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Event Notification Report for February 12, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/11/2008 - 02/12/2008

** EVENT NUMBERS **


43955 43965 43966 43970 43976 43977 43978

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General Information or Other Event Number: 43955
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: ISORAY
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/01/2008
Notification Time: 19:20 [ET]
Event Date: 02/01/2008
Event Time: [PST]
Last Update Date: 02/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
LARRY CAMPER (FSME)
MATT HAHN (E-MAIL) (ILTA)

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

Event Text

AGREEMENT STATE REPORT - DEPLETED CESIUM-131 SEEDS LOST FROM DAMAGED PACKAGE DURING SHIPMENT

The State provided the following information via email:

"The Licensee reported by phone that at 2:30 PST today a package of returned and depleted implant seeds containing Cs-131 with a 9.7 day half-life was found damaged upon receipt with some of the contents missing. The package was to have contained 15 seeds that were returned from a customer on the east coast. When the package arrived, the licensee upon receipt inspection noted the package had a hole in it that had been repaired with tape. The receipt inspection also detected higher than expected dose rates at slightly less than 1 mr/hr contact with the package. The package was taken to a controlled area suitable for bio-hazard work and opened by the RSO. The package was opened and discovered with loose seeds in the box. 11 seeds were recovered, 4 seeds are missing. An Isoray facility survey was performed between the receiving area and the controlled area where the package was opened. No additional seeds were located. The sender of the package is being contacted as well as the RSO for FedEx. Highest dose rate on contact with a single seed was 1 mr/hr. The seeds were reported to have aged seven half-lives as of this day and at 1/100th of original strength. The Licensee will update our office [the State of Washington] with additional information when it comes available."

The State does not know who originated the shipment or the initial strength of the CS-131 before the seven half-life decay.

Washington State Report Number: WA-08-007


* * * UPDATE FROM ARDEN SCROOGS TO BILL HUFFMAN ON 2/4/08 AT 1504 EST VIA E-MAIL * * *

The shipment originated from Geisenger Health in Danville, PA, and was shipped by FedEx.

The original strength of the seeds was nominally 4 to 5 millicuries each, or 14 to 20 for the four missing seeds. At seven half-lives, the strength would be approximately 1/100th of the original strength, or 40 to 50 microcuries.

R4DO (Mike Shannon), FSME EO (Larry Camper), ILTAB (Matt Hahn), and R1DO (Christopher Cahill) informed.


* * * UPDATE FROM ARDEN SCROOGS TO KARL DIEDERICH ON 2/11/08 AT 1134 EST VIA E-MAIL * * *

"The receipt inspection detected higher than expected dose rates at ~1.7 mR/hr contact with the package.

"Detailed Carrier Information from with delivery route and timeframe.
Jan 29, 2008:
4:15 PM - Picked up in Montoursville, PA.
7:51 PM - left Montoursville, PA.
11:46PM - Arrived FedEx location in Newark, NJ.
Jan 30, 2008:
8:38 AM - Departed FedEx location in Newark, NJ.
10:41AM - Arrived FedEx location in Memphis, TN.
3:36 PM - Departed FedEx location in Memphis, TN.
6:35 PM - At sort facility in Spokane, WA.
8:49 PM - At local FedEx facility in Spokane, WA.
Jan 31, 2008:
9:52 AM - On FedEx vehicle for delivery Pasco, WA.
11:46AM - Delivered."

R4DO (Dale Powers), FSME EO (Michelle Burgess), ILTAB (Jim Whitney), and R1DO (Glenn Dentel) informed.


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: 43965
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ANAZAO HEALTH CORPORATION
Region: 1
City: TAMPA State: FL
County: HILLSBOROUGH
License #: 2975-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/06/2008
Notification Time: 13:09 [ET]
Event Date: 02/06/2008
Event Time: [EST]
Last Update Date: 02/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - EXTREMITY OVEREXPOSURE TO TWO INDIVIDUALS

"Anazao Health contacted [the Florida Bureau of Radiation Control] Licensing and Materials Office by fax concerning an over exposure to two individuals on 28 January 2008. Initial determination was on 27 December 2008. During routine facility audit on 6 February 2008 inspector found documentation concerning over exposure. No verbal communication was sent by Anazao Health to state officials. One individual received 105.3 [REM] to right extremity TLD finger ring, and 82.3 [REM] to his left extremity TLD finger ring. Both are shallow dose equivalent for calendar year 2007. Second individual received 53.186 [REM] to right extremity TLD finger ring, and 80.066 [REM] to his left extremity TLD finger ring. Florida is investigating."

Florida Incident number FL08-018

* * * UPDATE AT 1423 EST ON 02/07/08 FROM STEVE FURNACE TO S. SANDIN * * *

The following information was received as an update via email:

"Anazao Health compounds radiopharmaceutical drugs. The company makes capsules of concentrated doses normally one quarter the size of standard capsules. The company primarily accomplishes these tasks by hand.

"Both employees worked with I-131 liquid in the preparation of nuclear medicine capsules. The I-131 stock contained up to 3 Curies and the individuals removed stock liquid into other vials for diagnostic or therapy capsule production. Operations were conducted within a fume hood. A buffer solution was added to vials in order to dilute the I-131 to required activity levels. The individuals removed liquid from these vials to make capsules.

"The individuals stood outside the flume hood behind lead shielding, while the forearms and hands were placed inside the fume hood in order to manually work with I-131 liquid vials and to prepare capsules of required activity. Employees wore double latex gloves, plastic sleeves and a disposable lab coat.

"Manually working with significant amounts of I-131 in the preparation of diagnostic and therapy capsules from liquid inside a fume hood caused both employees extremity finger rings to exceed State of Florida limits. Syringe shields were not used by the individual when extracting liquid I-131 from vials. There are no written procedures for this operation for the individual to follow. No remote tools were used during the preparation process.

"Florida is investigation this incident."

Notified R1DO (Cahill) and FSME (Burgess).

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General Information or Other Event Number: 43966
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH SCIENCES UNIVERSITY
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: OR-90731
Agreement: Y
Docket:
NRC Notified By: DARRELL YOUNG
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/06/2008
Notification Time: 14:58 [ET]
Event Date: 02/06/2008
Event Time: [PST]
Last Update Date: 02/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE GREATER THAN 25 REM

The 4Q07 dosimetry badge reading results indicated an exposure of 261,067 mrem shallow dose, beta, probably from P-32. It is believed that this reading may be a result of leaving a contaminated glove in a lab coat pocket following work, and then placing the badge in the same pocket, and the two remaining together for a period of over a month. The worker has been withdrawn from all radiation work. An investigation is in progress.

"02/06/08 - Radiation Safety Officer [REDACTED] of OHSU (License #OR-90731) notified [OREGON PUBLIC HEALTH] at the Agency that while reviewing dosimetry reports from Global Dosimetry Co., he discovered one user who had a 261,067 mrem shallow dose. [OREGON PUBLIC HEALTH] contacted [RSO] regarding the high dose and found that the dose was reported on a whole body badge for 4Q07. Further, it was found through this discussion that the isotope was P-32 and the user told [RSO] that he placed a contaminated glove in the pocket of his lab jacket and later placed his whole-body badge in the pocket with the glove. This was done approximately after 1 month into 4Q07 and the dosimetry and jacket were not used for 2 months. Unknown dose to the user during the first month from the glove. The glove was checked when found in the pocket and found to have 1100cpm (3400dpm) at that time. The user has been suspended from using radioactive material until an investigation (both OHSU and State Radiation Protection Services) can be performed and results determined. [RSO] is writing a preliminary report to be sent to [OREGON PUBLIC HEALTH] and [OREGON PUBLIC HEALTH] this afternoon or tomorrow.

"02/06/08: SA-300 consulted, potential dose exceeds 250 rem shallow dose level. Notified NRC Operations Center by phone per significant reportable event requirements at 1458 EST (11:58 PST) and received Event number 43966. Relayed preliminary information as acquired so far, will follow with fax of this information as well. Licensee to issue preliminary investigative report sometime this afternoon or early tomorrow."

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General Information or Other Event Number: 43970
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA BERKELEY
Region: 4
City: BERKELEY State: CA
County:
License #: 1333-01
Agreement: Y
Docket:
NRC Notified By: MARK GOTTLIEB
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/07/2008
Notification Time: 19:47 [ET]
Event Date: 08/09/2007
Event Time: [PST]
Last Update Date: 02/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)

Event Text

AGREEMENT STATE - LEAKING GENERAL LICENSED SOURCE FROM A GAS CHROMATOGRAPH

The State provided the following information via email:

"On August 9, 2007, a dry smear of an ECD at UC Berkeley indicated a gross count rate of 5171 cpm. It was determined that this count rate indicated an activity of 0.03 uCi of Nickel-63. The ECD was returned to Varian on August 21, 2007, who determined that the leakage was less than the reportable limit of 0.005 uCi. Varian returned the ECD with the original Nickel-63 foil to UC Berkeley on August 28, 2007.

"On October 16, 2007, the same 15 mCi Nickel-63 foil in the same Electron Capture Detector (ECD) in the Varian gas chromatograph was again found to be leaking. The activity of the leakage was determined to be 0.06 uCi. On October 17, 2007, the use of the gas chromatograph was immediately suspended, and a follow-up survey found that the contamination was limited to the top of the ECD, the exhaust funnel and a section of the exhaust tubing. On October 19, 2007, Varian representatives removed the ECD and transported it to their facility for analysis and repair. No adverse health effects resulted from this incident. UC Berkeley notified the RHB [Radiologic Health Branch] of this matter on November 9, 2007."

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Power Reactor Event Number: 43976
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE REANDEAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2008
Notification Time: 01:48 [ET]
Event Date: 02/10/2008
Event Time: 22:07 [CST]
Last Update Date: 02/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 97 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO INCREASING REACTOR VESSEL LEVEL

"On February 10, 2008, at approximately 2207 hours CST, the 'B' Reactor Recirculation pump tripped from fast speed to off. The resultant reactor pressure vessel level swell resulted in reactor pressure vessel level being greater than 48 inches and rising. Per Clinton Power Station operating procedures, the 'A' Reactor Operator placed the mode switch to the 'shutdown' position initiating a manual reactor scram. All control rods inserted [fully]. CPS is currently stable in Mode 3."

Decay heat is being removed to the main condenser via the turbine bypass valves. Reactor level is being maintained using the motor driven reactor feedpump. No SRVs lifted during the transient. Licensee is in progress of restoring the electrical plant to a normal shutdown lineup.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 43977
Rep Org: USAF SURGEON GENERAL
Licensee: USAF SURGEON GENERAL
Region: 4
City: DALLAS State: TX
County:
License #: 42-23539-AF
Agreement: Y
Docket: 30-00653
NRC Notified By: MAJOR CLINT ABELL
HQ OPS Officer: JOE O'HARA
Notification Date: 02/11/2008
Notification Time: 08:15 [ET]
Event Date: 02/11/2008
Event Time: 07:48 [CST]
Last Update Date: 02/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DALE POWERS (R4)
MICHELE BURGESS (FSME)
ILTAB VIA EMAIL ()

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

Event Text

POTENTIALLY LOST IMPROVED CHEMICAL AGENT MONITOR

The Radiation Protection Office of the U.S. Air Force Surgeon General was informed this morning that an improved chemical agent detector was lost at the Moody AFB in Georgia. The device is identified as a DuPont-Merck, model #NER004R, serial number 18465. The device contains 15 milliCuries Ni-63. It is also identified as a SSDR NR-1129-D-103-S. The permit number GA-00653-01/00AFP docket number 030-00653. The device was in the custody of the 820th Security Forces Group Commander and appears that the equipment was misplaced following a training exercise that was conducted on base. The USAF is investigating by conducting a search of all the gear associated with the exercise, and does not believe the device is in the custody of the general public.

Licensee is going to contact Rachel Browder in Region IV.

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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Other Nuclear Material Event Number: 43978
Rep Org: SCI ENGINEERING INC
Licensee: SCI ENGINEERING INC
Region: 3
City: SAINT CHARLES State: MO
County: SAINT CHARLES
License #: 24-20039-01
Agreement: N
Docket:
NRC Notified By: DAVID NOLAN
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/11/2008
Notification Time: 16:41 [ET]
Event Date: 02/11/2008
Event Time: 14:30 [CST]
Last Update Date: 02/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ERIC DUNCAN (R3)
ANDREW PERSINKO (FSME)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

At approximately 1430 CST, a moisture density gauge was damaged when it was run over by construction equipment at the Riverport 7 construction site, near the cross roads of Riverport Drive and Riverport Lane, in Maryland Heights, Saint Louis County, MO.

Make: Humboldt; Model: 5001; Serial Number: 1654C; Source: 10 millicuries Cs-137 and 40 millicuries Am-241:Be.

Consultants, RM Wester, have been contacted, and are in the process of taking surveys and taking possession of the gauge. There does not appear to be any damage to the source. The source is believed to be retracted and shielded. The rod on the top of the gauge was broken, and the source can not be readily moved in the normal manner.

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