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Event Notification Report for November 22, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2005 - 11/22/2005

** EVENT NUMBERS **


41938 42090 42147 42150 42159 42161 42162

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General Information or Other Event Number: 41938
Rep Org: NV DIV OF RAD HEALTH
Licensee: J A CESARE AND ASSOCIATES
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0295-01
Agreement: Y
Docket:
NRC Notified By: STAN MARSHAL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/22/2005
Notification Time: 16:01 [ET]
Event Date: 08/20/2005
Event Time: [PDT]
Last Update Date: 11/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
TOM ESSIG (NMSS)
DONNA-MARIE PEREZ (TAS)

Event Text

AGREEMENT STATE REPORT ON A STOLEN MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

The State of Nevada reported that a moisture density gauge (CPN Model MC-3, s/n M37037489 with a 50 millicurie Am-241:Be source and a 10 millicurie Cs-137 source) was stolen from a licensee technician's truck. The gauge was locked in the technician's truck at his home. The technician found that the lock had been cut and the gauge stolen sometime over the weekend. The licensee has reported the incident to the Las Vegas Metro Police Department.

Nevada State Report Number NV-05-007.

* * * UPDATE PROVIDED BY MATUS TO ROTTON AT 1737 EST ON 11/21/05 * * *

The State provided the following information via facsimile:

"The gauge was recovered on 11/18/05 from an impounded vehicle at Ewing Brothers Tow Service in Las Vegas, NV and released to the licensee."

Notified R4DO (Smith), NMSS EO (Holahan), and TAS (Danis via email)

This is less than the quantity of an IAEA Category 3 source.

Sources that are 'Less than IAEA Category 3 sources,' are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury.

For some of these sources, such as moisture density gauges or thickness gauges that are IAEA Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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General Information or Other Event Number: 42090
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GEORGIA PACIFIC
Region: 4
City: CROSSETT State: AR
County:
License #: ARK-321-BP-11
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2005
Notification Time: 15:56 [ET]
Event Date: 10/18/2005
Event Time: [CDT]
Last Update Date: 11/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
SCOTT MOORE (NMSS)
LANCE ENGLISH email (TAS)

Event Text

AGREEMENT STATE REPORT - MISSING PAPER THICKNESS GAUGE

On 10/18/05 while conducting leak checks of their equipment, the licensee discovered a NDC Model 104F Paper Thickness Gauge (80 millicuries Am-241 s/n 11480) missing. The device was not located in a search of the facility. The device was part of the production line. The licensee notified the Arkansas Department of Health at 1430 CDT on 10/28/05.

* * * UPDATE FROM MACK TO HUFFMAN ON 11/21/05 AT 12:37 EST * * *

On 10/31/05, authorities from the State of Arkansas performed a search of the licensee's facility but were still unable to locate the missing gauge. The State determined that the gauge had not been used in support of the production process at the facility for quite a while and had been retired in place on the production line by the licensee. The State also determined that the last inventory of the gauge had been in 2001. The licensee has provided the State with corrective actions related to this event. The State considers this gauge lost and is closing out this report.

The R4DO (Smith), NMSS( Karas), and TAS (Danis via e-mail) have been notified on this update.

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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General Information or Other Event Number: 42147
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PACIFIC ECOSOLUTIONS LLC(PECOS)
Region: 4
City: RICHLAND State: WA
County:
License #: WN-I0393-1
Agreement: Y
Docket:
NRC Notified By: MIKE ELSEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/16/2005
Notification Time: 23:33 [ET]
Event Date: 11/10/2005
Event Time: 17:00 [PST]
Last Update Date: 11/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

WASHINGTON AGREEMENT STATE REPORT - LEAKING SHIPMENT CONTAINER

"Licensee: Pacific EcoSolutions LLC (PEcoS) - Richland, Washington

"City and State: Richland, Washington
"PEcoS Radioactive Materials license Number: WN-I0393-1
"Type of License: Industrial- Radioactive Waste Processor

"Date and Time of Event: The licensee (PEcoS) notified the Department of Health on November 10, at approximately 5:00pm.

"Location of Event: The leaking container was found on a shipment that arrived at the PEcoS facility at 2025 Battelle Blvd. Richland, Washington

"Involved Persons: Pacific EcoSolutions LLC (PEcoS) - Richland, Washington, ADCO Services, Inc.-Tinley Park, Illinois

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"On Thursday November 10, 2005 the Department of Health was notified by the licensee that a shipment from ADCO Services, Inc. arrived at their facility. During offloading of the packages one drum on the shipment was found to be leaking liquid. The leak was not contained to the inside of the closed trailer. Evidence of the leak was also seen on the underside of the trailer's wood floor and undercarriage. The I beam of the trailer was visibly stained. There was no evidence that the container had tipped over.

"The shipping papers for this load indicated that the shipping date from ADCO was 29 October 2005 and that the drum contained approximately 21.0 millicuries of tritium. The physical and chemical form is listed as solid NETA Plates. The container was shipped as Radioactive Material - Limited Quantity. The generator of the waste was identified as Agouron Pharmaceuticals located in San Diego, California.

"The shipment arrived in Richland and was parked at a local hotel for approximately 5 days prior to arriving at the PEcoS facility. The department identified the location where the trailer was parked and have obtained samples of parking lot material and performed paper smear surveys. The licensee also obtained samples and performed smear surveys. Initial results showed contamination levels in the parking lot and on the frame of the trailer as 3,000 4,000 dpm/100 cm2. The contamination on the trailer floor prior to removal was approximately 118,000 dpm/cm2.

"Discussions with ADCO indicated that a container from the same lot of drums was found leaking at the time of shipment preparation. That drum was over-packed (put into a larger drum and filled with sorbent material) and shipped. ADCO had also indicated that the drums from this generator were new and not reconditioned. According to ADCO, the generator of this waste is no longer in business. It was sold to another pharmaceutical company. ADCO also indicated that the containers from this company was picked up in California and trucked to the Illinois facility. The drums were at the Illinois facility for approximately 4-5 months after arrival.

"This shipment entered the state of Washington through the Spokane Port of Entry, however personnel at the Port who conducted an inspection of the truck, including the undercarriage did not observe any leakage.

"Corrective Actions:

"The shipper (ADCO) has been notified that they are not to ship to the state of Washington until further notice. They must submit a root cause analysis, and a quality assurance program acceptable to the department that assures further shipments into the state of Washington will be in full compliance with all applicable state and federal regulations, as well as the PEcoS license.

"No known media attention yet.

"Notification Reporting Criteria: WAC 246-221-160.

"Isotope and Activity involved: Tritium, 7.9039 E+2 MBq (21.362 millicuries).

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None

"Lost, Stolen or Damaged? Not Applicable.

"Disposition/recovery: Unknown

"Leak test? Not Applicable

"Vehicle: Not Applicable.

"Release of activity ? Exact amount unknown

"Activity and pharmaceutical compound intended: Not applicable.
"Misadministered activity and/or compound received: Not applicable.
"Device (HDR, etc.) Mfg., Model; computer program: Not applicable.
"Exposure (intended/actual); consequences: Not applicable.
"Was patient or responsible relative notified? Not applicable.
"Was written report provided to patient? Not applicable
"Was referring physician notified? Not applicable

"Consultant used? No."

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General Information or Other Event Number: 42150
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: DEACONESS HEALTH SYSTEMS
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-21106-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL BRODERICK
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/17/2005
Notification Time: 16:18 [ET]
Event Date: 11/17/2005
Event Time: [CST]
Last Update Date: 11/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING LOSS OF PALLADIUM-103 SOURCES

On the morning of 11/17/05, Deaconess Health Systems inadvertently discarded a package of twenty-four (24) TheraSeed Palladium-103 Model 200 Implants. Each implant contains a 2.01 mCi Pd-103 source used in the treatment of prostate cancer. The error occurred due to a change in packaging which was not recognized by the recipient. The discarded material was buried at the East Oak Landfill. The licensee does not intend to attempt recovery due to the relatively short half-life, i.e., 17 days, and the small of amount of material involved. The landfill utilizes a portal alarm which did not activate since the material was discarded in it's shielded shipping container.


* * * UPDATE FROM STATE (K. SAMPSON) TO M. RIPLEY 0940 EST 11/18/05 * * *

The State provided the following additional information via facsimile:

"At approximately 1:00 PM on November 17, 2005 the licensee discovered the loss of 24 Theraseed 200 brachytherapy seeds. Each seed contained 2.01 mCi of Pd-103 at the time of the loss. According to the RSO, the manufacturer of the seeds had recently changed the packaging of the material. Prior to the change, the seeds were all packaged in one lead foil tray. However, the licensee had recently received them packed in three trays stacked one atop another in a single box. In this instance when the box was opened only two trays were removed, the box was discarded with the third tray still inside it. Trash receptacles in the hospital were searched, but the missing materials were not found. The local waste hauler and landfill were contacted and it was determined that the trash had already been delivered to the landfill that morning and had been covered. In light of the short half life of Pd-103 and the low energy of the gamma it emits, and the fact that the sources were still within their shielded tray, it was decided not to attempt to locate them at the landfill."

Note also that the name of the licensee on the Oklahoma license is Deaconess Health System, LLC doing business as Deaconess Hospital. Notified R4 DO (J. Clark), NMSS EO (G. Morell) and TAS DO (A. Danis via email)

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Other Nuclear Material Event Number: 42159
Rep Org: UNITED STATES AIR FORCE
Licensee: UNITED STATES AIR FORCE
Region: 1
City: BOLLING AFB State: DC
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: CAPTAIN CLINT ABELL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/21/2005
Notification Time: 14:12 [ET]
Event Date: 09/06/2005
Event Time: [EST]
Last Update Date: 11/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LAWRENCE DOERFLEIN (R1)
LINDA SMITH (R4)
GREG MORELL (NMSS)
AARON DANIS (E-MAIL) (TAS)

Event Text

LOST NICKEL-63 SOURCE

A representative for the Air Force Master Material License reported that a device containing a 10 millicurie Nickel-63 source is lost. The device containing the source is a Ion Track Vapor Tracer. The device was last inventoried in storage at Patrick Air Force Base at Cape Canaveral, Florida. The date of the last confirmed inventory of the device and source was in 2002. The Air Force has exhausted all its efforts to locate the source and declared it permanently lost following the an inventory in August 2005. The source serial number is s/n 01024892704. Other sources kept at the same storage location as the missing device have been moved to a more secure location. The licensee does not believe that the device was stolen. The licensee has notified NRC Regional Inspector (R. Browder).

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

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Power Reactor Event Number: 42161
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN MENG
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/21/2005
Notification Time: 17:42 [ET]
Event Date: 11/21/2005
Event Time: 10:42 [CST]
Last Update Date: 11/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
RICHARD SKOKOWSKI (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

DIVISION 3 EMERGENCY DIESEL GENERATOR DECLARED INOPERABLE

"The Division 3 Emergency Diesel Generator (EDG) was declared INOPERABLE following a trip during a routine monthly surveillance run. As soon as the Division 3 EDG was at full load it tripped off line (output breaker tripped). The Division 3 EDG supplies electrical power to the High Pressure Core Spray System in the event of a loss of offsite power.

"No problems occurred on the Division 3, 4160 volt, safety related bus.

"This event is being reported in accordance with 10CFR50.72(b)(3)(v)(B), Event or Condition That Could Have Prevented Fulfillment of a Safety Function for a single-train system failure.

"The NRC Resident inspector has been notified."

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Power Reactor Event Number: 42162
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/21/2005
Notification Time: 18:54 [ET]
Event Date: 11/21/2005
Event Time: 14:15 [EST]
Last Update Date: 11/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
LAWRENCE DOERFLEIN (R1)

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

POSTULATED FIRE SCENARIO AFFECTING REACTOR MAKEUP FROM A CHARGING PUMP

"On November 21, 2005, continued engineering evaluation determined that the Beaver Valley Power Station Unit No. 1 (BV-1) charging pump used to provide make-up to the Reactor Coolant System (RCS) may not perform its credited safety function during all postulated fire scenarios. This potential issue was first identified by a condition report on November 18, 2005. The BV1 Primary Plant Component Cooling Water System (CCR) is not credited during any postulated fire scenario. However, two postulated fire scenarios were identified where the absence of CCR could lead to elevated temperature of the water entering the charging pump suction, which could result in pump cavitation and subsequent pump damage. One scenario involves continued normal letdown entering the Volume Control Tank (VCT) at elevated temperatures raising VCT outlet water temperatures above 250 degree Fahrenheit which then goes to the charging pump suction. Another scenario involves elevated suction temperatures during a minimum flow scenario when charging flow to the RCS may be normally isolated by procedure.

"Hourly fire tours were immediately initiated as interim measures on November 18, 2005 in applicable areas to reduce the risk of an initiating fire to support continued plant operation. Plant procedure changes are being developed which will address these two scenario issues. These plant procedure revisions, expected shortly, will return the plant into compliance with the current fire protection licensing and design bases. Preliminary engineering evaluation also determined that the complete loss of RCS make-up during the two identified scenarios will not lead to core damage.

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(A) since the make-up function to the RCS may not be available during a postulated fire event which is credited for maintaining the reactor in a safe shutdown condition. The Beaver Valley Power Station Unit No. 2 (BV-2) Component Cooling Water System is credited and evaluated in its fire design bases. BV-2 operator action currently exists to protect the BV-2 charging pump during a fire event.

"The NRC resident inspector has been notified."

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