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Event Notification Report for July 1, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/30/2009 - 07/01/2009

** EVENT NUMBERS **


45160 45164 45167 45168 45175 45178

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General Information or Other Event Number: 45160
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HOAG MEMORIAL HOSPITAL PREBYTERIAN
Region: 4
City: NEWPORT BEACH State: CA
County:
License #: 0272-30
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/24/2009
Notification Time: 14:57 [ET]
Event Date: 03/20/2009
Event Time: [PDT]
Last Update Date: 06/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A POTENTIAL OVEREXPOSURE DURING GAMMA KNIFE TREATMENT

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

"The licensee reported a patient undergoing a gamma knife stereotactic radiosurgery (Elekta Instruments AB, Gamma Knife Perfexion, serial number 6021) on March 20, 2009 received a significant dose to an untargeted area due to an error in the imaging process used for treatment planning. The fiducial marker box (coordinate markers) used to register the CT images was misaligned (the CT locator box had not been firmly seated on the targeting frame as it should have been) which resulted in a target shift of approximately 2.0 mm. Due to the small size of the target (7mm x 4mm x 3mm) and the small size of the radiation shots (4 mm collimators), this shift of the 2.0 mm resulted in only about 52% of the target receiving the prescribed dose of 11 Gy. Therefore, a significant portion of this dose (48%) was shifted to normal tissue (temporal bone) outside of the intended treatment volume. This was a single fraction treatment. The patient is not expected to have any adverse consequences from this event. The physician did not feel additional treatment was advisable. The physician counseled the patient regarding this misadministration. Corrective actions taken by the licensee include: 1) additional training for the CT technologists on the correct placement of the fiducial box; 2) for all ongoing similar treatments, the medical physicist will double check the box placement; and 3) the policies and procedures were updated.

"On June 22, 2009, RHB-Brea RAM received a written report from Hoag Hospital that was dated April 1, 2009, and was faxed to RHB-Sacto on April 3, 2009 at 4 PM. The report was mailed from RHB-Sacto on June 12, 2009 to the RHB-Brea X-ray office and date stamped by that office on June 15, 2009 at 12:45 PM. The report stated they were reporting a misadministration which occurred on March 20, 2009 and that this event was previously reported on the evening of March 20, 2009 by telephone. Per the licensee, they had left a voice message on the answer phone at RHB-Sacto on the night of the incident instead of reporting the incident to the 24/7 radiological emergency assistance center."

CA 5010 Number: 032009

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: 45164
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FLINT HILLS RESOURCES LP
Region: 4
City: PORT ARTHUR State: TX
County:
License #: 00547
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/26/2009
Notification Time: 11:57 [ET]
Event Date: 09/01/2008
Event Time: [CDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILED TO CLOSE

The following information was received from the State via e-mail:

"On June 25, 2009, at 1630 the Agency was notified by the licensee that while looking for information requested by the State for a previous gauge failure ( EN 44981), the licensee discovered an additional event. This event occurred in early September, 2008, and had not been reported as required. The event involved an Ohmart/VEGA Model SH-F2 level gauge containing a 300 millicurie ( 228 mCi calculated current activity) Cesium (Cs) - 137 source. The gauge shutter would not close due to a sheared shutter rotor. The manufacturer was notified, and a technician arrived at the facility [located in Odessa, TX] on September 30, 2009. The technician replaced the rotor, cleaned and lubricated the gauge, and the gauge operated normally. The technician found that a great deal of material had collected in the source holder causing the failure. The licensee has removed all of their nuclear gauges and is in the process of terminating their license."

Texas Incident Report # I-8642

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General Information or Other Event Number: 45167
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNC CHARLOTTE
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0241-1
Agreement: Y
Docket:
NRC Notified By: SHARN JEFFRIES
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/26/2009
Notification Time: 15:30 [ET]
Event Date: 06/26/2009
Event Time: [EDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1DO)
JACK FOSTER (FSME)

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

Event Text

AGREEMENT STATE REPORT INVOLVING A MISSING TRITIUM SOURCE

The following information was provided by the State of North Carolina via email:

"NC Radioactive Materials [Agency] was contacted this afternoon regarding a lost portable gas chromatograph.

"Notification: June 26, 2009 at 15:00

"Device: Sentex Sensing Technology - Sentex Model Sentor Gas Chromatograph.
"No serial number available.
"SS&D: NY-1210-D-101-B

"Source: Hydrogen-3
"Safety light corp source 58508-3
"No serial number available

"Activity: 150 millicuries

"Manufacturer: Infacon, Inc.
"Manufacturer Address: 2 Technology Way, East Syracuse, NY 10357

"Summary: Licensee's RSO contacted Agency at 15:00 on 6/26/09. Conducted a physical inventory of sources at licensee's address, and could not locate the 150mCi Sentex Gas Chromatograph. Inquired whereabouts of device, and primary Authorized User speculated that the source/device could have been lost as a result of the renovations at the University in 2007-2008."

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: 45168
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KRAZEN & ASSOCIATES
Region: 4
City: CLOVIS State: CA
County:
License #: 4247-10
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/26/2009
Notification Time: 19:25 [ET]
Event Date: 06/26/2009
Event Time: [PDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
JACK FOSTER (FSME)
ILTAB VIA EMAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

"The licensee reported a M/D [moisture density] gauge was stolen from the residence of a Krazan and Associates employee. The gauge was a Troxler 3430 portable moisture density gauge, serial number 35729 containing approximately 8 mCi of Cesium 137 and 40 mCi of Americium 241. The gauge was stolen sometime between 5pm on Thursday, June 25 and 6:00 am on Friday, June 26, 2009. The gauge was stolen from the back of an open pickup bed at the employee's residence in Bakersfield, CA. According to the RSO, the gauge was stored in the locked gauge case that was chained to the vehicle frame. The licensee has reported the incident to the Kern County Police and the Kern County Sheriffs Office. The licensee will also be offering a reward in the local newspaper and on Craigslist."


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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Other Nuclear Material Event Number: 45175
Rep Org: LANGAN ENG. AND ENVIR. SERVICES INC
Licensee: LANGAN ENG. AND ENVIR. SERVICES INC
Region: 1
City: ELMWOOD PARK State: NJ
County:
License #: 29-15786-02
Agreement: N
Docket:
NRC Notified By: ART ROESLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/30/2009
Notification Time: 12:24 [ET]
Event Date: 06/29/2009
Event Time: 02:15 [EDT]
Last Update Date: 06/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

DAMAGED TROXLER MOISTURE DENSITY GAUGE

"Based on discussion between field personnel (authorized nuclear gauge user) and [the licensee], the rubber-tire wheels of a piece of construction equipment ran over [a Troxler] gauge. [The licensee] personnel, with assistance from the contractor, immediately cordoned off the area so that the appropriate steps could be taken to access the situation.

"Based on the pictures that were sent to [the licensee] and conversations with the field personnel, [the licensee] does not believe that the gauge was damaged severely enough to cause a radiation leak from the gauge.

"The source rod was inside the inner protective housing (i.e. shield) when it was damaged. It appears that only the outer plastic casing was cracked and the index rod was snapped. The inner protective housing (i.e. shield) protecting the CS-137 source and the Americium 241 source protective cover appear to still be intact. The source rod was not bent. The sliding block at the bottom of the gauge is fully closed.

"Since the index rod locks the source rod in place, [the licensee] instructed field personnel how to temporarily restrain the index rod and therefore keep the source rod inside the protective shield. After properly securing the source rod, [the licensee] had field personnel place the damaged gauge inside the yellow DOT transport box. The transport box / gauge was then properly secured inside a large steel container (dedicated to [the licensee]) at the construction site. Only [licensee] personnel have access to the steel container.

"[The licensee] sent down a radiation meter to field personnel via FedEx overnight. The radiation meter only showed that the radiation level immediately next to the gauge was 4 mrem. The measured radiation level several feet away from the gauge was about 0.12 mrem. No radiation was measured outside of the steel container.

"[The licensee has] scheduled for the gauge to be picked up on Thursday by [licensee's] repair service firm. The repair service will perform their own leak test in the field prior to transporting the gauge back to their shop.

"Gauge Make/Model: Troxler 3440
Gauge Serial Number: 28929
Langan Gauge No.: #22
Nuclide (Serial No.): AM-241:BE (47-25121), CS-137 (750-3218)"

Typical Troxler gauges of this series contain a 8 mCi Cs-137 source and a 40 mCi Am/Be source.

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Power Reactor Event Number: 45178
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY CHITWOOD
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2009
Notification Time: 21:49 [ET]
Event Date: 06/30/2009
Event Time: 15:13 [PDT]
Last Update Date: 06/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DALE POWERS (R4DO)

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

Event Text

POTENTIAL MEDIA INTEREST DUE TO FORCED OUTAGE

"On June 30, 2009, at 1513 PDT, Unit 2 commenced a ramp[-down] in accordance with the annunciator response guidance to enter Operating Procedure (OP) Abnormal Procedure AP-25 due to loss of forced cooling to main transformer bank (MTB) C-Phase transformer. At 1538, Unit 2 was separated from the grid in accordance with plant OP AP-25 initiation of a main generator unit trip. At 1554 PDT, the Reactor Trip Breakers (RTBs) were manually opened per OP AP-25 Step 24.j. [Reactor] power was being held in Mode 2 at about 3% reactor power per the procedure when the RTBs were opened.

"The investigation into the cause is continuing.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi), Offsite Notification, as Pacific Gas and Electric plans to make a news release regarding the event that may raise media interest."

The licensee notified the NRC Resident Inspector.

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