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Event Notification Report for August 25, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/22/2008 - 08/25/2008

** EVENT NUMBERS **


44219 44422 44424 44426 44427 44429 44433 44436 44437 44438

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Hospital Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."

* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *

"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.

"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).

R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.

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.


* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *

"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

"VHA provided an initial update on June 6, 2008. This update reflects the most current information.

"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

"Patient notification:

"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).

* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *

"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.

"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.

"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program is suspended and an external review is in progress.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.

"Patient notification:

"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."

Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).

* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *

"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).


* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *

A 15-day written report of one of the medical events was submitted to NRC Region III.


Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)

* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).

* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *
Bur
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "

Notified R1DO (Dentel), R3DO (Lara), and FSME (White).

* * * UPDATE ON 7/22/2008 AT 1500 EDT FROM WILLIAMS TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional five patients on July 22, 2008. This brings the total number of medical events to 37 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III."

The licensee will notify NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events.

Notified R1DO (Dentel), R3DO (Riemer), and FSME (Burgess).

* * * UPDATE FROM GARY WILLIAMS TO JOE O'HARA 1145 EDT ON 7/25/08 * * *

"As the result of an ongoing review, medical events were discovered for an additional two patients on July 25, 2008. This brings the total number of medical events to 39 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (W.Cook), R3DO (M.Phillips), and FSME (C.Flannery)

* * * UPDATE AT 0805 ON 08/06/08 FROM THOMAS HUSTON TO JEFF ROTTON * * *

"As the result of an ongoing review, medical events were discovered for an additional four patients on August 05, 2008. This brings the total number of medical events to 43 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (Gray), R3DO (D Hills), and FSME (C. Einberg)

* * * UPDATE AT 1002 EDT ON 8/13/08 FROM HUSTON TO SANDIN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional four patients on August 12, 2008. This brings the total number of medical events to 47 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these four additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Holody), R3DO (Kozak) and FSME (Burgess).


* * * UPDATE AT 1422 EDT ON 8/22/08 FROM HUSTON TO KNOKE * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional eight patients on August 21, 2008. This brings the total number of medical events to 55 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these four additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified by email: R1DO (Perry), R3DO (Lipa) and FSME (Burgess).

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General Information or Other Event Number: 44422
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: A&R ENGINEERING
Region: 4
City: HOUSTON State: TX
County:
License #: L05318
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2008
Notification Time: 13:31 [ET]
Event Date: 08/15/2008
Event Time: [CDT]
Last Update Date: 08/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
MICHELE BURGESS (FSME)
ILTAB EMAIL ()
MEXICO FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

"On Friday, August 15, 2008, the agency [State of Texas] received a phone call left as a message for an employee out on leave that a moisture density gauge [Humbolt model 5001EZ] was stolen after it was left at a work site. It was apparently left out of the transport case and the technician was distracted with other duties. When the employee returned there was no trace of the device.

"The RSO stated that a full investigation will be performed to ascertain how the instrument was left unattended and the local law enforcement authorities have been notified. A $300 reward has been offered for return of the device. Incident Investigation Program (IIP) has notified LEA and pawn brokers to be on alert for stolen device.

"Company (and State Agency) will conduct a thorough investigation. Protocols for proper storage and handling of gauges will be stressed at a future safety meeting and all employees will receive training on the consequences of mishandling company property.

"Sealed sources :Radionuclide(s): 10 mCi, Cs-137 & 40 mCi, Am/Be-241 Serial Numbers: device 515; Cs-137, 8567GF; Am-241, NJ00479"

TX-I-8541


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: 44424
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GREATER BALTIMORE MEDICAL CENTER
Region: 1
City: BALTIMORE State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BARBARA PARK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2008
Notification Time: 14:49 [ET]
Event Date: 08/17/2008
Event Time: 18:00 [EDT]
Last Update Date: 08/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
PATRICE BUBAR (FSME)
ILTAB EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOSS OF Ir-192 SEEDS

"At 1:30pm on Monday, August 18, 2008, a Maryland Department of the Environment radioactive material licensee, Greater Baltimore Medical Center, reported by phone to MDE RHP a loss of 5 Iridium-192 seeds of 0.59 millicuries each seed. The seeds were in a ribbon implanted in a cancer patient's neck along with 5 other strands of seeds. Numerous checks and plain films were obtained to verify correct location. The seeds had been implanted on Wednesday, August 13, 2008 and were checked daily. The loss of a strand of seeds was discovered on Sunday, August 17, 2008 at approximately 6pm, when the seeds strands were being removed.

"Investigative action: The patient was moved to a new room. The licensee reports extensive monitoring of all linens, surfaces, sink drain, other rooms in the unit, nurses station, hallways and the loading dock, where trash was monitored (even though a monitor is located on the loading dock.) A relative's car was also monitored. Being that the patient shaved with a non-electric razor, the outcome of the investigation was that during shaving the strand must have come loose and had fallen into the toilet.

"The RSO and radiation oncologists and physicists were involved in the investigation. Preventive action is for two radiation workers, (i.e. physician and physicist) to independently check the button crimped on the end of the ribbon strand to insure that the ribbon cannot slide out of the catheter.

"The written report from the licensee was received by fax on August 19, 2008, at 3:33 pm. Further investigation by MDE RHP is pending."


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.

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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General Information or Other Event Number: 44426
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS ONCOLOGY P.A. - KLABZUBA
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/19/2008
Notification Time: 16:13 [ET]
Event Date: 08/19/2008
Event Time: [CDT]
Last Update Date: 08/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
PATRICE BUBAR (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT TREATMENT CALCULATION

"Hospital cited for current calibration of SR-90 eye applicator. During previous inspection, after calibration, recalculation of recent treatments indicated 3 patients received 50% overdose over the past year. RSO reports Oncologist and referring physician were pleased with patients response to treatment."

Texas Incident # I 8539

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: 44427
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NOT APPLICABLE
Region: 4
City: DALLAS State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/20/2008
Notification Time: 08:57 [ET]
Event Date: 08/17/2008
Event Time: 10:00 [CDT]
Last Update Date: 08/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
MICHELE BURGESS (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - SURFACE CONTAMINATION AT LUFTHANSA CARGO FACILITY

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

" On 8/18/08 at 0655 CDT, [State of Texas] received a call from the answering service at approximately 10 PM on 8/17/08 requesting that [the State] call Lufthansa Cargo at DFW Airport. [State] contacted [Deleted] and he [reported] that customs had been at their facility and had found a spot on their concrete floor reading 132 microrem. The area [approximately 16' x 20' ] had been used to store a container from Protechnics out of Houston, Texas. The package had originated from Spectro Services in Albuquerque, NM. The package had been sent on to Germany on 8/14/08. The radionuclide was identified as Iridium (Ir) - 192 by the Dallas Fort Worth Fire Department. The area is currently roped off and posted no entry. A decontamination service [was scheduled] to decontaminate the area Monday 8/18/08 in the afternoon. [Deleted] agreed to contact us when the area was decontaminated. Copies of the surveys conducted were also requested. An Agency inspector performed a survey of the area and identified the contamination as Ir - 192. On 8/19/08 at 1410 CDT, NNSI was been contracted to decontaminate the area. The contractor states that the area should be released by this evening.

"Contamination appears to be in the form of dust. Several packages were in the contaminated area and were decontaminated prior to releasing for shipment. The contamination is readily removable. NNSI stated that they were going to survey the transportation area in Houston. The shipper stated that they had surveyed the location in Houston (Transaction Packaging 2928 B Greens Rd Suite 250) where the package was stored waiting to be sent to Dallas/Fort Worth and found no direct readings above background. NNSI has not provided the Agency with any of their readings. The original survey conducted by the state inspector found removable contamination levels of 4000 cpm/smear on 8/18/08 in the area in question. Shoes of all workers who could have traveled thru the area were surveyed and found to be free of contamination.

"The package originated in Albuquerque NM and was flown from there thru Memphis, TN To Houston, TX and then trucked to Dallas Fort Worth airport.

"The material first considered as the source was Ir - 192 tracer material. Surveys of the package when it arrived in Germany indicated that there was no contamination outside of the package. An engineer is waiting for the package in India. He will survey the package, then open the package to verify that there has been no damage. The engineer will take pictures of the boxes and forward to the Agency. There was a statement from NNSI that they had heard that there may have been a problem with the package in Houston and that it may have been over packed. Protechniques stated that this was not true.

"An Agency inspector will survey the transport trailer used to move the material to DFW on 8/20/08.

"The material first thought to create the problem was packaged in 20 mil vials, placed inside a lead shield, which was placed inside a plastic bag and placed in a DOT shipping container.

"The Agency has requested the records on all RAM passing thru this facility in the last 90 days from Lufthansa Cargo."

Texas Incident number: I-8536

* * * UPDATE ON 8/20/08 AT 1221 FROM A. TUCKER TO V. KLCO * * *

" At 0915, NNSI reported that the area at Lufthansa Cargo was released for unrestricted use at 9 PM on 8/19/08. They also reported that they conducted surveys at Lufthansa's warehouse in Houston, Texas and found no uncontrolled radioactive material. "

Notified R4DO (V. Gaddy) and FSME (M. Burgess) and e-mailed OIP (S. Dembek).

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General Information or Other Event Number: 44429
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 25-1323-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2008
Notification Time: 16:36 [ET]
Event Date: 08/19/2008
Event Time: [CDT]
Last Update Date: 08/20/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - FIRE IN RESEARCH LABORATORY

This information was received from the state via fax:

"The afternoon of 8/19/2008 DHS [Department of Health Services] staff became aware a fire had occurred at a licensee facility the previous evening. Reports indicated the local fire department and hazardous materials teams had responded to a fire in a molecular biology lab on the campus of the University of Wisconsin - Madison. The fire was extinguished within 15 minutes. Reports also indicated the Hazardous Incident Team used instruments to rule out the presence of any radioactive materials. Although no contamination was detected, fire equipment was rinsed with water to remove any reside from the fire.

"DHS contacted the licensee. The licensee indicated staff members from radiation safety had responded to the incident the next morning. The research lab performs molecular biology research using P-32. The safety department staff performed surveys of the fire scene and identified areas of contamination on the floor. The areas had been decontaminated. Initial information from the licensee indicates approximately 0.5 to 0.7 millicuries of P-32 in waste containers was involved.

"The licensee did not report the incident to DHS. DHS inspectors were dispatched to investigate."

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Power Reactor Event Number: 44433
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CALVIN WARD
HQ OPS Officer: VINCE KLCO
Notification Date: 08/22/2008
Notification Time: 14:36 [ET]
Event Date: 08/20/2008
Event Time: 06:00 [EDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
STEVE ROSE (R2)

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

Event Text

UNANTICIPATED OR EMERGENCY DISCHARGE OF WASTE WATER OR CHEMICAL SUBSTANCES

"Plant Technical Specifications, Appendix B, Section 4.1, Unusual or Important Environmental Events, states that the NRC Operations Center will be notified within 72 hours as described in 10 CFR 50.72 for an unanticipated or emergency discharge of waste water or chemical substances. This notification is due to an unanticipated emergency discharge of storm drain waste water beginning 8/20/08 at approximately 0600 due to Tropical Storm Fay. A 30 day letter detailing the event to the NRC is also required.

"On 8/20/08, St Lucie Plant water levels in all of the plant storm water basins and Unit 1 Condenser Pit experienced a significant level increase received due to approximately 15 inches of precipitation from Tropical Storm Fay. Over the next 24 hours the site pumped approximately 23 million gallons of water from the storm water basins into the intake canal from an approved outfall (008). The water level in the basin has decreased 8.7 feet to 6.7 feet. Pumping activities will continue until we reach a level of 5 feet in the pond. The total estimated amount of water expected to be discharged from outfall-008 is 40 million gallons.

"Chemistry obtained samples from the storm basin and Condenser Pit both and the samples were determined not to contain radioactivity. The non-radiological analysis will be forthcoming from an offsite laboratory (the FPL 45th street lab), however no oil sheen was observed prior to any discharge. The lab results will be included in the 30 day NRC letter detailing the event.

"The DEP [ Department of Environemntal Protection] was contacted and a verbal request was made and consent received to pump water from the U- I condenser pit to the intake canal. A final report will be sent to the DEP when pumping is concluded identifying total volumes and water profiles. The Plant NPDES permit does not regulate the volume of water discharged from 008.

"As a result of the Unit 1 Condenser Pit flooding, secondary Condensate and Feedwater chemistry levels sodium and chloride levels increased to Plant Action Level 3 conditions which require the Unit to be shutdown to at least Mode 2 conditions. Due to End of Cycle conditions and Xenon build-in, the Unit was shutdown and is currently in Mode 3. The Turbine was manually tripped and the Control Rods were driven to All Rods In, i.e., there was no reactor trip or RPS / AFAS actuation. Residual reactor heat is being removed by Atmospheric Dump Valves and Auxiliary Feedwater is providing makeup to the S/Gs. Repairs are being implemented to prevent Condenser Pit flooding and secondary inleakage. Unit 2 operations was not affected by this event. Off-Site power remained available during this event."

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 44436
Rep Org: U.S.ARMY
Licensee: U.S. ARMY
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: TOM GIZICKI
HQ OPS Officer: VINCE KLCO
Notification Date: 08/22/2008
Notification Time: 17:36 [ET]
Event Date: 03/21/2008
Event Time: [CDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
CHRISTINE LIPA (R3)
RICHARD DEESE (R4)
CHRISTIAN EINBERG (FSME)

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

Event Text

MISSING CHEMICAL AGENT ALARM DETECTOR

"On March 21, 2008 a MSARNG [Mississippi State Army Reserve National Guard] unit from Jackson, Mississippi at the United States Property & Fiscal Office (USP & FO) receiving warehouse loaded 60 M43A1 alarms for delivery to the United States Property & Fiscal Office (USP & FO) at Camp Shelby, MS. Inventory of the M43A1's was conducted at the time of packaging the detectors in Jackson, MS. All 60 M43A1's were packaged into a single white shipping container and loaded into a trailer. The shipping container was banded shut and secured inside the towed trailer. The trailer was locked during transport in an Army vehicle. The trailer containing the M43A1's was received at Camp Shelby on or about April 8, 2008. The shipping container was not tampered with and was still closed when received at Camp Shelby. An inventory was conducted at the USP & FO, Camp Shelby and it was discovered that one M43A1 detector was missing. On May 22, 2008 a financial liability investigation of property loss was initiated by the Mississippi National Guard. The Army conducted a financial investigation liability loss that was completed on August 19, 2008. The missing alarm detector was reported to the licensee on June 19, 2008. A physical search was conducted at Camp Shelby warehouse and Jackson warehouse locations with negative results. On July 18th the NGB U.S Property and Fiscal Office in Flowood Mississippi issued a memorandum dated July 18, 2008 directing a physical inventory be conducted at all USP& FO's within the state of Mississippi to search for the missing M43A1 detector. On August 19, 2008 the physical search was completed with negative results. On August 21, 2008 the Army fiscal officer performed one last search for the device at the warehouse in Camp Shelby, MS with negative results."

Based on discussion with the license RSO (Radiation Safety Officer) the lost chemical agent alarm detector activity is 250 micro-curie of Am-241.

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Power Reactor Event Number: 44437
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: POUL CHRISTIANSEN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/22/2008
Notification Time: 20:02 [ET]
Event Date: 08/22/2008
Event Time: 16:20 [EDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ROSE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

OFFSITE NOTIFICATION DUE TO HYDRAZINE SPILL

"At 1620 EDT, the following off-site agencies were notified of approximately 1.8 gallons of 35 weight-percent Hydrazine spillage into the storm drain system: National Response Center, State Emergency Response Commission, and Florida Department of Environmental Protection. The storm drain system discharges to an on-site settling pond. The amount of Hydrazine spilled was greater than the reportable quantity of 0.34 gallons of 35 weight-percent hydrazine. The leak has been identified and stopped, area has been cleaned. Notification due to 10CFR50.72(b)(2)(xi), due to notification of off-site agencies."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44438
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: WILLIAM KISNER
HQ OPS Officer: VINCE KLCO
Notification Date: 08/24/2008
Notification Time: 18:03 [ET]
Event Date: 08/24/2008
Event Time: 15:57 [EDT]
Last Update Date: 08/24/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
STEVE ROSE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO FEEDWATER FLOW OSCILLATIONS

"The 'A' Condensate Pump became uncoupled, lowering Condensate flow. Operators began to manually lower reactor power to maintain deaerator level. Reactor power was lowered to approximately 62 percent. At this power, [feedwater] flow oscillations began and were excessive. With these flow oscillations increasing the decision was made to manually trip the Reactor. The Reactor was manually tripped at 1557 hours. There were no safety system actuations other than RPS (Manual). The plant is stable in a normal post trip configuration."

All control rods inserted into the core during the reactor trip. Offsite power is available and powering safety loads. The steam generator safeties lifted during the transient and reseated. There is no known primary to secondary leakage. Decay heat is being removed via steam dumps to the condenser using normal feedwater to the steam generator. The emergency feedwater system was not initiated during the reactor trip.

The licensee notified the NRC Resident Inspector.

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