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Event Notification Report for June 12, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/09/2006 - 06/12/2006

** EVENT NUMBERS **


42619 42620 42623 42624 42626 42630 42631

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General Information or Other Event Number: 42619
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: LAKE CHARLES State: LA
County:
License #: LA-9098-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/06/2006
Notification Time: 15:40 [ET]
Event Date: 06/02/2006
Event Time: 09:30 [CDT]
Last Update Date: 06/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT - PERSONNEL OVEREXPOSURE

The State provided the following information via facsimile:

On June 1, 2006, a radiographer technician and an assistant from Team Industrial Services, Inc. performed multiple radiography exposures. After the 19th exposure, the radiographers reported "slightly more friction and resistance" when performing exposures at an elevated location. Approximately at 09:30, the final exposure was performed at an elevated location, the source was retracted with the fore noted additional resistance, and the "crank handle was rotated to the shielded position. No abnormal operation was noted and the lock plunger came up to the locked position. However, a survey of the exposure device is required by Team Industrial Services' Operating and Emergency procedures, the NRC and the LA DEQ [Louisiana Department of Environmental Quality]. No survey was performed." The radiographers then had difficulty disconnecting the source tube and control assembly. The camera was placed in the truck.

The truck was then driven to the control room, to the OSI trailer, and to the shop. The radiographers then went to lunch. After lunch, the radiographers went to their shop, unloaded the camera and realized the source pigtail was not in the camera. The calculated worst case dose to Control Room personnel was 0.38 milliRem, to OSI trailer personnel was 20.7 milliRem, an inhabited office near the OSI trailer was 10.83 milliRem, and a second inhabited location near the OSI trailer was 29 milliRem. "At no time during the sequence of events did any unmonitored personnel approach the truck."

Team Industrial Services, Inc. calculated the worse case dose for the technician as 13 Rem and the actual TLD dose was 1.1 Rem. The calculated worse case dose for the assistant was 14.5 Rem and the actual TLD dose was 2.2 Rem. These TLD doses included previous doses received in May. The licensee is performing radiation blood analysis on the two radiographers.

Source: Ir-192, 40.5 Curies.
Louisiana Report: LA060010

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General Information or Other Event Number: 42620
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MERCY HEALTH CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-07018-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/06/2006
Notification Time: 18:06 [ET]
Event Date: 06/05/2006
Event Time: 09:00 [CDT]
Last Update Date: 06/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL TREATMENT UNDERDOSE

The licensee administered a 66% under dose during one of a series of brachytherapy doses to a patient. On June 6, 2006, during the second fractional dose in the series, the licensee noted that the administration of the dose took a longer time period than the dose administered to the patient on June 5, 2006. This was unexpected so the licensee performed a preliminary investigation. The licensee discovered that the computer used to time the dose incorrectly recorded the time taken for a quality control (QC) check and the dose time to the patient as one period of time. This was a first time use of this equipment by the licensee. The licensee determined that the patient received a dose of 116 centigray instead of 360 centigray during the administration of the first dose on June 5, 2006. A sealed 6 curie Ir-192 brachytherapy source manufactured by Varian was used. The licensee has informed the patient of the dose discrepancy. Additional controls have been implemented by the licensee to ensure that the computer will not record the time taken for the QC check as dose time to the patient in the future.

The State of Oklahoma is following up on the report by sending an inspector to the site.

*** UPDATE FROM STATE TO KNOKE AT 10:34 EDT ON 06/07/06 ***

The State provided the following information via facsimile:

"This was the first use of a new HDR modality mammosite treatment. The QC on this instrument was done prior to patient treatment. The treatment plan was sent from dosimetry computer to HDR control computer. Computer (or possibly human, not clear at this writing) chose the plan used from QC. Computer interpreted this to mean that a particular amount of dose had already been given. The computer delivered the remainder of dose, 116 centigrays, out of the prescribed 360 centigrays. Time was noted to be shorter than expected, but no alarm raised at the time. A second fraction was given later that day, and it was noticed that the time to deliver the dose was longer than in first dose. Inspection of computer records showed the dose had been stopped during treatment on the first fraction. It was then realized for sure that there was a problem.

"Corrective Action: QC ACTIVITY WILL BE DONE IN A WAY THAT IT CANT BE CONFUSED WITH THERAPY."

Notified NMSS (Wastler ) and R4DO (Runyan).

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General Information or Other Event Number: 42623
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: PATHFINDER ENERGY SERVICES, INC.
Region: 4
City: LAFAYETTE State: LA
County:
License #: LA-9089-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/07/2006
Notification Time: 07:31 [ET]
Event Date: 05/22/2006
Event Time: 04:00 [CDT]
Last Update Date: 06/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - ABANDONMENT OF WELL LOGGING SOURCE

The State provided the following information via facsimile:

"[Pathfinder Energy Services (licensee) notified the State of LA that] during drilling operations on 17 May 2006 the drill string became stuck while making a connection. The hole had packed off around the drill string not allowing circulation, up and down movement or rotation of the drill pipe. All reasonable effort was used to attempt to free the drill string.

"[LADEQ Emergency & Radiological Services Division] was notified on 19 May 2006 that there might be a possibility of needing to abandon the sources over the weekend. He gave a verbal approval to abandon the sources and referred me [licensee] to [LADEQ] to follow up on Monday with the status of the abandonment. [LADEQ] was notified Monday 22 May 2006 that the sources were abandoned at 4:00 AM, 22 May 2006 and given details of the abandonment with the agreement that a formal report would be filed within 30 days of the abandonment. E-mail notification was also sent to Mr. Noble.

"It became apparent on Sunday 21 May 2006 that the drill string would be lost. A 370 foot cement plug was set above the sources. A total of 22 joints of HWDP (675 feet) were left on top of the radioactive sources to act as a mechanical deflection device to prevent inadvertent intrusion on the sources.

"A sidetrack well is planned to be drilled after 7 5/8" casing is set at 10,237' from the shoe to the original depth of 10,265 ft TVD. The sidetrack well is planned not to come within 15 ft of the sources. A liner (casing) will be set at completion of the bypass well and cemented in place.

"Description of Sources:
One 1.5 Curie, Cs-137, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number, 5080GW
AEAT Model CDC.CY6

"One 8 Curie, Am-241/Be, Doubly Encapsulated, Special Form,
Well Logging Sealed Source
Serial Number: DNS 013
Gammatron Model AN-HP"


THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example, level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 42624
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/07/2006
Notification Time: 08:54 [ET]
Event Date: 05/22/2006
Event Time: [CDT]
Last Update Date: 06/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - UNSECURED DELIVERY OF RADIOACTIVE MATERIAL

The State provided the following information via facsimile:

"On May 22, 2006, a package containing 300 [microcuries] of I-123 in two (2) capsules was prepared for shipment at the Cardinal Health Nuclear Pharmacy Services ('Cardinal Health') facility in Dallas, TX. This package was a Type 7A container and was given a Yellow II label. This package was consigned to a contract courier, Tradewind, Inc., for delivery to Cardinal Health in Shreveport, LA.

"Delivery of this package to Cardinal Health Shreveport was attempted sometime after it closed at 5:00 PM. It was discovered by a parking lot cleaning crew at approximately 11:30 PM that evening. The package had been left behind a dumpster outside the pharmacy and covered with a Tradewind jacket. The cleaning crew contacted the police, who arrived at the scene shortly afterwards and contacted the fire department, who dispatched a HazMat team. The police also contacted our pharmacist on call by using the emergency contact number posted on the outer vestibule door to our pharmacy. The fire and/or police departments took control of the material until a representative from Cardinal Health arrived on site. All radioactive material listed on the shipping paper was present and accounted for.

"Root Causes: The cause of this event was a failure by the courier, Tradewind, to properly perform their contracted duties. The package in question was left unsecured behind a dumpster. This is not how Tradewind has been instructed to deliver packages to our pharmacy. They have been instructed to deliver radioactive material packages in a designated area (that is appropriately marked) inside the vestibule, in the rear of our building. Tradewind was issued a vestibule key for this sole purpose.

"The driver who originally arrived to deliver the package did not have the vestibule key. An interview with him revealed that his intent was for another Tradewind driver to arrive later with the key and deliver the package into [licensee's] secured vestibule.

"Actions Taken to Prevent a Recurrence: Cardinal Health will be working with Tradewind to review training documents required by the DOT and to formulate corrective measures taken to prevent reoccurrence of this type of event."

LA Event Report ID No.: LA060008

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General Information or Other Event Number: 42626
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ALPHA TESTING AND INSPECTION
Region: 4
City: METAIRIE State: LA
County:
License #: LA-5856-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/07/2006
Notification Time: 09:11 [ET]
Event Date: 05/27/2006
Event Time: [CDT]
Last Update Date: 06/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SANDRA WASTLER (NMSS)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"The density/moisture gauge was stolen from the West Gate Tavern's parking lot located at 2725 Mississippi in Metairie, Louisiana, which is in Jefferson Parish. The gauge was stolen sometime between the evening of May 27, 2006 and the morning of May 28, 2006. The theft was reported to the Jefferson Police Department on May 28, 2006.

"The gauge was a Troxler Model T3440, Serial Number-20980, Source Activity: Cs-137 (8 millicuries, serial # 75-2404; Am-241:Be (40 millicuries), serial # 47-16481. Last leak test was March 17, 2006.

"[The gauge operator] stopped to have a drink at the tavern on Saturday after performing a job at the Michoud Canal. He did not return the gauge to the Hahnville storage location before visiting the tavern. [The gauge operator] had to have someone pick him up from the tavern and bring him home; leaving the truck and the chained container with gauge in the Tavern's parking lot. When [the gauge operator] returned to the truck on Sunday, May 28, 2006, the gauge container (with the gauge in it) was cut from its chains and was gone.

"The gauge container was chained and locked, and the gauge itself was locked at the time of the theft. The gauge was properly labeled with caution signs and contact phone numbers. The Department was notified immediately after the discovery of the stolen source. The facility spent countless hours trying to find the gauge.

"More training was provided to the operator. The facility ordered eight new bolt-in containers to secure the gauges in the bed of the trucks to deter theft. The Radiation Safety Officer stated that he will probably have it put in the newspaper as well. He also stated that he will write a letter to the Department within 30 days with description of the incident including corrective actions."

The state generated report number LA060009 for this event.

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: 42630
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ERIC KELSEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/11/2006
Notification Time: 03:51 [ET]
Event Date: 06/11/2006
Event Time: 01:26 [EDT]
Last Update Date: 06/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
LAWRENCE DOERFLEIN (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 45 Power Operation 25 Power Operation

Event Text

TECHNICAL SPECIFICATION SHUTDOWN DUE TO HIGH RCS DRYWELL LEAKAGE

"At 01:26 on 6/11/2006 Nine Mile Point Unit 1 experienced a rise in drywell leakage of 2 gallons per minute increase of unidentified leakage in a 24 hour period [placing the Unit in an LCO] per Technical Specification 3.2.5.a.2. Present Drywell leakage is 2.33 gpm.

"A normal orderly shutdown commenced at 01:26, per Technical Specification 3.2.5.b, [to] place the reactor in cold shutdown within 24 hours.

"Drywell leakage has trended up very slowly over the past several weeks. On 6/10/2006 the plant reduced power, deinerted the primary containment, [and] attempted to repair packing leak on VLV-32-194. [This valve is a 1 inch drain valve on recirculation pump #12]. Following attempts to repair [the] valve, [the] plant inerted the primary containment [and] raised power to approximately 45% while main condenser tube cleaning continued. Unidentified drywell leakage began rising at a faster rate beginning on 6/10/2006 at 17:55."

Drywell leakage has stabilized at a little over 2 gpm. The TS shutdown is required because of the 2 gpm increase in leak rate over the last 24 hour period. There are no other equipment operability concerns or TS LCOs that present a challenge to a normal safe plant shutdown.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42631
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: DEWAYNE BAGLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/12/2006
Notification Time: 02:35 [ET]
Event Date: 06/11/2006
Event Time: 22:56 [EDT]
Last Update Date: 06/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2)

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

LOSS OF 20% OF OFFSITE EMERGENCY SIRENS DUE TO SEVERE WEATHER

"As of 10:56 P.M. EDT, [on 06/11/06] more than 20% of the offsite emergency sirens were inoperable for greater than one hour due to loss of power caused by severe weather/thunderstorms passing through the area. At 10:56 P.M. 21 of 81 sirens were out of service. At this time, the Harris Plant cannot estimate the time of siren recovery. However, crews are currently in the field surveying the damage and restoring power. This requires an 8-hour non-Emergency notification per 10CFR 50.72(b)(3)(xiii) due to the loss of a significant portion of the offsite notification system. As of 01:40 A.M. 6/12/06, 16 of 81 sirens are out of service."

The state and local emergency response organizations will implement compensatory measure of route alerting in the areas of the siren malfunction if needed during an emergency.

The licensee notified the NRC Resident Inspector. The licensee also notified the North Carolina State EOC and the local counties of Chatham, Lee, Harnett, and Wake.

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