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Event Notification Report for July 16, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/15/2009 - 07/16/2009

** EVENT NUMBERS **


45192 45201 45202 45207

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General Information or Other Event Number: 45192
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA STATE UNIVERSITY
Region: 4
City: STILLWATER State: OK
County:
License #: OK-00237-03
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/10/2009
Notification Time: 10:46 [ET]
Event Date: 07/08/2009
Event Time: [CDT]
Last Update Date: 07/10/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING UNPLANNED CONTAMINATION

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

"An incident involving veterinary use of 3.7 milliCuries of Iodine 131 occurred at Oklahoma State University (OSU) on the afternoon of July 8. OSU holds a broad scope license OK-00237-03 and is located in Stillwater, OK. This was the licensee's first such treatment of a cat since an incident late last Fall where a veterinarian who was not an authorized user did a similar injection and stuck himself with the needle after the injection. An inspector from Oklahoma DEQ was present for the treatment, though not in the actual injection room because of space concerns. The University RSO directly observed the procedure and reports that the technician administering the dose appeared to follow the procedure precisely. She did not report anything unusual about the injection, though she observed that the cat (whose body was enclosed in a bag) struggled somewhat. The problem was discovered when a survey of the technician was done, and contamination was discovered on protective clothing covering the hand and the outer surface of the opposite forearm.

"Licensee measurements indicate that the cat reads 0.25 mrem/hr at 30 cm from the body, while measurements in the area where the cat was injected read over 60mrem/hr without the cat present. The licensee believes that the cat did not receive the majority of the dose and that the majority of the Iodine ended up on the injection shelf and the floor of the room. Thyroid screening of the technician, the RSO, and a control person with NaI probe does not indicate any internal absorption. The technician does not have any removable contamination on her skin, and meter readings of her skin are at background. A whole body scan at a hospital is being scheduled for her. She was given 0.13 cc of SSKI mixed with 2 ounces of water shortly after the incident.

"The area where the incident occurred has been closed off. The cat is being maintained in a cage in the room. The syringe assembly, its carrying case, and all protective garments worn by the technician have been preserved. The licensee is investigating, getting the advice of a team of experts.

"The licensee has not reached a conclusion of the cause of the problem, theories include mechanical failure in the preloaded syringe assembly or that the struggling cat may have caused the needle to stick out through the subcutaneous injection site causing the dose to be ejected outside the cat."

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General Information or Other Event Number: 45201
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: AMERICAN ENGINEERING AND TESTING
Region: 3
City:  State: MN
County:
License #: 1089-204-62
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/13/2009
Notification Time: 15:00 [ET]
Event Date: 05/20/2009
Event Time: 13:00 [CDT]
Last Update Date: 07/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MINNESOTA AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was obtained from the State of Minnesota via email:

"On Wednesday, May 20, 2009, at approximately 1300 hrs, a licensee was performing radiography at a temporary job site using a 41 Curie Ir-192 source when the stand holding the guide tube fell from its secured position and landed on the guide tube near the camera, crimping the guide tube. The radiographer attempted numerous times to retract the source and was unsuccessful. The radiographer performed radiation surveys to reset the boundaries and contacted the management. The Radiation Safety Officer was also contacted.

"The NDT [Non-Destructive Testing] manager used steel plates for shielding in order to disconnect the guide tube from the camera. Once disconnected, the NDT manager proceeded to the collimator end of the guide tube and pulled the guide tube to allow the source to pass through the crimped portion. When the source passed through the kink, the radiographer cranked the source into its shielded position. The NDT manger received 121 mrem, the radiographer received approximately 40 mrem. Leak tests results indicate that the source was not effected. The guide tube has been discarded.

"The root cause of the event was determined to be that the radiographers failed to ensure that all four legs of the magnets on the ring stand used to support the guide tube were not in contact with metal due to the curvature of the surface. The weight of the guide tube caused the stand to fall and to crimp the guide tube. "

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General Information or Other Event Number: 45202
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: BRAUN INTERTEC
Region: 3
City:  State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/13/2009
Notification Time: 15:04 [ET]
Event Date: 06/18/2009
Event Time: [CDT]
Last Update Date: 07/13/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MINNESOTA AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was obtained from the State of Minnesota via email:

"[On June 18, 2009, at a temporary job site,] the licensee was conducting radiography of circumferential welds. At approximately 1220 hrs, the radiographers heard a 'bang' from inside the horizontal heavy wall vessel. The licensee was using a 42 Curie Cobalt-60 source in an AEA 680 exposure device. The lead radiographer immediately attempted to retract the source but could not move the control handle. Thinking that the problem was the result of a tight radius, the radiographer attempted to withdraw the guide tube from the tank. That effort was abandoned when the guide tube began to slide out of the vessel. However, the radiographer identified a dent in the guide tube that was approximately 18 inches from the far end. The source was shielded with 3/8 inch lead plates.

"The radiographer conducted a survey and calculated the exposure to hammer out the crimp in the guide tube. After consultation with the Radiation Safety Officer, a radiographer approached the guide tube, turned it 1/4 of a turn, and hit it once with a hammer. The source was then successfully retracted.

"Total doses for the retrieval were 190 mrem to the lead radiographer and 20 mrem to the second radiographer. The damaged guide tube has been removed from service.

"The root cause of the problem has been determined to be that the guide tube was extended to its fullest length; therefore, the tension and/or weight of the tube caused the stand to fall over and crimp the guide tube. The corrective action was to add an additional guide tube and to secure the stand with weights to prevent tipping."

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Fuel Cycle Facility Event Number: 45207
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: BARRY COLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/15/2009
Notification Time: 20:18 [ET]
Event Date: 07/15/2009
Event Time: 19:45 [EDT]
Last Update Date: 07/15/2009
Emergency Class: ALERT
10 CFR Section:
70.32(i) - EMERGENCY DECLARED
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
LUIS REYES (R2 R)
MICHAEL WEBER (NMSS)
BRIAN McDERMOTT (IRD)
MARYANNE DOYLE (DHS)
TODD KUZIA (FEMA)
THOMAS YATES (DOE)
DAVID TIMMONS (USDA)
JOHN ALDAHONDO (HHS)

Event Text

LOSS OF CRITICALITY SAFETY CONTROLS FOR MATERIAL FOUND IN AN UNEXPECTED LOCATION

"On July 15, 2009 at 1945 B&W Nuclear Operations Group in Lynchburg, Va. activated [its] Emergency Operations Center due to an issue in [the] Uranium Recovery facility. A Do-All Saw used for sectioning of fuel components was found to have a collection of cutting fluid with an unknown amount of HEU in an unfavorable geometry. The volume is estimated at 54 liters. All IROFS [Items Relied On For Safety] have been lost. A criticality is not considered imminent. The situation with the equipment is stable.

"There were no radiological concerns with this event. There was no immediate risk or threat to the safety of workers or the public as a result of this event."

The NRC Resident Inspector has been notified.

* * * UPDATE AT 0043 EDT ON 7/16/09 BY BARRY COLE * * *

The licensee terminated its ALERT at 0035 EDT on 7/16/09 after "mass control" was re-established for the HEU material in the saw cutting fluid. The mass control determination was based on sampling and analysis of the fluid which provided an HEU mass assay indicating that there was significantly less than a critical mass of material present. The licensee stated that the fluid will be removed in a controlled manner later today.

The NRC Resident Inspector is onsite and has been notified. NRC Region 2 and HQ management informed via monitoring team. R2DO(O'Donohue), DHS(Doyle), FEMA(Kuzia), DOE(Parsons), USDA(Timmons), and HHS(Miller) notified.

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Thursday, March 29, 2012