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Event Notification Report for July 13, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/12/2006 - 07/13/2006

** EVENT NUMBERS **


42689 42694 42696 42697 42701 42702 42703

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General Information or Other Event Number: 42689
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BEN TAUB GENERAL HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: 01303
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/07/2006
Notification Time: 15:43 [ET]
Event Date: 06/18/2006
Event Time: 04:40 [CDT]
Last Update Date: 07/07/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG MORELL (NMSS)
GREG PICK (R4)

Event Text

AGREEMENT STATE - MISPLACED SOURCE

"At 0634 hrs on June 20, 2006, [the Director of the Texas Department of Health] received a call on the way to the office from the Director of Radiology for Ben Taub General Hospital in Houston, TX. He relayed brief details of a recovered source that was either taken out of a patient or never placed in an after loading appliance utilized for the treatment of a cervical cancer patient. In the words of the Radiation Safety Officer with proper names redacted:

"On Sunday, June 18, 2006 at 4:40 am a Cesium-137 source, 3M model 6501(6D6C-CA), serial # 06965, with an activity of approximately 17 mCi [milliCuries] was noted to be missing from a patient who was undergoing a tandem and ovoid implant for cervical cancer. The patient had applicator placement (uterine tandem and two Fletcher ovoids) at Ben Taub General Hospital (BTGH), on Friday 6/16/2006. The Cesium sources (4 in all; 2 in the tandem and 1 each in the ovoid) had been placed in the patient by the Radiation Oncologist at 3:40 pm for a 37 hour implant. When the right ovoid source was noted to be missing at the time of unloading; the patient, room, Nursing Unit 6B of the hospital, and the route of transport of the sources from the BTGH Radiotherapy Department to the patient's room were surveyed using both a sodium iodide detector and a conventional air-ionization type survey meter by both the Radiation Oncologist and Medical Physicist. The BTGH Radiation Safety Officer was notified at 8:20 am Sunday morning of the apparent missing source. Upon further investigation, it was learned that the bed sheets of the patient had been changed at 3 pm on Saturday, 6/17/2006, and this dirty linen was placed in the linen cart on 6B. It was subsequently taken to a truck at the BTGH loading dock and transported to the Texas Medical Center Laundry facility. On Monday morning, 6/19/06, the director of this facility was contacted and subsequently the facility was surveyed. The Cs-137 source was recovered at 10:30 a.m., from the third floor and transported back to the BTGH Radiotherapy Department using an appropriately shielded container.

"The names of all the persons who potentially may have come into contact with the Cesium source were obtained and notified. This list included thirty-five [35] individuals of both hospital and laundry services personnel.

"Upon further review by staff in assembling the documents for the incident file, the attachments to the June 26, 2006 e-mail was examined at 1400hrs on July 7, 2006. At that time DSHS staff realized that this was a lost/found source with quantities >1,000 X Appendix C value requiring immediate reporting to NMED. However, staff reviewed the operational setting and in the absence of the licensee's report demonstrating an exposure exceeding of 100mrem to a member of the public, the incident may not be reportable. Further investigation is on-going."

Texas Incident: I-8350

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General Information or Other Event Number: 42694
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: APAC, ATLANTIC, INC.
Region: 1
City: HICKORY State: NC
County:
License #: 018-0967-3
Agreement: Y
Docket:
NRC Notified By: GRANT MILLS
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/08/2006
Notification Time: 22:00 [ET]
Event Date: 07/08/2006
Event Time: 05:00 [EDT]
Last Update Date: 07/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
E. WILLIAM BRACH (NMSS)
ILTAB (e-mailed) (NSIR)

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via fax:

"Licensee: APAC Atlantic, Inc, Asheville Division / Hickory Branch

"Event Date &Time: 08 July 2006 between 02:00 and 05:00 am

"Report Date & Time: 08 July 2006, 15:00

"Event Location: Hickory, NC

"Event Type: Stolen Portable Nuclear Gauge

"Notifications: The following organizations have been notified, the FBI, the N.C Highway Patrol, Iredale County Sheriff, N.C. Division of Emergency Management.

"Event Description: N.C. Radiation Protection Section was notified on 08 July 2006 by the designee RSO for APAC Atlantic, Inc Asheville Division / Hickory Branch of the theft of a Troxler Electronics Model 4640 B portable moisture density gauge (Serial No. 765). The gauge contained one sealed source: Cesium-137, 9 millicuries.

"The device was stored in a locked steel transport box attached to the bed of a White 2006 Dodge Dakota, license plate no. VV2525, with 'APAC' signage on the doors. In addition to being locked in the steel over-pack, the gauge is locked in the required transportation container and the operating mechanism is locked. However, keys to all three locks are in the truck. The truck was stolen in the early morning hours from the licensee's gated and locked facility.

"The Radiation Protection Section is working with the licensee and local law enforcement to recover the gauge.

"Media Attention: N.C. Radiation Protection has not received any media attention as of this report. A potential news release is pending."

NC Incident No. 06-20.

* * * UPDATE AT 0415 ON 07/10/06 FROM LEE COX TO W. GOTT * * *

In the evening of 07/09/06 the abandoned gauge was found undamaged and in its case in a parking lot in Hickory NC. The source rod was still locked in the stowed position.

Notified R1DO (P. Henderson), NMSS EO (Brach) and emailed to ILTAB.

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: 42696
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BERKSHIRE MEDICAL CENTER
Region: 1
City: PITTSFIELD State: MA
County:
License #: 60-0005
Agreement: Y
Docket:
NRC Notified By: M. WHALEN
HQ OPS Officer: BILL GOTT
Notification Date: 07/10/2006
Notification Time: 09:30 [ET]
Event Date: 04/20/2004
Event Time: [EDT]
Last Update Date: 07/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN MEYER (R1)
GREG MORELL (NMSS)
Email to ILTAB ()

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

Event Text

AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The licensee provided the following information via email:

"As a result of a recent routine inspection, the licensee made report on June 12, 2006, of a lost/missing Pd-103 brachytherapy seed originally containing 3.39 millicuries of Pd-103 on April 20, 2004 and discovered lost/missing on the same date (April 20, 2004)

"The seed was never found and was believed to have been disposed of as non-radioactive trash within a cartridge on April 20, 2004. The Pd-103 contained in the seed has a short half-life of 17 days.

"A nurse handling the cartridge with one remaining seed in the operating room likely disposed of the cartridge and seed into non-radioactive trash. The licensee concluded that such disposal of the single seed contained in the cartridge would not generate any noticeable radiation exposure to the general public.

"The licensee provided additional training to nurses who handle cartridges in the operating room."

Report number 06-6414

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: 42697
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BURNS COOLEY DENNIS, INC.
Region: 4
City: RIDGELAND State: MS
County:
License #: MS-619-01
Agreement: Y
Docket:
NRC Notified By: B.J. SMITH
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/10/2006
Notification Time: 14:11 [ET]
Event Date: 07/09/2006
Event Time: 21:45 [CDT]
Last Update Date: 07/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The State provided the following information via email:

"Received notification on 7-9-06 from Mississippi Emergency Management (MEMA) that a Troxler 3440 moisture/density gauge, Serial # 31576, had been involved in a fire at a residential location. The gauge was chained and locked in its approved DOT transportation container to the bed of the pick-up truck. A neighbor had seen the fire and called 911. Ridgeland Fire Department extinguished the truck fire and secured the area. DRH responded to the incident and removed the melted gauge from the truck bed. Survey readings were taken at the truck after the gauge was removed and determined to be background (9 microR/hr).

"DRH responded to the scene and removed the gauge from the bed of the pickup. Gauge was secured in a plastic garbage bag and placed in DRH vehicle. Cesium-137 source rod was shielded with a lead pig. Gauge was brought to DRH office where leak tests were performed and gauge was stored until pick-up by disposal contractor.

"Isotopes: Cesium-137 (9 mCi) and Americium-241/Be (40 mCi)

"Survey readings were 95 mR/hr near the end of the Cesium-137 source rod. Survey readings of the Americium-241/Be source were 5 mR/hr. Survey readings of the sources in the bed of the DRH vehicle after shielding them were 15 mR/hr. Sources were leak tested by DRH and appear not to be leaking."

* * * UPDATE FROM S. SMITH TO W. GOTT AT 1006 ON 7/13/06 * * *

Updated to correct units of the background radiation levels and the survey readings.

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Power Reactor Event Number: 42701
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DANIEL HAUTALA
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/12/2006
Notification Time: 16:37 [ET]
Event Date: 07/12/2006
Event Time: 07:30 [MST]
Last Update Date: 07/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA SMITH (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 90 Power Operation 90 Power Operation
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

ONE SIREN IN EP ZONE IS OUT OF SERVICE

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On July 12, 2006 at approximately 07:30 Mountain Standard Time (MST), the Palo Verde Emergency Preparedness Department reported siren (#23) out of service. Siren #23 is estimated to impact approximately 119 members of population in the emergency planning zone (EPZ) within 5 miles. Palo Verde's reporting criterion is a loss of capability to inform greater than 5% of the population within 5 miles. This call is being placed due to the relatively large segment of the population affected. During an event, the Palo Verde Emergency Plan has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area(s) when sirens are inoperable.

"There are no events in progress that require siren operation.

"The NRC Resident Inspector has been notified of the siren 23 being out of service and this ENS call."

The total population within the 5 mile EPZ is 2120.

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Power Reactor Event Number: 42702
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JAY GAINES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/12/2006
Notification Time: 17:17 [ET]
Event Date: 07/12/2006
Event Time: 16:06 [EDT]
Last Update Date: 07/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GLENN MEYER (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION RELATED TO JELLYFISH INFLUX

The licensee was required to secure circulating water pump 26 due to a significant influx of jellyfish. Per the licensee's NPDES (National Pollution Discharge Elimination System) permit, the licensee is required to notify the Maryland Department of Environment of any significant aquatic impact on plant operation. The licensee remained at 100% power throughout and has already restarted the secured circ pump.

The licensee notified the NRC Resident Inspector.

See similar Event Notifications 42699 and 42700.

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Power Reactor Event Number: 42703
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: RALPH COX
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/12/2006
Notification Time: 17:33 [ET]
Event Date: 07/12/2006
Event Time: [EDT]
Last Update Date: 07/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
GLENN MEYER (R1)
WILLIAM RULAND (NMSS)
MARIE MILLER (NMSS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned

Event Text

LOSS OF OFFSITE POWER AT A DECOMMISSIONED FACILITY

The licensee reported a loss of ENS and commercial telephone lines due to a loss of power to the phone switch located offsite from the facility. The call was provided as a courtesy notification and the licensee indicated that cell phone and satellite phone communication were still available. These methods of communication were tested and verified to be working satisfactorily. During the initial notification, it was not made clear to the NRC Operations Center that the facility had lost all offsite power and was operating on backup propane generators. The licensee stated that there were no operability problems onsite and that power was expected to be returned to the phone system within approximately 1 hour.

Update calls were placed to the licensee by the Headquarters Operations Officer at 1930 EDT and again at 2200 EDT to determine phone status. At the 2200 EDT call, it became clear that the site had also experienced a loss of offsite power. The loss of power was due to a tree that had fallen on a power line away from the site and that the licensee did not have any information on when it would be restored. The licensee stated that all onsite power requirements were being met by a backup propane generator and all facility systems (other than the phones) were operable. The licensee stated that the loss of offsite power was not reportable and the loss of the ENS and commercial lines was reportable as information only. The licensee still did not have information on when the power would be restored.

R1DO (Meyers), NMSS EO (Ruland), R1 (Miller) were provided the updated information on the offsite power loss at the site when this information was clarified by the licensee.

* * * RECEIVED AN UPDATE FROM CHRIS POULOS TO JOE O'HARA ON 7/13/06 AT 0155 * * *

The licensee reports that power has been restored to the site and both ENS and commercial phones lines are operating properly.

R1DO (Meyers), NMSS EO (Ruland), R1 (Miller) notified.

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Friday, March 30, 2012