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Event Notification Report for May 22, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/21/2007 - 05/22/2007

** EVENT NUMBERS **


43170 43378 43379

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General Information or Other Event Number: 43170
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: MATERIALS TESTING OF ARKANSAS
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-859
Agreement: Y
Docket:
NRC Notified By: BERNIE BEVILL
HQ OPS Officer: JOE O'HARA
Notification Date: 02/19/2007
Notification Time: 08:56 [ET]
Event Date: 02/19/2007
Event Time: [CST]
Last Update Date: 05/21/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
SCOTT MOORE (FSME)
R. WARREN ILTAB ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING STOLEN TROXLER MOISTURE DENSITY GAUGE MODEL 3440

The Arkansas Department of Health reported that one of their licensees, Materials Testing of Arkansas, had a Troxler moisture density gauge stolen from a pickup truck in front of a Wal-Mart in Little Rock, Arkansas between 6:00 a.m. and 6:30 a.m. CST. When the licensee returned to the vehicle, he found that the chain securing the gauge had been cut, and the Troxler and some other personal equipment had been stolen from the back of the vehicle. The Troxler is a Model 3440 S/N 19914 and contains 9 milli Curies of Cs-137 and 44 milli Curies of Am-241. The Little Rock Police Department is investigating the theft under case number 07-18990.

The Arkansas Department of Health is preparing a press release on this event.

*** UPDATE FROM STEVE MACK TO KNOKE AT 15:28 EDT ON 5/21/07 ***

The State provided the following information via facsimile:

"On Friday, May 18, 2007, the moisture density gauge stolen on February 19, 2007, was recovered in a vacant residence in Little Rock, Arkansas. The gauge transport case, as well as, the gauge handle were not locked when found. The gauge appeared to be undamaged and was transported to the licensee's authorized storage facility. Representatives from the Arkansas Radiation Control Program conducted a leak test in the field and the RSO was conducting a leak test for analysis by the licensee's consultant prior to placing the gauge back in service.

"The Department [Arkansas Department of Health] considers this event closed."

Notified R4DO (Johnson), FSME (Burgess), ILTAB (Via Email)


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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General Information or Other Event Number: 43378
Rep Org: WASHINGTON HOSPITAL CENTER
Licensee: BEST VASCULAR, INC.
Region: 1
City: WASHINGTON State: DC
County:
License #:
Agreement: N
Docket:
NRC Notified By: S. MOHAPATRA
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/21/2007
Notification Time: 15:08 [ET]
Event Date: 03/23/2007
Event Time: [EDT]
Last Update Date: 05/21/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
EUGENE COBEY (R1)
SCOTT MOORE (FSME)

Event Text

PART 21 DEFECT - BRACHYTHERAPY SEEDS UNABLE TO RETURN TO TRANSFER DEVICE AFTER TREATMENT

"Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect:

"Facility: Washington Hospital Center;
"Activity: IVRT using a Beta Cath System.

"Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect:

"Best Vascular, Inc. (formerly known as Novoste Corporation).

"Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply:

"The patient is treated with beta radiation using the Beta Cath device. For the treatment, the sources are monitored and confirmed in the correct treatment position by fluoroscopy. At the completion of treatment, sometimes the seeds are unable to return to the transfer device. Therefore, the beta-rail catheter with all the seeds in it is taken out immediately and placed in the bail out box. The box is then transported back to the storage area. Patient and the area are surveyed to ensure that they are free from all radiation sources. The patient receives the full dose as prescribed. No additional or unnecessary dose is delivered to the patient. There were no medical events. The hospital's Radiation Safety Officer and Best Vascular (Novoste) are notified when this incident occurs. A faulty device is returned to the manufacturer and not used on patients. An incident report is filed for each incident. The device with the catheter is shipped back to Best Vascular for disposal and a new replacement source is requested. The incident is deemed as equipment malfunction. It is an inherent problem with the device itself.

"The date on which the information of such defect or failure to comply was obtained:

"2007: 1/18/07, 2/12/07, 3/7/07 and 3/23/07
"2006: 9/7/06, 11/6/06
"2005: 2/18/05, 4/8/05, 4/14/05, 8/3/05, 10/6/05

"In the case of a basic component which contains a defect or fails to comply, the number and location of all such components in use at, supplied for, or being supplied for one or more facilities or activities subject to the regulations in this part:

"The device consists of a hydraulic system and it fails while retracting the sources after the treatment is complete. It happens for both 60 mm and 40 mm devices that we currently use.

"The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action:

"Corrective Action: The licensee always followed the manufacturer's emergency procedure.
"Organization: Washington Hospital Center

"Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees:

"Recommend the vendor to perform an extensive QC test before shipping the device to the customer. It may reduce the number of occurrences."

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Power Reactor Event Number: 43379
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: VERN CARLSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/21/2007
Notification Time: 19:17 [ET]
Event Date: 05/21/2007
Event Time: 12:31 [CDT]
Last Update Date: 05/21/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CLAUDE JOHNSON (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

POTENTIAL DIVISION 1 EDG DAMAGE DUE TO LOSS OF SERVICE WATER COOLING DURING CONTROL ROOM FIRE

"During a review of an Operating Experience issue (LO-GLO-2006-0090 CA5), a condition was found which is not consistent with the assumptions of the River Bend post-fire safe shutdown analysis. 10CFR50 Appendix R states that for alternate shutdown capability (i.e shutdown from outside the main control room) support systems (service water cooling) for critical post-fire safe shutdown components must remain free from fire damage. Generic Letter 86-10, 'Implementation of Fire Protection Requirements' state that the following assumptions are required for evaluation of a control room fire: 1) fire induced spurious operation of safe shutdown components has occurred; 2) offsite power is lost and; 3) loss of automatic starting of the onsite AC generators as well as the automatic function of valves and pumps whose circuits could be affected by a control room fire.

"In addition to loss of automatic start of the emergency diesel generators, the post-fire safe shutdown analysis must also evaluate the consequences if the diesel generators do start concurrent with fire induced multiple spurious actuations. Since control circuits for motor operated valves for the standby service water system are routed in the control room, fire induced shorts could place these valves in a position that would prevent service water from cooling the Division 1 emergency diesel generator. In the time required for Operations personnel to evacuate the control room and re-establish control of the standby service water system at the Division 1 Remote Shutdown panel, thermal damage to the diesel generators could render the Division 1 generator incapable from performing its post-fire function.

"The RBS [River Bend Station] post-fire safe shutdown analysis is based on the assumption that the diesel generator high temperature trip function would remain functional based on the fact that the trip logic is located outside of the main control room and therefore would remain free from fire damage. The investigation performed during the OE review uncovered the fact that at RBS when the emergency diesel generator is started in the emergency mode the non-safety trips (such as high temperature) are by-passed. The loss of off-site power starts the diesel generator in the emergency mode; therefore the high temperature trip is by-passed. With the non-safety trips by-passed, the diesel generator will continue to run even without sufficient cooling.

"This condition involves compliance with 10CFR50, Appendix R. Plant equipment remains capable of performing the remaining design functions. The scope of this analysis deficiency is limited to the Main Control room fire scenario, with multiple concurrent failures. The Control Room is continuously manned. The affected cables in the MCR under-floor area are protected by automatic fire detection and automatic suppression systems, which would rapidly detect and smother a fire. Introduction of ignition sources, such as work involving welding or grinding is strictly controlled by station procedures. Furthermore Standing Order #193 Revision 3 limits hot work in the main control room during Modes 1,2 and 3."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012