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Event Notification Report for September 29, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/28/2009 - 09/29/2009

** EVENT NUMBERS **


45378 45379 45381 45386

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General Information or Other Event Number: 45378
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/22/2009
Notification Time: 18:32 [ET]
Event Date: 09/21/2009
Event Time: [CDT]
Last Update Date: 09/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT- PATIENT RECEIVED IMPROPER DOSAGE

On September 21, 2009, a patient undergoing mammosite brachytherapy did not receive the proper dose administration due to the Ir-192 (9.6 Ci) source failing to retract. The administering physician retrieved the source from the patient and placed it back in the device. A dose estimate is in progress, however, the licensee does not expect the dosage to exceed 50 percent of the prescribed dose. The afterloader was cleaned recently and the licensee does not expect any debris from the device. The State will report any results of the dose assessment.

Texas Incident Number: #8673

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: 45379
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: J.L. SHEPHARD & ASSOCIATES
Region: 4
City: SAN FERNANDO State: CA
County:
License #: 1777
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/23/2009
Notification Time: 19:05 [ET]
Event Date: 09/23/2009
Event Time: [PDT]
Last Update Date: 09/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

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

"J.L. Shepherd & Associates (JLS&A) performed a source exchange on a Model 44, serial number 7079, category 1 panoramic irradiator of their own manufacture.

"The source is identified as JLS&A Type 7810 capsule, manufactured by General Electric Company, Nuclear Center. The serial number is GEC-05-04. CA Sealed Source & Device registry: CA0598S122S

"At the time of source exchange, the Co-60 source was estimated to have [approximately] 250 Ci of activity. Wipe tests were taken at the location of the resourcing and showed no indication of leaks. The source holder rod was discolored and had evidence of corrosion. Source assembly was shipped to JL Shepherd's facility in San Fernando, CA.

"On September 22, 2009, the source was removed from the transport container in their hot cell with remote manipulators. The source was wiped and determined to have 0.0688 microCi of removable contamination. The source was decontaminated to between 0.001 - 0.0025 microCi level on smears, and placed into a stainless steel pipe and sealed with caps. This will remain in storage at their facility until disposed of in a proper manner."

California reference number: 092209

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General Information or Other Event Number: 45381
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COLORADO STATE UNIVERSITY
Region: 4
City: FORT COLLINS State: CO
County:
License #: 002-19
Agreement: Y
Docket:
NRC Notified By: JAMES JARVIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/24/2009
Notification Time: 17:46 [ET]
Event Date: 08/31/2009
Event Time: [MDT]
Last Update Date: 09/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
LANCE ENGLISH (EMAIL (ILTA)
KEVIN HSUEH (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL

The following report was received from the state via facsimile:

"On September 21, 2009 the Radiation Safety Officer for a Colorado Licensee - Colorado State University (CSU), provided verbal notification of a past error in its inventory of unsealed radioactive materials used in one of its laboratories on campus. The specific laboratory had been using unsealed radioactive materials since the 1980's and accumulated numerous containers of improperly characterized and labeled waste materials. The licensee followed up the verbal report with a written report dated September 18, 2009 that was received via fax by the Colorado Department of Public Health and Environment on September 22, 2009. Colorado State University is a broad scope non-human use research licensee and has approximately 150 labs using unsealed radioactive materials. The reported inventory discrepancy applies to only one of these labs.

"In accordance with Section 4.51.1.2 (equivalent to 10 CFR 20.2201) of the Colorado Rules and Regulations Pertaining to Radiation Control, within 30 days the licensee is required to report to the Colorado Department of Public and Health and Environment (CDPHE) any lost, stolen, or missing radioactive materials exceeding 10 times the Appendix 4C (equivalent to 10 CFR Part 20 Appendix C) quantities.

"Following completion of an in-depth, multi-year radioactive materials inventory review that was first initiated in 1997, re-established in 2004, and ultimately concluded in August 2009, CSU reported an inventory discrepancy of radioactive materials in one of its laboratories. The inventory review consisted of evaluation of thousands of records, and collection and analysis of greater than 1000 samples from greater than 700 vials, test tubes, and bottles of unknown substances potentially containing radioactive materials that had accumulated over many years in the specific laboratory. Upon completion of the data and inventory review in August 2009, the licensee reported that it could not account for approximately 24 milliCi of H3 (tritium), based upon an accounting evaluation of incoming radioactive materials and outgoing radioactive materials (disposal records). The licensee however, believes that the radioactive material was in fact disposed of properly with other waste materials, but cannot necessarily provide the records to demonstrate this. The licensee has stated that they do not believe the radioactive materials have been stolen, but rather the discrepancy is attributed to poor inventory and waste disposal records by the laboratory personnel over many years and personnel changes."

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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Power Reactor Event Number: 45386
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOSHUA SISAK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/28/2009
Notification Time: 15:55 [ET]
Event Date: 09/28/2009
Event Time: 07:54 [EDT]
Last Update Date: 09/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARIE MILLER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text

PLANT PROCESS COMPUTER OUTAGE RESULTING IN A LOSS OF ERDS AND SPDS

"At 07:54 hours EDT, on September 28, 2009, the Plant Process Computer (PPC) was removed from service to replace the Intelligent Remote Control Units (IRCUs). The expected duration of PPC inoperability is approximately 16 to 24 hours. The PPC provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS) and Safety Parameter Display System (SPDS). The loss of PPC requires alternate methods, as described in plant procedures, to be used for the above described functions. Therefore, appropriate assessment of plant conditions, notifications and communications can still be made, if required, during the time that the PPC is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii) which is any event that results in a major loss of emergency assessment capability, offsite response capability or offsite communications capability. As previously stated, alternate means remain available to assess plant conditions, make notifications and accomplish required communications, as necessary. An additional notification will be provided when the PPC operability is restored."

The licensee notified the NRC Resident inspector.

* * * UPDATE AT 2309 ON 9/28/2009 FROM JOSHUA SISAK TO MARK ABRAMOVITZ * * *

"At 2255 hours EDT on Sept 28, 2009, the Plant Process Computer was restored to service. Emergency Response Data System (ERDS) and Safety Parameter Display System (SPDS) were returned to service. All offsite communication capabilities and all emergency assessment capabilities have been restored."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Miller).

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