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Event Notification Report for September 26, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/25/2006 - 09/26/2006

** EVENT NUMBERS **


42819 42850 42851 42853 42860 42861

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Other Nuclear Material Event Number: 42819
Rep Org: ALASKA INDUSTRIAL X-RAY, INC
Licensee: ALASKA INDUSTRIAL X-RAY, INC
Region: 4
City: ANCHORAGE State: AK
County:
License #:
Agreement: N
Docket:
NRC Notified By: PETE MILLAR
HQ OPS Officer: JASON KOZAL
Notification Date: 08/31/2006
Notification Time: 14:36 [ET]
Event Date: 08/31/2006
Event Time: 10:30 [YDT]
Last Update Date: 09/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MICHELLE BURGESS (NMSS)
CHUCK CAIN (R4)

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

Event Text

LOST RADIOGRAPHY CAMERA ON WAKE ISLAND

The licensee reported a loss of a 10 Ci [based on source decay starting December of 2005] IR-192 radiography camera on Wake Island. In preparation for evacuation of the island on 8/29/2006 the camera was loaded in a type B(U) storage container. On 8/30/2006 Super Typhoon Yoke made land fall on Wake Island producing 150 mph winds and 30 - 40 ft storm surge. The status of the camera is unknown due to the uncertain condition of Wake Island. There currently is no information of the habitability of Wake Island and thus it is uncertain when a search can be conducted.

The licensee will update the status of the material as more information becomes available.


* * * UPDATE ON 09/25/06 AT 1300 ET BY PETE MILLAR TO MACKINNON * * *


Per Pete Millar the US NAVY landed on Wake Island and the CONEX shipping container, in which the Industrial Nuclear Radiography Camera is stored, is still on the island and it has not been opened. In about 2 weeks a barge will leave Wake Island to ship the CONEX shipping container back to Alaska Industrial X-Ray. Mr. Millar said that they should have Industrial radiography camera back in their possession in about 3 weeks.

R4DO (Zach Dunham) & NMSS EO (Greg Morell) notified.


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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event.

Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3"

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Hospital Event Number: 42850
Rep Org: PENNSYLVANIA HOSPITAL
Licensee: PENNSYLVANIA HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-06864-06
Agreement: N
Docket:
NRC Notified By: LEONARD SHABASON
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/20/2006
Notification Time: 12:56 [ET]
Event Date: 05/19/2006
Event Time: [EDT]
Last Update Date: 09/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1)
CINDY FLANNERY (NMSS)

Event Text

MEDICAL EVENT INVOLVING UNDERDOSE DUE TO POSSIBLE PATIENT INTERVENTION

On May 19, 2006 an elderly patient was framed and imaged for the treatment of a single large metastatic lesion. The measurements indicated that there would be a "collision" between the anterior left post and the gamma knife helmet. The neurosurgeon who was responsible for the patient decided that it would be in the best interest of the patient to remove the anterior left pin and post rather than having to re-frame and re-image the patient. After the left post was removed the other pins were checked to confirm that the frame was still firmly attached to the patient. In the middle of the first of nine shots, the patient became very agitated and her body was observed to shift. The patient's head is not observable with either of the closed circuit TV cameras when the patient is in treatment position. The treatment was halted after the first shot to examine the patient and found that she was not held in place by the pins. The patient's neurosurgeon immediately spoke with the patient's daughter to explain what had happened and they decided to reschedule the treatment for the following week. On May 26, 2006, the patient was treated to a dose of 18 Gy to a volume of about 6.5 cc. If the patient was in one position during the shot delivered on May 19, the delivered dose is estimated to be 6 Gy to a volume of about 0.6 cc. There is no way of knowing the exact position of the patient's head during this 3.86 minute treatment. At the end of the shot, it was observed that her head was at the correct level but that her head may have dropped down. This would have resulted in a dose delivered anterior to the lesion. Since dose homogeneity is not important for gamma knife treatment and the volume in question is a small fraction of the volume prescribed treatment volume and the position was uncertain, the dose from May 19 was not considered for the treatment of May 26. The area of the patient's brain that could have received unintended incorrect dose did not include an area that would be detrimentally affected by the dose given.


A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 42851
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA
Region: 3
City: IOWA CITY State: IA
County: JEFFERSON
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: DAN MCGHEE
HQ OPS Officer: JASON KOZAL
Notification Date: 09/20/2006
Notification Time: 17:17 [ET]
Event Date: 09/20/2006
Event Time: [CDT]
Last Update Date: 09/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
JOSEPH HOLONICH (NMSS)

Event Text

IRRADIATOR SOURCE TEMPORARILY STUCK IN THE EXPOSED POSITION

On the night of 8/28- 8/29/2006 the large irradiator was being used for an all night procedure. The principle investigator for the irradiator was present to conclude the operation on the morning of August 29. At the time designated for source retraction, the irradiator source in fact did not retract to the stowed position. The source actuation system uses air pressure to expose the source and spring force to stow the source. The principle investigator tried to house the source by operating the "override" button. The source remained exposed. After approximately 15 minutes the source returned to the housed condition with no operator action. The irradiator will not be used until J.L. Shepard [the manufacturer] is contacted and the cause identified and corrected. The source is currently stowed.

The irradiator is an 8800 Curie Cs-137 self shielded irradiator.

Iowa event number I806004

The state notified Region 3 (Lynch).


* * * Update on 09/21/06 at 1510 ET from Randy D' Ahlin to MacKinnon * * *

The following updated information was called in by the State of Iowa Department of Public Health:

The irradiator type is an open beam irradiator. The irradiator has been repaired, tested and placed back in service on 09/21/06.

R3DO (Julio Lara) and NMSS EO (Cindy Flannery) notified.

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General Information or Other Event Number: 42853
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: TERRATECH CONSULTANTS
Region: 1
City: MIAMI State: FL
County:
License #: 3210-1
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/21/2006
Notification Time: 14:05 [ET]
Event Date: 09/21/2006
Event Time: 12:00 [EDT]
Last Update Date: 09/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
CINDY FLANNERY (NMSS)
ILTAB VIA EMAIL ()

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

Troxler Gauge model 3440, Serial number 24024, was stolen from the locked box in the back of the work truck at 1200 EDT on 09/21/06. The work truck was located at 1090 NW North River Drive, Miami during the theft. The lock on the storage box was cut with bolt cutters and the box remains in the vehicle. Miami-Dade Police have been notified and a police report is pending. The gauge contained a Cs-137 8 millicurie source, serial number 75-6012, and an Am-241 40 millicurie source, serial number 47-20055.

Florida Incident Number: FL06-119

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.

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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Power Reactor Event Number: 42860
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: MIKE MASON
HQ OPS Officer: BILL GOTT
Notification Date: 09/25/2006
Notification Time: 14:33 [ET]
Event Date: 09/07/2006
Event Time: 07:50 [CDT]
Last Update Date: 09/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
ZACH DUNHAM (R4)

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

Event Text

INVALID SYSTEM ACTUATION

"On September 7, 2006 at about 0750 CDST, an invalid actuation of B train Engineered Safety Features Actuation System (ESFAS) occurred during maintenance on ESFAS relay K110 B. The following B train Engineered Safety Features Actuation System (ESFAS) relays de-energized: K101, K102, K103, K108 and K109.

"The event is reportable per 10CFR 50.73(a)(2)(iv)(A) as a 60 day notification and is being reported to the NRC by phone within 60 days.

"The invalid actuations did not occur when the systems had already been properly removed from service nor after the safety function had already been completed.

"The 32B buss de-energized which resulted in loss of pressurizer heaters Bank B and Containment Fan Coolers B and D actuated by shifting to slow speed. There was no actual Emergency Core Cooling System (ECCS) system flows actuated.

"All of the affected equipment functioned as designed when the relays deenergized

"The NRC Senior Resident was informed of the event."

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Other Nuclear Material Event Number: 42861
Rep Org: WEAVER BOOS CONSULTATNS
Licensee: WEAVER BOOS CONSULTANTS
Region: 3
City: GRIFITH State: IN
County:
License #: 13-26305-01
Agreement: N
Docket:
NRC Notified By: DON WARD
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/25/2006
Notification Time: 15:08 [ET]
Event Date: 09/25/2006
Event Time: 13:00 [CST]
Last Update Date: 09/25/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
SONIA BURGESS (R3)
GREG MORELL (NMSS)

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

Event Text

TROXLER MOISTURE DENSITY GAUGE LOST DURING SHIPMENT


On 09/20/06 Troxler Naperville, IL office sent a Troxler Model # 3430 to Weaver Boos Consultant office located at 5677 DTC Blvd, Suite 102, Greenwood Village, CO. The gauge was to have arrived at the Weaver Boos Consultant, Greenwood Village, CO office on 09/22/06. Licensee contacted the shipper, FedEx. Fedex is looking for the gauge. The gauge contains 8 millicuries of Cesium-137 and 40 millicuries of Am-241/Be. The serial number of the gauge is 29815. The licensee reported this incident to NRC Region III office.

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.

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