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Event Notification Report for July 31, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/30/2007 - 07/31/2007

** EVENT NUMBERS **


43515 43516 43519 43521 43522 43536

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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: 07/30/2007
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.

* * * UPDATE ON 07/30/07 AT 1449 EDT FROM MARK LOOSBROCK TO MACKINNON * * *

Technical Support Center (TSC) Ventilation System is now operable. R3DO (Steve Orth) notified.

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

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Hospital Event Number: 43516
Rep Org: LESTER COX MEDICAL CENTER
Licensee: LESTER COX MEDICAL CENTER
Region: 3
City: SPRINGFIELD State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: JOHN PACYNIAK
HQ OPS Officer: JASON KOZAL
Notification Date: 07/24/2007
Notification Time: 14:15 [ET]
Event Date: 07/24/2007
Event Time: 10:00 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD SKOKOWSKI (R3)
CINDY FLANNERY (FSME)

Event Text

MEDICAL EVENT - ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE

The treatment consisted of 3 fractionated high dose rate (HDR) brachytherapy procedures. The dose was prescribed by the physician at 5 millimeters from the surface of the cylinder, however, the dose was calculated at the surface of the cylinder. The HDR brachytherapy was administered at 5 millimeters as prescribed. Due to the discrepancy between the prescribed and calculated dose an under dose of the patient of over 4 Grays (Gy) resulted. The prescription was for an administration of 15 Gy. Only 10.3 Gy was administered. The physician is planning to add one more fraction to complete the intended treatment of 15 Gy. The patient will be informed of this misadministration.

The licensee indicated that they will verify the prescription and the film prior to administration to insure consistency between the two. Additionally, when the dose distribution is plotted, the licensee will overlay the cylinder over the dose distribution to visually verify the dose.

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: 43519
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: TEAM INDUSTRIAL
Region: 4
City: TULSA State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/25/2007
Notification Time: 06:52 [ET]
Event Date: 07/25/2007
Event Time: 04:30 [CDT]
Last Update Date: 07/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
CINDY FLANNERY (FSME)
RANDY ERICKSON (R4)

Event Text

SOURCE STUCK OUTSIDE OF RADIOGRAPHY CAMERA

Team Industrial was performing radiography at the Sinclair Refinery in Tulsa, Oklahoma approximately 25 feet above the ground. During the exposure, the camera fell approximately 3-4 feet onto scaffolding. The fall damaged the ball joint connecting the source to the retraction wire i.e. the source will not retract. The RSO has contacted their corporate office and is contracting with a source retrieval company. The area has been secured and cordoned off. Inability to enter this area does not affect continued refinery operation. The radiography technician received a dose of 40 mR during this incident.

Source: 27 Ci Ir-192
Camera: Amersham 880D

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General Information or Other Event Number: 43521
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SAVOY TECHNICAL SERVICES
Region: 4
City: SULPHUR State: LA
County:
License #: LA-11235-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2007
Notification Time: 14:17 [ET]
Event Date: 07/23/2007
Event Time: [CDT]
Last Update Date: 07/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA STUCK CONTROL ASSEMBLY

The State provided the following information via facsimile:

"During a routine maintenance inspection it was noted that the control assembly [of the radiography camera] would not project or retract the drive cable. After an investigation, it was found that 2 of 4 'small gear housing' screws were interfering with the gear teeth of the large gear.

"The two screws that interfere with the operation of the large gear only interfere when they are loose in the housing. Since the outside of the small housing is where the handle for the controls is kept, the screws inevitably come loose over time and use. Since the screws are applied in the housing there is no way to tighten the small housing screws with out disassembling the control arm assembly.

"A small design change is needed on these 4 small housing screws to prevent a source from stuck out in the shielded position."

Equipment involved: SPEC 150, (no serial number provided), Source: Ir-192 (no source strength provided), Control assembly: SPEC 'Red-Red' conduit control.

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Hospital Event Number: 43522
Rep Org: LOUDOUN HOSPITAL
Licensee: LOUDOUN HOSPITAL
Region: 1
City: LEESBURG State: VA
County:
License #: 45-16806-01
Agreement: N
Docket:
NRC Notified By: ANNE PATTERSON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2007
Notification Time: 16:02 [ET]
Event Date: 07/24/2007
Event Time: 15:30 [EDT]
Last Update Date: 07/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAT FINNEY (R1)
ILTAB (E-MAIL) ()
CINDY FLANNERY (FSME)

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

Event Text

LOST I-125 SEED

The licensee was performing a prostate seed case requiring 12 loose I-125 seeds with an activity of .34 mCi each. The seeds were assayed in the licensee hot lab and transported to the operating room for the procedure. After completion of the procedure only 11 seeds were accounted for. The RSO was notified. The seed was verified to not be in the patient. The licensee completed search for the material throughout the operating room and hot lab with no success. The licensee contacted the NRC Region 1 representative.


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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Other Nuclear Material Event Number: 43536
Rep Org: US EPA
Licensee: US EPA
Region: 3
City: CINCINNATI State: OH
County:
License #: 34-12736-02
Agreement: Y
Docket:
NRC Notified By: RICK FALK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/30/2007
Notification Time: 16:25 [ET]
Event Date: 07/30/2007
Event Time: 16:25 [EDT]
Last Update Date: 07/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)
ILTAB (e-mailed) ()

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

Event Text

MISSING/LOST NICKEL-63 15 MILLICURIE SOURCE

The Radiation Safety Officer (RSO) for The United States Environmental Protection Agency located in Cincinnati, OH reported they are missing a 15 millicurie Ni-63 source. The source was last seen December 01, 2006 when its 6 month leak test was performed. After the source was leak tested, the source was placed back in an unlocked drawer, where it has been kept since December 2001. The source was located below the HP Model # 5890 Series II Gas Chromatograph in which is it was used. The RSO said that they have been looking for the missing source since early June and they have been unable to find the source. The RSO said that anybody working for the US EPA in their building can enter the room in which the source was stored.



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.

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