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Event Notification Report for October 6, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/03/2008 - 10/06/2008

** EVENT NUMBERS **


44529 44531 44537 44538 44539 44540 44541 44542

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General Information or Other Event Number: 44529
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: HWA GEOSCIENCES
Region: 4
City: LYNNWOOD State: WA
County:
License #: I0176
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2008
Notification Time: 16:50 [ET]
Event Date: 09/29/2008
Event Time: [PDT]
Last Update Date: 09/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
ANNA BRADFORD (FSME)

Event Text

WASHINGTON AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The State of Washington provided the following information via e-mail:
"The licensee reported to the Washington State Department of Health (DOH) that a Troxler 3440 nuclear density gauge, serial number 28433, with 8 mCi of Cs-137 and 40 mCi of Am-241/Be, was struck by a truck at a landfill site at about 12:45 p.m. on 9/29/08. The gauge was struck while the operator was taking measurements with the source rod extended into the soil. It was reported that a truck tried to skim by the operator and gauge, narrowly missing the operator and hitting the gauge. The truck caught the gauge handle breaking it and the guide rod from the gauge. The source rod and the rest of the gauge remained intact and in place. The licensee field engineer and lead gauge operator went to the scene to assist with the incident. Since the handle was broken from the gauge, the source rod was placed back into the gauge by turning the gauge on its side and striking the bottom of source rod with a mallet. This action caused the source rod to move completely out of the top of the gauge. The lead individual put the source rod into a bucket and found a max reading of 20 mR/hr. The lead [operator] returned the source rod back into the shielded position in the gauge and secured [it] in place with duct tape. Additional wraps of duct tape were made around the top and bottom of the gauge to keep the source rod from coming out again. A reading of 2.4 mR/hr was found on contact with the gauge with the licensees' TroxAlert. Additional readings were taken on the bucket and the testing site indicating background readings. The gauge was placed back into the transport case and taken to the licensed storage location prior to determining its final disposition. DOH staff will visit the licensee to make confirmatory measurements and start an investigation."

Washington Report Number: WA080072

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General Information or Other Event Number: 44531
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA - SAN DIEGO
Region: 4
City: LA JOLLA State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: KATHLEEN HARKNESS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/01/2008
Notification Time: 12:24 [ET]
Event Date: 09/25/2008
Event Time: [PDT]
Last Update Date: 10/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
MICHELE BURGESS (FSME)
JOHN JANKOVICH (FSME)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LEAKING NI-63 SOURCE

"On September 25, 2008, a leak test was performed on a nickel-63 source in an Electron Capture Device (ECD) which was found to have removable contamination of 89 nanoCuries, which is above the reporting requirement of 5 nanoCuries in CA Title 17, section 30275. The ECD is not in service, it has been in storage for two years and in the Environmental Health and Safety waste facility [at the University of California - San Diego (UCSD)], awaiting disposal. We [the California Department of Public Health] have notified UCSD to return the device to Agilent Technologies, in Delaware for their analysis.

"Manufacturer: Hewlett Packard; original activity: 15 mCi; current activity: 13.44 mCi; reference date 12/1/1992, source model number G1223A, serial number F5350.

"SSD registry NR-0348-D-111-B, currently made by Agilent Technologies in Delaware under NRC authority.

"Gas Chromatograph Information: Manufacturer- Hewlett Packard, Model 5890 Series II."

The State of California considers this a potential Part 21 issue.

California Incident Number: 5010-093008.

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Hospital Event Number: 44537
Rep Org: WILLIAM BEAUMONT HOSPITAL
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: ROYAL OAK State: MI
County: OAKLAND
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/03/2008
Notification Time: 14:45 [ET]
Event Date: 09/08/2008
Event Time: [EDT]
Last Update Date: 10/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
STEVE ORTH (R3)
ANNA BRADFORD (FSME)

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

Event Text

LOST I-125 SEED

"One I-125 sealed source ('seed') intended for permanent prostate implantation on 9/8/08 cannot be located definitively inside the patient or inside the hospital and is assumed lost. The calibrated activity was 0.481 mCi on 8/25/08.

"On the morning of 9/8/08, a permanent prostate implant was performed in our high dose rate (HDR) treatment room in Radiation Oncology under sterile conditions. The implant was to consist of 62 seeds, in twenty needles each containing a varying number of seeds of 0.408 milliCurie of I-125. Seventy I-125 seeds were ordered and pre-loaded in a cartridge and were received sterilized from Isotron. Prior to treatment, one of the seeds was expelled from the cartridge and used for calibration. It was stored in a separate shielded container, and not used in the patient treatment.

"The written directive and treatment plan intended implantation of 62 I-125 seeds into a patient's prostate for the treatment of cancer. Using the Nucletron seedSelectron remote afterloading system, each needle was placed under ultrasonic guidance in the patient's prostate. The seedSelectron was connected to each needle and the seeds ejected from the cartridge into the needle. This procedure was performed for each of the twenty needles with only one needle being implanted at a time injecting a total of 62 seeds. The treatment progressed normally as planned and was successfully completed. At the conclusion of the treatment, X-rays were taken to verify the number of seeds implanted, and the count of 61 instead of 62 was confirmed radiographically. Prior to exiting the room, all staff (radiation oncologist, nurse, physicist, brachytherapy specialist) completed the routine required survey which included the soles of the shoes.

"The residual seeds in the cartridge were x-rayed and seven I-125 seeds were identified by at least 3 medical physicists. At least 3 medical physicists and the authorized user examined the patient's x-rays, and each could clearly identify only 61 seeds in the patient. The one I-125 seed used for calibration was accounted for in the inventory. The patient was scheduled to return for bi-plane views on 9/10/08, so that additional radiographs could potentially identify the missing seed. When the patient returned on 9/10/08, he had excreted four I-125 seeds which were properly handled and placed in the secure designated storage area. On the follow up x-rays, only 57 seeds were clearly identified. The anatomy surrounding the prostate was also imaged, but only 57 seeds were clearly identified. The entire pelvic region, abdomen and chest were also imaged with no results. It is possible that the seed may have migrated to an area inside the patient which was not included on the follow up x-rays.

"The pre-loaded cartridge of seeds was not x-rayed prior to the treatment, so the presence of all 70 seeds was not confirmed prior to the treatment. It is conceivable that only 69 seeds were shipped. We contacted Isotron and they provided us with their documentation showing that they shipped 70 seeds.

"The most probable disposition is that the seed is located inside the patient, but has migrated to an area which does not allow us to confirm its presence radiographically. The second most likely explanation is that we only received 69 seeds instead of 70 seeds. It is unlikely that the seed is lost inside our HDR suite, given the normal progression of the implantation procedure and the thoroughness of our search. It is very unlikely that the seed was disposed of in the landfill or sewer, since it was not detected when the team of medical physicists individually surveyed each item of linen and trash, and thoroughly surveyed the sink.

"No exposure of individuals to radiation from the one missing I-125 in restricted and unrestricted areas is expected.

"A thorough search was initiated immediately, using a pancake thin end window Geiger-Mueller detector in the micro-R/hr range (Ludlum Model 14C, calibrated on June 4, 2008). The surgical table, floor, each item of trash, each item of linen and all personnel were carefully surveyed. All cartridges and needles were rechecked several times. A thorough survey of the surgical table was conducted, urine collection bag and patient (even near the pelvis, although exposure from the implant made detection in this vicinity unlikely). The low survey readings in adjacent areas of the patient made it unlikely that the seeds were on the patient. The patient was released and removed from the HDR room and transferred to Phase I recovery. The survey also included the entire entrance hallway to the HDR room and the radiation oncologist's office. The Radiation Safety Officer designate for Radiation Oncology was notified and an additional survey of the room was conducted with the Johnson survey instrument (GSM-15) with a plastic scintillator (GLE-1), calibrated with an I-125 source on January 4, 2008. The surface of the floor including the small cracks in the floor covering and at the baseboards was surveyed. Each item of trash and linen was checked separately. The Corporate Radiation Safety Officer was notified and conducted an independent search with the Johnson survey instrument which included the entire floor, baseboards, sink, each item of equipment in the HDR room, the linen and trash. When nothing was found, the room was released so that patient treatments could be resumed in the room. A repeat survey of the patient using a Geiger-Mueller detector in the microR/hr range (Victoreen model 190 with pancake probe, calibrated April 24, 2008) as well as the areas surrounding the patient, trash and linens was performed in the Phase I area. All readings were low indicating the source was not in the vicinity. The patient was then discharged to Phase II. A survey including the patient, stretcher, linens, trash, urinary catheter, urinary bag and area was performed in Phase II. Low readings were again observed indicating the source was not in the area. The unused seeds were returned to the locked cabinet in the other HDR room for inventory and storage.

"Procedures or measures that have been, or will be, adopted to ensure against a recurrence of the loss of licensed material: (1) All personnel involved with prostate implants will receive refresher training regarding proper procedure. (2) An image of the loaded cassette will be taken to verify the receipt of the correct number of seeds. This image will be retained along with the patient records. In the event the seed count on the image does not agree with the count per the manufacturer, the situation will be reconciled prior to treatment. (3) Every effort will be made to obtain a seed count that accounts for all of the seeds received from the manufacturer prior to the discharge of the patient."

The licensee has reported this event to NRC Region III.

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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 2" is different than the calculated value "Less than Cat 3"

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General Information or Other Event Number: 44538
Rep Org: NAMCO
Licensee: NAMCO
Region: 1
City: LANCASTER State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TONY KING
HQ OPS Officer: VINCE KLCO
Notification Date: 10/03/2008
Notification Time: 14:06 [ET]
Event Date: 09/19/2008
Event Time: [EDT]
Last Update Date: 10/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN WHITE (R1)
SCOTT SHAEFFER (R2)
STEVE ORTH (R3)
RUSS BYWATER (R4)
PART 21 GROUP-EMAIL ()

Event Text

PART 21 REPORT - THREAD SEALANT

The following information was received from NAMCO via facsimile:

"On September 19, 2008, Namco determined that it had shipped product that did not meet the customer purchase order requirements. Namco supplied clear thread sealant instead of white thread sealant. The thread sealants are the same except that the white has an additional pigmentation additive. Namco began an evaluation and on September 29, 2008, determined that it did not have the capability to determine the impact to the supplied users. Therefore in accordance with 10CFR Part 21, Namco provided notification [to the NRC and the affected licensees]."

Namco has reviewed previous purchase orders of thread sealant and determined that the affected users are TVA-Watts Bar Nuclear Plant, Dominion Nuclear Connecticut, Ameren-Callaway Plant and Alabama Power-Farley Nuclear Plant.

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Power Reactor Event Number: 44539
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: LAWRENCE DERTING
HQ OPS Officer: VINCE KLCO
Notification Date: 10/03/2008
Notification Time: 19:52 [ET]
Event Date: 10/03/2008
Event Time: 18:21 [EDT]
Last Update Date: 10/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
JOHN WHITE (R1)
ANNA BRADFORD (FSME)

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

TRUCK SHIPMENT EXTERNAL RADIATION LEVELS EXCEED LIMITS

"Received Shipment from Pilgrim Station of temporary lead shielding that exceeds 10CFR20 requirements for a non-exclusive use limited quantity shipment of 0.5 mR on contact.

"Receipt inspection readings of the last container in the shipment measured between 1.3 mR and 1.85 mR (taken via 3 readings, using 3 separate meters and 2 different technicians).

"Per 10CFR20 subpart 1906 paragraph D, which states:
(d) The licensee shall immediately notify the final delivery carrier and the NRC Operations Center (301-816-5100), by telephone, when --
(1) Removable radioactive surface contamination exceeds the limits of section 71.87(i) of this chapter; or (2) External radiation levels exceed the limits of section 71.47 of this chapter."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44540
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WILLIAM BAKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/05/2008
Notification Time: 01:16 [ET]
Event Date: 10/04/2008
Event Time: 22:08 [CDT]
Last Update Date: 10/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
SCOTT SHAEFFER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM FOLLOWING REVERSE POWER SIGNAL ON MAIN GENERATOR

"On 10/04/08 at 2008 [CDT] the Unit 2 reactor scrammed due to turbine generator reverse power signal on the Main Generator. The cause of the reverse power signal is unknown and the investigation is continuing. All systems responded as expected to the generator reverse power signal. Reactor pressure was automatically controlled by the Main Turbine bypass valves. No Emergency Core Cooling System (ECCS), nor Reactor Core Isolation Cooling (RCIC) reactor water level initiation set points were reached, and reactor water level is being automatically controlled by the feedwater system. This report is being made as required by 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)."

The licensee characterized the scram as uncomplicated. All control rods fully inserted. No safety valves lifted during the transient. All safety systems were available at the time of the scram. There were no impacts on Units 1 or 3.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 44541
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID HALL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/05/2008
Notification Time: 12:17 [ET]
Event Date: 10/05/2008
Event Time: 04:31 [EDT]
Last Update Date: 10/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN WHITE (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

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE

"During repair activities associated with the HPCI NUMAC [Nuclear Measurement Analysis And Control] display, the NUMAC drawer failed upon restoration of power. The drawer failure resulted in HPCI isolation signal and [HPCI] turbine trip signal. At the time the HPCI isolation valve was de-energized as planned so the isolation did not occur, but the failure mode resulted in a [HPCI] turbine trip signal, which resulted in an unavailability and inoperability of HPCI. The condition existed for 29 minutes during maintenance activities. Repair activities were unsuccessful and the NUMAC is still inoperable."

The event occurred during the restoration of the HPCI steam leak detection system.

The licensee will be notifying the NRC Resident Inspector.

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Power Reactor Event Number: 44542
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BUD HINCKLEY
HQ OPS Officer: PETE SNYDER
Notification Date: 10/06/2008
Notification Time: 04:49 [ET]
Event Date: 10/06/2008
Event Time: 04:45 [EDT]
Last Update Date: 10/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3)

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

Event Text

UNAVAILABILITY OF TSC VENTILATION SYSTEM AND CHARCOAL FILTER FOR SCHEDULED MAINTENANCE

"At 0445 on Monday, October 6, 2008, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) ventilation system and charcoal filter was removed from service for scheduled preventive maintenance. The charcoal bed filtration system is also out of service in support of the maintenance on the TSC ventilation system.

"Under certain accident conditions the TSC may become unavailable due to the inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary based upon results of procedurally required monitoring of TSC radiological conditions.

"The TSC ventilation system maintenance is scheduled to complete at 16:00 on Monday, October 6,2008.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss an emergency response facility."

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