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Event Notification Report for August 12, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/11/2009 - 08/12/2009

** EVENT NUMBERS **


45226 45246 45249 45255 45256 45258

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General Information or Other Event Number: 45226
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/24/2009
Notification Time: 16:35 [ET]
Event Date: 07/15/2009
Event Time: [EDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
PATRICE BUBAR (FSME)
ILTAB (via email) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING THE LOSS OF A CALIFORNIUM-252 SOURCE

On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility.

The following information is a portion of an email forwarded by the State of North Carolina:

"TUNL staff today formally reported the loss of a Californium-252 source:

"(1) Source description: 3.4 microcuries of Cf-252 with an active layer of 8 mm diameter on the platinum backing 15 mm in diameter, 0.2 mm thick. The source was inside an ionization chamber, which was purchased in 1995 from Physikalish-Technische Bundesanstalt, Berlin with an initial activity of 5.17 MBq (86 microcuries; T = 2.645 y)

"(2) Circumstances: A physical inventory of TUNL sources during mid-July determined that this source was missing. A search of the TUNL facility failed to locate this source. Although the investigation is continuing, TUNL staff have concluded that the source is lost.

"(3) Disposition or probable disposition of lost source: This source was incorporated into a piece of equipment (ion chamber) composed of a metal tube with several smaller metal tubes (vacuum lines) coming off of it. TUNL staff suspect that this piece of equipment containing the source may have been left with other scrap items shipped off site for disposal as radioactive waste during the Fall of 2008. However it is quite possible that this ion chamber and the source inside are still somewhere inside the TUNL facility. TUNL staff have been instructed to report if they happen upon it.

"(4) Possible radiation exposure: None under any reasonably probable scenario.

"(5) Actions taken to recover the material: TUNL staff conducted a search of the TUNL facility; the investigation into this incident is ongoing.

"(6) Steps taken to prevent a recurrence: TUNL staff are developing and implementing a series of measures to tighten control over TUNL radioactive sources. The development of these policies and procedures is still underway."

The RSO at the TUNL facility said the lost source is a target foil used in the TUNL linear accelerator (032-247-A1), and it was stored at TUNL. The loss occurred under the Duke University broad scope academic license 032-0247-1 and not the TUNL license. No manufacturer, make, model, or serial number reported at this time (16:45 7/24/09)."

North Carolina Incident ICD 09-30

* * * UPDATE PROVIDED BY JAMES ALBRIGHT TO JASON KOZAL ON 08/11/09 AT 1702 * * *

The following information is a portion of an email forwarded by the State of North Carolina:

"The source was found at approximately at 1:30 PM on Monday, July 27, 2009 in room K101 of the Keck Building. The source was on a table among an assortment of other research equipment. The area where the source was found is a radiation controlled area and is not accessible to the general public. Combining the circumstances of the discovery of the source with details of our search for the source and a review of our source checkout logs, we conclude that the source has likely been mixed with research equipment in the same research area where it was discovered since the summer 2008.

"Findings: The loss of inventory control of this source and our failure for timely discovery was due to three contributing factors: (1) improper removal of the source from its storage location, (2) a clerical error in the quarterly source inventories and (3) our practice of using source checkout log sheets to augment physical inspection in our quarterly inventories. Our radioactive materials (RAM) inventory control is based on proper checkout of sources by completing entries on a sign-out/in sheet for each usage and quarterly RAM inventories. Normally failures to properly sign out/in sources are caught in the quarterly inventories. However, because of our practice of augmenting the physical inspection in our quarterly RAM inventory check with information on the sign-out/in log sheets, it is possible for this check to fail due to either logging errors on the sign-out/in sheets or clerical errors made in reviewing the sheets for inventory assessment. In this rare event, both occurred. During the September 2008 inventory check, the most recent entries for this source on the sign-out/in sheets were overlooked and earlier entries were used that indicated that the source was in use by a student. We have no reason to believe the source was not in use at TUNL because he was not present at the July 2008 accelerator scheduling meeting when a faculty member mentioned that the source wasn't in the storage safe, and [the professor] forgot to alert him of the potential problem with this source. Also contributing to this oversight that delayed discovery of the problem was our policy of allowing source usage without time limitations; it is not unusual for a source to be used by an individual for several quarters.

"Corrective Actions: This unfortunate event has caused us to review our practices in managing the RAM inventory at TUNL. Based on our findings, the following actions will be taken to reduce risk of loss of control of any items in our RAM inventory in the future:

"1. We will discontinue the use of information from the checkout log sheets to augment physical inspections in the quarterly inventories. In the future, all sources will be physically inspected. For sources that are permanently embedded in equipment, the seal on the equipment where the source is installed will be inspected and the presence of the source will be checked with particle detectors whenever practical;

"2. Open ended source usage will be discontinued source usage will be limited to a duration of one week;

"3. The number of people with authorization to checkout sources will be more restrictive - Only TUNL faculty members, research scientists, post docs and selected technical staff members will be allowed to check out radioactive sources (graduate students, undergraduate students and visitors will no longer be allowed to checkout radioactive sources);

"4. Substantial consequences will be imposed on individuals who do not properly checkout sources - failure to sign out radioactive sources properly will put research groups at risk of losing their privilege to use radioactive sources in the TUNL inventory;

"5. Security in the area around our main source storage will be increased - the main area for radioactive materials storage at TUNL will be monitored with video cameras to record removal and return of radioactive sources; and

"6. The radioactive materials in the TUNL inventory will be sorted into categories according to the reporting requirements by the State: high, medium and low. We are investigating technologies for electronic inventory control on the materials in the high and medium reporting categories.

Notified R1DO (Cook), FSME EO (Mauer), and ILTAB via e-mail. 252

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: 45246
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: PETE SNYDER
Notification Date: 08/05/2009
Notification Time: 14:08 [ET]
Event Date: 08/05/2009
Event Time: [EDT]
Last Update Date: 08/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL DOSE DIFFERENT THAN PRESCRIBED

During an embolization procedure delivering Yttrium-90 spheres to the liver an interruption occurred resulting in only 35 Gy of the 52 Gy prescribed dose being delivered. The interruption was due to unexpected contamination due to a leaking septum v-vial Contamination was contained in a container and did not enter the patient. The patient and referring physician will be notified.

GA report number: 2009-09i.

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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Hospital Event Number: 45249
Rep Org: YALE - NEW HAVEN HOSPITAL
Licensee: YALE - NEW HAVEN HOSPITAL
Region: 1
City: NEW HAVEN State: CT
County:
License #: 06-30445-01
Agreement: N
Docket:
NRC Notified By: MIKE BOHAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/06/2009
Notification Time: 12:11 [ET]
Event Date: 08/05/2009
Event Time: [EDT]
Last Update Date: 08/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

DOSAGE TO PATIENT WAS POTENTIALLY DIFFERENT FROM PRESCRIBED DOSE DUE TO EQUIPMENT MALFUNCTION

"Two patients were scheduled for treatment using a Leksell GammaKnife Model C/B-2 stereotactic radiosurgery unit on August 5, 2009. This model uses an Automatic Positioning System (APS) to automatically change patient position during the treatment. The APS reported positioning error codes to the treatment console and the operators called Elekta, the manufacturer's US representative for help. They were told to undock the patient and reinitialize the APS system and then to complete treatment. This happened again during the second patient treatment and the local Elekta service person was called to inspect the unit.

"The service representative arrived after the completion of treatment to the second patient and it was noted then that while trying to drive the APS system back to it's nominal position, one of the axis indicators was off by 5 mm. It is not known if this happened during the treatment, so this is a provisional report until a thorough analysis can be performed. The console logs have to be analyzed by the manufacturer's representatives to see if the error occurred during treatment and as a result of an APS malfunction."

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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Power Reactor Event Number: 45255
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: GEORGE KELLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/10/2009
Notification Time: 23:55 [ET]
Event Date: 08/10/2009
Event Time: 20:32 [EDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
WILLIAM COOK (R1DO)
TIM McGINTY (NRR)
ANTHONY McMURTRAY (IRD)

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

Event Text

INDIAN POINT UNIT 3 AUTOMATICALLY TRIPPED DURING THUNDERSTORM

"Indian Point Unit 3 automatically tripped from 100% power at 2032 [EDT] on 8/10/2009 due to [a] generator trip. Indian Point Unit 3 is currently in mode 3. All control rods inserted on the trip. No safety relief valves lifted due to the trip. The motor driven aux feedwater pumps automatically started on low steam generator level and are being used to maintain steam generator level. Condenser steam dumps are maintaining reactor temperature.

"After the trip , [the] 6.9kv bus 2 did not transfer to offsite power and is de-energized resulting in a loss of [the] '34' RCP [Reactor Coolant Pump]. [The] 480v bus 2A was energized by the diesel generator.

"Plant operators are investigating the cause of the generator trip and loss of bus 2.

"Unit 2 was unaffected and remains in mode 1 at 100% power.

"The licensee has notified the NRC Resident Inspector."

The licensee informed the State of New York and plans on issuing a press release.

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Other Nuclear Material Event Number: 45256
Rep Org: ATC ASSOCIATES
Licensee: ATC ASSOCIATES
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-17732-01
Agreement: N
Docket:
NRC Notified By: BOB RAMSEY
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/11/2009
Notification Time: 13:55 [ET]
Event Date: 08/10/2009
Event Time: 08:00 [EDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JAMNES CAMERON (R3DO)
ANGELA MCINTOSH (FSME)
ILTAB VIA EMAIL ()

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

Event Text

STOLEN MOISTURE DENSITY GAUGE

An employee drove home [Crawfordville, IN] with the density gauge in the back of his car on Friday August 7, 2009. Sunday morning he locked the density gauge into the trunk of another car parked in the front of his home. He then left to attend a family event. The employee noticed the gauge was missing on Monday morning.

The licensee notified Montgomery County Police and Indiana Department of Health.

Seaman Nuclear Moisture Density Gauge
Model: C75A SC757582
Source: Radium-226
Activity: .00616 TBq

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: 45258
Rep Org: STATE OF CALIFORNIA
Licensee: CHEVRON REFINERY
Region: 4
City: RODEO State: CA
County:
License #: 5299-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/11/2009
Notification Time: 16:09 [ET]
Event Date: 08/05/2009
Event Time: [PDT]
Last Update Date: 08/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE - LOSS OF CONTROL OF NUCLEAR MATERIAL

The following was received from the state via email:

"On 08/05/09 during the evening a T.C. Inspection radiographer was performing radiography at the Chevron refinery in Richmond, CA. The job was completed around 8:30 p.m. The radiographer loaded the gear into the truck leaving the locked camera (INC, Model IR100, S/N 7019, 49 Ci activity) at the job site. Approximately 10 to 15 minutes later, Chevron maintenance noticed the exposure device and notified the Chevron fire department. The A T.C. Inspection radiographer who was at the refinery heard the call on the radio and responded to the event location, however, he did not have a survey meter to approach the camera. He noticed that the plug was in and the device appeared to be locked with no key in the lock. They barricaded the area, and kept the camera under surveillance until a survey meter was brought in. The radiographer surveyed the camera and confirmed that the source was in a shielded position and transported the camera to the storage location. The radiographer who left the camera at the job site is no longer employed by T.C. Inspections."

CA Report #: 80609

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