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Event Notification Report for March 18, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/17/2009 - 03/18/2009

** EVENT NUMBERS **


44895 44898 44900 44902 44905

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General Information or Other Event Number: 44895
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CENTER
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-1022-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/11/2009
Notification Time: 14:00 [ET]
Event Date: 03/09/2009
Event Time: [CDT]
Last Update Date: 03/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY OVERDOSE

"The Wisconsin Radiation Protection Section (RPS) was notified on 3/10/09 of a possible medical event that occurred on 3/9/09. The medical event occurred at Lombardi Cancer Center, which is affiliated with Aurora Health Center in Sheboygan (RML #117-1022-01).

"The treatment was a permanent prostate brachytherapy implant using I-125 seeds. The intended total dose was 107 Gy and the patient was administered a total dose of 144 Gy. The overdose was discovered on 3/9/09, following review by the dosimetrist.

"The patient was notified on 3/10/09. The referring urologist and the patient's primary care provider were also notified.

"RPS has had telephone communications with the RSO and the Authorized User (AU) and has requested additional documents. The RSO will be unavailable (out-of-town). A team of RPS staff will be conducting a site visit at the facility when the AU returns."

Wisconsin Radiation Protection Section Event Report ID Number: WI090003.

An on-site investigation is planned by Wisconsin Radiation Protection Section beginning 3/12/09. A follow-up report will be issued after the investigation is completed.

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: 44898
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: STONE INDUSTRIAL
Region: 1
City: COLLEGE PARK State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOE O'HARA
Notification Date: 03/12/2009
Notification Time: 08:55 [ET]
Event Date: 03/06/2009
Event Time: [EDT]
Last Update Date: 03/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()

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

Event Text

MISSING STATIC ELIMINATOR CONTAINING POLONIUM-210

"This report is in reference to a lost 13 [inch] Nuclestat ionizer bar that contains Polonium-210. The model number is P-2001-012, and the serial number is A2FS026. [The licensee] entered into a lease agreement for 13 ionizer bars, 2 Nuclecel in-line ionizers, and 1 Nuclecel ion air blower with NRD, LLC to minimize the amount of static present in our operation.

"On Friday, March 6, 2009, it was reported by [the licensee's] Maintenance Department that an ionizer bar was missing from Winder #23. They were in the process of removing all of the ionizer bars from the winders to return them to NRD, LLC. The security cable was found attached to the winder, but it appeared someone had unscrewed the ionizer bar. All bars were attached to the end of the plastic winders with a steel cable and two screws. Upon investigation, [a licensee representative] found [that] the operators [remembered] the ionizer bar [being] present the week of February 23 - 27th on Winder #23, but they [did] not remember seeing the ionizer bar when [they] returned from a two day shutdown on Wednesday, March 4, 2009. After learning [that] the ionizer bar was missing on March 6th, the Plastic Winding Department was shutdown in the afternoon to search for it. About 15 employees searched the entire building including the trash and the building next door that contains old equipment. On Monday, March 9, 2009, the trash from the trash compactor was dumped in the parking lot, and the department searched through it for the missing ionizer bar. Once it was determined the ionizer bar was still missing, [a licensee representative] reported the lost device to [a State of Maryland representative] on March 9th.

"The remaining in-line ionizer bars, Nuclecel in-line ionizers and Nuclecel ion air blower will be returned to NRD, LLC to terminate our lease agreement. We will replace them with carbon bars and electronic air ionizers to reduce static in our operation."

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: 44900
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DR. PEPPER
Region: 4
City: IRVING State: TX
County:
License #: G01697
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 03/12/2009
Notification Time: 15:04 [ET]
Event Date: 03/06/2009
Event Time: [CDT]
Last Update Date: 03/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
JOHN RAMSEY (OIP)
ANDREW MAUER (FSME)
ILTAB EMAIL (ILTA)

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

Event Text

AGREEMENT STATE REPORT - TWO SOURCES DISPOSED AS SCRAP

"On February 20, 2009 during an internal audit/inspection, it was discovered that two Filtec Model FT 50 level detection devices each with 100 mCi of Am-241 were missing [and] apparently moved off the facility as scrap metal. Notification to state offices were through inappropriate channels and thus Incident Investigation staff were not informed of [the event] until March 12, 2009. A preliminary investigation has determined that the metal scrap along with these devices was subsequently shipped to a mill in India and [has] probably been melted. Specific details of the shipping, route and mode of transport, vendors as well actual location in India are being gathered. The serial numbers are 112733/5393 and 116813/2555."

Texas Incident # I-8618

* * * UPDATE ON 03/13/2009 AT 1400 FROM RAY JISHA TO DAN LIVERMORE * * *

Report received via e-mail:

"The gauges were accidentally removed from the plant and placed into a metal scrap dumpster and picked up from our property by MC3 International Scrap Salvage on December 8, 2008.

"MC3 International Scrap Salvage delivered the mixed shear cut metal to Lone Star Fox Export Metals on December 8, 2008. Lone Star Fox Export shipped the mixed cut metal to India before or around December 13, 2008. The licensee provided a list of 10 containers.

"The mixed metal was sent to Nhava Sheva, India. The licensee does not have any information on the mill in India. They do not have any information on products that may have been produced from the scrap.

"The state is in the process of contacting the scrap metal dealers. Additional information will follow as it is obtained."

Notified R4DO (Farnholtz), FSME EO (McIntosh), OIP (Ramsey), and ILTAB (via email).


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: 44902
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: ABILENE State: TX
County:
License #: 04590
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/12/2009
Notification Time: 15:15 [ET]
Event Date: 03/05/2009
Event Time: 16:45 [CDT]
Last Update Date: 03/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREW MAUER (FSME)

Event Text

SOURCE DISCONNECT FROM RADIOGRAPHY CAMERA DRIVE CABLE

The Agency (State) was notified (at 1645 PDT) by the licensees RSO that they had a source disconnect and that the source was later retracted. The event involved an INC IR-100 camera containing a 94 curie Ir-192 source. The source was in use for about one week, about 6 jobs. A local Texas inspector went to the site to investigate the event.

The licensee later notified the Agency (State) that in this case, the connector crimped fitted on the source pig tail had separated from the source drive cable. The two individuals who returned the source to the camera housing received 425 millirem by self reading dosimeter for one worker, and between 750 and 800 millirem calculated for the other worker. The RSO stated that neither worker exceeded the annual DDE limit. TLD's for the workers involved have been sent to their processor and the results should be back on 3/9/09. The State of California has been informed of the event.

On March 13, 2009, the RSO notified the Agency (State) that the radiography camera had been packaged and will be returned to the manufacturer today.

Texas Incident # I-8614

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Power Reactor Event Number: 44905
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TOM MORSE
HQ OPS Officer: VINCE KLCO
Notification Date: 03/13/2009
Notification Time: 00:42 [ET]
Event Date: 03/13/2009
Event Time: 00:25 [EDT]
Last Update Date: 03/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JULIO LARA (R3)

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

Event Text

PARTIAL LOSS OF PLANT COMPUTER FOR SCHEDULED MAINTENANCE TAKING ERDS OOS

"The Perry Nuclear Power Plant has taken a portion of the Plant Computer out of service for scheduled maintenance. This has resulted in a portion of ERDS being out of service. From 0025 hours EDT on March 13, 2009 for approximately 36 hours, personnel will be performing maintenance activities which result in a partial loss of the Plant Computer. During this planned maintenance, portions of the Safety Parameter Display System (SPDS) and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) will be unavailable.

"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 Private Branch Exchange, 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 10CFR50.72(b)(3)(xiii), as a condition that results in a major loss of offsite communication capability. A follow-up notification will be made when the maintenance activities are completed and the equipment is restored."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1132 ON 3/14/2009 FROM TONY JARDINE TO MARK ABRAMOVITZ * * *

The plant has extended the expected plant computer outage time by 60 hours (ending 3/16/2009 at 2400).

Notified the R3DO (Lara).

* * * UPDATE AT 1907 EDT ON 3/16/2009 FROM TOM STEC TO BILL HUFFMAN * * *

The licensee has extended the expected outage time for the plant computer maintenance by an additional 24 hours. Repairs are now expected to be completed by 2400 EDT on 3/17/09.

The licensee will notify the NRC Resident Inspector. R3DO(Ring) notified.

* * * UPDATE AT 1723 EDT ON 3/17/2009 FROM ANTHONY JARDINE TO BILL HUFFMAN * * *

The licensee states that that the plant computer and all associated functions (SPDS, CADAP, and ERDS) were returned to service at 1313 EDT on 3/17/09. The licensee has notified the NRC Resident Inspector.

R3DO(Ring) notified.

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