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Event Notification Report for February 12, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/11/2009 - 02/12/2009

** EVENT NUMBERS **


44834 44835 44838 44840 44845 44846

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General Information or Other Event Number: 44834
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CITY OF HOPE/BECKMAN RESEARCH INSTITUTE
Region: 4
City: DUATE State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/06/2009
Notification Time: 13:26 [ET]
Event Date: 02/04/2009
Event Time: 18:00 [PST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A DOSE DELIVERED TO THE WRONG TREATMENT SITE

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

"On February 5, 2009, [the Radiation Safety Officer (RSO) for the] City of Hope/Beckman Research Institute, contacted LA County Radiation Management regarding a misadministration that occurred at approximately 6:00 pm on February 4, 2009. The incident involved HDR treatment of the wrong site.

"Using HDR, a patient was scheduled for groin sarcoma therapy treatment. The treatment planning comprised of administration of approximately 4000 cGy to the tumor. The dose is to be administered in 10 fractions of 400 cGy/fraction; 2 fractions per day for 5 days. Six catheters to be administered/fraction. Per [the RSO], an error was made in the interpretation of the CT data, and therefore, the wrong distance was calculated. On February 4, 2009, the first day of the treatment, the catheters administered went to the body, past the tumor site, then to the outside of the thigh. [The RSO] stated that there was no dose administered to the tumor. All the dose was administered to the skin of the thigh. The patient had two treatments, and received approximately 800 cGy to the skin of the thigh.

"A written report will be submitted by the licensee within 15 days.

"Based on the current report of 800 rad to the wrong treatment site (skin), this medical event does not meet the criteria for an Abnormal Occurrence (see SA-300, Appendix section 6.3.IV)."

CA 5010 Number: 020509

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: 44835
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: DUNN ROADBUILDERS
Region: 4
City: PETAL State: MS
County:
License #: MS-870-01
Agreement: Y
Docket:
NRC Notified By: B. J. SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/06/2009
Notification Time: 15:33 [ET]
Event Date: 02/03/2009
Event Time: 14:30 [CST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was received from the State of Mississippi Division of Radiological Health (DRH) via email:

"Location of Incident: Petal, Mississippi (temporary jobsite off Hwy. 42)

"Description of Incident: Approximately 2:30 pm on 2-3-09, an employee who uses the nuclear gauge with Dunn Roadbuilders notified the Radiation Safety Officer that a Troxler 3440 moisture/density gauge, SN# 23209, had been run over by a company pick-up and dragged about 5 feet. The operator told the RSO that the plastic case of the gauge was broken and a battery was outside the device. The area was blocked off with a 15 foot radius around the damaged gauge until the RSO arrived. When the RSO arrived, he surveyed the gauge with a TroxlerAlert survey meter, SN# 2163, and observed readings of 16 mR/hr at gauge surface. He observed that the sources were still shielded and the source rod was not bent or broken. The gauge was put in the transport box and taken back to the company facility. A leak test was performed on the sources and sent to Troxler for analysis. DRH was notified of the incident at 4:30 pm on 2-3-09.

"Pictures of the gauge were taken by the RSO and emailed to the Division of Radiological Health.

"Upon further review of the incident, the authorized user for the moisture/density gauge was trained and certificates are on file with the Division of Radiological Health. The gauge was also last leak tested on 10/08.

"Isotope(s) and Activity: Cesium-137 (8 mCi) and Americium-241:Be (40 mCi)

"Describe clean-up actions taken by DRH: DRH did not respond to incident after RSO confirmed normal survey readings observed and pictures showed only gauge plastic cover damaged."

Incident No.: MS 09002

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General Information or Other Event Number: 44838
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STEVENS, FERRONE & BAILEY ENG.
Region: 4
City: CONCORD State: CA
County:
License #: 6808-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: VINCE KLCO
Notification Date: 02/07/2009
Notification Time: 17:14 [ET]
Event Date: 02/06/2009
Event Time: 06:00 [PST]
Last Update Date: 02/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4)
MARK SHAFFER (FSME)
ILTAB via email (ILTA)
MEXICO by fax ()

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

Event Text

AGREEMENT STATE - STOLEN TROXLER GAUGE

On 2/6/09, between the hours of 0200 and 0600 PST, a 3400 series Troxler gauge was stolen from a residence. The gauge was in a camper on the premises of the residence located in Martinez, California. The licensee (Stevens, Ferrone & Bailey Engineering Co.) reported the stolen gauge to the State of California on 2/7/09 at 1300. The density gauge contains approximately 8 mCi of Cesium 137 and 40 mCi of Americium 241. The Sheriff was notified and the licensee plans to offer a reward. This notification is preliminary and will be updated by the state of California as more information is available.

* * * UPDATE AT 1629 EST ON 2/9/09 FROM PRENDERGAST TO HUFFMAN VIA E-MAIL * * *

"[The licensee RSO reported] on 2/7/09 that [a] portable gauge had been stolen early in the morning on 2/7/09. Apparently, one of [the licensee's] employees had transported a Troxler model 3440 portable gauge to his residence [deleted] in Martinez, CA. 94553, after work on 2/6/09. According to [the RSO], the Troxler model 3440 series moisture density gauge (serial number T344-33708 containing 9 mCi of cesium 137 and 44 mCi of Am-241) gauge was stolen from the back of a locked camper shell between 12:00 a.m. and 6:45 a.m. on 2/7/09. [The RSO] stated that the gauge was stored inside a locked camper shell that was backed up to the garage at the employee's residence. The camper shell was broken into, the chains were cut and the gauge was removed from the vehicle. According to [the RSO], the gauge had been covered inside the camper shell to prevent detection. The Martinez Police were also notified and filled out Martinez Police report # 09-513.

"The [California Radiologic Health Branch] was notified by [the RSO] that a trucker had called [the RSO] at 10:00 a.m. on 2/9/08 to inquire on the reward. The trucker, who did not give his name, indicated that he had found the gauge and case on the side of the road. The anonymous trucker was concerned and stated that he had to notify his management before he turned over the gauge."

CA Report #020909

R4DO(Miller), FSME EO (Shaffer), and ILTAB (via e-mail) were notified.


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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Research Reactor Event Number: 44840
Facility: REED COLLEGE
RX Type: 250 KW TRIGA MARK I
Comments:
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: STEPHEN FRANTZ
HQ OPS Officer: VINCE KLCO
Notification Date: 02/08/2009
Notification Time: 20:18 [ET]
Event Date: 02/08/2009
Event Time: 16:02 [PST]
Last Update Date: 02/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
JEFF CLARK (R4)
DAN HUGHES (NRR)

Event Text

TEST REACTOR EXCEEDED LICENSED POWER LIMIT DURING CALIBRATION

"Performing routine thermal power calibration of nuclear instruments at indicated power of 230 kW per SOP-33. Calculation indicated actual power of 263 kW after collecting data. Licensed power limit is 250 kW.

"No apparent cause for the calibration error. [The previous] calibration was successfully done on January 16, 2009."

The reactor was shutdown. All systems functioned as required. The licensee noted that the pool temperature was about 7 degrees Celsius cooler than the historical pool temperature.

The licensee will notify the NRR Project Manager and the State of Oregon.

* * * RETRACTION AT 1850 EST ON 2/11/09 FROM FRANTZ TO HUFFMAN * * *

The licensee re-performed the thermal calibration per SOP-33 to check results obtained on 2-08-09. The difference this time is the licensee extended the calibration for a much longer period (approximately 7 hours). The licensee has determined that data obtained during the first 30 to 60 minutes of calibration indicated erratic information.

"[The licensee has] concluded that when [the reactor was] operating on 2-08-09 at an indicated power of 230 KW, actual power was 245 KW. [This power] is less than [the reactor's] licensed limit of 250 KW. Thus Reed did not violate its licensed power limit on 2-08-09 as previously reported. SOP-33 will be revised to avoid this error in the future."

Notified the NRR PM (Hughes via e-mail) and NRR EO (Lee). R4DO (Miller) was notified for information.

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Other Nuclear Material Event Number: 44845
Rep Org: WAYNE STATE UNIVERSITY
Licensee: WAYNE STATE UNIVERSITY
Region: 3
City: DETROIT State: MI
County:
License #: 21-00741-08
Agreement: N
Docket:
NRC Notified By: MAHA SRINIVASAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/11/2009
Notification Time: 15:40 [ET]
Event Date: 02/10/2009
Event Time: 19:00 [EST]
Last Update Date: 02/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
SONIA BURGESS (R3)
REBECCA TADESSE (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

MISSING VIAL CONTAINING 5 MILLICURIES OF CHROMIUM - 51

The RSO for the Wayne State University's School of Pharmacy reported a missing vial containing 5 millicuries of Chromium-51 in a saline solution. The vial was received at the licensee's laboratory on February 6 along with two cartons of tritium. The tritium was removed from its shipping cartons and placed in a lab storage refrigerator. The Chromium was left on a desk in the carton to be leak tested prior to being placed in the refrigerator.

Apparently, the lab student did not perform the leak test on the Chromium before leaving the lab. The carton with the Chromium vial was left on the desk near the trash can with the empty tritium containers. The facility custodian came in later that day and put the empty tritium containers in the trash as well as the Chromium container (not realizing it still had the radioactive material inside).

On February 10 around 1900 EST it was discovered that the Chromium vial was missing. The licensee performed a search of the facility including radiological surveys and has concluded that the vial was likely thrown out in the trash. The trash dumpster had already been emptied by the waste management firm used by the university. The waste management firm has been notified.

It should be noted that the amount of Chromium-51 in the vial is only 5 times the 10 CFR Part 20, Appendix C limit.

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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Power Reactor Event Number: 44846
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: TIM GAFFNEY
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2009
Notification Time: 19:31 [ET]
Event Date: 02/11/2009
Event Time: 13:18 [MST]
Last Update Date: 02/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEOFFREY MILLER (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
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

POSSIBLY INADEQUATE BACKUP NITROGEN SUPPLY FOR ATMOSPHERIC DUMP OPERATION

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS of under the reporting requirements of 10 CFR 50.73.

"Palo Verde Nuclear Station declared all three Unit's atmospheric dump valves (ADV) inoperable at 1318 MST. The reason for the inoperability is the discovery by engineering personnel that the ADV backup nitrogen capacity, required to operate the valves to mitigate certain accident scenarios, was not adequate.

"There are 4 ADVs (one on each steam line with two steam lines per steam generator) for each of the three units. Engineering review of a loss of offsite power event determined that the current nitrogen supply of 13.3 hours will not be adequate to get the plant to shutdown cooling entry conditions during a natural circulation asymmetric cooldown (i.e. Feedwater Line Break, Main Steam Line Break, and Steam Generator Tube Rupture).

"Actions are in progress to restore the operability of the ADVs. If unsuccessful, all three units will be required by the Technical Specifications to be in Mode 3, Hot Shutdown, by 1918 MST on February 12, 2009."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012