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Event Notification Report for May 16, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/15/2008 - 05/16/2008

** EVENT NUMBERS **


43979 44203 44204 44210 44216 44217

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General Information or Other Event Number: 43979
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ONCOLOGY SYSTEMS, INC.
Region: 4
City: ST. ROSE State: LA
County:
License #: LA-11598-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/11/2008
Notification Time: 16:44 [ET]
Event Date: 02/09/2008
Event Time: 09:00 [CST]
Last Update Date: 05/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING FAILURE OF HDR SOURCE TO RETRACT DURING TESTING

The following information was provided by the State of Louisiana via email:

"On February 9, 2008 at around 9:00 am, a Model Number AccuSource 1000, with a Model M-19 Iridium-192 High Dose Rate Brachytherapy Source failed to retract automatically while pre-operational acceptance testing was being performed at New York Radiation Oncology Associates, Queens, New York City, New York. The AccuSource 1000 is manufactured by Oncology Systems, Inc. Their license number is LA-11598-L01, amendment# - initial, with an expiration date of July 31, 2012. Agency Interest Number is 147139.

"Model M-19 Iridium-192 source SSD number is LA-0612-S-115-S. The sources maximum quantity is 12 curies of Iridium-192.

"Oncology Systems, Inc. according to their license condition number eight, states that 'The licensee shall report to the Department, immediately by phone and written notice with ten (10) days of occurrence of any irregularities pertaining to inability to retract the source to its fully shielded [position], and failure of any component or software (critical to safe operation of the device) to properly perform its intended function under the authority of this license.'

"This was reported by SPEC who is the manufacturer of the Model M-19 Iridium-192 source. Talking with SPEC, it does not seem that Oncology Systems, Inc. have any personnel located at the 119 Teal Street, St. Rose, LA 70087 location."

The source, which was extended approximately 10 cm when it stuck, was manually retracted. There was no reported personnel overexposures, however, the individual's film badges involved in returning the source to the shielded position have been sent out for processing. The City of NY Rad Health Department was notified by the State of Louisiana of this incident.

* * * UPDATE PROVIDED AT 1512 EDT ON 05/15/08 FROM PENROD TO ROTTON * * *

The State provided the following information via facsimile:

"The incident involved an OSI AccuSource 1000, lr-192 HDR Brachytherapy unit. The unit malfunctioned, during an initial systems check, resulting in the source disconnecting from the source cable and the source capsule. The source strength was 8.62 curies. The source remained in a shielded position and was shipped back to Source Production & Equipment Company (SPEC), RAM License # LA- 2966-L01, the source manufacturer. No patients were involved and no overexposures were noted. This investigation is still in progress. One area of concern was noted.

"On February 9, 2008, an Oncology Systems. Inc. (OSI) Field Engineer, was performing quality assurance testing on the AccuSource 1000, lr-192 Brachytherapy High Dose Rate Remote Afterloader (HDR), at the new York Radiology Associates, located in Queens, New York (RAM License # 91-3338-01). Field Engineer first performed a systems and software check on the HDR using a nonradioactivce source. All quality assurance tests passed during this time. He then loaded the HDR with the inner vault/spool cartridge assembly, which had an 8.62 Curie lr-192 sealed source. Field Engineer performed several tests on the HDR unit before running the source cable out, to insure that the inner vault was installed correctly to the outer vault (which is part of the HDR unit). The tests passed. He then extended the source out of vault when a force error sensor was triggered between the vault and the turret. When the force error was triggered this triggered an emergency retraction of the source. During the emergency retraction of the Ir-192 source, the vault door closed on the source tip resulting in a source disconnect and the loss of the top part of the source capsule. The source did retract to the inner vault where it was shielded and did not leave the AccuSource unit. The inner vault/spool cartridge, with the Ir-192 source was packaged in a Type A shipping container, provided by SPEC, held at the facility in a locked room until it could be shipped to SPEC. SPEC received the container on 2/26/2008. The source capsule tip loss was not known until the inner-vault was inspected by SPEC on 03/18/08.

"Surface readings were 19mR/hr and 0.7mR/hr at one foot away. Survey readings of the package, before it was sent to SPEC, highest survey reading at one foot away from the package was 1.4mR/hr. This was taken at the bottom of the package. The highest reading taken from its side at one foot away was 0.51 mR/hr, similar to the reading at SPEC.

"Once the package was open, several wipes were performed by SPEC. Two areas above background were noted. The wipe from the tip of the cap/wire where the source capsule was missing (the lr-192 source would have direct contact with this piece) had a wipe count of 327cpm and back end of the cable had a wipe count of 101cpm. Background was 37cpm. Survey readings of the vault were done by SPEC and the department at the time of this investigation. Survey readings on the side of the vault were 200 mR/hr and 100 mR/hr at the end of the vault. The source was located in the inner vault, but the inner vault was not opened at the time of this inspection. The facility wanted the lr-192 source to decay before opening the inner vault.

"The inner vault was disassembled by SPEC on 03/18/2008. They found the bare lr-192 pellet in the straight exit channel of the front vault slug. The source capsule was not in the inner vault. The shipping package was re-surveyed and the capsule was not found. SPEC immediately notified the department and OSI. Wipe tests of the inside of the vault was performed by SPEC. The highest reading was taken from the center vault slug which was 33,000 nanoCuries. OSI field Engineer was going to the New York Facility during the week of 04/15/2008 to do a survey of the AccuSource and the therapy room to see if the missing capsule can be located. The results have not been received by the department as of 04/23/2008.

"OSI states that the force error could have been triggered by many reasons and that the cause is unknown. The source became 'stuck' due to the vault door closing partially on the capsule. OSI is in the process of making design and software changes to prevent this problem from occurring in the future."

Notified R4DO (Powers) and FSME EO (Tadessee).

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General Information or Other Event Number: 44203
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL INC.
Region: 1
City: BURLINGTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB WALKER
HQ OPS Officer: PETE SNYDER
Notification Date: 05/12/2008
Notification Time: 13:45 [ET]
Event Date: 05/12/2008
Event Time: 13:45 [EDT]
Last Update Date: 05/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
JIM WHITNEY (ILTA)
BRIAN McDERMOTT (IRD)
MICHELE BURGESS (FSME)
LEE (DHS)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING IRIDIUM-192 SOURCE

QSA Global reported to the Commonwealth of Massachusetts that a shipment containing a 149.2 Curie Ir-192 source that was originally shipped on 5/7/08 was missing. The shipment arrived in Miami and was transferred from FedEx to Amerijet. Amerijet reported to an agent of QSA Global, on 5/9/08, that the shipment could not be found at the time of its originally scheduled flight to Trinidad, its final destination.

As of 1345 on 5/12/08 Amerijet still could not locate the package. The company initiated a warehouse search. The signature that FedEx had on record as receiver was reported to be "not an eligible" receiver by Amerijet.

* * * UPDATE AT 1710 FROM BOB WALKER TO HOWIE CROUCH * * *

Amerijet has located the missing shipment in their Miami facility. The package is undamaged and will shortly resume transport to its final destination of Trinidad.

Notified ILTAB (Whitney), R1DO (Krohn), FSME (Reis), IRD (McDermott), and DHS (Lee).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

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General Information or Other Event Number: 44204
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: WAL-MART
Region: 4
City: GLENDALE State: AZ
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/12/2008
Notification Time: 18:54 [ET]
Event Date: 05/12/2008
Event Time: 14:30 [MST]
Last Update Date: 05/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
TERRANCE REIS (FSME)

Event Text

ARIZONA AGREEMENT STATE REPORT - CONTAMINATION EVENT DUE TO A BROKEN TRITIUM EXIT SIGN

The following information was provided by the Arizona Radiation Regulatory Agency via email on 5/12/08 @ 1854 EST:

"By letter dated May 7, 2008, the Licensee reported that their contractor had detected a broken 20 curie tritium exit sign at their Glendale store. A second contractor with a Certified Health Physicist, was called in to decontaminate and investigate the circumstances on April 25, 2008. The second contractor found up to 16,900 dpm/100 cm2 removable contamination on the wall where the sign had been located. On the floor beneath the sign, the contractor reported contamination up to 1,400 dpm/cm2. The date of breakage is unknown and could have actually occurred up to one year prior to discovery.

"The device was a SRS Technologies, Inc. Serial number 304150, 20. The sign has been shipped to Canada to Shield Source, Inc., a Canadian licensee.

"The Agency is investigating the delay in reporting this event since the report was not made within 24 hours."

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General Information or Other Event Number: 44210
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: A SQUARED INC.
Region: 1
City: ORLANDO State: FL
County:
License #: 3727-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 05/13/2008
Notification Time: 17:13 [ET]
Event Date: 05/13/2008
Event Time: 16:48 [EDT]
Last Update Date: 05/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
REBECCA TADESSEE (FSME)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

At the intersection of Toll Road 528 east of Highway 417 in Orlando a CPN Model MC-3, serial number 8027 moisture density gauge was damaged. "A water truck backed up over the gauge and bent the rod. The rod was later retracted to the shielded condition. The gauge will be returned to CPN for repair. No further action will be taken on incident. "

Typically this model gauge contains a 10 milliCuries Cs-137 source and a 50 milliCuries Am-247/Be source.

The State of Florida incident number is FL08-075.

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Fuel Cycle Facility Event Number: 44216
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/15/2008
Notification Time: 15:01 [ET]
Event Date: 05/15/2008
Event Time: 14:25 [EDT]
Last Update Date: 05/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
70.32(i) - EMERGENCY DECLARED
Person (Organization):
MARVIN SYKES (R2)
BRITTAIN HILL (NMSS)
LUIS REYES (RA)
MIKE WEBER (NMSS)
WILLIAM GOTT (IRD)
WILLIAMSON (DOE)
DUNKER (FEMA)
LEE (DHS)
LEDBETTER (USDA)
TURNER (HHS)

Event Text

ALERT DECLARED DUE TO REQUEST FOR OFFSITE ASSISTANCE CONCERNING LOSS OF PLANT WATER

Licensee declared an Alert due to requesting offsite assistance related to loss of plant water service. Water service line break is onsite. Plant water service is used to operate facility process equipment. Licensee is presently shutting down plant facility process equipment. Notified Richland County and State of South Carolina. Local fire department providing temporary water service via fire trucks.

Currently there are no releases to the environment and no threat to public health and safety.

* * * UPDATE AT 1755 EDT ON 05/15/08 FROM COUTURE TO ROTTON * * *

Licensee terminated Alert at 1745 EDT. Plant Water system has been restored. Plant personnel are flushing water system prior to returning to service and starting up plant process systems.

Licensee notified state and local agencies.

Notified R2DO (Sykes), NMSS EO (Hill), IRD (Gott), DHS (Turner), FEMA (Cannupp), DOE (Yates), USDA (Timmons), and HHS (Howard).

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Power Reactor Event Number: 44217
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: DAVID NOYES
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/15/2008
Notification Time: 20:51 [ET]
Event Date: 05/15/2008
Event Time: 20:00 [EDT]
Last Update Date: 05/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAUL KROHN (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 STATE OF MASSACHUSETTS REGARDING PRESS RELEASE

"Entergy Pilgrim Station has reached a tentative 4-year agreement with UWUA Local 369. This notification is in anticipation of media interest and Entergy Press Releases."

Licensee notified the NRC Resident Inspector and the Massachusetts Emergency Management Agency.

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