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Event Notification Report for December 19, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/16/2005 - 12/19/2005

** EVENT NUMBERS **


41189 41647 42085 42188 42200 42205 42211

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 41189
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HARRIS METHODIST FORT WORTH
Region: 4
City: FORT WORTH State: TX
County:
License #: L01837-000
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/10/2004
Notification Time: 14:21 [ET]
Event Date: 05/16/2004
Event Time: 12:00 [CST]
Last Update Date: 12/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT FROM TEXAS: EQUIPMENT FAILURE THERAPY DEVICE AT HOSPITAL

"On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device."

Texas Incident No.: I-8179

* * * UPDATE FROM HANSON TO KNOKE AT 17:27 ON 12/13/05 * * *

The State provided the following information via email:

"A letter was sent to the licensee on 9/14/05 from Robert Free [State] informing the licensee that Condition 21 on their Texas License L01837, required them to report as follows:

"The licensee shall cease treatment of patients when any safety related system of a LDR device is found inoperative, to include the source drive mechanisms treatment timing system, safety interlocks and radiation field alarms. The licensee shall report to the Deputy Director, Emergency Response and Incident Investigation, any malfunction that requires the termination of patient treatments for more than 24 hours and submit a written report of the incident and corrective actions within seven calendar days.

"The response letter from the licensee dated 10/04/05, stated that there were actually 5 events affecting a total of patients; on 3 of these events there were 2 patients being treated simultaneously with the same LDR machine. In each case the attending physician was either on the premises or notified immediately. The physician either deemed the treatment received was sufficient or the treatments were rescheduled, some within 3 hours.
It was discovered by the licensee that during the investigation of these events that severe thunderstorms preceded all LDR malfunctions. It was the conclusion that the LDR had functioned as designed by detecting the significant change in power & shut itself down. No misadministrations occurred.

"The manufacturer replaced the column, interface board, printer mechanism and power supply. The LDR has not been used in the past 12 months. In August 2005 the decision was made to take the LDR machine out of service."

Notified R4DO (Johnson) and NMSS (Essig).

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General Information or Other Event Number: 41647
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CTL ENGINEERING
Region: 1
City: DURHAM State: NC
County:
License #: 032-1046-1
Agreement: Y
Docket:
NRC Notified By: SHAM JEFFRIES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/28/2005
Notification Time: 09:20 [ET]
Event Date: 04/27/2005
Event Time: 17:00 [EDT]
Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1)
JOHN HICKEY (NMSS)
TAS (VIA E-MAIL) ()

Event Text

AGREEMENT STATE REPORT OF STOLEN TROXLER GAUGE

A Troxler gauge was stolen from the back of a truck parked at the licensee's address sometime between 1700 EDT on 4/27/05 and 0800 EDT on 4/28/05. Bolt cutters were used to remove the Troxler which was locked. The State noted that the Troxler should not have been left in the truck overnight. The licensee will be contacting the Police.

The Troxler was a model 3440, Serial Number 15579, with an 8 millicurie Cs-137 and a 44 millicurie Am-241/Be source.

State Report number is 05-17

* * * UPDATE ON 12/16/2005 AT 10:30 FROM JEFFRIES TO ABRAMOVITZ * * *

The Troxler Moisture Density Gauge has been recovered. The thief was apprehended and as part of a plea agreement, on 12/14/2005, notified the Durham Public Defender of the location of the density gauge. The Troxler was found partially buried in the woods. It was not in its case but was protected from the elements by a vinyl container. The gauge was transported a few miles to the Troxler plant.

Notified the R1DO (Dimitridis), NMSS EO (Karas) and TAS (via E-mail).

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: 42085
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: COLUMBIA IRON AND METAL
Region: 3
City: GIRARD State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/27/2005
Notification Time: 11:04 [ET]
Event Date: 10/26/2005
Event Time: [EDT]
Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
MICHELE BURGESS (NMSS)

Event Text

SOURCE DISCOVERED AT METAL SCRAP YARD

The State provided the following information via facsimile:

Gauge containing a Sr-90 sealed source was discovered at a metal scrap yard in Girard, Ohio. The gauge is a Betamike model manufactured by Taylor Instruments (Model 015020; Serial 781-35). The activity as of 8/70 was 100 mCi (millicuries). The activity as of 10/27/05 was calculated to be 44 mCi (millicuries). The Ohio Department of Health dispatched an inspector to the scrap yard on October 26. The gauge is secure and a leak test of the source showed no removable contamination. Radiation levels are 5 Mr/hr (milliRem per hour) on contact and 1 Mr/hr at 30 cm. Disposal options for the device are being investigated.

Ohio Report OH05-134

* * * UPDATE FROM S. JAMES TO W. GOTT AT 1114 ON 12/16/05 * * *

"The source was packaged and removed for disposal by a contractor to the USEPA."

Notified NMSSEO (B. Karas) and R3DO (S. Burgess)

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: 42188
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WILLIAM MATHER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/05/2005
Notification Time: 10:45 [ET]
Event Date: 12/05/2005
Event Time: 09:00 [CST]
Last Update Date: 12/16/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATTY PELKE (R3)

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

PLANT PROCESS COMPUTER SYSTEM (PPCS) WILL BE TAKEN OUT OF SERVICE FOR APPROXIMATLEY 2 WEEKS.

"The Plant Process Computer (PPCS) will be taken out of service for an approximately 2 week period to implement a planned modification. The current PPCS is being replaced and the computer outage is required to allow cutover to the new PPCS. During this time period ERDS and SPDS will not be available. ERDS and SPDS parameters will be monitored by control board indications. Compensatory actions have been developed.

"This is an 8-hour reportable event per 10 CFR50.72(b)(3)(xiii) Major Loss of Assessment Capability. The operation of plant systems will not be affected due to this planned action.

"The PPCS outage is expected to commence around 0600 CST on 12/5/05. The licensee has informed the NRC Resident Inspectors of the modification and schedule. The NRC was previously notified of this planned outage via letter dated November 7, 2005."

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

* * * UPDATE PROVIDED BY JOHNSON TO ROTTON AT 0324 EST ON 12/16/05 * * *

"The Plant Process Computer System was restored at 2330 CST on 12/15/05. The Safety Parameter Display System (SPDS) has been returned to service. The Emergency Response Data System (ERDS) portion of the system will be turned over once the testing has been completed."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Burgess).

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General Information or Other Event Number: 42200
Rep Org: ALABAMA RADIATION CONTROL
Licensee: GOODWIN, MILLS & CAWOOD, INC
Region: 1
City: BIRMINGHAM State: AL
County:
License #: 1404
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/13/2005
Notification Time: 14:00 [ET]
Event Date: 12/12/2005
Event Time: 18:30 [CST]
Last Update Date: 12/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
MICHELE BURGESS (NMSS)
TAS email (TAS)

Event Text

STOLEN MOISTURE DENSITY TROXLER GAUGE

The licensee provided the following information via facsimile:

"On the evening of December 12, 2005 at approximately 6:30 pm CST, a Troxler model 3440 moisture density gauge, serial number 503557, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be was stolen from the back of a pickup truck at a Home Depot parking lot in Birmingham, Alabama. The licensee, Goodwyn, Mills & Cawood, Inc., notified the Birmingham Police Department and the Alabama Office of Radiation Control. The Alabama Office of Radiation Control advised the Alabama Emergency Management Agency of the event. Goodwyn, Mills & Cawood, Inc. is authorized to possess and use radioactive material under their Alabama Radioactive Material License No. 1404. The licensee representative stated that the transport case was not locked and chained in the bed of the truck as required. The licensee representative did state that the gauge shutter was locked. A pressure meter was stolen in addition to the gauge. The Agency advised the licensee to consider issuing a press release and a reward. The licensee has been able to view surveillance tapes from Home Depot which appear to indicate that the gauge was stolen by individuals riding around the parking lot looking for unsecured items to steal in the back of trucks. The licensee has provided the Birmingham Police Department with a picture of the gauge and is checking with the local businesses and pawn shops. This is all the information that this Agency has at this time and is current as of 11:20 am CST."

Alabama Event 05-70.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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: 42205
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: EAST COAST ISOTOPES, INC.
Region: 1
City: BEAUFORT State: SC
County: BEAUFORT
License #: 705
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: RONALD HARRINGTON
Notification Date: 12/14/2005
Notification Time: 16:30 [ET]
Event Date: 12/14/2005
Event Time: 06:30 [EST]
Last Update Date: 12/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
THOMAS ESSIG (NMSS)
DONNA-MARIE PEREZ (TAS)
GEORGE PANGBURN (R1)

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOACTIVE MATERIAL

The State provided the following information via facsimile:

"Event type: Theft of Nuclear Pharmacy delivery vehicle en route to hospital

"Notifications: Local Police Department.

"Event description: The SC Department of Health and Environmental Control was notified on Wednesday (a.m.), December 14, 2005, by the pharmacist/RSO for the facility that one of their delivery vehicles had been stolen at gunpoint. The vehicle was en route to a hospital to deliver radiopharmaceuticals. The vehicle was carrying approximately 795 millicuries of Technetium 99m, 42 millicuries of Thallium 201 and one Iodine 123 capsule at 0.36 millicuries. The Port Royal Police Department was contacted and responded to the incident. The search is still ongoing at this point. The event is still under investigation and updates will be made through the national NMED system as they become available."

Contact the NRC Headquarters Operations Officer for additional details

South Carolina Event Report ID No.: SC050007

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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: 42211
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TONY COOK
HQ OPS Officer: PETE SNYDER
Notification Date: 12/17/2005
Notification Time: 03:45 [ET]
Event Date: 12/17/2005
Event Time: 03:11 [EST]
Last Update Date: 12/17/2005
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):
THOMAS DECKER (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 REACTOR TRIP FROM FULL POWER DUE TO A FAILED FEED FLOW CHANNEL

"'A' Steam Generator hi/hi level caused a turbine trip which in turn caused a Unit 1 reactor trip. The hi/hi steam generator level also caused both feedwater pumps to trip which caused the auxiliary feedwater pumps to auto-start. The hi/hi level also caused a feedwater isolation. Appropriate emergency procedures have been implemented and the plant is currently stable."

All control rods fully inserted on the trip. Offsite power is available and powering safety related buses. The emergency diesel generators are available if required. There are no known primary to secondary leaks in the steam generators.

The licensee will notify the NRC Resident Inspector.

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