notification Time: 03:01 [ET]
Event Date: 11/22/2004
Event Time: 17:30 [PST]
Last Update Date: 11/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEFFERY CLARK (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

INADVERTENT ISOLATION OF THE REACTOR CORE ISOLATION COOLING SYSTEM

"This ENS notification is made to report that on November 22, 2004 at 17:30 PST the Reactor Core Isolation Cooling (RCIC) system was rendered inoperable when its inboard steam supply containment isolation valve inadvertently closed during the performance of a routine surveillance procedure. The surveillance procedure was stopped and plant operators entered the appropriate Technical Specification Action Statements. The RCIC system was restored to its normal standby lineup and declared operable two hours and three minutes after the isolation.

"NRC guidance in NUREG 1022 (Rev. 2), 'Event Reporting Guidelines,' and NRC Regulatory Issue Summary (RIS) 2001-14, 'Position on Reportability Requirements for Reactor Core Isolation Cooling System Failure,' indicates that RCIC failures are not reportable unless the RCIC system is specifically credited in the plant's Final Safety Analysis Report for mitigating the consequences of a Control Rod Drop Accident (CRDA). Columbia Generating Station has determined that the current licensing basis and docketed correspondence is not clear regarding RCIC credit for CRDA mitigation. Proposed FSAR changes were recently submitted by Energy Northwest to the NRC that would clarify that RCIC is not credited for CRDA mitigation. However, the NRC staff has not yet approved these proposed changes. Therefore, Columbia Generating Station has decided to conservatively report this event under 10 CFR 50.72(b)(3)(v)(D). A follow-up LER will be issued under 10 CFR 50.73(a)(2)(v)(D)."

The licensed has notified the NRC Resident Inspector.

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Power Reactor Event Number: 41217
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: CHUCK OLSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/23/2004
Notification Time: 12:07 [ET]
Event Date: 11/23/2004
Event Time: 09:45 [CST]
Last Update Date: 11/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JEFFERY CLARK (R4)

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

LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO FAILURE OF SPDS

The Safety Parameter Display System (SPDS) is not transmitting data to the Technical Support Center. The cause of the failure is unknown at the present time. The Computer Support Group is attempting to restore transmission capability.

The licensee will inform the State of Arkansas as a courtesy and has informed the NRC Resident Inspector.

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Power Reactor Event Number: 41219
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DONALD C. SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/23/2004
Notification Time: 14:20 [ET]
Event Date: 11/23/2004
Event Time: 10:02 [CST]
Last Update Date: 11/23/2004
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):
CHARLIE PAYNE (R2)

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

Event Text

AUTOMATIC REACTOR SCRAM DUE TO TURBINE TRIP

"At 1002 on 11/23/2004 with Unit 3 @ 100% power, a full reactor scram signal (RPS) was received due to a Turbine Trip. Unit 2 was also @ 100% power and was unaffected by the event. Reactor water level lowered to approximately -30 [inches] as expected and was recovered with normal feed water flow. All expected PCIS ISOLATIONS, Group 2 (RHR S/D Cooling), Group 3 (RWCU), Group 6 (Ventilation) & Group 8 (TIP) were received along with the auto start of CREVS and the three SBGT Trains. One PCIS Scram Discharge Volume Drain (85-37F) failed to close but the flowpath did isolate. The Unit remains Shutdown and an investigation is underway to determine the cause of the Turbine Trip and resulting Reactor Scram.

"This event is reportable as a 4-hour & 8-hour Non-Emergency Notification along with a 60 day written Report in accordance with 10CFR50.72(b)(2)(iv)(B), 10CFR50.72(b)(3)(iv)(A) & 10CFR50.73(a)(2)(iv)(A) as 'Any event or condition that results in valid actuation of RPS & PCIS . . . "

The licensee informed the NRC Resident Inspector.

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Other Nuclear Material Event Number: 41220
Rep Org: XENOGEN BIOSCIENCES
Licensee: XENOGEN BIOSCIENCES
Region: 1
City: CRANBURY State: NJ
County:
License #: 29-30350-01
Agreement: N
Docket:
NRC Notified By: JOSEPH D'IPPOLITO (RSO)
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/23/2004
Notification Time: 15:56 [ET]
Event Date: 11/23/2004
Event Time: [EST]
Last Update Date: 11/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANTHONY DIMITRIADIS (R1)
DANIEL GILLEN (NMSS)

Event Text

REPORT OF THEFT OR LOSS OF LICENSED MATERIAL

The following information is excerpted from an email submitted by the licensee describing in detail the circumstances and conclusions concerning the missing rad material:
.
.
II. DESCRIPTION OF LOSS OF LICENSED MATERIAL

Radioisotope: Phosphorous-32

Chemical Form: Deoxycytidine 5'-Triphosphate [alpha-32P]

Physical Form: Aqueous Solution

Amount: Xenogen appears to be missing material from 2 separate vials as outlined below:

1. 150 ÁCi (15 Ál of material at 10 ÁCi/Ál) from a vial sent from GE HealthCare (formerly Amersham Biosciences) to Xenogen Biosciences on November 4, 2004. This vial was received at Xenogen Biosciences on Friday, November 5, 2004. The supplier's catalog number for the material is AA0005-1 mCi and the lot number for the material received is AC0445. The quantity requested was 1000 ÁCi (37 MBq) under Purchase Order No. 36348. This vial was designated internally within Xenogen Biosciences as vial No. 491.

2. 100 ÁCi (10 Ál of material at 10 ÁCi/Ál) from a vial sent from GE HealthCare (formerly Amersham Biosciences) to Xenogen Biosciences on November 11, 2004. This vial was received at Xenogen Biosciences on Friday, November 12, 2004. The supplier's catalog number for the material is AA0005-1 mCi and the lot number for the material received is AC0446. The quantity requested was 1000 ÁCi (37 MBq) under Purchase Order No. 36348. This vial was designated internally within Xenogen Biosciences as vial No. 492.

Activity: 3000 Ci (111TBq)/mmole
.
.
V. PROBABLE DISPOSITION OF THE LICENSED MATERIAL INVOLVED

As of November 23, 2004, our current hypothesis is that the volume discrepancies (loss) of material in vials 491 and 492 were due to two conditions. First, the material appears to be evaporating in the vials. Second, any evaporated moisture that condensed on the lid of the vial is not being concentrated through centrifugation prior to removal of material by research associates. Evidence that supports this conclusion is listed below:

1. We have found that when this material is separated into 5 Ál aliquots, placed in screw cap tubes with o-rings, and stored at 4░C for several days, the liquid evaporates and a dried and visible red pellet forms (concentrated dye). In addition, the volume of the pellet appears to be less than 1 Ál (visual inspection). However, when the tube is centrifuged after storage, the full volume reappears in the bottom of the tube and can be confirmed by using a pipetting device. The experiment mentioned above was performed using one vial of 1000 ÁCi of Redivue[TM] [alpha-32] deoxycytidine 5'-Triphosphate (dCTP) from GE Healthcare that was received at Xenogen Biosciences on Friday, November 19, 2004. This vial was designated internally as vial 493. Volume discrepancies were first noticed on Monday, November 22, 2004.

2. The occurrence of volume discrepancies in vial 491 and 492, along with a similar incident involving vial 486, which was reported to the U.S NRC on October 13, 2004, coincides with the recent switch (July 2004) by Xenogen from [alpha -32P] dCTP supplied by PE Life Sciences to material supplied by GE Healthcare. Unlike the material supplied by PE Life Sciences, the material from GE Healthcare is not kept frozen during transit and storage, but rather at 4 degrees Celsius. Hence, the material is subject to evaporation and condensation at the top of the vial.

3. Upon arrival, we have found that these vials need to be centrifuged in order to collect the material at the bottom of the vial. If the vials are not centrifuged, we are unable to verify that the volume sent is correct. Because it was determined that the volume of both vials was correct prior to any removal of material, we have eliminated the possibility that an incorrect volume was shipped to our facility by GE Healthcare.

4. During the November 18 meeting with the researchers, one employee notified [the RSO] with the EHS department, that he failed to make a log entry for which he removed 50 ÁCi from vial 492. Other than this particular instance, there is no further evidence that a research associate or scientist removed material from vial 491 and 492 and failed to record this removal in the Isotope Inventory Log. Importantly, this discrepancy has been accounted for in the total amount of material missing from vial 492 as detailed in this report.

5. There appears to be no evidence that the volume discrepancies are due to inaccurate pipetting devices. Last month, all three P-20 pipetman that are used by users to remove radioactive material from P-32 vials were checked for accuracy by [the RSO]. Importantly, this evidence does not rule out the possibility a user had the pipettor accidentally set to a higher volume prior to removal or that the user did not use the pipetting device correctly.

6. There is no evidence that an employee or visitor intentionally stole licensed material from vial 491 and 492. Because of the number of employees (approximately 65) at the facility, employees, in general, know one another and work in an environment where they are likely to observe any unusual behavior. In addition, there are relatively few visitors come to the facility. Furthermore, the refrigerator that is used to store the vials of P-32 material is locked with a combination lock. Only users of radioactive material have access to this combination. Moreover, the room (Radioisotope Laboratory) is locked by a punch combination lock. Only users of radioactive material have access to this combination. All employees, whether they are a user or nonuser of radioactive material, receive training that explicitly informs them that it is a crime to remove radioactive material from the facility.

7. There is no evidence that a research associate or scientist recorded an inaccurate amount of material withdrawn from vial 491 or 492 because all employees who used vial 491 and 492 verified, through interviews conducted by [the RSO], that the amount of material indicated on the Isotope Inventory Log is the amount that was intended to be used.

8. There is no evidence that the loss was due to spillage because:

a. There were no reports of a spillage by anyone who worked with the material;

b. The amount of material presumed missing would have easily been detected through our weekly monitoring program by swipe analysis using a Liquid Scintillation Counter. Furthermore, 100 ÁCi would have easily been detected from monitoring conducted with a GM survey meter by other employees who used the Radioisotope Laboratory over the time in question.

VI. EXPOSURE OF INDIVIDUALS TO RADIATION

Following an intensive survey of the laboratory area and other sections of the building, there is no indication of radiation exposure to individuals due to the unaccounted material.

VII. ACTIONS TAKEN TO RECOVER MATERIAL

At this time, our current hypothesis is that the volume discrepancies with vials 491 and 492 are due to two conditions: 1) evaporation of material within the vial and 2) lack of centrifugation of vials prior to removal of material. Hence, it is not anticipated that the material will be found. More importantly, if it is true that the lost volume was due to evaporation, then radioactivity may not be actually missing. Again, the Radiation Safety Officer does not believe that any employee, or non-employee, unlawfully removed licensed material from vial 491 and 492. . . . .

VIII. PROCEDURES OR MEASURES THAT WILL BE ADOPTED TO ENSURE AGAINST A RECURRENCE OF THE LOSS OR THEFT OF LICENSED MATERIAL.

The company has implemented the following Standard Operating Procedures immediately to insure that 1) the material is not being removed by a user without correct documentation; 2) the material is not being taken or removed for purposes other than those purposes outlined in Materials License 29-30350-01; and 3) the proper amount of material is being used in each experiment.

1. Every commercial vial of P-32 entering the facility and which will be used for DNA/RNA labeling experiments will be separated into 5 Ál aliquots (or the volume typically used for one reaction) at the time the package is surveyed and its contents verified. The aliquots will be consecutively numbered for tracking purposes. Aliquots will be stored in Eppendorf tubes and these tubes will be stored in shielded centrifuge test tube racks. The rack will be made of acrylic and will be a solid-block design with drilled wells. One rack will hold aliquots from only one source vial (e.g. Shielded rack reads "vial no. 500" . Eppendorf tubes within read 1-20).

2. A user should use the lowest consecutive numbered aliquot when removing an aliquot from the rack for use.

3. [The RSO] (or his designee) will check daily the supply of P-32 aliquots and determine if there are any inconsistencies with the number of aliquots versus the number used by researchers based on the Isotope Inventory Log (or equivalent).

In addition, all pipetting devices used during the handling or dispensing of P-32 will be calibrated immediately by a commercial vendor, unless recently calibrated in the last 2 months. As mentioned earlier, [the RSO and another individual] met with all users of P-32 at the Cranbury Facility on November 18, 2004 to make them aware of the problem, to review pipetting techniques, and to train them on the new SOPs.

HOO Note: See similar Event Report #41126.

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