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Event Notification Report for September 8, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/04/2009 - 09/08/2009

** EVENT NUMBERS **


45301 45308 45318 45321 45322 45325 45328 45329 45330 45331

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General Information or Other Event Number: 45301
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: KAISER PERMANENTE
Region: 1
City: JONESBORO State: GA
County: CLAYTON
License #: GA1276-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/26/2009
Notification Time: 16:00 [ET]
Event Date: 08/22/2009
Event Time: 07:30 [EDT]
Last Update Date: 09/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
LANCE ENGLISH (ILTA)
GREG SUBER (FSME)

Event Text

AGREEMENT STATE REPORT - EXTERIOR ACCESS DOOR TO RADIOLOGY LAB FOUND OPEN

While responding to an audible alarm, the Clayton County Police Department found an exterior door open to the Radiology Lab at the Kaiser Permanente Nuclear Medicine Clinic located in Jonesboro, Georgia. The Clayton County Police Department notified the Federal Bureau of Investigations and the Georgia Information Sharing and Analysis Center. The Georgia Information Sharing and Analysis Center then contacted the Georgia Radioactive Materials Program.

The licensee is authorized to possess diagnostic imaging isotopes. At this time, no information is available whether radiological material is missing, or if the open door was the cause of the alarm. The investigation is ongoing.

* * * UPDATE FROM IRENE BENNETT TO JOHN KNOKE AT 1036 EDT ON 09/04/09 * * *

The State conducted an inspection at the licensee's facility and determined that no material was missing. A complete report will follow later.

Notified FSME (Angela McIntosh), R1DO (James Dwyer), and ILTAB (via e-mail).

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General Information or Other Event Number: 45308
Rep Org: KARMANOS CANCER CENTER
Licensee: KARMANOS CANCER CENTER
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/28/2009
Notification Time: 17:05 [ET]
Event Date: 08/27/2009
Event Time: 18:00 [EDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

MEDICAL EVENT - PATIENT RECEIVED 60% LESS DOSE THAN PRESCRIBED

The licensee was performing reviews on past procedures when they discovered the following reportable event:

On March 3, 2009, a patient received a permanent prostate implant with a prescribed D90 dose of 144 Gy. The implant used fifty-eight I-125 seeds.

On April 3, 2009, the patient returned to the facility for a post-implant CT/dose reconstruction and it was determined that the D90 dose received by the patient was 85 Gy which is 60% of the prescribed dose.

The patient and prescribing physician were notified and the patient underwent an external radiation treatment to compensate.

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: 45318
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: NTH CONSULTANTS, LTD.
Region: 3
City: CLEVELAND State: OH
County:
License #: 31210180007
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/01/2009
Notification Time: 14:38 [ET]
Event Date: 08/31/2009
Event Time: [EDT]
Last Update Date: 09/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following notification was received via email:

"Received call from licensee at 4:58 PM on 8/31/09, regarding a Troxler Model 3400 portable gauge containing 44 mCi of Am-241 and 9 mCi of Cs-137 which was damaged at a job site in Olmstead Falls, Ohio. Serial numbers and manufacturer of sources not currently available. Serial number of gauge not currently available.

"The gauge user completed work with the gauge, locked the gauge, and then placed it on the ground under the tailgate of his truck. The user then went to the cab of the truck to perform some other tasks. While in the cab of the truck, the user noticed that heavy equipment operating at the job site was moving closer to his location, so he decided to move his truck. Forgetting that the gauge had been left outside the vehicle under the tailgate, the user backed over the gauge, causing damage to the case and shearing off the source rod at the case top. The portion of the rod containing the radioactive material remained inside the shielded body of the gauge.

"The licensee's RSO immediately responded to the event and took readings to verify that the source was in the shielded case and that there was no contamination on the ground where the gauge was run over. The damaged gauge has been moved to the licensee's facility in Cleveland where it is in secure storage. The licensee intends to transport the damaged gauge to their licensed repair contractor's facility in Michigan.

"ODH will be inspecting the licensee"

Ohio Report No.: OH090009

Notified R3DO (Lipa) and FSME (McIntosh).

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General Information or Other Event Number: 45321
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENNSYLVANIA STATE UNIVERSITY
Region: 1
City: STATE COLLEGE State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/01/2009
Notification Time: 22:28 [ET]
Event Date: 08/25/2009
Event Time: 14:30 [EDT]
Last Update Date: 09/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE - SURFACE CONTAMINATION LEVELS IN EXCESS OF LIMITS

The following was received via facsimile:

"An empty Type B, 30 gallon drum container was shipped on August 20, 2009 via public carrier from NSSI Sources and Services Inc. from Houston, Texas. It was delivered on August 25, 2009 to a Los Alamos National Laboratory (LANL) job site within a building at Penn State University in State College, PA. The shipping container was found to have external removable alpha contamination in excess of the US DOT limits noted in 49 CFR 173. LANL personnel informed their management and the carrier. Steps were also taken to verify that the contamination did not originate at Penn State. The individual truck that delivered the package to Penn State was surveyed by LANL personnel at about 2100 on 8/25/09. No contamination was found in the truck or the driver's area. There was no risk to any personnel at this facility due to this event. The first wipe found removable alpha contamination well in excess of the 2.2 dpm/centimeter squared DOT limit. After hours of decon, the removable contamination on the shipping containers was still over the limit. Onsite measurements noted little or no associated gamma radiation, and a sample was sent to LANL for alpha spectrum analysis. The material has been tentatively identified as curium-244 (Cm-244).

"PA DEP (Department of Radiation Protection) Bureau of Radiation Protection (BRP) was initially notified August 26, 2009 and has continued to receive more complete information through September 1st. LANL will put a new lid on the drum, package up the waste, and get things ready for shipping on September 2, 2009.

"The Commonwealth of PA has provided email notices of preliminary information related to this event to the NRC Region 1 State Liaison, and will continue to keep NRC informed of the status of our investigation."

See also EN #45309 for the Texas report on the same event.

State Event #: PA090028

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General Information or Other Event Number: 45322
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: LIBERTY PRESSURE PUMPING
Region: 4
City: FORT WORTH State: TX
County:
License #: G02259
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/02/2009
Notification Time: 10:43 [ET]
Event Date: 09/02/2009
Event Time: 08:40 [CDT]
Last Update Date: 09/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE REPORT - MOBILE SLURRY UNIT CAUGHT ON FIRE

The following report was received via email from the State of Texas:

"A mobile slurry unit (authorized under TX license G02259) in which a 200mCi, Cs-137, Thermo Fischer Scientific Model 5190 density gauge was mounted, caught fire. This occurred at an oil field temporary job site south of Fort Worth, TX. It was relayed that the fire had melted the lead at the top of the shield exposing the source as evidenced by elevated readings with a survey meter. It is believed that the source remains in the holder and has not been breached. Further, the gauge housing is still intact and [the] plan (already instituted) is to have the manufacturer remove the gauge for disposal at their facility. The device and source serial number are B7274 and CN-3171 respectively.

"There was no exposure to anybody in excess of agency limits due to the manner in which the units were parked."

Texas report # I-8662

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General Information or Other Event Number: 45325
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: ACT ELECTRONICS
Region: 1
City: HUDSON State: MA
County:
License #: G0317
Agreement: Y
Docket: 09-8637
NRC Notified By: JOHN SUMARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/03/2009
Notification Time: 11:25 [ET]
Event Date: 09/01/2009
Event Time: [EDT]
Last Update Date: 09/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB via email ()

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

Event Text

AGREEMENT STATE REPORT - MISSING STATIC ELIMINATOR DEVICES

The following report was received via fax from the Commonwealth of Massachusetts:

"In 2009, the Agency [Commonwealth of Massachusetts] billed the general licensee for the 2008 annual fee. The licensee was unresponsive and attempts to contact the licensee failed. On 9/1/09, the Agency discovered a published article in 'Business Week' that reported that the licensee, ACT Electronics, filed for bankruptcy in August 2008. Agency records indicate the licensee received these devices [static eliminators] in March 2007 and October 2007. The Agency contacted the manufacturer of the static eliminator devices, NRD Inc., and confirmed that the devices were not returned to the manufacturer. The Agency has declared the static eliminator devices as 'missing'."

Manufacturer: NRD, Inc.
Model #: P-2021
Serial Number: A2FL283, A2FW008, and AF2W009.

Sources: (3) Polonium 210, 10 mCi each.

MA Report No.: 09-8637

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: 45328
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: MIKE McBREARTY
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/03/2009
Notification Time: 23:18 [ET]
Event Date: 09/03/2009
Event Time: 17:30 [PDT]
Last Update Date: 09/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION TO LOS ANGELES COUNTY PUBLIC HEALTH RADIATION MANAGEMENT DIVISION

"On September 3, 2009, at approximately 1730 PDT, Southern California Edison [SCE] was notified by a metal recycling vendor that a metal recycle load that was picked up at SONGS had been rejected at Terminal Island (Long Beach, CA) because it set off a radiation portal monitor as it was being processed through. The vendor (Alpert and Alpert) was requested to immediately ship the material back to SONGS. The County of Los Angeles Public Health, Radiation Management Division (Joji Ortego) called to confirm final destination, and a Special DOT Permit was issued to return the shipment to SONGS.

"The truck is currently returning to San Onofre where SCE Health Physicists will evaluate the load.

"SCE is reporting this event in accordance with 10CFR50.72(b)(2)(xi). SCE will provide an update to this report after the truck has returned to SONGS and the contents evaluated.

"At the time of this report, Unit 2 and Unit 3 were operating at about 99 and 100 percent power respectively.

"The NRC Resident Inspectors have been notified of this occurrence and will be provided with a copy of this report."

* * * UPDATE FROM DAVID AXLINE TO CHARLES TEAL AT 1456 ON 09/04/09 * * *

"The truck returned to SONGS site and SONGS has performed surveys on the contents of the truck cargo containers. SONGS' preliminary investigation did not identify any licensed radioactive material either internal or external to the containers. Surveys indicate that the source of the radiation appears to be boxes of ceramic tiles being removed from a storage area outside the Owner Controlled Area (OCA). Gamma isotopic analysis indicate the tiles appear to contain naturally occurring radioactive material (thorium byproducts). SONGS will continue to perform additional surveys to validate our initial conclusions.

"The NRC Resident Inspectors have been notified of this occurrence and will be provided with a copy of this report."

Notified R4DO (Farnholtz).

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Power Reactor Event Number: 45329
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: MICHAEL HEIM
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/04/2009
Notification Time: 14:46 [ET]
Event Date: 09/04/2009
Event Time: 08:15 [CDT]
Last Update Date: 09/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
CHRISTINE LIPA (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - LICENSED EMPLOYEE CONFIRMED POSITIVE FOR ALCOHOL

A licensed employee had a confirmed positive for alcohol during for-cause fitness-for-duty test. The employee's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45330
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: JASON KOZAL
Notification Date: 09/06/2009
Notification Time: 20:17 [ET]
Event Date: 09/06/2009
Event Time: 18:05 [CDT]
Last Update Date: 09/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTINE LIPA (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

OFFSITE NOTIFICATION DUE TO LOSS OF AMERTAP BALLS

"Xcel environmental notified the State of Minnesota duty officer of the loss of approximately 1200 Amertap balls from the Unit 1 circulating water system. The Amertap balls are made of foam and are used for condenser tube cleaning. No further actions or notifications are required."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45331
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: NEWTON LACY
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/07/2009
Notification Time: 22:02 [ET]
Event Date: 09/07/2009
Event Time: 21:20 [EDT]
Last Update Date: 09/07/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
DANIEL RICH (R2DO)
JOSEPH GIITTER (NRR)
WILLIAM GOTT (IRD)

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

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION UNUSUAL EVENT

"This report documents a condition in which WBN [Watts Bar Nuclear] Unit 1 met the criteria to declare a NOUE [Notification of Unusual Event] based on RCS [Reactor Coolant System] unidentified leakage. Prior to declaration, the event was terminated thus no declaration was made. This event is reportable within one hour as an acceptable alternative to reporting in accordance with 10CFR50.72(a)(1)(i) - declaration of any of the emergency classes specified in the licensees approved emergency plan.

"During tagout installation in support of planned maintenance on the cation bed flush valve (1-FLV-62-921) in the CVCS/Letdown system, isolation boundary valve leakage of approximately 80 gpm was present for approximately three minutes. The leakage was terminated by reclosing opened vent (1-VTV-62-917) and drain valves (1-DRV-62-920). Cation Bed Inlet (l-ISV-62-915) and Outlet (1-ISV-62-916) and all other boundary valve isolations were verified to be in the correct, closed position per the tagout instructions. This RCS leakage was directed to the Tritiated Drain Collector Tank, thus all leakage was contained within plant systems and no radiological releases resulted. A work order will be initiated to troubleshoot and repair the faulty isolation valve.

"This amount of leakage is in excess of the amount specified in WBN Emergency Plans for declaration of an NOUE based on >10 gpm unidentified leakage per EAL 2.5. Prior to declaration, the event was terminated, thus no declaration was made."

The State of Tennessee and the NRC Resident Inspector has been notified.

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