Event Notification Report for May 31, 2007

ONE HOUR REPORT NOTIFICATION: COMBUSTIBLE MATERIAL EXCEEDING ITEM RELIED ON FOR SAFETY (IROFS) LIMITS FOUND

"BACKGROUND:
"AREVA NP Richland routinely stores unmoderated uranium oxide powder ( < 1.0 wt.% moisture and < 1.0 wt.% moisture equivalent of approved additives) in metal 45-gallon drums with neutron absorbing inserts in warehouse #6. Metal 5-gallon pails containing no more than 18 kg of powder placed 4 per 25 inch X 25 inch metal pallet are also allowed to be stored in this warehouse in the same locations authorized to store 45-gallon drums. The option to storage of 5-gallon buckets in warehouse 6 is only occasionally used.

"EVENT DESCRIPTION:
"On May 31, 2007 at approximately 1640 PDT, a member of the AREVA safety staff completed a calculation to determine the volume of combustible material present in wooden pallets being used to store empty 45-gallon drum in the aisle between storage locations in warehouse 6. The presence of 27 wooden pallets had been observed during a previous walkthrough of the SNM storage warehouse. The volume of combustible material present in these pallets was about 56 [cubic feet]. The definition of failure of the administrative IROFS that restricts the amount of combustible material in this area is 54 [cubic feet].

"Currently the only SNM storage containers present in warehouse 6 are 45-gallon drums with neutron absorbing inserts. When these 45-gallon drums are stored in this area accidental nuclear criticality remains 'highly unlikely' even when the IROFS limiting the presence of combustible material fails.

"However, if the restriction on the amount of combustible material fails and uranium oxide powder is stored in 5-gallon containers in this warehouse only a single IROFS would be present and accidental criticality does not remain highly unlikely.

"SAFETY SIGNIFICANCE OF EVENT:
"The safety significance of this condition is low because an accidental nuclear criticality for the as-found condition (only 45-gallon drums are currently being used to store uranium oxide powder) is still highly unlikely. Note: The condition being reported is only a potential but authorized plant condition. Furthermore, the municipal fire department works closely with the AREVA emergency response organization (ERO) when they respond to plant abnormal events and emergencies. The NCS organization is an integral part of the ERO and participates in the decision making during such events if NCS concerns exist.

"There have been no known fires in this warehouse during its existence of over 20 years.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR):
"Criticality could potentially occur during firefighting if the SNM in storage looses geometry control coincident with moderation.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):
"The process parameters controlled in the various storage warehouses include geometry, mass, moderation and neutron absorbers depending upon the storage configuration.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
"Plant-wide fire controls are established to ensure that large fires that would require the intervention by the municipal fire department are highly unlikely. This assures that the potential NCS concerns relative to fire-fighting with water are compliant with regulatory requirements.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
"After discovery of the deficiency, the combustible material was removed from the warehouse. The material is currently compliant with the above listed requirements."

AGREEMENT STATE REPORT OF A MEDICAL EVENT INVOLVING AN UNDERDOSE

The following information was received via email from the State of Wisconsin:

"Event Report ID No.: WI070011

"License No.: 079-1281-01
"Licensee: Aurora St. Luke's Medical Center

"Event Location: Aurora St. Luke's Medical Center, Milwaukee, WI

"Event Type: Medical Event
"Notifications: RSO called DHFS 5/31/2007

"Event description: On the morning of 5/31/2007 a Y-90 TheraSphere procedure was attempted. 1.05 GBq (28.3 mCi) was prescribed by the authorized user's written directive to deliver 123 Gy to the patient tumor. The activity in the dose vial was in agreement with this written directive. The TheraSphere Delivery Device (TDD) was appropriately set up by the radiopharmacist and the RSO, following the check list provided by the TheraSphere manufacturer, MDS Nordion. The interventional radiologist prepared the patient under fluoroscopy and positioned the catheter to fit his desired treatment site. This was completed at 9:30 a.m. At 9:40 the TDD was attached to the catheter. The TheraSphere injection was then started by the authorized user. The RSO was monitoring the radiation exposure in the room and did not see the normally-expected rise in exposure rate as the TheraSpheres enter the catheter and then the patient. After a few moments (after the injection of about half the balloon-inflator/syringe) the injection was stopped to evaluate what had happened. The authorized user and RSO then noticed that the blue stopcock was in the wrong position, directing the TheraSpheres into the waste vial and not into the patient.

"A radiation survey revealed that most of the radioactivity was now in the waste vial, very little (if any) in the patient, and some possibly remaining in the dose vial. It was decided to complete the normal four flushes of the dose vial into the patient, and to estimate the administered dose based on the activity in the waste vial.

"After the procedure the activity in the waste vial was measured in the dose calibrator in nuclear medicine. 25.9 mCi Y-90 was measured at 10:40 a.m. This constitutes approximately 94% of the activity that was originally in the dose vial (accounting for decay).

"The RSO estimates the dose delivered to the target volume in the patient liver is 6% of the intended dose, or 7 Gy.

"At 11:00 a.m. the RSO measured the exposure rate at the surface of the patient to be 0.00 Mr/hr with a GM survey meter and 0.0 Mr/hr with an ionization survey meter. Therefore, very little of the activity was injected into the patient. The waste vial is now being held for decay-in-storage. All personnel in the procedure, the TDD, and the room were surveyed and found to be free of contamination.

"The patient will be scheduled for re-treatment in the next few weeks.

"The licensee is evaluating the checklist provided by the manufacturer. DHFS will review the licensee's 15-day report and evaluate the licensee's proposed corrective actions.

"Media attention: None"

* * * UPDATE AT 1128 EDT ON 6/1/07 FROM FSME (FLANNERY) TO J. ROTTON * * *

This event (EN43398) has been reviewed and determined to be a reportable medical event.

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.

AGREEMENT STATE REPORT - POTENTIAL PERSONNEL OVEREXPOSURE

The State provided the following information via facsimile:

"Agreement State Agency: Louisiana Department of Environmental Quality

"Event Report ID No.: LA070019

"License No.: LA-7396-L01

"Licensee: Oceaneering International, Inc

"Event date and Time: May 2007

"Event Location: Houma, LA

"Event type: Overexposure

"Notifications: LA DEQ

"Event description: Oceaneering received a notification from Landauer that one of Oceaneering's employees was over exposed for the month of May 2007. The dose that was reported for this employee was 5467 mrem (deep), 5677 (eye), and 5892 (shallow). This incident will be investigated and DEQ will forward new information once it is received.

Transport vehicle description: N/A

AGREEMENT STATE REPORT - DAMAGED TROXLER

This event took place in the Southmoor Subdivision, Phase 2, Eagle Mountain, UT.

"This event involved Troxler, model 3440, serial number 28420, containing 8 [millicuries] of Cs-137 and 40 mCi of Am-241:Be. The technician was testing sidewalk compaction ahead of the cement crew and was trying to keep ahead of the concrete truck. To do so, the technician would put the gauge in the back of his truck and drive about 200 feet along to the next test site. The gauge was not put in the transportation box nor was it secured. The technician drove off the asphalted road onto a 'roughed in' dirt road. When the truck hit the bump, the Troxler gauge slid or bounced out of the truck and hit the asphalt. The technician realized very quickly that the gauge was no longer in the truck and could see it approximately 200 feet behind the vehicle. Initially, the source rod remained in the safe shielded position, but the technician tried to lift the gauge by the handle and the source rod totally detached from the remaining portion of the gauge.

"The Am-241:Be source was not damaged and remained in place."

UT Event Report ID No.: UT-07-006

LOSS OF EMERGENCY PLAN SIRENS DUE TO 69KV DISTRIBUTION SYSTEM FAULT

"At 02:10 am CDT Wolf Creek's surrounding area experienced a power loss when a fault occurred in the 69KV distribution system. Power was lost in the cities of Burlington, New Strawn and the surrounding area. Wolf Creek's emergency plan sirens are powered from substations fed from the 69 KV distribution system. Associated with this power loss, Wolf Creek initially lost power to seven [of 11 total] Emergency Sirens. Four of the sirens had power restored in approximately 5 minutes, the remaining three Emergency Sirens remained without power for greater than 2 hours. Power was restored to the area surrounding Wolf Creek at approximately 04:30 am CDT. The Coffey County Sheriff's office was kept informed of siren status in the event that they would need to make local notifications. Wolf Creek remained connected to the electrical grid through all three 345 KV lines during the loss of the 69 KV system.

"Coffey County, Kansas Department of Health and Environment, Kansas Department of Emergency Management and the Federal Emergency Management Agency Region 7 have been notified of the loss of sirens.

"The Wolf Creek Communications Group has physically verified that all sirens have been returned to service."

The licensee notified the NRC Resident Inspector.