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Event Notification Report for March 24, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2009 - 03/24/2009

** EVENT NUMBERS **


44893 44912 44913 44915 44917 44919 44928 44929 44931

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General Information or Other Event Number: 44893
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNIVERSITY OF NORTH CAROLINA HOSPITALS
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/06/2009
Notification Time: 10:47 [ET]
Event Date: 03/05/2009
Event Time: 12:00 [EST]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1)
KEITH McCONNELL (FSME)

Event Text

UNDERDOSE TO PATIENT DIFFERS >20% OF INTENDED DOSE

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

"Incident is a Medical Event per 15A NCAC 11.0364(a)(1)(A) where the EDE [effective dose equivalent] exceeds 5 Rem, and the total dose delivered differs from the prescribed dose by 20% or more.

"[This incident] occurred during the use of Y-90 TheraSpheres. It appears that the TheraSpheres became stuck in the source vial, and the entire dose could not be administered to the patient. This resulted in a 26.4% underdose to the patient. The licensee is investigating why the Medical Event occurred. The Agency [NCDENR] has requested that the licensee submit the source vial lot or batch number in the report to assist in the determination if it may have been a manufacturing error."


* * * UPDATE FROM JAMES ALBRIGHT TO JOE O'HARA VIA E-MAIL ON 3/20/09 AT 1715 * * *

"We were unable to obtain complete administration of the Y-90 TheraSphere dosage even after repeated flushes of thee dosage vial. The unadministered dosage appeared to remain in the dosage vial. Proper administration protocol was followed, and included four flushes of the vial. Two attempts were made to agitate and remove the remaining material by inverting the vial. The inversions were not completely successful at removing the remaining dosage.

"The decision was made to stop the administration after four flushes since the previous inversion and flush did not lower the dosimeter readings (a dosimeter is mounted on the delivery device which serves as an indicator of relative activity remaining in the dosage vial).

"The prescribed dosage was 44,7 mCi. It was estimated that [about] 32.9 mCi of the prescribed dosage was administered (73.6%). The intended dose to the right lobe of the liver was 120 Gy. The actual delivered dose to the right lobe was [about] 88.3 Gy. Although the other lobe of the liver (left) will be treated, there are no plans at this time to treat the right lobe again.

"MDS Nordion is conducting an investigation of this event. If deemed necessary upon completion of their investigation, supplemental procedures or recommendations will be provided to prevent further events of this type. Manufacturer representatives will be on-site on March 19, 2009 for further evaluation and follow-up. The TheraSphere dosage lot number was 9990019."

Notified R1DO (J. Dwyer) and FSME EO (L. Camper)

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: 44912
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/18/2009
Notification Time: 09:44 [ET]
Event Date: 03/17/2009
Event Time: [CDT]
Last Update Date: 03/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER HANDLE BROKE

"On the afternoon of 3/17/09, while closing the shutter of a Ohmart/Vega SH-F1 level detection gauge, the handle separated from the shutter closure device. The gauge contains a 10 milliCurie Cesium (Cs) - 137 source serial # 5747 GK. The license can not confirm the exact position of the shutter, but they are sure that it is not closed yet. Lubricants have been used on the shutter mechanism to aid in its operation. The licensee will continue their attempts to close the shutter on 3/18/09. If unable to close, they will request assistance from the manufacturer. Additional information will be provided as it is received."

Texas Event: I-8620

* * * UPDATE FROM ART TUCKER TO HOWIE CROUCH VIA EMAIL @1745 ON 3/18/09 * * *

"The Radiation Safety Officer notified the [State of Texas] that the gauge had not been fully closed yet, but area dose rates were normal therefore the gauge does not create additional risk of exposure to their workers."

Notified R4DO (Hay) and FSME EO (Camper).

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General Information or Other Event Number: 44913
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LANTHEUS MEDICAL IMAGING, INC.
Region: 1
City: BILLERICA State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: LARRY HARRINGTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/18/2009
Notification Time: 14:37 [ET]
Event Date: 03/18/2009
Event Time: 10:55 [EDT]
Last Update Date: 03/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DEFRANCISCO (R1)
LARRY CAMPER (FSME)

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT - HIGH RADIATION ON OUTSIDE OF A RADIOPHARMACEUTICAL PACK

The following information was obtained from the Commonwealth of Massachusetts via facsimile:

"Lantheus Medical Imaging was receiving a delivery from Cardinal Health Nuclear Pharmacy [MA License# 41-0366] of F-18 and found the dose rate on the outside of package to be 1.7 R/hr. Lantheus immediately contacted Cardinal Health and notified them of the dose rate. Cardinal Health believed the shielding somehow moved in route. Lantheus accepted the delivery and placed the package in a restricted room to check out later in the day."

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General Information or Other Event Number: 44915
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: WALMART
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RALPH JOHNSON
HQ OPS Officer: JOE O'HARA
Notification Date: 03/19/2009
Notification Time: 09:14 [ET]
Event Date: 01/07/2009
Event Time: [CDT]
Last Update Date: 03/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
ANGELA MCINTOSH (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 Oklahoma was notified by a Walmart corporate representative located in Bentonville, AR, indicating that Walmart was unable to account for 276 tritium exit signs (which are general licensed materials) that were used at one time in Walmart stores throughout the State of Oklahoma. 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 Oklahoma 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.


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: 44917
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/19/2009
Notification Time: 12:57 [ET]
Event Date: 03/19/2009
Event Time: [CDT]
Last Update Date: 03/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK RING (R3)
ANGELA McINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING IMPROPERLY PACKAGED MATERIAL

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

"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Officer, but was shipped directly to the University calibration lab on March 18, 2009 and received about 3:30 pm. Alarms went off at the loading dock and the calibration lab when the package was delivered. The [transportation index] TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The licensee wipe tested the package and found no removable contamination. The package has been placed in a secured area and has not been opened.

"The RSO has contacted the shipper's contact person at LAC + USC and the courier. The package is approximately 10 inches x 10 inches x 10 inches in size. The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public dose limit may have been exceeded."

Wisconsin Event Report ID No.: WI09004

* * * UPDATE AT 1646 EDT ON 03/20/09 FROM CHERYL K. ROGERS TO S. SANDIN * * *

The following information was provided as an update via fax:

"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Office as required, but was shipped directly to the University Calibration Lab on March 18, 2009. It was received and signed for at the Wisconsin Institute for Medical Research (WIMR) loading dock at around 9:00 am and delivered to the calibration lab at 9:52 am. An area monitor in the lab shipping/receiving room alarmed when the package was delivered. A student worker immediately notified the Technical Director of the UW Calibration Lab.

"The Director used a meter to identity the package and noted that the exposure rate on one package exceeded 50 mR/hr on contact. The package was placed on a cart and transported to a secure location. The TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The package was approximately 10 inches x 10 inches x 10 inches in size. The licensee conducted a thorough wipe test and confirmed that there was no removable contamination on the outside of the package. He then left a message for UW Safety.

"The call was returned about noon and the Safety Office staff arrived around 2 pm. The RSO and Assistant RSO concluded that the two sealed sources were outside of the lead shielded container due to the high radiation readings on contact with the package. The RSO called the shipper's contact person named on the shipping papers at LA County, University of Southern California and the courier. The individual who had prepared the package stated that the package must have been opened either in transport or by the Calibration Lab. The UW-Madison RSO emphatically stated that the package had not been opened.

"The State of Wisconsin was notified on the morning of March 19, 2009 and made an immediate notification to the NRC Operations Center. Contact was established with the California jurisdiction for the shipper/licensee in order to facilitate contact with the licensee's radiation safety office. The State of Wisconsin inspector made arrangements to be present on the morning of March 20, 2009 to monitor and video the package opening.

"On March 20, 2009, the Director of the UW Radiation Calibration Laboratory carefully opened the package and conducted multiple wipe tests to assure there was no contamination inside the package. The package contained an open lead pig. The sources were loose in the box. One source was located under the bottom of the styrofoam tray and one source was stuck in the styrofoam tray. There were multiple problems with the packaging, markings and shipping paperwork. The main problems were that the lead pig was not adequately taped shut and the inner packaging was not sufficient to hold the pig in place, thus, the pig moved about in the package. It does not appear that this was an approved shipping container. The sealed sources were wipe tested and were not leaking, however, the Director would like to take a closer look at the sources to assure that they were not damaged.

"The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public close limit may have been exceeded."

Notified R3DO (Ring) and FSME (Camper).

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General Information or Other Event Number: 44919
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SAY PLASTICS, INC.
Region: 1
City: McSHERRYSTOWN State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/19/2009
Notification Time: 19:32 [ET]
Event Date: 03/04/2009
Event Time: [EDT]
Last Update Date: 03/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DEFRANCISCO (R1)
LARRY CAMPER (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING A MISSING GENERAL LICENSED SOURCE

The following information was received from the Commonwealth of Pennsylvania via fax:

"PA DEP Bureau of Radiation Protection [BRP] was notified in writing, dated March 9, 2009, by the Purchasing / Customer representative of Say Plastics. The device has not been found but they will continue to search for it. To prevent future incidents, they have created a sign out sheet that is to be signed when a worker checks the device out and returns the device.

"The State has an inspection scheduled for March 19, 2009 and will continue to keep NRC informed of the status of our investigation.

"Event description: Lost a model P2021 Nuclecel Static Eliminator
"City, State: McSherrystown, PA
"Description: (Serial Number A2GB696) (Manufacturer NRD, LLC) Device was discovered missing on March 4, 2009.
"Eliminator containing Po-210 (originally 10 mCi; decayed to approximately 1.4 mCi)

"PA Event Report ID No: PA090012"

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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Fuel Cycle Facility Event Number: 44928
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: VINCE KLCO
Notification Date: 03/23/2009
Notification Time: 10:51 [ET]
Event Date: 03/23/2009
Event Time: 07:30 [EDT]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
MARVIN SYKES (R2)
JAMES RUBENSTONE (NMSS)

Event Text

DEGRADED ITEM REQUIRED FOR SAFETY IN THE PELLETING AREA

"Reason for Notification

"Notification is being made based on following criteria:

'10 CFR 70 Appendix A (b)(2) Loss or degradation of IROFS [Items Relied On For Safety] that result in failure to meet the performance requirements of 10CFR70.61'

"WEC CFFF [Westinghouse Electric Company, Commercial Fuel Fabrication Facility) has identified a degraded IROFS condition exists in the Pelleting Area. Safety Bulletin No: M-01-09-01, issued by GE FANUC has been evaluated by CFFF Engineering and this evaluation has identified a degraded IROFS condition exists in the Pelleting Area. GE PLC of the type discussed in the Safety Bulletin (IC695CPU310) is used in Pelleting Area Furnaces 1B, 2B, and 4C. This common mode failure is applicable to IROFS PELSINT-903, PELSINT-904, & PELSINT-905.

"These IROFS are preventive controls for a Hydrogen Deflagration Event in the sintering furnaces. While several potential initiating sequences can lead to this event, the only scenario where the performance requirements are not met due to this degraded condition is if the furnace is above the auto ignition temperature for hydrogen and the PLC CPU fails as the furnace is cooling, then the hydrogen shut-off valve could remain open with a potential to result in an explosive atmosphere in the furnace. This event is evaluated in the CFFF ISA-08 Summary for the Pelleting Area.

"See Reason for Notification. Impacted Pelleting Area Furnaces are 1B, 2B and 4C. Furnace 1B is currently at normal operating temperature (above auto ignition temperature) and in operation with approximately 550 kg's of Uranium. The other two Furnaces, 2B and 4C are currently at normal temperature (above auto ignition temperature) with no uranium present in either furnace."

The licensee will contact NRC Region 2.

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Power Reactor Event Number: 44929
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ANDREW SMOLINSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 03/23/2009
Notification Time: 10:56 [ET]
Event Date: 03/23/2009
Event Time: 07:31 [CDT]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
HIRONORI PETERSON (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

NON-FUNCTIONAL STEAM EXCLUSION BARRIER

"On 3/23/09 at 0731 an I&C Supervisor transiting though a steam exclusion double door found the door sweep misaligned causing one side to catch and stick open. This prevented the door from closing automatically until the sweep was readjusted back to its original position. The door was then closed and monitored while permanent repairs took place. While the door was open and could not close automatically, the barrier was Non-Functional for Steam Exclusion. In accordance with TRM 3.0.9 Section A.1 all equipment supported by that steam exclusion barrier was immediately declared inoperable. This zone includes both trains of ECCS and support equipment (i.e., SI, RFIR, ICS, CCW, etc ). TS 3.0.c was entered and exited during the time the door could have stuck open (6 minutes) with both trains of ECCS inoperable. Permanent repairs were completed on the door at 0809 on 3/23/09.

"Therefore, this is reportable under 10 CFR 50.72 (b)(3)(v), 'Any event or condition that at the time of discovery could have prevented the fulfillment of a safety function, and under 10 CFR 50.72(b)(3)(ii)(B) 'any event or condition that results in the nuclear plant being in an unanalyzed condition that significantly degrades plant safety.'

The licensee is also reporting this event under 10 CFR 50.72 (b)(3)(v)(D), Accident Mitigation.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 44931
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WILLIAM BODINE
HQ OPS Officer: JOE O'HARA
Notification Date: 03/23/2009
Notification Time: 23:10 [ET]
Event Date: 03/23/2009
Event Time: 17:00 [CDT]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
HIRONORI PETERSON (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

UNANALYZED CONDITION FOR POSTULATED MISSILE HAZARD THAT COULD DISABLE BOTH TRAINS OF COMPONENT COOLING

"At 1700 on 3/23/09 Prairie Island staff declared both trains of Unit 1 Component Cooling (CC) system inoperable due to discovery that a postulated missile hazard in the Fuel Handling Area could fail a CC line to 122 Spent Fuel Pool Heat Exchanger (SFP HX), affecting both trains of CC. This condition represented an unanalyzed condition reportable under 10 CFR 50.72(b)(3)(ii)(B) since the event might represent a significant degradation of plant safety. The inoperability of Unit 1 CC caused entry into Technical Specification LCO 3.0.3. The CC line in question does not have automatic closure and the resulting loss of CC inventory would eventually affect both trains of CC. This condition represents a loss of safety function for safe shutdown capability and is reportable per 10 CFR 50.72 (b)(3)(v)(A).

"122 SFP HX was last modified by design change 99SF02 to allow for full redundant capacity of the 121 SFP HX. While seismic was addressed in the design change, tornado protection was not.

"The CC line to the 122 SFP HX was isolated at 1759 on 3/23/09 returning Unit 1 CC to operable status. Unit 1 remained at 100% power.

"121 SFP HX is currently in service and is in a location that meets the missile protection requirements.

"The condition was discovered during a tornado protection vulnerability walk-down. A similar line on Unit 2 was already isolated. The NRC Resident Inspector has been notified."

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