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Event Notification Report for August 6, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/03/2007 - 08/06/2007

** EVENT NUMBERS **


43535 43539 43540 43546 43548 43549

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General Information or Other Event Number: 43535
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOE O'HARA
Notification Date: 07/30/2007
Notification Time: 14:30 [ET]
Event Date: 07/17/2007
Event Time: 10:00 [PDT]
Last Update Date: 07/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
MICHELE BURGESS (FSME)

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

Event Text

AGREEMENT STATE REPORT - SIX LOST PALLADIUM - 103 SEEDS

The following information was received via e-mail:

"This is notification of an event in Washington State as reported to the WA Department of Health, Office of Radiation Protection.

"STATUS: Update/Closed
"Licensee: Swedish Medical Center
"City and State: Seattle, Washington
"License Number: WN-M008-1
"Type of License: Broad, Medical
"Date and time of Event: July 17, 2007, about 10 am.
"Location of Event: First Hill Campus, Operating Room, Seattle WA.

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"The licensee reported that beginning at 7:30 am on July 17, 2007; they administered 96 of 102 Palladium-103, prostate cancer therapy seeds. The 6 remaining seeds were counted and placed in a glass storage vial. The vial was labeled and put into a leaded storage container and then placed in the procedure room source storage area.

"At 10 am, it was noted that only a single storage vial was present where two were expected since two cases had been completed by that time. The rooms, waste containers and other items and adjacent areas were searched and surveyed. A survey of the biohazard storage room was also conducted with no readings above background detected at any of the locations. Others involved with the implants searched and were also unable to find the seeds.

"At 2:30 pm the RSO was notified. Another search and survey with a Ludlum Model 2221 scaler/rate meter using a model 44-3 probe was conducted at that time. An on site search through the trash compactor of approximately of the total waste in the compactor was also unsuccessful at finding them. The staff reviewed the implant records and determined that 6 seeds were still missing. At 8:50 pm, the RSO stopped the search and declared the seeds lost. At approximately 9:20 pm, the RSO transmitted an electronic notification to Washington DOH regarding the 6 missing prostate seeds.

"On July 18, 2007, at 8:30 am, the RSO learned the majority of the linens from the previous day's procedure were still on the loading dock. The RSO had the linen carts segregated and conducted a search and survey. The RSO completed this search and did not find the seeds in the linens. The off site laundry facility was contacted. The laundry facility manager indicated that no containers were found and they would be on the lookout for such a container.

"After reviewing the timeline and interviewing staff regarding the events, the RSO has determined the cause of the event was inattention to detail and human error on the part of the staff responsible for seed count and reconciliation.

"An analysis of the seed count and reconciliation process indicates that keeping the unused seeds in the procedure room until all cases for the day have been completed may have contributed to this event. The RSO has immediately required that at the completion of each individual procedure the unused seeds are removed from the procedure room and an independent count of the seeds conducted. This is to be performed before the next case occurs to allow immediate survey of the procedure room in the event the seed count cannot be reconciled. The RSO also has stipulated that trained staff must be present for all procedures while seeds are in use.

"The RSO has scheduled training for July 26, 2007 to review this event with all operating room staff involved with this procedure. The RSO will also review the procedural changes that have occurred as a consequence of this event. Immediately contacting the RSO will also be emphasized to other users of radioactive material at their periodic radiation safety training and to new users during their orientation.

"The department considered the licensee to have made every reasonable effort to locate the seeds. Therefore the department did not conduct an on-site investigation.

"Notification Reporting Criteria: WAC 246-221-240 Reports of Stolen, Lost, or Missing Radiation Sources .
"Isotope and Activity involved: Palladium-103 seeds (six), 1.08 mCi/seed average.
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): No
"Lost, Stolen or Damaged? (mfg., model, serial number): LOST: Six Palladium-103 therapy seeds (no SN's), TheraSeed model 200 , manufactured by TheraGenics, 1.08 mCi/seed average, total of 6.48 mCi.
"Disposition/recovery: Irretrievably lost, no recovery expected.
"Leak test? N/A
"Vehicle: N/A.
"Release of activity? Other than the loss of the 6 seeds, none.
"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual): consequences: None expected.
"Was patient or responsible relative notified? No.
"Was written report provided to patient? No.
"Was referring physician notified? Yes, on July 18, 2007.
"Consultant used? No.

Washington Report: WA-07-068

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: 43539
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/31/2007
Notification Time: 15:40 [ET]
Event Date: 07/16/2007
Event Time: 12:00 [CDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM WISCONSIN - LOSS OF TWO PALLADIUM-103 SEEDS

RSO telephoned DHFS July 31, 2007.

"The RSO notified DHFS by telephone of the possible loss of two Pd-103 implant seeds. The two seeds were unaccounted for following a July 16, 2007 prostate seed implant procedure.

"During the procedure, the Physicist was making the strands using the BARD QuickLink system. About half way through the case he made a relatively long link. When the authorized User tried to load this link it was easily traveling through the implant needle so he retracted it and emptied the entire strand on the OR table backwards through the needle. A new link was made and properly implanted into the patient. Because they needed to use nearly all the ordered seeds for the procedure, the Physicist attempted to take apart the problem link using a pair of tweezers. This required some force to separate the links and seeds. While doing this at least two of the links separated and 'flew' off the table. The past experience with seeds falling in the operating room was that they were relatively easy to find immediately post procedure with the survey meter, so they completed the implant. The on-going inventory indicated there would be 5 leftover seeds. Multiple surveys of the operating room resulted in the recovery of 3 seeds. Surveys of all bed linens were conducted, no additional seeds were located."

The patient will be returning to the facility for routine post implant CT imaging. The implant seed count will be repeated at that time.

Event Report ID No.: WI070015


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: 43540
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: DBA WELDSONIX INC
Region: 3
City: ROME State: WI
County:
License #: TX L05718
Agreement: Y
Docket:
NRC Notified By: KURT PEDERSEN
HQ OPS Officer: JOE O'HARA
Notification Date: 07/31/2007
Notification Time: 16:07 [ET]
Event Date: 07/31/2007
Event Time: [CDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3)
SANDLER ILTAB ()
DENNIS RATHBUN (FSME)

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

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOACTIVE MATERIAL

"On July 31, 2007, the licensee notified DHFS of the theft of a control device for a Masterminder 2 x-ray crawler. It has been stored in a locked storage trailer at a temporary jobsite located a few miles north of Rome, WI. The lock had been cut, and other equipment had been stolen. The device contains a Cs-137 source with an approximate activity of 126.5 mCi. Local law enforcement and the Federal Bureau of Investigation have been notified, and are investigating. State and local emergency management have been notified, and a DHFS emergency responder has been dispatched to the site.

"The company was doing radiography on a natural gas pipeline. WeldSonix has provided a picture of the device.

"DHFS is planning on issuing a press release."

The state indicated that the device was 25 years old, and the activity level should be reduced by one half-life.

"Event Report ID No.: WI 07-0014"

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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Power Reactor Event Number: 43546
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TIM SHELTON
HQ OPS Officer: PETE SNYDER
Notification Date: 08/03/2007
Notification Time: 10:18 [ET]
Event Date: 08/03/2007
Event Time: 08:55 [EDT]
Last Update Date: 08/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES MOORMAN (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

SAFETY PARAMETER DISPLAY SYSTEM (SPDS) OUT OF SERVICE

"Loss of [SPDS] for greater than 8 hours [is expected] because of a failed plant computer system. Troubleshooting to resolve computer issues is in progress." The licensee entered established contingency procedures to compensate.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY JAY LEBERSTIEN TO JEFF ROTTON AT 1407 ON 08/03/07 * * *

"At 1205 hours, the Unit 2 SPDS was returned to operable."

The licensee notified the NRC Resident Inspector. Notified R2DO (Moorman)

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Other Nuclear Material Event Number: 43548
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/03/2007
Notification Time: 16:32 [ET]
Event Date: 07/30/2007
Event Time: [CDT]
Last Update Date: 08/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
STEVE ORTH (R3)
JACK DAVIS (FSME)
PAT FINNEY (R1)
ILTAB (via email) ()

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

Event Text

TWO MISSING M114 A1 ELBOW TELESCOPES

"Location : Anniston AD [Army Depot], Anniston, AL

"Date reported to the licensee: 2 Aug 2007 by the Anniston AD RSO

"Licensed material involved: M114A1 elbow telescopes 2 each. NSN 1240-00-150-8889. Each elbow telescope contains 5.6 curies of tritium ( gaseous form).

"Historical information: On 30 June, two M102 howitzers left the maintenance repair facility at Anniston Army Depot from bldg. 418. Each howitzer contains a carrying case that contains the M114A1, M140 alignment device and M137 pantel telescope. The M102 howitzers and associated cases were transported to a contractor operated paint facility located on post in bldg 143. The howitzers were to be painted. When work was completed by the contractor, the howitzers and associated carrying cases (containing the tritium fire control devices) were moved to the Defense Logistics Agency (DLA) shipping area on or about July 23rd. During the week of July 23rd, DLA personnel inspected the howitzers and associated components prior to them being shipped. It was at this time that DLA discovered that the M114A1 elbow telescopes were missing from each of the respective cases. The other tritium devices in the carrying case (M140 and M137) were still present. The licensee RSO contacted Army CID on 3 August for assistance in investigating the loss of the devices. Army CID from Ft. McPherson, GA office will begin their investigation on Monday August 6th 2007.

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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Fuel Cycle Facility Event Number: 43549
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PIKETON State: OH
County: PIKE
License #: GDP-2
Agreement: Y
Docket: 0707002
NRC Notified By: RON CRABTREE
HQ OPS Officer: PETE SNYDER
Notification Date: 08/05/2007
Notification Time: 09:33 [ET]
Event Date: 08/04/2007
Event Time: 10:25 [EDT]
Last Update Date: 08/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JAMES MOORMAN (R2)
JACK DAVIS (FSME)

Event Text

X-342 FACILITY CONTAINMENT SHUTDOWN

"On Saturday August 4th 2007 at 1025 hours, Autoclave # 1 in the X-342 Facility experienced a Containment Shutdown due to the actuation of both 'A' and 'B' EXTREME PRESSURE AUTOCLAVE alarms. The autoclave was in (applicable) TSR MODE II 'Heating' for 55 minutes when these actuations occurred. After reviewing the other autoclave operating parameters and the results of the as-found pressure loop values, it is evident that there was no release of UF6 inside this autoclave. Operations and Engineering Personnel are continuing their investigation into the circumstances surrounding this event in an attempt to identify the cause of the alarm actuations. With no evidence to suggest these alarms were caused by an invalid signal, the Plant Shift Superintendent's (PSS) Office is reporting this event as a valid actuation of a 'Q' Safety System.

"The autoclave was placed in MODE VII 'Shutdown' and declared inoperable by the Plant Shift Superintendent (PSS). No release of radioactive material occurred as a result of the incident. This event is being reported in accordance with UE2-RA-RE1030 Appendix D. J. 2. Safety Equipment Actuations."

The licensee notified the Department of Energy and the NRC Resident Inspector.

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