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Event Notification Report for July 19, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/18/2007 - 07/19/2007

** EVENT NUMBERS **


43477 43489 43491 43493 43502 43503

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General Information or Other Event Number: 43477
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROFESSIONAL SERVICES INDUSTRIES, INC
Region: 4
City: DALLAS State: TX
County:
License #: L04940-00
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/09/2007
Notification Time: 15:38 [ET]
Event Date: 07/07/2007
Event Time: [CDT]
Last Update Date: 07/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
JOE GIITTER (FSME)
JIM WHITNEY EMAIL (TAB)
MEXICAN GOV'T EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - MISSING MOISTURE DENSITY GAUGE

The licensee provided the following information via email:

"On July 9, 2007, Corporate RSO for Professional Service Industries, called to report a moisture density gauge missing during quarterly inventory. The RSO reported that Troxler model 3430 S/N 30189 was missing when inventory was conducted on 07/07/07. The gauge contains two radioactive sources; an 8 mCi Cs-137 source S/N 750-2295, and a 40 mCi Am-241 source S/N 47-27166. The sources were leak tested on 03/14/07. The last known use of the device was on 06/09/07. The employee assigned the moisture density gauge returned the truck and keys to the office and did not return to work. It was assumed the gauge had been placed back into storage. It is possible the employee stole the gauge. The RSO reported that a list of about 20 pawnbrokers in the area were contacted and informed that there was a $500.00 reward offered for the return of the gauge. The RSO reported that the employee was wanted in California for back child support. Company representatives searched his former residence, but didn't find evidence of the gauge there. I [State] told the RSO that we would place a notice to the State Pawnbrokers Association. I [State] also suggested that, if they will accept it, he [RSO] should file a theft report with Dallas Police Department. The RSO asked that we notify the Pawnbrokers' Association of the reward offer and that it is a 'no questions asked' offer."

Texas Incident # I-8424

* * * UPDATE ON 7/18/2007 AT 1618 FROM LATISCHE HANSON TO MARK ABRAMOVITZ * * *

The State provided the following information via email:

The licensee has checked e-bay and local pawn shops and failed to find the gauge. On the advice from LLEA, a certified letter was sent on 7/11/2007 to the ex-employee who last had the gauge. When ten days expire, the licensee will re-contact LLEA and submit a theft report.

Notified the R4DO (Pick), FSME (Brach), ILTAB (e-mail) and Mexico (e-mail).

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: 43489
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: CARDINAL HEALTH PHARMACY SERVICES
Region: 1
City: WOBURN State: MA
County:
License #: 41-0366
Agreement: Y
Docket:
NRC Notified By: KANATH TRAEGDE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/13/2007
Notification Time: 13:59 [ET]
Event Date: 07/06/2007
Event Time: 04:10 [EDT]
Last Update Date: 07/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
SANDRA WASTLER (FSME)

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

Event Text

VEHICLE ACCIDENT DURING TRANSPORT OF RADIOPHARMACEUTICAL SOURCES

"On Friday, July 6, 2007, at approximately 4:10 am, an accident involving a vehicle transporting radiopharmaceuticals occurred on Route 3 North near Exit 32 in Chelmsford, Massachusetts. The Radiation Control Program (RCP) was informed about the accident via the State Police at approximately 5:15 am. The first responder from the RCP arrived at the scene of the accident at about 6:15 am.

"A vehicle carrying patient radiopharmaceutical doses had rolled over on Route 3 North beyond Exit 32, emptying 18 Type A transport containers onto the highway and over an embankment. A brook tributary to a lake is at the bottom of the embankment where the accident occurred. Six of the containers had dropped into brook. The rest were strewn about the highway and the embankment.

"The containers were carrying radiopharmaceuticals in the form of Tc-99m bulk and patient doses, F-18 in the form of FDG for PET imaging, and I-131 for patient therapy. The Tc-99m was transported in an internally shielded Type A nylon covered container and the I-131 and F-18 were transported in Type A shielded ammo boxes.

"In all, 17 of the 18 containers were recovered. None of the containers recovered had any external contamination. One ammo box had a torn off lid, but the tungsten syringe shield containing a dose of F-18 was not breached. The 18th ammo box container with 2 F-18 doses totaling 271.21 mCi was not recovered. However, the F-18 had decayed approximately 7 half-lives by 4:00 pm, so there was no radiological consequence. Since this box had fallen onto the bottom of the brook and, due to the fact that no other container was breached, it was concluded that the two tungsten syringe shields would not have been breached.

"There was no release of radioactive material in this event. There was not breach of any internal container housing the radioactive material.

"This event is considered closed. There were no radiological consequences to members of the public and emergency workers."

Attempts to recover the last container included using divers and metal detectors.

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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Hospital Event Number: 43491
Rep Org: FLORIDA BUREAU OF RAD CONTROL
Licensee: UNIVERSITY OF FLORIDA
Region: 1
City: GAINESVILLE State: FL
County:
License #: 0031-1
Agreement: Y
Docket:
NRC Notified By: GEORGE SNYDER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/13/2007
Notification Time: 15:53 [ET]
Event Date: 07/11/2007
Event Time: [EDT]
Last Update Date: 07/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAYMOND LORSON (R1)
JOSEPH HOLONICH (FSME)

Event Text

AGREEMENT STATE - INADVERTANT DOSE TO PATIENT GALLBLADDER

The State provided the following information via facsimile:

"On July 11 a SIR-Spheres procedure was performed to treat a carcinoma on the liver. After review of the CT images on July 12, the physicist believes that 20% of the dose went to the gallbladder (which sits on top of the liver). The doctor and patient were notified on July 12. Licensee will follow up with patient in future visits to determine if there is any gallbladder damage. This office was notified on July 13. Licensee will submit a written report. Florida is investigating."

Typically, a sphere contains 2270 MBq of Y-90.

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: 43493
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CITY OF HOPE
Region: 4
City: DUARTE State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/16/2007
Notification Time: 20:38 [ET]
Event Date: 07/15/2007
Event Time: 22:00 [PDT]
Last Update Date: 07/16/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
JOSEPH HOLONICH (FSME)

Event Text

AGREEMENT STATE REPORT - UNPLANNED EXPOSURE DURING CALIBRATION TEST

The State provided the following information via facsimile:

A doctor was performing a monthly calibration test and position verification test. During the test, an error message was received using a dummy source. The doctor entered the room with a survey meter which showed no elevated radiation reading. The emergency handwheel was used to retract the dummy wire. After about 12 turns, the room radiation alarms initiated and the doctor left the room. Troubleshooting disclosed that the source had become exposed and the doctor received approximately 75 Mr exposure.

Source: Ir-192, 5.2 Curies
Varian Medical Systems model Varisource HDR

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Power Reactor Event Number: 43502
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2007
Notification Time: 18:07 [ET]
Event Date: 07/18/2007
Event Time: 15:49 [EDT]
Last Update Date: 07/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JIM KRAFTY (R1)

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

Event Text

SPILL OF ETHYLENE GLYCOL REPORTED TO STATE

"Notified New Jersey D.E.P. [Department of Environmental Protection] of a spill of ethylene glycol in the Site Emergency Building at Oyster Creek. The spill was reported to NJDEP in accordance with N.J.A.E. 7:1.E, 7:26. The spill was contained and cleaned."

The spill occurred during work on the Site Emergency Building air conditioning system.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43503
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE BRUNSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2007
Notification Time: 18:43 [ET]
Event Date: 07/18/2007
Event Time: 12:20 [EDT]
Last Update Date: 07/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MARK LESSER (R2)

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

UNANALYZED CONDITION - VENT SPACE LESS THAN DESIGN BASIS

"During an inspection of the Unit 2 Reactor Building Steam Chase as a result of a similar situation being previously discovered on Unit 1, a storage gangbox was noted to be resting on one of the two hinged blowoff panels in the floor of the Steam Chase (elevation 130') and the hinged blowoff panels were determined to be restrained which would prevent their opening. The blowoff panels are designed to open to provide pressure and temperature relief between the torus room and 130 ft elevation of the reactor building for high energy steam line breaks. The 'as found' configuration of the blowoff panels hinder their capability to open, which constitutes a non-conforming and unanalyzed condition in that the vent area between the torus room and main steam chase in the reactor building is less than the area assumed in the analysis for a HPCl steam line break.

"As such, for a HPCl steam line break in the torus room, the short term pressure across the torus room ceiling would likely be greater than 2.3 psid, which is the maximum differential pressure stated in Chapter 15A of the Unit 2 FSAR. There is no known analyzed limit for the differential pressure between the torus room and the 130 ft elevation of the reactor building. The actual differential pressure given the 'as found' condition is not known at this time.

"Corrective actions have been taken to restore the assumed vent area between the torus room and the reactor building 130ft elevation. The gang box has been removed and both blow off panels no longer have restricted movement. The remaining 3' x 3' floor plug has also been removed, completely restoring the assumed vent area into compliance. Based on this information there is reasonable assurance that an adequate vent path currently exists such that the plant is no longer considered to be in a condition that significantly degrades plant safety.

"However, since the actual differential pressure given the 'as found' condition is not known at this time, the 'as found' condition as previously discussed is assumed to be an unanalyzed condition that represents a condition that significantly degraded plant safety; however, additional information is needed in order to more conclusively determine this. If more conclusive information is provided that indicates otherwise an update notification will follow."

This was also reported under 10CFR50.72(b)(3)(v)(D).

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012