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Event Notification Report for August 27, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/26/2008 - 08/27/2008

** EVENT NUMBERS **


40376 44428 44430 44434 44435 44440

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General Information or Other Event Number: 40376
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: STATE OF FLORIDA
Region: 1
City: DAVIE State: FL
County:
License #: 0109-1
Agreement: Y
Docket:
NRC Notified By: JERRY EAKINS
HQ OPS Officer: GERRY WAIG
Notification Date: 12/05/2003
Notification Time: 11:54 [ET]
Event Date: 12/04/2003
Event Time: [EST]
Last Update Date: 08/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT- FLORIDA - LOST OR STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received via facsimile and telephone conversation:

"Loss of Control - Lost, Abandoned, or Stolen Materials

"Incident Location: Suspected Florida Department of Transportation (FDOT) job site at US1 just north of North Bridge Road, St. Lucie, Florida in unrestricted area.

"Incident Description: POC [Point of Contact] reported he looked for gauge in the bed of transport truck this AM. Gauge was not in carrying case. He believes he left the gauge at the job site on 4 Dec. He has the locks for the transportation case and the box attached to the truck bed and they were intact. The gauge handle was locked and he has the keys. He had a crew in Ft. Pierce make a futile search for the gauge at the work site. He called the Ft. Pierce PD [Police Department] and they had no reports of a gauge being found. This office requested a press release and reward for the return of the gauge be issued and the gauge be reported lost or stolen to the Ft. Pierce PD. Further investigation of this incident will be by the Radioactive Materials section."

The subject gauge is a Troxler model 3440, serial number 20515, 40 milliCuries Am-241:Be, 8 milliCuries Cs-137 moisture density gauge licensed to the FDOT.

Florida incident number FL03-217.

* * * UPDATE FROM THE STATE OF FLORIDA (FURNACE) TO HUFFMAN AT 1031 EDT ON 8/26/08 VIA FACSIMILE * * *

"[On August 13, 2008,] a scrap truck tripped portal alarm [at a metal recycling facility - Trade Mark Metals]. [The scrap metal container] was rejected and returned to owner. [Redacted information] [The scrap metal] owner found what appear[ed] to be a bus door opener handle [as the] source [of the radioactivity]. An investigator [from the State] was dispatched to survey the source. The remaining load was accepted by Trade Mark Metals.

"[The] 'Handle' [was determined to be] a part of a soil moisture density gauge [containing the CS-137 source and] originally belonging to Florida DOT, and reported stolen 05-Dec-03. Incident number FL03-217, original NRC Event number 40376 [see above]. Other parts of the load were surveyed for the Am-241/Be source, [however] no radiation [was] found emitting neutrons [and no other parts of the gauge found]. [The original gauge] owner [DOT] will take control of item and properly dispose of. No further action will be taken on this incident [by the State]."

The State indicated that the CS-137 source was undamaged and the source serial number used to trace the original owner.

Followup State Report is FL08-121

Notified R1DO (Powell); FSME (Burgess); and ILTAB (Whitney via e-mail).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44428
Rep Org: OAKWOOD HOSPITAL & MEDICAL CENTER
Licensee: OAKWOOD HOSPITAL & MEDICAL CENTER
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: THOMAS KUMPURIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2008
Notification Time: 15:16 [ET]
Event Date: 06/03/2008
Event Time: 11:14 [EDT]
Last Update Date: 08/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
SONIA BURGESS (R3)
MICHELE BURGESS (FSME)

Event Text

MEDICAL EVENT - PRESCRIBED DOSE DIFFERED BY MORE THAN 20 PERCENT

"A written directive, signed and dated on 5/30/08 by an authorized user was prepared. The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma. An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08. On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied. On 6/03/08 the patient was properly identified, a negative pregnancy status was confirmed and the dosage assayed. A recorded dosage of 2.7 mCi was recorded in the hot lab computer and on the front of the written directive form. The hot lab computer with technologist data input produced a printed label of 2.7 mCi as of 6/03/08 at 1114 hours. However, at the time of dosage administration the calculated dosage available was 2.00 mCi.

"The dosage was administered to the patient and the patient was released with written radiation safety instructions for return 48 hours post administration for performance of the actual scan. At interview today, the technologist confirms that all administrative dosage information was recorded by her and her alone. She could not give any reason as to why a dosage of 2.7 mCi could or would have been administered or recorded.

"A recreation of these events today notes that the hot lab computer advises the technologist that the +/-20% threshold has been exceeded with a visual warning which can be bypassed upon consultation with the authorized user. We can find no documentation of a consultation and neither the authorized user nor the technologist can confirm that one took place. A conservative estimate of organ and EDE doses was made using ICRP 53 and an ultra conservative estimate of a thyroid uptake of 5%."

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.

* * * RETRACTION PROVIDED AT 1050 EDT ON 08/21/08 FROM CHAD MORGAN TO JEFF ROTTON * * *

"Upon further investigation we have determined that a Medical Event did not occur at Oakwood Hospital and Medical Center. We do believe that a documentation error did occur instead and have taken steps internally to prevent a reoccurrence (see below). We would like to retract our report of a medical event. This is due to the following conclusions:

* A written directive, signed and dated on 5/30/08 by an authorized user was prepared.

*The directive noted that 2.0 mCi of I-131 was prescribed to be given orally on 6/3/08, for the performance of a Whole Body Scan to a patient previously diagnosed with thyroid carcinoma.

*An order of 2.0 mCi of Na I-131 was placed with Anazao Health on 5/30/08.

*On 6/02/08 at 1300 hours, an order of 2.17 mCi was dispensed by Anazao Health to Oakwood Hospital & Medical Center. A dosage calibration sheet from Anazao Health was supplied.

"Upon further investigation, at the time of dosage administration the calculated dosage available was 2.00 mCi, though the documentation states the dosage given was 2.7mCi. We believe the documentation to be in error and not the actual dose given to the patient.

"Measures to Prevent Reoccurrence:

1. Prior to dosage administration, all documentation will be verified by either a second certified nuclear medicine technologist or an authorized user via review and signature on the written directive.

2. Extensive re-education for all technical staff will be conducted concerning the written directive program and patient release requirements.

3. A written internal time-out retrospective audit will be conducted on a random number of directives on a monthly basis.

4. Medical Physics Consultants, Inc. will continue to perform a full quarterly written directive program audit.

"Summary: It is our belief that the correct patient received the correct prescribed dosage for the ordered procedure, however our internal documentation notes otherwise. This documentation error would not constitute a Medical Event ."

Notified R3DO (Sonia Burgess) and FSME (Michele Burgess)

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General Information or Other Event Number: 44430
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County: USA
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: ROBERT GALLAGHAR
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/21/2008
Notification Time: 08:19 [ET]
Event Date: 08/20/2008
Event Time: 16:41 [EDT]
Last Update Date: 08/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
PATTY BUBAR (FSME)

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT POTENTIAL OVEREXPOSURE

"[A] technician working with a 113 Ci Ir-192 source set off high radiation alarms at [the QSA Global facility] which caused the immediate evacuation of the building. Radiation surveys outside the building indicated a dose rate of approximately 3 mR/hr at a distance of 25 feet from the exterior of the building. Radiation safety staff performed a source retrieval to recover the source and place it in a shielded container; the building was reoccupied approximately 30 minutes later.

"Preliminary investigation of the technician indicated his electronic dosimeter (worn on the side of the body closest to the source) showed an exposure of 720 mRem. The technician was not wearing his extremity ring badge at the time, however the radiation safety officer calculated a maximum exposure to the tips of the maximally exposed fingers to be approximately 2 Rem. Dosimetry for both the technician involved and another that was nearby when the incident occurred have been sent to the vendor for immediate processing.

"Radiation Safety staff from QSA are performing additional investigations and will report back to the [MA Radiation Control Program Office] when more information becomes available."

State of Massachusetts was notified by the licensee of this incident at 0621 on August 21, 2008.

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General Information or Other Event Number: 44434
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: BRAUN INTERTEC CORPORATION
Region: 3
City:  State: MN
County:
License #: 1082-102-27
Agreement: Y
Docket:
NRC Notified By: BRANDON JURAN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/22/2008
Notification Time: 14:10 [ET]
Event Date: 08/22/2008
Event Time: 12:00 [CDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

The following information was received from the State of Minnesota via email:

"Licensee was performing radiography on steam pipes in a bunker under the road (temporary jobsite). The bunker is accessed by two manholes in the street. At approximately 10:40 a.m. on 8/21/08 the licensee had a disconnect. The assistant under the supervision of the radiographer was cranking the source in, but did not feel it lock into place. The radiographer used the survey meter while the assistant cranked in and out. The readings on the survey meter did not change so they knew they had a disconnect and called the RSO.

"The RSO was notified at approximately 11:00 a.m. The RSO and another employee (former RSO) went to the scene. When they arrived onsite the readings at the manhole entrances were 80 mR/hr and 150 mR/hr, a couple of feet to the sides was background. The radiographer had roped off the area around the manhole entrances and the roped area was maintained until the RSO arrived on-site.

"The RSO, former RSO, and radiographer used telescopic poles to manipulate the camera, and guide tube into a position where the could lower bags filled with lead shot to shield the source. They were then able to enter the bunker and use a 'fishing' cable run through the camera and guide tube to grab the source. They exited the bunker and pulled the 'fishing' cable back until the source locked into the camera.

"The RSO and other employee were wearing dosimeters, direct reading dosimeters (DRDs), and alarming rate meters. At the end of the retrieval the RSO and former RSO had reading on there DRDs of 30 - 35 mR each. The radiographer had a reading on his DRD of 25 mR.

"In looking at the pig tail after the incident, the licensee thinks there is a faulty pig tail connection. The connection between the drive cable and pig tail needed to be forced to get connected, but once connected 'felt sloppy.' The licensee contacted the manufacturer and will be returning the source and cables to the manufacturer for investigation."

"Camera: QSA 660B"

"Source: QSA 424-9, Ir-192, 142 Ci"

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Fuel Cycle Facility Event Number: 44435
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/22/2008
Notification Time: 14:46 [ET]
Event Date: 08/21/2008
Event Time: 22:30 [EDT]
Last Update Date: 08/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
STEVE ROSE (R2)
ABY MOHSENI (NMSS)
FUELS OUO via Email ()

Event Text

MATERIALS CONTROL & ACCOUNTABILITY ALARM PROCEDURE INITIATED

"10CFR74.57(f)(2) requires notification within 24 hours that an MC&A [Material Control & Accountability] alarm resolution procedure has been initiated. Because an alarm investigation was initiated, a notification to the NRC Operations Center was made. Additional sampling later indicated the value was below the abrupt alarm value and this was communicated to the NRC Operations Center. There is no indication that a material loss has occurred.

"There were no actual or potential safety consequences to workers, the public, or the environment. MC&A alarm tests were run as specified by applicable procedures and requirements. Based on the alarm test for the Building 333 Oxide Dissolution area, the alarm test value was exceeded. Additional sampling later indicated that the input minus the output value is below the alarm value. An investigation was initiated and additional sampling has indicated that the input minus the output value is below the alarm value."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 44440
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE BROGAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/26/2008
Notification Time: 09:27 [ET]
Event Date: 08/26/2008
Event Time: 08:14 [EDT]
Last Update Date: 08/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (R3)

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

ERDS AND SPDS OUT OF SERVICE DUE TO PLANT COMPUTER MAINTENANCE

"The Perry Nuclear Power Plant took the Plant Computer out of service for scheduled maintenance which will take ERDS out of service. From 0814 hours EDT, on August 26, 2008 for approximately 6 hours personnel will be performing disk maintenance activities on the Plant Computer. During this planned maintenance, the Safety Parameter Display System (SPDS) and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) will be unavailable. The unavailability period is necessary to replace a disk drive.

"In the event of an emergency, plant parameter data will be orally transmitted to the facilities through the Status Board Ring Down circuit with back-up by the Plant Branch Exchange, the Off Premise Exchange, and various redundant intra-facility circuits throughout the emergency facilities. The dose assessment function will be maintained during the out of service time period by manual input of data into CADAP and, if required, by manual calculation. The ability to open and maintain an 'open line' using the Emergency Notification System will not be affected and will be the primary means of transferring plant data to the NRC as a contingency until the ERDS can be returned to service during the period of unavailability.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii), as a condition that results in a major loss of offsite communications capability. A follow-up notification will be made when the activities are completed and the equipment is restored. The resident inspector has been notified."

* * * UPDATE PROVIDED AT 1425 EDT ON 08/26/08 FROM MIKE BROGAN TO JEFF ROTTON * * *

Computer maintenance is complete and the Plant Computer has been restored to service. SPDS, CADAP and ERDS are available. The licensee will notify the NRC Resident Inspector.

Notified R3DO (Ring).

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