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Event Notification Report for August 21, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/20/2009 - 08/21/2009

** EVENT NUMBERS **


45209 45266 45267 45268 45271 45272 45279 45280

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General Information or Other Event Number: 45209
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RADIOGRAPHIC SPECIALISTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02742
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/17/2009
Notification Time: 17:31 [ET]
Event Date: 07/16/2009
Event Time: [CDT]
Last Update Date: 08/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
TERRENCE REIS (FSME)

Event Text

POSSIBLE RADIOGRAPHER OVEREXPOSURE

Texas Incident #8646

"On July 17, 2009, the Agency [Texas Department of Health] was notified by the licensee that they had been informed by their dosimetry processor that a radiographer had received an exposure exceeding the annual exposure limit. The licensee stated that the individual's thermoluminescent dosimeter was reading 9,000 millirem for the exposure period of June 9, 2009, through July 10, 2009. The licensee conducted a preliminary interview with the employee and was not able to determine how the exposure could have occurred. The radiographer stated that he had not received any dose rate alarms while performing his duties during the monitoring period. He also stated that his self reading pocket dosimeter had never indicated any unusual readings. The licensee's Radiation Safety Officer stated that the individual's duties during the exposure period were almost exclusively dark room operations grading film. The licensee is continuing to investigate and will provide additional information to the Agency [Texas Department of Health] as it becomes available."

* * * UPDATE ON 8/13/2009 AT 1243 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"7/21/09 0830 Contacted the RSO. He stated that they had completed a review of the individuals daily exposure recorded for the previous 6 months and had not found any reason for the exposure. I asked him if they were going to seek any medical assistance for the individual involved. He stated that he was unsure of what action he should take in this area. I provided him with REACTS contact information.

"7/21/09 1320 Received a call from the RSO. He stated that he had just received a call from his dosimetry processor informing him that the same individual's badge for the exposure period of May 10, 2009, and June 9, 2009, was 17,840 millirem. The RSO stated that he was making arrangements to have a medical exam for the individual done. He was also going to contact REACTS again to seek advice on how to proceed.

"7/21/09 1530 The RSO for Radiographic Specialist contacted the Agency [Texas Department of Health] and stated that they had scheduled the worker for blood test and that REACTS had shipped him a study kit to analyze the workers blood to help determine if he had received the dose indicated by his badge. REACTS stated that it would take a few weeks after they received the sample to have the results. I told the RSO that the Agency [Texas Department of Health] is planning to conduct their investigation at his facility on July 29, or 30, 2009, and requested copies of the dosimetry processors reports for the individual.

"7/21/09 1614 Received the dosimetry reports. The report for the June 2009 period indicates 9,470 millirem for the exposure period. The processor states that the reading appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The film for the May exposure period indicates 17,840 millirem and the reading also appears normal and they cannot determine if the exposure is static or dynamic. No radioactive contamination was found on the film. The RSO still believes that this is a badge only exposure.

"Additional information

"On August 6, 2009, the Licensee provided a copy of the Cytogenetic Biodosimetry report from Cytogenetic Biodosimetry Laboratories - REAC/TS performed on their employee reported as receiving the overexposure. The initial report indicated that the dose received was not significantly different from background. The Agency [Texas Department of Health] requested clarification of what REAC/TS used as a background. On August 12, 2009, the licensee provided a copy of a document from REAC/TS, which indicated that their background would be a dose of 14 rad for the study conducted. The Agency [Texas Department of Health] will perform an on-site investigation of the event on or about August 19, 2009."

Notified the R4DO (Whitten) and FSME (McIntosh).

* * * UPDATE ON 8/20/2009 AT1844 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On August 19, 2009, the Agency [Texas Department of Health] completed an on-site investigation with the licensee. The investigation was not able to determine how that much exposure was recorded on the individual's badge. The licensee presented the Agency [Texas Department of Health] with a copy of an email sent from the Cytogenetic Biodosimetry Coordinator at REAC/TS in which he stated that they found no evidence that an overexposure to this individual had occurred. The licensee stated that he would be requesting a dose assignment of 417 millirem for each of the two exposure periods of May and June 2009, reducing the TEDE for the year of 2009 to less than 5 rem."

Notified the R4DO (Jones) and FSME (Camper).

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General Information or Other Event Number: 45266
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UNIVERSITY OF MASSACHUSETTS - LOWELL
Region: 1
City: LOWELL State: MA
County:
License #: 60-0049
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: KARL DIEDERICH
Notification Date: 08/17/2009
Notification Time: 13:49 [ET]
Event Date: 08/10/2009
Event Time: [EDT]
Last Update Date: 08/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - IMPROPERLY PACKAGED RADIOACTIVE SHIPMENT

The following was received from the State via FAX:

"The Radiation Safety Officer (RSO) for the University of Massachusetts - Lowell (UMASS - Lowell) reported an improper shipment of radioactive material where the package was prepared for shipment as a regular package and should have been prepared for shipment as a Class 7 (radioactive) package.

"On Friday, August 14, 2009, the RSO discovered, from information received by General Dynamics C4 Systems (GD), that GD received, on Tuesday, August 12, 2009 a regular package sent by UMASS-Lowell on Monday, August 10, 2009 that should have been prepared as Class 7. The package was reported by GD to UMASS-Lowell to have radiation levels of 2.6 mrad/hr at 2 cm above the package or contents of package as measured with a Ludlum G-M instrument.

"The RSO reports that the package contained electronic components subjected to irradiation from UMASS - Lowell's research reactor and that the radioactive materials contained in the package was likely Bromine-82. The RSO reports that he does not believe that there was any contamination discovered on the outside of the package.

"The RSO reports that based on calculations performed, the estimated activity of the package, for Bromine-82, was one (1) MBq and that the specific activity of bromine-82 of the samples (electronics) was likely between 42 and 170 Becquerel's/gram. The address reported for GD, the recipient of the package, is Scottsdale, AZ 85252 and any radioactive materials license number for GD was not known at time of this report."

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General Information or Other Event Number: 45267
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS
Region: 4
City: PASADENA State: TX
County:
License #: L04322
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: KARL DIEDERICH
Notification Date: 08/17/2009
Notification Time: 15:55 [ET]
Event Date: 08/17/2009
Event Time: 04:00 [CDT]
Last Update Date: 08/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECTED FROM ITS CABLE

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

"On the morning of August 17, 2009, a 79.1 Curie Ir-192 source in a Sentinel Model 880 exposure device (S/N D5517) could not be retracted into the fully shielded position. After several attempts to back the source out, it was surmised that the source remained at the end of the source tube and the Radiation Safety Officer (RSO) was notified. A 2 mR/hr line was established by the radiographers and the licensee's report indicated that visual surveillance was maintained at all times. The RSO then utilized additional shielding and remote handling tools to retrieve the source and place it into another camera. It was determined after the recovery that the ball shank broke from the drive cable leaving the source pigtail in the source tube. The RSO reported that all personnel were monitored with direct reading devices and no exposures exceeded regulatory limits."

Source: QSA Global model 424-9, Serial #56552B

Texas Incident Report I-8658

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General Information or Other Event Number: 45268
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TAPPAN PHOTOMASK
Region: 4
City: ROUND ROCK State: TX
County: WILLIAMSON
License #:
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: KARL DIEDERICH
Notification Date: 08/17/2009
Notification Time: 17:40 [ET]
Event Date: 08/17/2009
Event Time: [CDT]
Last Update Date: 08/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
ANDREW MAUER (FSME)
ILTAB VIA E-MAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - FOUR PO-210 STATIC ELIMINATORS LOST

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

"In the afternoon of August 17, 2009, the licensee had concluded that four static eliminators, NRD Model P-2021-Y000 containing 500 microCi each could not be located and were presumed lost, probably discarded in the general refuse. The sources were removed from the machines they were mounted on while the area was undergoing some renovation or relocation of equipment. However, when the equipment in which the devices were housed were attempted to be placed back in service, the devices were noted as missing. Repeated attempts to locate the sources and devices have proved futile."

Texas Report I-8659

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: 45271
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MACTEC ENGINEERING & CONSULTING, INC.
Region: 1
City: CHANTILLY State: VA
County:
License #: 107-133-1
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/18/2009
Notification Time: 10:10 [ET]
Event Date: 08/14/2009
Event Time: 08:00 [EDT]
Last Update Date: 08/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE RUN OVER BY CONSTRUCTION EQUIPMENT

The following information was received from the State via facsimile:

"The Virginia Radioactive Materials Program received a telephone message on Monday, August 17, 2009 (message was left at 6:30 PM on Friday, August 14, 2009) concerning the licensee's Troxler gauge. The gauge had been run over by a roller while in operation. The Radioactive Materials Program returned the call to the licensee's RSO at 7:45 AM on Monday, August 17. The accident occurred at 8AM on Friday, August 14. The guide rod and source rod were broken off the gauge, but the instrument's case was otherwise intact. The operator of the gauge placed it into the shipping container, placed the shipping container in the locked box on the back of the pickup truck, and transported the gauge back to the shop. The licensee's RSO surveyed the gauge and took wipe samples. Two radiation safety specialists from the Radioactive Materials Program visited the licensee, arriving at 12:00 noon on Monday, August 17. The radiation safety specialists visually inspected the gauge, took survey measurements with a maximum level of 100 mR/hr at the surface and 4 mR/hr at one meter from the shipping container, and also took wipe samples. When the gauge was run over, it was operating in "backscatter" mode, so the Cs-137 source was within the case of the gauge. The accident did damage the shutter mechanism for the Cs-137 source so that it could not be closed. The gauge in its shipping container was placed in a locked storage cabinet in the shop pending disposal. The local Troxler vendor had been contacted by the licensee's RSO. The licensee was advised to give the vendor the current radiation survey of the package and to obtain the results of the wipe tests prior to allowing the vendor to transport the gauge. The radiation safety specialists also visited the site of the accident, where they surveyed the ground at the site of the accident, the roller that ran over the gauge, and the pickup truck that transported the gauge. All surveyed areas at the accident location were at background."

VA Event Report ID No.: VA-2009-03

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General Information or Other Event Number: 45272
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: TTM TECHNOLOGIES
Region: 4
City: REDMOND State: WA
County:
License #: R0012
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/18/2009
Notification Time: 12:33 [ET]
Event Date: 08/06/2009
Event Time: [PDT]
Last Update Date: 08/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
ANGELA MCINTOSH (FSME)
EMAIL ONLY (ILTA)
CANADA VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - NINE MISSING PO-210 AND PM-147 SEALED SOURCES

"On 19 June 2009, TTM Technologies in Redmond was contacted as part of a routine check of their inventory of generally licensed devices. It was discovered at this time that the facility was closing and that the gauges and static eliminators had been sent to TTM Technologies facilities in other states. TTM Technologies has since tracked down as many of the missing devices as possible. Those facilities that have received sources have been informed of the reporting requirements and regulations surrounding those generally licensed devices. NRD, Inc. was contacted to see if any of the remaining unaccounted for sources had been returned to them. They have not been. The remaining missing sources are being reported as lost.

"This report lists eight devices/sources. A ninth device/source (exactly the same as number 8 except for the serial number) is being included here instead. This device/source is serial number A2CK423. Seven of the nine devices/sources are Po-210 static eliminators and have gone through more than ten half-lives. The other two devices are sources of Pm-147 in beta backscatter gauges and have gone through approximately 8 half-lives. It is therefore concluded that the missing sources are of little threat to human health and safety.

"Source of Radiation:
Source Number: 1
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PM-147
Source Use: OTHER
Activity:0.9E-3 Ci 0.0333 GBq
Manufacturer: OXFORD INSTRUMENT
Model Number: GM-1
Serial Number: 75125P

"Source Number: 2
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PM-147
Source Use: OTHER
Activity:0.6E-3 Ci 0.0222 GBq
Manufacturer: OXFORD INSTRUMENT
Model Number: GM-1
Serial Number: 65986P

"Source Number: 3
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2001
Serial Number: A2EA910

"Source Number: 4
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2001
Serial Number: A2BM653

"Source Number: 5
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2DY847

"Source Number: 6
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2CE789

"Source Number: 7
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2BM653

"Source Number: 8
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2CK423

"Corrective Actions: 1 Personnel received additional training."

Washington state reporting requirement WAC 246-221-240
Washington Report No: WA090061

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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Power Reactor Event Number: 45279
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: LEROY ANDERSON
HQ OPS Officer: PETE SNYDER
Notification Date: 08/20/2009
Notification Time: 15:19 [ET]
Event Date: 08/20/2009
Event Time: 08:38 [CDT]
Last Update Date: 08/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JACK GIESSNER (R3DO)

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

BOTH DIVISIONS OF VITAL SWITCHGEAR INOPERABLE BECAUSE FLOOD DOOR FOUND CLOSED

"At 08:38 on 08/20/09, a plant operator identified that DOOR-18, which is a normally open fire door, had closed due to a failed fusible link. With this door closed, the pathway for a potential flood due to a high energy line break (HELB) is blocked therefore closing off a drain path for the water. This represented an unanalyzed condition where both divisions of essential switchgear could be impacted. As a result, both divisions of essential switchgear were declared inoperable and Technical Specification LCO 3.0.3 was entered.

"With both switchgear divisions being inoperable, this condition is also an event that could have prevented fulfillment of a Safely Function and reportable under 50.72(b)(3)(v). At 0942 on 08/20/09, the closed fire door was restored to the open state. Both divisions of switchgear were declared Operable and LCO 3.0.3 was exited. No system actuations occurred as a part of this event."

A continuous fire watch was posted as a compensatory measure while the fire door is being repaired.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45280
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE BORGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/20/2009
Notification Time: 20:14 [ET]
Event Date: 08/20/2009
Event Time: 16:43 [EDT]
Last Update Date: 08/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD CONTE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 94 Power Operation 94 Power Operation

Event Text

LOSS OF PLANT INTEGRATED COMPUTER SYSTEM RESULTING IN LOSS OF ERDS AND SPDS

"At 0950 the Plant Integrated Computer System started to fail as indicated by a loss of computer link to Generation. Investigation by computer maintenance personnel was initiated. The failure mode of the computer precluded accessing screens to allow use of Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS). Computer core thermal power indication remained available to the control room operators. Redundant, normal control room indications are still available to the operators. At 1217 hours on 08/20/09, a planned loss of computer core thermal power indication occurred due to ongoing computer maintenance activities.

"At 1458 hours on 08/20/09, the Plant Integrated Computer System was fully restored to service, including the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) functions. At 1643 hours on 08/20/09, the Plant Integrated Computer System started to fail again as indicated by loss of computer link to Generation. This problem with the computer again precluded accessing Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS). Core thermal power indication remained available via the plant computer system. However, anticipated troubleshooting actions will require a reduction in power by approximately 0.25-0.33% by reducing core flow.

"Due to the cumulative impacts of the loss of the plant computer system, this notification is being communicated ahead of the 8 hour unavailability of the Unit 2 SPDS and ERDS computer system. This is considered a Loss of Emergency Assessment Capability and therefore reportable under 10CFR50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector.

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