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Event Notification Report for January 25, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/24/2007 - 01/25/2007

** EVENT NUMBERS **


43035 43110 43117 43118

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General Information or Other Event Number: 43035
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: JASON KOZAL
Notification Date: 12/06/2006
Notification Time: 16:16 [ET]
Event Date: 11/29/2006
Event Time: [PST]
Last Update Date: 01/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
GARY JANOSKO (NMSS)

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

Event Text

AGREEMENT STATE REPORT - LOST CANCER THERAPY SEEDS

The State provided the following information via email:

"Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006)

"Location of Event: Seattle, Washington (main campus operating room)

"ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention.

"Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries).

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected.

"Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known.

"Disposition/recovery: To be determined.

"Leak test? Original, by Manufacturer, within past six months.

"Release of activity? The seeds were apparently released to the waste water drain. No contamination was found.

"Consequences: None so far, none expected."

WA-06-068

* * * UPDATE FROM A. SCROGGS TO W. GOTT AT 1455 ON 01/24/07 * * *

The State provided the following information via email:

"The actual cause was determined to be inadequate training of the CS employee. The licensee has revised the procedure for handling seed implants. Now only a properly trained scrub nurse or tech will handle the applicator and accessories. At this time no consequences are expected and there has been no media attention." The six missing sources were never recovered.

Notified R4DO (M. Hay) and NMSSEO (G. Morell)


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: 43110
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MIDWEST INSPECTIONS INDUSTRIAL RADIOGRAPHY COMPANY
Region: 4
City: MCALESTER State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JASON KOZAL
Notification Date: 01/21/2007
Notification Time: 19:43 [ET]
Event Date: 01/21/2007
Event Time: 14:00 [CST]
Last Update Date: 01/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
SCOTT FLANDERS (NMSS)
BENJAMIN SANDLER (TAS)
JEFFREY CRUZ (IRD)
BOMER (DHS)
BARDEN (FEMA)
YATES (DOE)
PAULES (EPA)
JIMINEZ (USDA)
MILLER (HHS)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST RADIOGRAPHY CAMERA

On 1/20/07 at approximately 1400 CST, a licensee radiographer was transiting down a lease road in his vehicle (white 2001 or 2002 Dodge diesel pickup truck with a fiberglass radiographer dark room on the back) with a radiography camera secured in a yellow box in the back. The radiographer attempted to cross moving water. When the radiographer attempted to cross the water the engine was stalled by the flow of water. The water started to flow into the truck over the doors. The radiographer evacuated the truck. The truck was subsequently swept away. Oklahoma Emergency Management, Local Law Enforcement and the Oklahoma State Police were notified and initiated a search for the lost camera. The search was conducted on the ground and in the air via a helicopter. The licensee RSO was notified and is en route to the area.

At this time the camera has been not located, but a log jam was discovered down stream of where the truck was swept away and it is not believed that the truck could have passed this log jam. The search has been called off due to darkness. The area that the camera is suspected to be is very remote and lightly populated. It is between the towns of McAlester, OK and Calvin, OK. It is unlikely that the camera could relocate to a populated area. The search will resume on 1/22/07 at 0700 CST.

The camera is a new Industrial Nuclear Corporation model Ir-192 camera. The source strength is 100 Ci.

Notified NORTHCOM (via e-mail)

* * * UPDATE FROM STATE OF OKLAHOMA (BRODERICK) TO HUFFMAN AT 0940 EST ON 1/22/07 * * *

The State of Oklahoma representative reports that the pickup truck is believed to have been located downstream of where it was swept into the water. The location is known as "Coal Creek." Only the shell of the truck can be seen but it is the judgment of those at the scene that the shell is still attached to the truck. Local law enforcement is at the site and has secured it from unauthorized entry. The camera was reported to be in an ammo box that was locked and welded to the bed of the pickup truck so it is likely also still attached to the truck. Because of the unsafe conditions in the creek at this time, the site will remain secured and attempts to retrieve the truck will be made when the water flow is reduced and the levels receded. The State estimates that retrieval will not be until sometime in the morning of Tuesday, January 23. The State indicated that there is media interest in this event and that a press release is being prepared.

R4DO (Hay), NMSS EO (Burgess), IRD (Cruz), and ILTAB (Sandler) notified.


* * * UPDATE FROM STATE OF OKLAHOMA (BRODERICK) TO KOZAL AT 1459 EST ON 1/22/07 * * *

The State provided the following information via email:

"The search was resumed on the morning of the 22nd, and searchers quickly located the truck. The top of the camper was visible from the bank. This area was impacted by the snow and ice storms of recent weeks, and the creek is high because of runoff of snow melt. The water is fast moving and cold. Searchers felt there was substantial risk in accessing the truck in these conditions. Local sources estimate the creek will return to a more normal level enabling safe access to the source sometime Tuesday. The licensee plans to maintain security on the truck and source, but let it stay where it is until then. DEQ concurred with this decision.

"At about 1 PM on the 22nd, the licensee reported that the water level had dropped and about half the camper shell is above water. It looks intact, and the door of the camper appears to still be locked. They still expect to be able to access the truck on the 23rd.

"The camper appears intact, and it is assumed that the source is inside the camera inside the locked ammo box in the camper. The ammo box is bolted to the bed of the truck [not welded, as was previously erroneously reported to NRC], and it is assumed that the source is still present. This incident was reported on television and print media. DEQ has prepared a press release in case one is needed, but does not plan to issue it at this time. DEQ staff are en route to the area and will be present tomorrow during recovery. They will also interview the radiographer and assistant involved in the accident."

R4DO (Hay), NMSS EO (Burgess), IRD (Cruz), and ILTAB (Sandler) notified.

* * * UPDATE FROM STATE OF OKLAHOMA (BRODERICK) TO KOZAL AT 1031 EST ON 1/23/07 * * *

The State provided the following information via email:

"The water has not gone down enough to allow safe access to the truck this morning, and is not expected to drop enough today to allow it. The licensee is now hoping for access to the truck tomorrow."

The licensee will continue to provide security for the truck.

R4DO (Hay), NMSS EO (Morell), IRD (Blount), and ILTAB (Sandler) notified.

* * * UPDATE FROM STATE OF OKLAHOMA (BRODERICK) TO GOTT AT 1450 EST ON 1/24/07 * * *

The State provided the following information via email:

"The licensee has recovered the camera. It appears to be intact. As a precautionary measure, DEQ staff will take surveys and wipe tests of the camera and return to the office."

Notified R4DO (Hay), NMSS EO (Morell), IRD (Blount), ILTAB (Sandler), DHS (Constantopoulos), FEMA (M. Laforty), DOE (M. Smith), USDA (A. Paris), NORTHCOM (Maj. Martin), and HHS ( M. Dalziel).


THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

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Other Nuclear Material Event Number: 43117
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: LARRY RUSSELL
HQ OPS Officer: PETE SNYDER
Notification Date: 01/24/2007
Notification Time: 14:05 [ET]
Event Date: 01/13/2007
Event Time: 12:30 [YST]
Last Update Date: 01/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL HAY (R4)
GREG MORELL (NMSS)

Event Text

FAILURE OF RADIOGRAPHY CAMERA SOURCE TO FULLY RETRACT

On January 13, 2006, at 12:30 am local time, while performing a radiography at the facility in Kuparuk, Alaska, the radiography camera source failed to fully retract into the shielded position. The radiographer contacted the Level 2 Radiographer who shielded the camera and was able to fully retract the source. No over-exposures occurred.

The camera is a INC Model IR-100, serial number 6631 with a source serial number of J744. The typical original Ir-192 source strength of this type of radiography camera is about 100 curies. Kakivik Asset Management has contacted the manufacturer of the camera about this occurrence and other similar occurrences.

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Power Reactor Event Number: 43118
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ELLIS VANN
HQ OPS Officer: PETE SNYDER
Notification Date: 01/24/2007
Notification Time: 18:08 [ET]
Event Date: 01/24/2007
Event Time: 09:55 [CST]
Last Update Date: 01/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVE PASSEHL (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

MISSING PIPE CLAMP BOLT FOUND ON HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM

"During a RFO-20 pre-outage inspection of HPCl Injection Line Pipe Support EBB-5-SR-9, it was noted that one of the two pipe clamp bolts (i.e. stud, nuts, and spacer) was missing. This rendered HPCl and Primary Containment inoperable. Technical Specifications 3.5.1 Condition F for HPCl inoperable, and 3.6.1.1 Condition A for Primary Containment inoperable, were entered. Since Primary Containment operability was not restored within one hour, Technical Specification 3.6.1.1 Condition B to be in Mode 3 in 12 hours and Mode 4 in 36 hours was entered.

"At 1649 the pipe clamp was restored, HPCl and Primary Containment were declared operable, and Technical Specifications 3.5.1 Condition F and 3.6.1.1 Conditions A and B were exited.

"This event is reportable as an 8 hour event under 10 CFR 50.72(b)(3)(ii)(A), Any event or condition that results in: (A) The condition of the nuclear power plant, including its principal safety barriers, being seriously degraded and 10CFR 50.72(b)(3)(v)(D), Any event or condition that alone at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (D) Mitigate the consequences of an accident."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012