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Event Notification Report for November 23, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/22/2005 - 11/23/2005

** EVENT NUMBERS **


42150 42154 42156 42165

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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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General Information or Other Event Number: 42154
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: USKH, INC.
Region: 4
City: SPOKANE State: WA
County:
License #: WN-I0409-1
Agreement: Y
Docket:
NRC Notified By: TERRY FRAZEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/18/2005
Notification Time: 19:53 [ET]
Event Date: 11/17/2005
Event Time: 17:45 [PST]
Last Update Date: 11/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
PATRICIA HOLAHAN (NMSS)
CANADA via fax ()
AARON DANIS (email) (TAS)

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via email:

"Event Report # WA-05-062

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"STATUS: new

"Licensee: USKH, Inc.
"City and state: Spokane, Washington
"License number: WN-I0409-1
"Type of license: Portable Gauge

"Date of event: 17 November 2005, Called in 5:45 PM.
"Location of Event: Spokane, Washington
"ABSTRACT: The license's Radiation Safety Officer reported that sometime between 2 and 5 PM a Troxler, Model 3411B, moisture density gauge, Serial Number 5541, was stolen out of the operator's transport vehicle parked in a Diamond Parking lot adjacent to the 'Flour Mill' where the company's offices are located at 621 W. Mallon Avenue, Suite 309, Spokane, Washington. A police report was filed on 17 November 2005 but Spokane police declined to investigate the scene.

"Bolt cutters were used to liberate the gauge/transport box from 2 separate chains with a padlock on each attaching the box to the rear of the operator's pick-up truck. The parking lot (of over 75 vehicles) has an attendant who did not observe the theft.

"The operator appears to have violated at least one DOH requirement that may have contributed to the theft to the device. Department of Health Order, dated 2 December 2002, requires that when the licensee's portable gauge is not physically under the control of the operator that the device must be covered or carried in such a way that the passer-by cannot see the device.

"Another potential contributing factor to the theft, is that the operator was planning on transporting the gauge to his residence to recharge and take it to the work site the next morning because the work site was halfway between the operator's residence and the primary storage location. Preliminary information indicates that the work site is within 50 miles of the primary storage location. This is still under investigation. The licensee will be cited for at least one violation as a result of the event, and corrective actions will be discussed with the licensee.

"The event is currently under investigation. This report will be updated to include any new findings. No media attention noted at present.

"What is the notification or reporting criteria involved? WAC 246-221-240 Reports of stolen, lost or missing radiation sources

"Activity and Isotope(s) involved: 296 megaBq (8 millicuries) Cesium-137 and 1480 megaBq (40 millicuries) Americium 241/Beryllium.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) N/A

"Lost, Stolen or Damaged? STOLEN (mfg., model, serial number) noted above

"Disposition/recovery: pending

"Leak test? Unknown

"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) pick-up truck with no cap

"Release of activity? N/A

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided? Pending
"Was referring physician notified? N/A

"Consultant used? N/A"

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: 42156
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: IRIS NDT
Region: 4
City: TULSA State: OK
County:
License #: OK30246-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 11/19/2005
Notification Time: 11:54 [ET]
Event Date: 11/18/2005
Event Time: 20:00 [CST]
Last Update Date: 11/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

At 2000 on 11/18/05 during a radiography job at P2S in Sand Springs, OK, a radiographer received a 23 Rem calculated dose. He went out to change the camera film when he thought his assistant had fully retracted the source. The radiographer was in front of the camera for approximately 3 minutes. The licensee stated that the cause of the overexposure was miscommunication.

When the radiographer was on his way to the camera he set down his radiation detection instrument and answered a cell phone call. At the same time the assistant who was responsible for retracting the source was sending a text message on his cell phone. The radiographer's alarming rate meter was turned off. The camera was a SPEC Model 150 with a 66 Curie Iridium-192 source. The camera was tested after the event and found to be in good operating condition.

Both the radiographer and the assistant have been suspended pending further investigation. The dosimeters of the individuals have been sent to be read and readings should be available on 11/21/05. The licensees radiation safety officer made the report to the state after taking both individuals to the hospital for blood tests as a precautionary measure. On 11/21/05 the state will investigate this incident further at the jobsite.

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Fuel Cycle Facility Event Number: 42165
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2005
Notification Time: 15:54 [ET]
Event Date: 11/22/2005
Event Time: 12:05 [CST]
Last Update Date: 11/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
KERRY LANDIS (R2)
SCOTT FLANDERS (NMSS)

Event Text

IMPROPER CRITICALITY SPACING FOR WASTE DRUM

"At 1205 CST, on 11-22-05 the Plant Shift Superintendent was notified that during waste drum remediation activities, a drum was discovered that was in violation of one leg of double contingency. Drum #39666W has been determined to contain up to (deleted) g (grams) U235 exceeding the allowed (deleted) gram limit for NCS Spacing Exempt drums. This drum was previously located in an NCS (Nuclear Criticality Safety) Spacing Exempt storage area in violation of NCSA WMO-001 requirements. The drum was moved to the C-335 storage area under an approved Remediation Guide which established a safety basis for the movement of drums that had been roped off and posted per earlier direction. This drum is currently stored in a Temporary Fissile Storage Area maintaining a minimum 2 foot edge-to-edge spacing under NCSA WMO-001, which maintains double contingency."

SAFETY SIGNIFICANCE OF EVENTS

"While the (deleted) gram U235 limit was exceeded for this drum; DAC-832-2A1280-0001 demonstrates that drums containing less than (deleted) grams U235 in an NCS Spacing Exempt array are subcritical. The storage area is roped off and posted to prevent the addition of fissile material to the area; therefore another upset would be required before a criticality is possible."

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

"This drum is currently stored in the Temporary Fissile Storage Area under NCSA WMO-001, meeting double contingency. In order for a criticality to occur, two independent, unlikely, and concurrent events would have to occur."

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

"Double contingency is maintained by implementing two controls on mass."

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

"The drum has been determined to contain (deleted) grams U235. Calculations performed demonstrate that drums containing less than (deleted) grams U235 each, in an NCS Spacing Exempt array are subcritical."

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

"Although the drum contains greater than the WMO-001 limit of (deleted) grams U235 for NCS Spacing Exempt drums, it has been shown to be less than (deleted) grams U235 based on independent sample results. Calculations performed demonstrate that drums containing less than (deleted) grams U235 each, in an NCS Spacing Exempt array, are subcritical. Therefore, an additional process upset (i.e., spacing upset) would be necessary in order to have a criticality. Therefore, while the drum contained greater than (deleted) grams U235 in the spacing exempt array, the array has been shown to be subcritical for drums containing less than (deleted) grams U235 thus maintaining one leg of double contingency."

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED

"At the time of discovery, the drum was being stored according to NCS approved spacing controls. The drum will continue to be handled according to approved controls until the U235 mass can be reduced to meet the NCS Spacing Exempt criteria per NCSA WMO-001.

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

See Related Event Report #40700.

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