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Event Notification Report for January 25, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/24/2006 - 01/25/2006

** EVENT NUMBERS **


42273 42275 42279 42285

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General Information or Other Event Number: 42273
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City: HOUSTON State: TX
County:
License #: L01911
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/19/2006
Notification Time: 09:35 [ET]
Event Date: 01/18/2006
Event Time: [CST]
Last Update Date: 01/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT OF AN EXTREMITY EXPOSURE GREATER THAN LIMIT

The State provided the following information via email:

"A Nuclear Pharmacy Technician was preparing Tc-99m doses in a very busy pharmacy when his weekly extremity monitor reached an annual limit with a reading of 53,440 mrem for the calendar year of 2005. The licensee's corrective action includes additional training, possible modification of technique, and having corporate health physics staff investigate the incident. The dose was being monitored and management did not anticipate that the employee would exceed the maximum but he had a 'hard week' (12/26-01/06) where his right hand received 3,120 mrem. Corrective action will include hiring new techs since two other dose drawing techs have been 'benched' earlier in the year before their extremity doses would have exceeded the regulatory maximum. Reportedly the RSO and manager [redacted] did not receive the report until today. This is the 3rd busiest nuclear pharmacy in the world supplying ~1,000 doses/day to the greater Houston area. "

TX Event Report ID: TX-06-42273
TX Incident # I-8289

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General Information or Other Event Number: 42275
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SARASOTA MEMORIAL HOSPITAL
Region: 1
City: SARASOTA State: FL
County:
License #: 2219-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL GOTT
Notification Date: 01/19/2006
Notification Time: 17:02 [ET]
Event Date: 01/19/2006
Event Time: 13:00 [EST]
Last Update Date: 01/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST IODINE SEED

"Thirteen I-125 seeds were implanted in a patient on 1/11/2006 and removed on 1/18/2006. After removal, seeds were transferred to Hot Lab at which time it was discovered that one of the seeds [1.43 millicuries I-125] was missing. All seeds were moved from patient. A search was conducted of the O.R., the patient and the traverse route. The seed has not been found at this time. The licensee stated that a doctor rinsed the item containing the sources in the sink in the O.R., and that it is possible that the missing source was rinsed down the drain. Florida is investigating."

Incident Number: FL06-012

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: 42279
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: J.R.J. PAVING INC.
Region: 4
City: DALLAS State: TX
County:
License #: L05307-002
Agreement: Y
Docket:
NRC Notified By: DAN JISHA
HQ OPS Officer: PETE SNYDER
Notification Date: 01/20/2006
Notification Time: 16:44 [ET]
Event Date: 01/20/2006
Event Time: 14:00 [CST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)
TAS (e-mail) ()
MEXICO (via-fax) ()

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

At about 1400 hours Central Standard Time, while working at a site in Fort Worth, a 2003/2004 Chevrolet pick-up carrying a Troxler Moisture Density Gauge belonging to the licensee was stolen. The gauge is a model number 3440 with a serial number of 28640. It has two sources. One is a 44 millicurie Americium-Beryllium source (model # A/S AmBe Model 997 Type X-LP 3021 and 3027) and the other is a 9 millicurie Cesium-137 source (model # A/S CDCW556; IPL Model HEG/137-AM). The licensee called the state an hour after the truck and gauge were stolen.

The licensee filed a police report. The state of Texas is continuing to investigate the incident.

Texas Incident #: I-8290

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: 42285
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: CHAD G. BLANCHARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/25/2006
Notification Time: 01:33 [ET]
Event Date: 01/24/2006
Event Time: 19:32 [CST]
Last Update Date: 01/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BLAIR SPITZBERG (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

Event Text

INVALID HIGH PRESSURE CORE SPRAY (HPCS) INITIATION SIGNAL DURING SURVEILLANCE TESTING

"50.72 (b) (3) (vi) Non-Emergency 8Hr Reportable

"When I&C was performing STP-051-4256, HPCS Drywell Pressure High Channel Calibration and Logic System Functional Test (B21-N067R, B21-N667R), a human performance error resulted in an invalid HPCS Initiation signal. Division III Diesel Generator and the HPCS Pump started. The HPCS injection valve stroked open and was manually overridden closed after full open indication, thus HPCS system injection was terminated. HPCS System was unavailable due to being overridden with an initiation signal present from 1932 until 2109 [CST] for a total of 1 Hr and 37 minutes.

"NUREG 1022 states that single-train systems that perform safety functions (i.e., HPCS), when lost, prevents the fulfillment of the safety function of that system."

The licensee informed the NRC Resident Inspector.

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Friday, March 30, 2012