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Event Notification Report for July 25, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/24/2007 - 07/25/2007

** EVENT NUMBERS **


43504 43506 43507 43509 43515 43517 43518

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General Information or Other Event Number: 43504
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TEAM INDUSTRIAL SERVICES
Region: 3
City: EAST PALESTINE State: OH
County:
License #: 03320-99
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/19/2007
Notification Time: 09:39 [ET]
Event Date: 07/18/2007
Event Time: 11:00 [EDT]
Last Update Date: 07/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3)
SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT - DEFECTIVE RADIOGRAPHY CAMERA

The licensee provided the following information via email:

"Licensee notified [Ohio] Bureau of Radiation Protection (BRP) at approximately 11:00 AM on 7/18/07. Licensee reported that an Ir-192 radiography source in the guide tube of a radiography camera could not be fully retracted. Source is housed in an Amersham Model 660B camera (Serial number: B1558). Source activity is 86 curies. Source was being used at a temporary job site in East Palestine, Ohio. Radiography crew was from licensee's Pennsylvania office. Source was being used in a building away from customer's main production facilities, in a make-shift chamber behind 3 foot concrete block walls. Area has been secured by licensee personnel, roped off, with boundaries established to ensure no exposure to non-radiological workers or members of the public. Licensee stated that no over exposure licensee personnel are expected as a result of this occurrence. QSA Global has been contacted by licensee to assist with source retrieval. Information current as of 11:45 AM, 7/18/07.

"UPDATE: Ohio BRP Duty Officer received call from QSA Global requesting waiver of 3-day notification for reciprocity work to enter Ohio and retrieve stuck source. Permission was granted. QSA Global rep stated that they would not be on-site until Thursday, 7/19. Information current as of 5:00 PM, 7/18/07.

"UPDATE: BRP Duty Officer contacted Licensee rep at temporary job site to discuss security of the camera and source. Licensee stated that boundaries are being maintained at the site and that the licensee would have a two-man crew (radiographer and assistant) on site throughout the night until QSA Global arrived to effect repairs. Information current as of 5:30 PM, 7/18/07.

"UPDATE: BRP Duty Officer spoke with licensee personnel Thursday morning, 7/19/07. Licensee had crews in attendance at the site throughout the night to maintain security of temporary job site. Licensee stated that the radiography camera had been maintenenced and resourced approximately two weeks ago. After discussions with the manufacturer the licensee suspects that a spring clip at the connecting nut may have dislodged, causing the nut to become misaligned and preventing the source from retracting. QSA Global is expected on site at approximately 1:30 PM on today (7/19/07). Information current as of 9:25 AM, 7/19/07."

Equipment is being returned to manufacturer for repair or disposal.

Ohio Notice: OH070004

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General Information or Other Event Number: 43506
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SOUTH TEXAS CARDIOVASCULAR CONSULTANTS, PLLC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L03833-003
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/19/2007
Notification Time: 14:16 [ET]
Event Date: 07/18/2007
Event Time: 15:50 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF TEXAS

"On 07/18/07 at 3:50 pm, the agency received a telephone call from (deleted), the Chief Tech for the licensee, reporting the misadministration of patient involving Thallous Chloride. The nuclear medicine tech reported that a patient was injected twice with a total of 4mCi of Thallous Chloride.

"The licensee reported that the patient was informed the same day of the misadministration.

"Licensee was informed that the 30-day report is due 08/17/07."

Agency Action Taken: The licensee will submit the required written report within 30-days as per 25 Texas Administrative Code (TAC) 289.202(xx).

Texas Incident number: I-8427


* * * UPDATE PROVIDED BY CINDY FLANNERY TO JEFF ROTTON AT 0741 ON 07/24/07 * * *

This event (EN43506) has been reviewed and determined to NOT be a reportable medical event.

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General Information or Other Event Number: 43507
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: I Q DISTRIBUTORS/DIVERSIFIED MATERIALS SERVICES/DIVERSIFIED
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/19/2007
Notification Time: 17:08 [ET]
Event Date: 07/19/2007
Event Time: 14:32 [CDT]
Last Update Date: 07/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
E. WILLIAM BRACH (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF TEXAS


EVENT: Radioactive Material (RAM) found - sealed

License Number: "Unlicensed"

"The agency received a call at 2:15 p.m. today (7/19/07) from DSHS Food & Drug Inspector, (DELETED) inquiring about four radiation devices found with 1994 inspection stickers on each of them. She said there appears to be some concern as of what company owns them and the facility they are located at. She gave me three names of possible companies, or owners:

"I Q Distributors
"Diversified Materials Services
"Diversified Medical Services Inc.

"The facility is located at: 2400 Central Parkway, Suite LP in Houston, Texas 77092. She is currently on location.

"Agency Action Taken: Region 6 RAM Inspector to go to the facility as soon as possible to conduct incident investigation & identify sources."


Texas Incident Number: I-8428



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: 43509
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON-DICKINSON INFUSION THERAPY SYSTEM, INC
Region: 4
City: BROKEN BOW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: DEFRAIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/20/2007
Notification Time: 17:28 [ET]
Event Date: 07/19/2007
Event Time: 12:00 [CDT]
Last Update Date: 07/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
E. WILLIAM BRACH (FSME)

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF NEBRASKA


On 07/20/07 at 1445 CDT the Radiation Safety Officer for Becton-Dickinson Infusion Therapy System, Inc Pool Irradiator located in Broken Bow reported a component failure at the Pool Irradiator.

The Irradiator was operating on 07/19/07 when one of the totes carrying medical supplies to be sterilized became jammed in the irradiator. The alarm sounded as expected. The source of the Pool Irradiator went back to its shielded position, lowered back into the pool. The Control Panel for the pool irradiator did not indicate, light did not come on, that the source had gone back into the pool. The licensee went to the penthouse, above the irradiator pool, and found that there was no extra cable in the penthouse which indicated the source had gone to its safe position, entered the pool. Radiation readings taken in the penthouse also indicated that the source was in the pool.

The licensee tried to unlock the door to enter the maze to unjam the tote but they were unable to unlock the door because the control panel indicated that the source had not gone to its safe position.

The licensee then called MDS Nordion, manufacturer of the irradiator and owner of the irradiator fuel, and informed them of the problem. MDS Nordion informed them how to over ride the access system. After three tries they successfully over rode the access system, required 3 people at 3 different locations at the same time to over ride the system. After opening the access door 2 people with 2 separate radiation survey meters entered the maze. Normal back ground radiation levels were detected. It was found that the control switch indicating that the source was in its safe position was not in its correct position, down. The switch was replaced.

As of 07/20/07 the Pool Irradiator is operating.

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Power Reactor Event Number: 43515
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/24/2007
Notification Time: 10:40 [ET]
Event Date: 07/24/2007
Event Time: 02:56 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD SKOKOWSKI (R3)

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

Event Text

TECHNICAL SUPPORT CENTER VENTILATION INOPERABLE

"During performance of the Technical Support Center (TSC) Ventilation System Operability Test, an outside air damper failed to close causing a failure of the TSC Ventilation System to attain the required 0.125 inches water column positive pressure. If an emergency condition occurs during the time the repairs are being made, plans are to utilize the TSC as long as radiological conditions allow. Procedure F3-6 ACTIVATION AND OPERATION OF THE TSC, section 7.6, directs TSC management to relocate TSC activities to a radiological safe area if necessary."


The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43517
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: J. SCHROEDER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/24/2007
Notification Time: 19:51 [ET]
Event Date: 07/24/2007
Event Time: 09:02 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
LINDA SMITH (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

PLANT EMPLOYEE TESTED POSITIVE FOR ALCOHOL DURING A RANDOM FITNESS-FOR DUTY TEST

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been revoked. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector was notified of this event notification by the licensee.

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Power Reactor Event Number: 43518
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM A GOLDEN
HQ OPS Officer: JASON KOZAL
Notification Date: 07/24/2007
Notification Time: 22:05 [ET]
Event Date: 07/24/2007
Event Time: 16:45 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (R2)

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

HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO FAILED POWER SUPPLY

"At 1645 on 7/24/07 during the transfer to the Normal Power Supply of the 3A 250 RMQV Board upon completion of scheduled maintenance. Unit 3 High Pressure Coolant Injection system received a 120 VAC Power Failure and was declared inoperable. 120VAC HPCI power is supplied by the Unit 3 ECCS Div 2 Analog Trip Unit Inverter. The Inverter lost power during the 250vdc board transfer and was not able to be restored to service.

"Investigation is still continuing on the failure of the Div 2 ECCS Inverter.

"This event is reportable as an 8-hour Non-Emergency Notification in accordance with 10 CFR 50.72 (b)(3)(v)(B) as; 'Any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to: Remove Residual Heat' ; and 10 CFR 50.72 (b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to; mitigate the consequences of an accident.'

"This event also requires a 60 day written report in accordance with 10 CFR 50.73 (a)(2)(v)(B) and 10 CFR 50.73 (a)(2)(v)(D).

"NRC EVENT # 43518 was reported to Mr. Kozal and the NRC Resident (C. Stancil) was notified at 1925 CDST on 07/24/07."

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Thursday, March 29, 2012