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Event Notification Report for September 18, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/17/2007 - 09/18/2007

** EVENT NUMBERS **


43639 43640 43645 43646 43647

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General Information or Other Event Number: 43639
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037152AAB
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: JASON KOZAL
Notification Date: 09/13/2007
Notification Time: 15:04 [ET]
Event Date: 02/01/2005
Event Time: [CDT]
Last Update Date: 09/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE DIFFERS BY GREATER THAN 50% OF PRESCRIBED

The State provided the following information via email:

"A teletherapy patient received a dose greater than 50% of the prescribed fractionated dose due to an improperly calculated dose delivery time. The medical physicist used a fractionated dose of 200 cGy instead of the prescribed dose of 100 cGy. This overexposure occurred during the first fraction to the patient. Before the second scheduled treatment, a different therapist questioned the long treatment time and brought the matter to the medical physicist. The physicist checked the calculations, discovered the error and cancelled the treatment for the day. The radiation oncologist anticipates no unusual acute or late effects from the delivered dose. The University of Iowa no longer is in possession of this device. It was de-sourced on November 16, 2005."

The device was a sealed Co-60 teletherapy source. The therapy was targeting the bone marrow.

Iowa report number: IA070003

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General Information or Other Event Number: 43640
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ASSET MANAGEMENT
Region: 3
City: HUGO State: MN
County:
License #: 1008-200-82
Agreement: Y
Docket:
NRC Notified By: GEORGE F. JOHNS, JR.
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/13/2007
Notification Time: 17:11 [ET]
Event Date: 09/13/2007
Event Time: 14:00 [CDT]
Last Update Date: 09/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
PATRICE BUBAR (FSME)
ILTAB (via email) ()
CNSC (via fax) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via email:

"The Minnesota Department of Health (MDH) has been notified that on September 13, 2007 at approximately 2:00 PM, a moisture-density gauge containing sealed sources of radioactive material was stolen from a pick-up truck owned by Asset Management. The truck was parked at a residence in Forest Lake, Minnesota, and the gauge was believed to have been stolen sometime during the previous night.

"The MDH, which regulates the use of these types of radioactive materials in Wisconsin, is working with the Forest Lake Police Department and officials of Asset Management to recover the stolen gauge.

"The moisture density gauge is used to measure the moisture content and density of soils and building materials. The gauge is a yellow box measuring approximately 30 inches in length, 14 inches in width and 17 inches in height (see attached picture). The gauge and the case weigh a total of 90 pounds. The gauge itself weighs 29 lbs. The case and the gauge are clearly marked as containing radioactive materials. . ."

The gauge is a Troxler Model 3430 (S/N 33277) containing two (2) sources; 9 millicuries Cs-137 and 44 millicuries Am-241:Be. The State of Minnesota issued a press release with contact information for the return of the gauge.

MN Report No.: MN070006.

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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Power Reactor Event Number: 43645
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: NED DENNIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/17/2007
Notification Time: 03:16 [ET]
Event Date: 09/17/2007
Event Time: 01:49 [EDT]
Last Update Date: 09/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES TRAPP (R1)

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

HPCI UNABLE TO PERFORM IT'S SAFETY RELATED FUNCTION

"During performance of the quarterly HPCI valve stroke test the HV-055-2F093, HPCI Vacuum Breaker Outboard PCIV, failed to close. The PCIV was declared inoperable. The valve was subsequently closed and de-energized to meet Technical Specification requirements. The valve did close from the handswitch on the subsequent attempt, investigation into the cause is in progress. The closure of this valve at 0149 on 9/17/07 prevents Unit 2 HPCI from performing it's safety related function. Unit 2 RCIC and all other Unit 2 ECCS systems remain operable."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43646
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MIKE TAYLOR
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2007
Notification Time: 07:36 [ET]
Event Date: 09/17/2007
Event Time: 05:59 [EDT]
Last Update Date: 09/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES TRAPP (R1)

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

OFFSITE NOTIFICATION TO LOCAL LAW ENFORCEMENT

"On 9/17/07 at 0559, an accidental discharge of a security officer's firearm occurred while conducting shift turnover and arming functions in the Station's security guard house. The officer was injured in the right leg below the knee and at this time, the injury is believed to be non-life threatening. The officer has been transported to a local hospital for treatment. No plant systems have been affected. The local NRC resident has been informed of the event. Local law enforcement [Seabrook Police and New Hampshire State Police] has also been notified and is onsite providing investigative assistance."

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General Information or Other Event Number: 43647
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-30957-01
Agreement: N
Docket:
NRC Notified By: RICHARD PICCOLO
HQ OPS Officer: JOE O'HARA
Notification Date: 09/17/2007
Notification Time: 17:19 [ET]
Event Date: 07/15/2007
Event Time: [EDT]
Last Update Date: 09/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
PAUL KROHN (R1)
JOEL MUNDAY (R2)
HIRONORI PETERSON (R3)
VIVIAN CAMPBELL (R4)
PATRICE BUBAR (FSME)

Event Text

ACTIVE SOURCE CAN BECOME DISLODGED IN HDR AFTERLOADER DEVICE

The following information was received via fax:

Manufacturer submitted this notification based on an event involving a High Dose Rate (HDR) Afterloader that occurred at City of Hope Hospital in Duarte, California on July 15, 2007 [See EN# 43493]

"Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect- VariSource HDR Afterloader model 200 and VariSource HDR Afterloader model ID

"Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect:
The VariSource HDR Afterloader is manufactured by: Varian-TEM Ltd., Gatwick Road, Crawley, West Sussex RH102RG, United Kingdom

"Nature of the defector failure to comply and the safety hazard which is created or could be created by such defect or failure to comply:
The active source can become dislodged from the internal tungsten safe if the emergency source retract hand crank is used when the active source is safely parked in the internal shield. (1) This event can only occur if the operator turns the emergency hand crank while the source is safely parked. (2) The emergency source retract hand crank is to be used only when the active source is in the out or exposed position. It is not designed, nor intended to be operated when the source is safely parked. (3) The emergency hand crank is only connected to the active source wire. It is not connected to the dummy source and its operation has no effect on the dummy source."

Customer Technical Bulletin, CTB-VS-366A, "Clarification on the use of the emergency retract hand wheel to prevent accidental exposure" was issued to all users of the VariSource HDR unit on April 27, 2004. This CTB will be reissued to all domestic customers. A warning label addressing the proper use of the emergency hand crank was attached to all VariSource HDR units in 2004. A new warning label is being developed that will restate the proper use of the hand crank. Also a formal revision was made to user training to emphasize that this event is possible if the user makes an error by operating the emergency hand crank when the active source wire is safely parked in the tungsten shield.

There are 186 VariSource HDR units in the United States and a list was provided to the NRC.

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