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Event Notification Report for October 23, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/22/2007 - 10/23/2007

** EVENT NUMBERS **


43726 43727 43728 43730 43736 43737 43740

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General Information or Other Event Number: 43726
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINAS MEDICAL CENTER
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: JOE O'HARA
Notification Date: 10/17/2007
Notification Time: 09:13 [ET]
Event Date: 10/12/2007
Event Time: [EDT]
Last Update Date: 10/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
GREG MORELL (FSME)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING I-125 PROSTATE BRACHYTHERAPY SEED

"Patient was implanted with 100 Iodine 125 seeds (0.36 milliCuries per seed) on Friday October 12, 2007. Five (5) seeds were left over. The 5 leftover seeds were emptied from the loading cartridge into a lead pig. The cartridge was deposited in the regular trash. The leftover seeds were assayed by [DELETED], Rad Safety Tech on October 16, 2007. After assaying the seeds, [DELETED] surveyed the lead pig, and discovered elevated exposure rates of the empty pig. Further surveys and wipes indicated removable contamination of the lead pig.

"The five Iodine 125 seeds were leak/wipe tested, and one seed showed 0.02 microCuries of removable contamination (29,000 dpm). The loading cartridge was tracked down in the regular trash, and showed removable contamination. The patient was recalled, and a thyroid scan of the patient on 10/16/07 showed no elevated thyroid uptake. The surgeon [DELETED] and all surgical staff showed no removable contamination. The surgery suite and all adjacent/pertinent areas showed no removable contamination.

"The leaking source has been packaged, and is ready to be shipped back to Core Oncology, Oklahoma City for evaluation. Mills Pharmaceuticals (Core Oncology) manufactures sources.

"North Carolina Incident No. 07-52"

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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Hospital Event Number: 43727
Rep Org: ONCOLOGY INSTITUTE OF GREATER LAFAY
Licensee: ONCOLOGY INSTITUTE OF GREATER LAFAYETTE
Region: 3
City: LAFAYETTE State: IN
County:
License #: 13-32087-01
Agreement: N
Docket:
NRC Notified By: PHIL DITTMER
HQ OPS Officer: JOE O'HARA
Notification Date: 10/17/2007
Notification Time: 11:39 [ET]
Event Date: 08/14/2007
Event Time: [EDT]
Last Update Date: 10/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3)
GREG MORELL (FSME)

Event Text

POTENTIAL MEDICAL EVENT

A patient received a series of 3 vaginal cylinder HDR treatments on 08/14/07, 08/28/07, and 09/11/07 at the Arnett Cancer Care Center [also known as the Oncology Institute of Greater Lafayette which is the name on their license]. The treatment was planned with a source spacing of 5 millimeters. The electronic transfer of source spacing from the planned console to the treatment console did not function properly and the source spacing information was entered into the treatment console manually and inadvertently a source spacing of 2.5 millimeters was used. The dose distribution was different than planned due to the spacing difference, but the overall dose was correct. The prescribed dose per fraction was 700 cGray using an Ir-192 source with 13 dwell positions spaced 5 millimeters apart.

The physician has been notified and does not believe that there will be any adverse effects to the patient. At this time the patient has not been notified, but the licensee is attempting to contact her to inform her that the overall dose was delivered differently that planned.

The licensee has taken corrective action to set the device default spacing at 5 millimeters and they will be revising their procedures to prevent reoccurrence. An inspection by the NRC Region 3 Inspector (Bob Gattone) on 10/16/07 discovered the source spacing error.

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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Fuel Cycle Facility Event Number: 43728
Facility: BWX TECHNOLOGIES, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: BARRY COLE
HQ OPS Officer: PETE SNYDER
Notification Date: 10/17/2007
Notification Time: 13:53 [ET]
Event Date: 10/16/2007
Event Time: 22:30 [EDT]
Last Update Date: 10/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
EUGENE GUTHRIE (R2)
GREG MORELL (FSME)
J. PAULEY (DOE)
J. CREWS (EPA)
P. SHAFOVALOFF (USDA)
M. DALZIEL (HHS)
D. SULIVAN (FEMA)
FUELS OUO (EMAIL) ()

Event Text

REPORTABLE QUANTITY OF WASTE ACID RELEASED ONSITE

"A second-shift Waste Treatment operator discovered acidic wastewater (a mixture of nitric acid, hydrofluoric acid and water) discharging from a sump on the Bay 5A Pickle Acid Scrubber pad at approximately 10:30 PM on 10/16/2007. The acidic wastewater ran downhill onto the roadway to the north and eventually onto a concrete pad near the bottom of the hill. By the time of the discovery, or very shortly thereafter, the overflow stopped. The operator notified area supervision and verified that all valves and pumps at the Waste Treatment facility were functioning normally and wastewater was being received in the equalization tanks.

"Estimates on 10/17/2007 by Environmental Engineering of the amount of flow discharged to the line versus the amount received at Waste Treatment, combined with visual observation of the spill area, suggest that approximately 275 gallons of acidic wastewater were released from the trench, of this amount, approximately 25 gallons potentially reached uncovered surfaces adjacent to the road (gravel/grass). This was deemed to be a Reportable Quantity of a hazardous substance and appropriate notifications were made to the National Response Center (Notification #851841), the EPA Region 11 Consent Order Coordinator and the Virginia Department of Environmental Quality.

"The spill area was neutralized with soda ash and thoroughly rinsed. The small gravel/grass areas that may have been impacted are being assessed for additional remediation as necessary."

BWXT will notify the NRC Resident Inspector.

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General Information or Other Event Number: 43730
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROFESSIONAL SERVICES INCORPORATED
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOE O'HARA
Notification Date: 10/18/2007
Notification Time: 14:53 [ET]
Event Date: 10/18/2007
Event Time: 12:15 [CDT]
Last Update Date: 10/18/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4)
GREG MORELL (FSME)
ILTAB VIA E-MAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - LOST AM241/BE SOURCE FROM DAMAGED TROXLER GAUGE MODEL 3430

The State provided the following information via email:

"On October 18, 2007, the agency was contacted at 12:49 p.m. by their emergency answering service, reporting that a licensee had lost a gauge in Houston and was requesting Incident Investigation Program (IIP) to call them back to assist them with [the lost gauge].

"IIP called the licensee back and talked with [DELETED], Site RSO for their LaPorte, TX location. [RSO] reported that his technician was driving down the highway in Houston and discovered that the gauge had fallen out of his truck around 12:15 -12:30 p.m. on 10/18/07. The RSO stated that the tailgate was up, but the gauge may not have been braced down.

"The technician immediately called the RSO, who drove down the highway and found pieces of the gauge, the handle, and the Cs-137 source. The RSO stated the Cs-137 source is intact. He remains on location with the agency's investigator. The agency's investigator has surveyed the area and the gauge pieces that were recovered with a NaI detector and was not able to locate the AmBe source.

"The gauge specifications are: Mfg: Troxler Model 3430, Serial #: 29328, Last Leak test: 10/11/07

"Source Information: 1) Cs-137 Serial #: 750-2544; 8 mCi 2) AmBe Serial #: 47-26370; 40 mCi. The source is double-encapsulated in stainless steel, with dimensions of: .4 in.x.3 in. and is less than 1/2 in. long and 1/4 in. in diameter.

"Mfg states that the chance of the source encapsulation being broken and breached is remote.

"The agency has notified local law enforcement (LLE) to shut down the 3-lane highway (so that) safe surveying for the AmBe source can be accomplished. The agency has asked LLE to contact and coordinate with the local HAZMAT team. IIP will continue to investigate and assist with locating the lost AmBe source. Additionally, the licensee was given contact information for two consultants to assist with this incident and location of the lost source. Incident Investigations will continue to update this incident as current information is received.

"Disposition/Action Taken: 1) Report to NRC and NMED, 2) Contacted local law enforcement (LLE) and local HAZMAT.

"Texas Incident Number: I - 8449, Event Report: TX-07-43606"

* * * UPDATE FROM ART TUCKER TO JOE O'HARA AT 2125 ON 10/18/07 * * *

The state along with DOD personnel performed a search of highway 225 for the missing source. However, the search was unsuccessful. The highway has been reopened, and the state will meet tomorrow to discuss further follow-up actions.

Notified R4DO(Proulx), FSME EO(Tschiltz), ILTAB(e-mail), and Mexico(fax).


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: 43736
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: RAY BUZARD
HQ OPS Officer: PETE SNYDER
Notification Date: 10/22/2007
Notification Time: 09:27 [ET]
Event Date: 10/22/2007
Event Time: 03:11 [MST]
Last Update Date: 10/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
CHUCK CAIN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Hot Standby

Event Text

SHUTDOWN DUE TO INOPERABLE STEAM DRIVEN AUXILIARY FEEDWATER PUMP

"The following report is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"On Monday October 22, 2007, at 0311 Mountain Standard Time (MST) Palo Verde Nuclear Station Unit 1 initiated a normal reactor shutdown to comply with condition C of Technical Specifications (TS) Limiting Condition for Operation (LCO) 3.7.5. At 0504 MST Mode 3 was entered.

"LCO 3.7.5 requires that three auxiliary feedwater (AF) pumps be operable in Modes 1, 2, and 3. The shutdown was necessary due to an inoperable steam supply for the essential steam driven AF pump turbine. The steam supply had been declared inoperable on October 15, 2007, at 0904 MST and will not be restored to operable status within the TS required 7 day completion time. Efforts are in progress to correct the condition.

"The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public."

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 43737
Rep Org: AGILENT TECHNOLOGIES
Licensee: AGILENT TECHNOLOGIES
Region: 1
City: WILLMINGTON State: DE
County:
License #: 07-28762-01
Agreement: N
Docket:
NRC Notified By: DAVID BENNETT
HQ OPS Officer: PETE SNYDER
Notification Date: 10/22/2007
Notification Time: 10:16 [ET]
Event Date: 09/27/2007
Event Time: 12:00 [EDT]
Last Update Date: 10/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JOHN CARUSO (R1)
MICHELE BURGESS (FSME)
ILTAB (EMAIL) ()

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

Event Text

LOST ELECTRON CAPTURE DETECTOR

On 6/20/07, a previously manufactured electron capture detector was returned to the New Castle, DE facility because it was not able to reach its final shipment destination. The detector was stored in an area for returned shipments containing radioactive materials. On 9/27/07 the licensee attempted to locate the device for proper dispositioning but could not find it. The licensee ensured that employees knew the description and labeling of the box. The licensee then conducted a search of the entire building but was unable to locate the device.

The device contained a 15 millicurie Ni-63 source.

As part of their corrective actions the licensee ensured that the employees were trained in their responsibilities concerning this type of material. In the future the licensee plans to increase the frequency of periodic training.

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: 43740
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JASON L. SWEATMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/22/2007
Notification Time: 16:19 [ET]
Event Date: 10/22/1976
Event Time: 14:00 [EDT]
Last Update Date: 10/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE GUTHRIE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO A SMALL LEAK - TRITIUM


"On October 20, 2007, Surry Power Station workers detected a minor water leak from an underground concrete storm drain pipe inside the station's protected area. This storm drain line flows into the station discharge canal and is monitored by station personnel. Workers had excavated this pipe to conduct inspection activities when they noticed water leaking at a rate of 1 to 2 drips per minute from a pipe joint. The leak rate was estimated at one-half a gallon per day.

"A sample of the leaking water was evaluated for tritium as part of an industry ground water protection initiative and determined to have a concentration of 31,900 picoCuries per liter. This tritium leak poses no threat to employees or the public. There is no indication that tritium has migrated off the Surry site undetected. Monitoring wells on the perimeter of the Surry site and on-site drinking water well samples have not shown any indication of tritium. Leakage from this section in the storm drain line is ultimately recaptured by the building foundation dewatering system surrounding adjacent site structures and returned to the storm drain line.

"This leak has been contained and maintenance activities are under way to repair the storm drain line.

"This notification is being transmitted due to Notification of Other Government Agencies under 10CFR50 72(b)(2)(xi) The Surry County Administrator was notified. The Senior NRC Resident, Virginia Department of Health, Virginia Department of Emergency Management and Virginia Department of Environmental Quality will be notified."

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