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Event Notification Report for January 26, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/23/2009 - 01/26/2009

** EVENT NUMBERS **


44703 44780 44781 44785 44786 44787 44788 44789 44792 44800

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Power Reactor Event Number: 44703
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: RAMON PETER
HQ OPS Officer: JOE O'HARA
Notification Date: 12/07/2008
Notification Time: 23:52 [ET]
Event Date: 12/07/2008
Event Time: 20:10 [CST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVID PROULX (R4)

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

INADVERTENT EDG START

"On 12/7/08 at 2010 CST, Emergency Diesel Generator 2 was started manually from its local control cabinet. The diesel started and operated as designed upon operation of the local Emergency Start Push button. This was an inadvertent start of the diesel during an alarm test on the local engine panel. The alarm test and emergency start push buttons are in close proximity and of similar design and color. The diesel has since been shutdown and returned to a standby condition. The Emergency Diesel Generator remains capable of performing its designed function and was considered operable throughout the evolution. Therefore this report is being made in reference to 10CFR 50.72(b)(3)(iv)(A) .

"The licensee notified the NRC Resident Inspector."

* * * RETRACTION AT 1549 EST ON 12/10/2008 FROM ERICK MATZKE TO MARK ABRAMOVITZ * * *

"On 12/7/2008, Fort Calhoun reported an inadvertent start of a diesel generator (event Number 44703). Based on a detailed review of NUREG-1022, this event has been determined not to be reportable under 10 CFR 50.72(b)(3)(iv)(A) . As reported, the diesel generator was not intentionally manually started by the operator. Therefore, this event was an invalid actuation of the safety system and this notification is being retracted. An appropriate report will be forthcoming as required by 10CFR50.73(a)(2)(iv)(A) and 10CFR50.73(a)(1)."

The licensee notified the NRC Resident Inspector.

Notified the R4DO (Cain).

* * * RETRACTION WITHDRAWN AT 1125 EST ON 1/23/2009 FROM ERICK MATZKE TO VINCE KLCO

"As allowed by 10 CFR 50.73(a)(1), the following information is provided:

"On December 7, 2008, an equipment operator inadvertently started emergency diesel generator 1 using the local Emergency Start push button. The operator was distracted and failed to apply appropriate self checking.

"This report is being made under 10 CFR50.73(a)(2)(iv)(A):

"a) The train that was actuated was diesel generator train 2.

"b) The train actuation was complete. The diesel started and operated as designed. The associated emergency bus was not deenergized so the diesel did not connect to the bus.

"c) As previously noted, the diesel started and functioned successfully for the plant conditions at the time."

The licensee notified the NRC Resident Inspector.

Notified the R4DO (Farnholtz).

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General Information or Other Event Number: 44780
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: JANX INTEGRITY GROUP
Region: 4
City: HATTIESBURG State: MS
County:
License #: 21-16560-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: JASON KOZAL
Notification Date: 01/16/2009
Notification Time: 13:16 [ET]
Event Date: 01/15/2009
Event Time: [CST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - FIRE INVOLVING RADIOGRAPHY CAMERA

The following was provided by the State via e-mail:

"On 1-15-09, DRH was notified by the Forrest County ERC that JANX Integrity Group had an accident with one of their darkroom trucks off Hwy 59 N., in Hattiesburg, MS. The driver for JANX struck a tree off the side of the interstate causing the vehicle to catch fire. The driver then left the scene of the accident. The radiography camera, SPEC-150, SN 150 (Ir-192, 65 Ci), was not discovered until the fire department saw a 'Caution Radiation Area' sign in the bed of the darkroom truck after extinguishing the fire. Surveys were conducted by firefighter personnel for their safety and to pinpoint the location of the radioactive device in the darkroom truck. The Forrest County ERC contacted an industrial radiography company and MS Licensee located in Hattiesburg to take possession of the camera and secure it in their storage vault. The radiography camera was retrieved off the darkroom truck and out of its locked storage box by the MS Licensee. The radiography camera was surveyed by the MS Licensee before being transported to their storage facility. On 1-15-09, JANX retrieved the radiography camera out of storage for transport back to the manufacturer to assess the damage.

"DRH took surveys of the darkroom truck and the radiography camera. Radiation measurements were as follows: 24 mR/hr at the surface of the camera; 4 mR/hr at 6 inches from the camera; levels were background at the vehicle. DRH coordinated the receipt of radiography camera between JANX and a MS licensee for delivery back to the manufacturer."

MS report number - MS 09001

* * * UPDATE FROM JAYSON MOAK (VIA EMAIL) TO HOWIE CROUCH @ 1739 ON 1/23/09 * * *

"On 1-15-09, swipes were taken on the camera and revealed no removable contamination. Leak test results for the source and DU shielding were received from SPEC on 1-23-09 and also revealed no removable contamination."

Notified FSME EO (Chang) and R4DO (Farnholtz).

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General Information or Other Event Number: 44781
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: WAL-MART
Region: 3
City:  State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 01/16/2009
Notification Time: 17:08 [ET]
Event Date: 01/16/2009
Event Time: [CST]
Last Update Date: 01/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
ANDREA KOCK (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The State of Illinois was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 469 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the state of Illinois. The Wal-Mart representative informed the state office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The state of Illinois was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers, and curie content where known.

Illinois report number: IL0900003


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: 44785
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: WAL-MART
Region: 4
City:  State: UT
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: DAVID HOGGE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/20/2009
Notification Time: 09:45 [ET]
Event Date: 08/27/2008
Event Time: [MST]
Last Update Date: 01/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TRITIUM EXIT SIGNS

The State of Utah reported that it had received information from Corporate Wal-Mart of the discovery of damaged tritium exits signs. A summary is as follows:

On August 27, 2008, a report of one damaged sign was received concerning a Wal-Mart store at 10 East 1300 South, Richfield, UT; the activity of the sign was 20 Curies; the sign serial number was 306796.

On September 3, 2008, a report of two damaged signs was received concerning a Wal-Mart store at 4848 S. 900 West St. Riverdale, UT; the activity of the signs was 20 Curies each; the serial numbers were 265518 and 265533.

On October 30, 2008, a report of two damaged signs was received concerning a Wal-Mart store at 1052 South Turf Farm Road, Payson, UT; the activity of the signs was 20 Curies each; the serial numbers were 300305 and 300977.

An environmental services contractor was retained and remediated the areas, as necessary. The signs were returned to the manufacturer for disposal.

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General Information or Other Event Number: 44786
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: WAL-MART
Region: 4
City:  State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOE O'HARA
Notification Date: 01/20/2009
Notification Time: 13:11 [ET]
Event Date: 05/21/2008
Event Time: [PST]
Last Update Date: 01/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TRITIUM EXIT SIGNS

The State of Oregon provided the following information on damaged tritium exit signs (TES) contained in 7 separate reports from Wal-Mart.

1. Serial # 256279, Activity: 11.5 Curies, Date of Damage: unknown: Store Location: 3025 Lancaster Drive, NE Salem, Oregon

2. Serial # 275536, Activity 20 Curies, Damage Date: unknown: Store Location: 3002 Stacy Allison Way, Woodburn, OR

3. Serial # 283177, Activity 20 Curies, Damage Date: unknown: Store Location: 3002 Stacy Allison Way, Woodburn, OR

4. Serial # 271065, Activity 20 Curies, Damage Date: unknown: Store Location: 2051 Newmark Ave., Coos Bay, OR

5. Serial # 286545, Activity 11.5 Curies, Damage Date: unknown: Store Location: 3600 Washburn Way, Klamath Falls, OR

6. Serial # 292245, Activity 20 Curies, Damage Date: unknown: Store Location: 135 N.E. Terry Lane, Grants Pass, OR

7. Serial # 292236, Activity 20 Curies, Damage Date: unknown: Store Location: 135 N.E. Terry Lane, Grants Pass, OR

"Wal-Mart retained Shaw, an environmental services contractor with extensive experience with management of radioactive material, for its company wide program to inventory TES." Shaw has remediated the areas, if necessary, and has either returned the signs to the manufacturer for repair or proper disposal.

"Wal-Mart has implemented and communicated protocols to its stores for the proper handling of TES to ensure public health and safety and protection of its employees."

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General Information or Other Event Number: 44787
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: WAL-MART
Region: 4
City:  State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SEIBERT
HQ OPS Officer: JOE O'HARA
Notification Date: 01/20/2009
Notification Time: 13:11 [ET]
Event Date: 01/08/2009
Event Time: [PST]
Last Update Date: 01/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREA KOCK (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The State of Oregon was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 230 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the state. The Wal-Mart representative informed the state office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The state was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers, and curie content where known.


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: 44788
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MARY BIRD PERKINS CANCER CENTER
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2651-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: JASON KOZAL
Notification Date: 01/20/2009
Notification Time: 14:11 [ET]
Event Date: 12/23/2008
Event Time: [CST]
Last Update Date: 01/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE - MEDICAL MISADMINISTRATION

The following was provided by the state via facsimile:

Description and Analysis of event:

"A medical event was discovered at 11:00 AM on January 2, 2009 involving a patient who was undergoing high dose rate brachytherapy (HDR) for papillary serous adenocarcinoma of the uterus. The patient completed 4600cGy of external beam radiation therapy on 9/11/08 and was currently undergoing 3 high dose rate brachytherapy fractions, approximately 3 cm in length, at 500 cGy per fraction. During the patient's second HDR treatment, a review of the first HDR plan showed that the tandem was not fully inserted into the cylinder. The visualization on the CT scan of the placement of the tandem being partially inserted was not recognized by the planner or reviewer of the plan. The dwell positions were therefore placed in the airspace where the tandem should have been inserted versus at the retracted location. The first fraction (12/23/08) was therefore treated approximately 6 cm distal to what was represented by the isodoses on the plan printout. The x-ray (port film) at the time of treatment also showed the tandem not fully inserted into the cylinder.

"A plan was run with the isodoses placed 6 cm distal to the tip of the tandem channel. The isodoses show that the patient received dose (3 cm of active dwell positions as planned) to the distal vagina versus the proximal vagina as prescribed.

"The radiation oncologist was immediately notified of the tandem placement after discovery. The prescribing physician (radiation oncologist) notified the patient and the referring physician about the variance that had occurred in the patient's treatment as well as the possible complications.

"Patient Management:

"The radiation oncologist explained to the patient that there was no clinically significant increase in possible complications as a result of the HDR treatment to the distal vagina for 1 fraction (12/23/08). After careful review, the radiation oncologist decided he will continue as planned with the third HDR fraction at 500 cGy. He does not expect any increase in bladder or rectal toxicity and expects to see a decrease in normal tissue toxicity.

"Prevention of Future Occurrence:

"1. When the nurse assembles the cylinder applicator, the nurse will measure the tandem length outside the cylinder to ensure the tandem has been inserted to the maximum extent.

"2. The dosimetry and physics staff will receive an in-service on the difference in CT image based plans with an emphasis on how the tandem channel looks in the cylinder with the tandem fully inserted versus a partial insertion.

"3. The physicists will begin looking at the pre-treatment port film along with the radiation oncologist prior to initiating treatment."

Louisiana event number - LA090007

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 44789
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: WALMART
Region: 4
City:  State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/20/2009
Notification Time: 14:29 [ET]
Event Date: 01/07/2009
Event Time: [CST]
Last Update Date: 01/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREA KOCK (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The state of Louisiana was notified by a Walmart corporate representative located in Bentonville, AR, indicating that Walmart was unable to account for 281 tritium exit signs (which are general licensed materials) that were used at one time in Walmart stores throughout the state of Louisiana. The Walmart representative informed the state office that Walmart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The state of Louisiana was provided a listing from corporate Walmart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers, and curie content where known.

Louisiana Event Report Number: LA090008.

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: 44792
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CENTRAL TESTING LABORATORY
Region: 1
City: LEESBURG State: FL
County:
License #: 3187-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/21/2009
Notification Time: 12:40 [ET]
Event Date: 01/21/2009
Event Time: 12:00 [EST]
Last Update Date: 01/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the State of Florida via fax:

"Troxler gauge run over by dump truck at job site. Sources allegedly in shielded position. State inspector sent to investigate. Upper control rod bent, some damage to outer container. Sources in shielded position, radiation readings nominal. Gauge being transported to Troxler representative in Orlando for repair. No further action will be taken by this office."

Sources: 40 mCi Am:Be, 8 mCi Cs-137

Florida Report: FL 09-006

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General Information or Other Event Number: 44800
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PITTSBURGH MEDICAL CENTER
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2009
Notification Time: 17:04 [ET]
Event Date: 12/04/2008
Event Time: [EST]
Last Update Date: 01/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO PATIENT WAS LESS THAN 50% OF PRESCRIBED DOSE

The following information was obtained from the Commonwealth of Pennsylvania via email:

"Dose administered to patient was only 44% of the prescribed amount of Y90.

"Cause: the treatment catheter became occluded and prevented further delivery of the Y-90 microspheres to the patient. It is not known what caused the occlusion. A later radiation survey of the catheter indicated a relative increased amount of radioactivity within the last 2cm from the tip. The catheter will be sent to the manufacturer for further analysis.

"Effect to the Patient: None

"Notifications : The referring physician was verbally notified of the medical event by the Authorized User. The referring physician verbally notified the patient.

"Corrective Action: Equipment returned to manufacturer for repair or disposal."

Dose given was 5.3 mCi of Y-90. Dose intended was 12.1 mCi.

PA Reference Number: PA080033

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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Thursday, March 29, 2012