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Event Notification Report for November 5, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/02/2007 - 11/05/2007

** EVENT NUMBERS **


43337 43758 43761 43762 43763 43764 43765 43766 43768 43769

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General Information or Other Event Number: 43337
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: AROOSTOOK MEDICAL CENTER
Region: 1
City: PRESQUE ISLE State: ME
County:
License #: 03803-02
Agreement: Y
Docket:
NRC Notified By: SHAWN SEELEY
HQ OPS Officer: PETE SNYDER
Notification Date: 05/02/2007
Notification Time: 14:00 [ET]
Event Date: 01/16/2007
Event Time: [EDT]
Last Update Date: 11/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO PATIENT

On March 9, 2007, a consultant for the Aroostook Medical Center (TAMC) notified the TAMC Nuclear Medicine Department a medical event may have taken place on January 16, 2007.

The licensee investigated the report and found that a 4 millicurie dose of I-131 was given to a patient on the date in question as a whole body scan. However, the licensee determined that the ordering physician actually wanted an I-131 uptake and scan of 150 microCuries of I-131. Upon further investigation, the licensee determined that the scheduling person (who does not have a background in Nuclear Medicine) ordered the I-131 whole body scan. The licensee initiated a report of medical event and contacted the patient's physician.

The licensee calculated the whole body effective dose equivalent and the dose to the thyroid from the excess dose of I-131. The dose to the patients thyroid gland was calculated to be approximately 14000 rem and the whole body effective dose equivalent was calculated to be approximately 6.4 rem. The licensee determined that if the proper amount of I-131 had been administered, the doses would have been 525 rem and 0.24 rem respectively. A doctor at the licensee's facility determined that the dose given to the patient on March 16, 2007 will not have any effects on the patient.

"To prevent further events as this one, the Hospital and Radiation Safety Officer has decided that any further requests for I-131 procedures will be verified directly with the referring physician." There are now policies in effect to prevent this situation from happening again.

The state of Maine entered this report into NMED as number ME070016.

* * * UPDATE AT 07:07 ON 5/3/2007 FROM CINDY FLANNERY TO MARK ABRAMOVITZ * * *

"This event (EN43337) has been reviewed and determined to be a reportable medical event."

* * * UPDATE PROVIDED AT 1622 EDT ON 11/02/07 VIA FAX FROM STATE OF MAINE (SEELEY) TO JEFF ROTTON * * *

"Nature and Probable Consequences: The licensee reported that a patient undergoing treatment for malignant melanoma and presenting an asymmetric thyroid, received a Tc-99m scan and ultrasound was subsequently scheduled for a whole body scan utilizing I-131 to further diagnose the problem. The scan was ordered and the CNMT questioned the whole body scan and asked the physicians office to clarify what they wanted: an uptake or a whole body scan. The oncologist's secretary confirmed a whole body scan. On January 16, 2007 the patient received 0.1458 MBq (3.94 mCi) of I-131.

"On March 6, 2007 during a follow-up visit with an endocrinologist it was recognized that the wrong scan was performed. Upon investigation by the licensee and the licensee's consultant it was discovered that a medical event had indeed occurred. The administration (0.1458 MBq (3.94 mCi) vs the intended dosage of 5.55 MBq (150 microCuries)) of [I-131] resulted in a thyroid dose of 51.22 Gy (5,122 rad) and a whole body dose of 15.37 Sv (153.66 Rem) using NUREG-CR-6345 methodology. (if ICRP#30 or FGR #11 methodology used, results are 70 Gy (7000 Rad) for a thyroid dose and 21.25 Sv (212.5 Rem) dose to the whole body.

"The patient and referring physician were notified of the error. No negative health effects from this administration are expected. On March 28, 2007, the licensee sent a letter to the State confirming that a medical event had occurred.

"Cause(s): This medical event was caused by human error. The licensee failed to verify the prescribed dosage for a specific patient directly with the referring physician and a written directive was not filled out.

"Actions Taken to Prevent Recurrence:

"Licensee - Corrective actions taken by the licensee included revising procedures to improve communication with referring physicians to include the CNMT speaking directly with the referring physician or Authorized User to confirm test to be done. Also, written directives will be done for all administrations of I-131 in quantities greater than 30 microCuries.

"State Agency - The State Radiation Control Program (RCP) performed an on site investigation on May 24, 2007 and requested corrective action by the licensee. The RCP issued a Notice of Violation on November 1, 2007 and awaits the licensee's response. The RCP did initially review and accept the licensee's proposed corrective actions during the on-site investigation.

"This event is closed for the purpose of this report."

Notified R1DO (Dentel) and FSME EO (Morell).

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: 43758
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: NUMEDRX
Region: 4
City: JACKSON State: MS
County:
License #: MS-1006-01
Agreement: Y
Docket:
NRC Notified By: JEFF ALGEE
HQ OPS Officer: JASON KOZAL
Notification Date: 10/30/2007
Notification Time: 11:48 [ET]
Event Date: 10/25/2007
Event Time: 08:00 [CDT]
Last Update Date: 10/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - ACCIDENT INVOLVING TRUCK CARRYING RADIOPHARMACEUTICALS

The State provided the following information via email:

"DRH notified by NuMedRx Nuclear Pharmacy RSO that one of their delivery vehicles had been involved in an accident on Highway 49 North at the Highway 16 intersection. Apparently, the vehicle was struck by a school bus while it was en route to making a delivery to a Greenville, MS facility. No students were on the bus at the time of the collision. Apparently, law enforcement personnel did not realize the vehicle was transporting radioactive materials and no notifications were made to MEMA. DRH was not notified until after the vehicle was removed by the wrecker service. DRH responded to the wrecker service facility to survey and retrieve the transport container. The transport container was not ejected from the vehicle; however, the package was turned over and was not secured by the straps anymore. The package was labeled 'Yellow II' and still secured by the tamper seal. No leakage was detected [levels were 0.4 mR/hr at the surface of transport container] and radioactive doses/package were returned to RSO at the Jackson, MS nuclear pharmacy."

The delivery vehicle was carrying Thallium-201 and Technetium-99m totaling 13 millicuries.

Mississippi report number: MS 07007

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General Information or Other Event Number: 43761
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CONAM INSPECTION & ENG
Region: 4
City: COMMERCE CITY State: CO
County:
License #: 963-01
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 10/31/2007
Notification Time: 10:55 [ET]
Event Date: 10/29/2007
Event Time: 23:00 [MDT]
Last Update Date: 10/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
M BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE UNATTENDED FOR SIX HOURS

The State provided the following information via facsimile:

"This is the initial notification for an incident that was reported to this Department on this date. Conam Inspection & Engineering Services, Inc., 6900 East 47th Ave. Unit 200 Denver, CO 80216, a Radiography Licensee (Colorado License # 963-01) provided the Department with the attached Preliminary Incident Investigation report (two pages). Initial details indicate that a radiography source was left unattended and improperly secured on a jobsite for approximately six hours. A member of the job site staff identified the problem and notified the licensee. It appears that this was a result of an ill employee leaving the job site without properly securing the source. An investigation has been initiated by the Colorado Department of Public Health and Environment. No other details are available at this time."

The Conam Preliminary Incident Investigation Report follows:

"Date and time of incident: October 29, 2007 at 11:00 p.m.
Location of the incident: Suncor USA in Commerce City, CO.
Date and time investigation began: October 30, 2007 at approximately 4:30 a.m.

"Description of the Incident/Chronology of Verifiable Events: Conam I&ES performed radiography services at Suncor Refinery in Commerce City, CO on October 29, 2007. These services were being performed on a 24 hour basis. An exposure device was maintained on site and transferred from day shift personnel to night shift personnel. On October 29, 2007 the exposure device was not stored properly in the transport vehicle by the day shift radiographer. The day shift radiographer neglected to lock the outer door to the darkroom and the tailgate on the transport vehicle prior to leaving visual surveillance of the transport vehicle. The vehicle was parked on Suncor property approximately 40 feet from the Conam office. The day shift radiographer departed the job site at approximately 6:45 p.m. The night shift radiographer was on site prior to the departure of the day shift radiographer. The night shift radiographer became ill, and left the lob site at approximately 11:30 p.m. The night shift radiographer left the exposure device on site unattended by any approved Conam I&ES personnel. The night shift radiographer did not access the darkroom at any time on site prior to his departure since the radiography assistant was not present that evening. A Suncor representative noticed the darkroom on site without any Conam representation at approximately 4:30 a.m. The Suncor representative locked the darkroom and removed the keys to the vehicle then notified Conam management. Conam management responded at approximately 5:15 a.m. and representation was on site to properly secure the exposure device at 6:15 a.m. There were no exposures to the Public during this time period.

"List of Contributing Factors: Radiographers failed to follow proper security procedures for securing radioactive materials with IC orders.

"Proposed Corrective Actions: Conam management had a safety stand down for all radiographic personnel at Suncor. All additional radiographic personnel will have a safety stand down this week. The staff will be reinstructed as to the proper protocol for securing radioactive materials with the IC order. The two radiographers have been suspended from radiographic services at this time.

"Corrective Action Plan Complete? No

"If Not, Reason: Corrective action will be completed upon the final outcome of the investigation and the completion of reinstruction to radiographic personnel."

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General Information or Other Event Number: 43762
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CORPADINO INC
Region: 1
City: MIAMI State: FL
County: DADE
License #: 2770-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/31/2007
Notification Time: 13:33 [ET]
Event Date: 10/31/2007
Event Time: [EDT]
Last Update Date: 10/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1)
MICHELE BURGESS (FSME)
ILTAB (EMAIL) (NSIR)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

"Received initial notification from [the RSO] that a Troxler gauge was stolen. Gauge was in a conex box at job site. Miami office will investigate. No further action will be taken on this incident."

Location of job site: 13th Ave & Martin L King Blvd, Pompano Beach, FL
Troxler Model number: 3430
Serial Number: 37992
Sources: Cs-137 (8 milliCuries), Am-241:Be (40 milliCuries)

This incident was reported to the Broward County Police.

Florida Incident Number: FL07-170

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: 43763
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: C. WARD
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/02/2007
Notification Time: 10:33 [ET]
Event Date: 11/01/2007
Event Time: 17:00 [EDT]
Last Update Date: 11/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
JAMES MOORMAN (R2)

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 N 0 Refueling 0 Refueling

Event Text

NON-LICENSED EMPLOYEE TESTED POSITIVE FOR ALCOHOL DURING RANDOM TESTING

A non-licensed employee supervisor, not involved in plant operations, had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access to the plant has been denied. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 43764
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: BRIAN FERGUSON
HQ OPS Officer: KARL DIEDERICH
Notification Date: 11/02/2007
Notification Time: 10:55 [ET]
Event Date: 11/02/2007
Event Time: 07:44 [MST]
Last Update Date: 11/03/2007
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DALE POWERS (R4)
ELMO COLLINS (R4)
JIM DYER (NRR)
BRIAN McDERMOTT (IRD)
JOHN FROST (DHS)
RONNIE FOOT (DOE)
ANDREW WATTS (USDA)
CHRIS HARPER (HHS)
RAWLS (EPA)
GENE CANUPP (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 2 Startup 2 Startup
2 N Y 100 Power Operation 100 Power Operation
3 N N 0 Refueling 0 Refueling

Event Text

SUSPICIOUS EXPLOSIVE DEVICE DISCOVERED IN VEHICLE AT OCA ACCESS CHECKPOINT

"On November 2, 2007 at 0744 [MST], Palo Verde Nuclear Generating Station Units 1, 2 and 3 declared a Notification of an Unusual Event as specified in the Emergency Plan. The basis for the Emergency Class declaration was detection of a credible threat: an explosive device was detected during a vehicle search at the site access check point. The site has entered its Deliberate Acts procedure. The device was discovered in a contract employee's vehicle at 0525 MST. It was confirmed to be an explosive device at 0730 MST by the Maricopa County Sheriff's Office (MCSO). The explosive device was removed from the site by MCSO and Federal Bureau of Investigation (FBI) at 0852. The individual driving the vehicle has been detained by MCSO. No other individuals were in the vehicle at the time.

"Palo Verde Unit 1 is in Mode 2 at approximately 2% power. Unit 2 is in Mode 1 at 100% power. Unit 3 is defueled undergoing steam generator replacement. No reactor protection system or engineered safety feature system actuations have occurred and none are required. No major structures, systems, or components are inoperable impacting the continued safe operation of the units. Plans are to continue Mode 2 operations in Unit 1 and Mode 1 full power operation in Unit 2.

"Further investigation is ongoing in cooperation with MCSO and the FBI. Security is conducting searches of the site. No additional concerns have been identified at this time. The security event has not resulted in any challenges to the fission product barrier or result in any releases of radioactive materials. There were no adverse safety consequences or implications as a result of the security event declaration. A news release was made at 11:10 a.m."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM DON VOGT TO J. KNOKE AT 1809 EDT ON 11/02/07 * * *

At 1447 MST site security posture has changed from Code Red to Code Yellow Heightened Awareness, and at 1504 MST licensee exited the Unusual Event,. The licensee has notified the NRC Resident Inspector, state and local agencies, and will be issuing a press release this evening.

Notifications were given to the following: R4 (Art Howell), R4DO(Powers), NRR EO (Bateman), IRD Manager (Blount), ILTAB (Sandler), DHS (York), FEMA (Dunker), DOE (Wyatt), FBI-SIOC (Curry), HHS (White), USDA (Phillip).

* * * UPDATE FROM WAREN HENDRIX TO J. KNOKE AT 1416 EDT ON 11/03/07 * * *

The licensee downgraded the security posture at the site from Code Yellow Heightened Awareness to Code Yellow. The licensee notified the NRC Resident Inspector. Notified R4DO (Powers) and ILTAB (Sandler).

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Other Nuclear Material Event Number: 43765
Rep Org: ENGINEERING CONSULTING SERVICES
Licensee: ENGINEERING CONSULTING SERVICES
Region: 1
City: CHANTILLY State: VA
County:
License #: 45-24974-01
Agreement: N
Docket:
NRC Notified By: OMAR DUZYOL
HQ OPS Officer: PETE SNYDER
Notification Date: 11/02/2007
Notification Time: 10:53 [ET]
Event Date: 11/02/2007
Event Time: 10:00 [EDT]
Last Update Date: 11/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GLENN DENTEL (R1)
GREG MORELL (FSME)

Event Text

MOISTURE DENSITY GAUGE RUN OVER BY PAVER

At a construction site in Park Plaza (133 - 143 Park Street in Vienna, Virginia 22180) a paver ran over a CPN model MC1DR moisture density gauge. The paver dragged the device 6 to 8 feet before stopping. The device was found to be in the shielded position. The Radiation Safety Officer verified this with a meter that read 0.4 millirem per hour at 1 meter which was expected for a shielded device.

The licensee plans to return the gauge to the manufacturer for a damage assessment .

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Hospital Event Number: 43766
Rep Org: PENN STATE HERSHEY MEDICAL CENTER
Licensee: PENN STATE HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: 37-13831-01
Agreement: N
Docket:
NRC Notified By: KENNETH L. MILLER
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/02/2007
Notification Time: 13:13 [ET]
Event Date: 10/10/2007
Event Time: 09:30 [EDT]
Last Update Date: 11/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GLENN DENTEL (R1)
JANET SCHLUETER (FSME)
ILTAB (EMAIL) ()

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

Event Text

MISSING I-131 GEL CAPSULE

"To assist the Hot Lab Tech, at 9:20 AM on October 10, 2007, another Nuclear Medicine Technologist placed a gel capsule containing 55 microCuries of I-131 into a Leucite thyroid neck phantom and oriented the phantom for an anterior projection to calibrate the thyroid uptake counting system for dosimetry measurements needed on a thyroid treatment patient . After setting the counter for a ten-minute count she informed the Hot Lab Tech that the sample was counting. She did not stay with the thyroid neck phantom and counting system which was located in an alcove approximately twenty feet from the door to the Hot Lab. While the neck phantom was visible from the doorway of the Hot Lab, the Hot Lab Tech did not have it under constant observation. However, there were Nuclear Medicine personnel in the corridor between the Hot Lab and this alcove almost continuously during the counting procedure.

"At 9:38 AM, the Hot Lab Tech oriented the neck phantom for a posterior projection and set the system for a second ten-minute count. When the Hot Lab Tech returned to the Thyroid counter at 10:15 AM, she discovered that only background counts had been recorded for the ten-minute counting period. A check of the neck phantom revealed that it contained no radioiodine capsule.

"After an extensive but unsuccessful search by Nuclear Medicine personnel, Health Physics was called for assistance at 11:30 AM. A Health Physics team spent several hours searching all conceivable areas but, no capsule was found.

"Security was notified along with the local police. The local police responded, took fingerprints but, as of yet, have not responded further.

"A review of the DVD from the security camera located outside the Hot Lab and Injections rooms failed to determine the fate of the radioiodine capsule but did confirm that there were Nuclear Medicine personnel in sight of the neck phantom for essentially the entire procedure and especially for the 18 minute window (from the end of the first count to the beginning of the second count) when the capsule went missing.

"An investigative Committee was formed to query all Nuclear Medicine Technical personnel and Nuclear Medicine nurses and to determine the fate of the lost capsule and/or the root cause of the event. This committee was chaired by the Radiation Safety Officer and included the Assistant Manager of Radiology, the Chief of Nuclear Medicine, the Operations Director for Radiology, the Associate RSO and the Director of Human Resources.

"The investigation failed to determine the fate of the missing radioiodine capsule.

"The investigation revealed that the Chief Technologist had approved the calibration of the thyroid uptake counting system in the alcove rather than a locked room because he considered the capsule in the neck phantom to constitute 'secure.'

"The investigation revealed some attitude problems on the part of the technical staff and some deviations from required 'good radiation safety practices' unrelated to the missing capsule.

"Corrective actions implemented include:

"1. Dismissal of the Chief technologist.
2. Dismissal of the Hot Lab technologist responsible for the calibration of the thyroid uptake counting system.
3. Year long probation for all remaining Nuclear Medicine Technologists.
4. Increased training sessions for all Nuclear Medicine technologists.
5. Relocation of the office of the Assistant Manager of Radiology to the Nuclear Medicine area.
6. Additional security cameras ordered for other areas of Nuclear Medicine.
7. Random review of recordings from security cameras by Health Physics to verify adherence to good radiation safety practices.
8. Changes to the door locks to severely restrict traffic flow in and access to the Nuclear Medicine areas.
9. Increase observation of Nuclear Medicine activities by Health Physics.
10. Increased observation of Nuclear Medicine activities by physicians and residents.
11. Relocation of the Thyroid uptake counting system to a room that can be locked when no-one is in attendance during a calibration procedure.
12. Requiring that sources being used outside of the Hot Lab will be under the control and responsibility of a single individual for the entire time that the source is out of the Hot Lab.

"This incident has been thoroughly reviewed with our Radiation Safety Committee and our Subcommittee on Human Use of Radioisotopes.

"The licensee will continue to search for the missing source and will continue close scrutiny of all Nuclear Medicine operations. As of this date, the fate of the capsule is still unknown. The current activity, due to decay, would be approximately 8 microcuries."

The licensee notified NRC Region I (Pam Henderson), Dairy Township Police Department, and Director, PA Bureau of Radiation Protection.

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: 43768
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: P. FALLON
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/03/2007
Notification Time: 17:26 [ET]
Event Date: 11/03/2007
Event Time: 17:22 [EDT]
Last Update Date: 11/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN MADERA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF SPDS AND ERDS DUE TO PLANNED MAINTENANCE

"At 1722 hours, on 11/3/2007, the SPDS and ERDS system was removed from service to support activities for a planned maintenance outage on the UPS vital bus power supply. The duration of work is expected to be approximately 48 hours. During this time, Control Room indications and alternate methods will be available. Since the SPDS computer system will he unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10CFR50.72(b)(3)(xiii). The licensee will notify the NRC Resident Inspector."

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Other Nuclear Material Event Number: 43769
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: FAIRBANKS State: AK
County:
License #: 50.27667-01
Agreement: N
Docket:
NRC Notified By: PAUL CASEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/04/2007
Notification Time: 16:10 [ET]
Event Date: 11/03/2007
Event Time: 15:00 [YDT]
Last Update Date: 11/04/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DALE POWERS (R4)
JANET SCHLUETER (FSME)

Event Text

RADIOGRAPHY CAMERA SOURCE FAILS TO FULLY RETRACT INTO CAMERA

The licensee was using a radiography camera on the Alaska pipeline approximately 50 miles North of Fairbanks (near pump station 7). The temperature was approximately 5 to 8 degrees F. Moisture entered into the locking mechanism causing the latch to trip prematurely i.e. the source was not fully retracted into the camera. The RSO took the latching mechanism apart and fully retracted the source. The RSO and assistant each received a dose of 30 millirem during this repair.

Radiography camera: Industrial Nuclear Corporation model IR-100
Source: 72 Curie Ir-192

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