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Event Notification Report for March 4, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/03/2010 - 03/04/2010

** EVENT NUMBERS **


45681 45725 45727 45733 45736 45743

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General Information or Other Event Number: 45681
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: GEORGIA PACIFIC TOLEDO
Region: 4
City: TOLEDO State: OR
County:
License #: ORE-90708
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/04/2010
Notification Time: 18:30 [ET]
Event Date: 02/04/2010
Event Time: 14:20 [PST]
Last Update Date: 03/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT - FAULTY SHUTTER ON FIXED GUAGE

Licensee, Georgia Pacific Toledo, notified the Agency [Oregon Department of Health and Radiation Protection] that the 6 month inspection on their K-Ray fixed gauge (model 7062B) revealed the shutter would not close correctly. The gauge was still able to perform it's function as a level indicator on a coal bin. Licensee called the manufacturer for repairs. Source is 50 mCi of Cs-137.

Incident Report # 10-0005

* * * UPDATE FROM DARYL LEON TO VINCE KLCO ON 3/3/10 AT 1154 EST* * *

On February 10, 2010 the licensee's RSO (Radiation Safety Officer) and the vendor technician verified the fixed gauge shutter functioned correctly. It was observed that the time constant on the detector was quite long. The RSO and the vendor determined that the initial report of a shutter malfunction was in error because personnel did not wait long enough to see the result of closing the shutter on the control system.

The licensee will add a note to the inventory form for this source as to the name of the control tag for the detector in order to verify the closed/open shutter transition and to see an adequate response.

No other action is required on this incident and the State of Oregon recommends that that the incident be closed.

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

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General Information or Other Event Number: 45725
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS SAN ANTONIO
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 05217
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 02/25/2010
Notification Time: 14:13 [ET]
Event Date: 01/26/2010
Event Time: [CST]
Last Update Date: 02/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL SHALLOW DOSE EQUIVALENT OVEREXPOSURE

"On 1/26/10, the Agency [State of Texas] received a report from the licensee's Radiation Safety Officer stating they had received a report from their dosimetry processor indicating one of their workers had received 230 rem to the badge worn on his left hand. The right hand badge read 1.420 rem for the same period. The RSO stated that the individual involved handled predominantly Fluorine (F)-18. His deep dose equivalent (DDE) for the same period was 439 millirem. The RSO stated that the typical exposure to the hands is between 500 and 1,200 millirem and that the DDE was about 250 millirem per exposure period. The RSO believed the exposure was to his badge only. The RSO stated that on December 23, 2009, the individual was involved in a spill of F-18 and his badge may have become contaminated causing the exposure. The RSO stated that he was waiting on a statement from the individual involved.

"On February 25, 2010, the Agency received a written report of the event from the licensee. A review of the report indicated that the information provided did not appear to substantiate the conclusion made by the licensee that this was a badge only event. The Agency's position is that the actual shallow dose equivalent (SDE) is currently unknown, and may have exceeded the limit. The Agency has begun their investigation. Additional information will be provided as obtained."

Texas Incident Number I-8707

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General Information or Other Event Number: 45727
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 02/25/2010
Notification Time: 18:54 [ET]
Event Date: 01/21/2010
Event Time: [EST]
Last Update Date: 02/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY IMPLANTS OUTSIDE OF THE INTENDED TREATMENT AREA

The following information was received via fax:

"Notifications: The licensee called the PaDEP Southeast Regional Office on the morning of February 25, 2010 to provide a 24-hour verbal notice of a possible Medical Event. The SERO and Central Office discussed the known facts around noon time, and understood the U Penn RSO would be providing more information via email. DEP also provided a verbal notice to NRC Region 1 regarding this possible ME on 2-25-2010.

"On January 21, 2010 a patient was treated by brachytherapy for prostate cancer with sixty five (65) iodine-125 (I-125) seeds. The I-125 seeds were implanted using real time dosimetry under ultrasonic guidance. The written directive called for a therapeutic radiation dose of 145 gray (Gy) [14,500 rad] to the prostate volume, plus 5 millimeters of margin, using interoperative planning. On February 23, 2010, the patient returned for a 30 day post-implant CT. The scan showed that the implanted seeds were "in an appropriate pattern," but outside the intended target. On February 24th the licensee's Radiation Oncology group determined that an additional quality assurance review was warranted, but the RSO should notify PaDEP/BRP [Pennsylvania Department of Environmental Protection/Bureau of Radiation Protection] regarding the case. Based on the information known at this time, PaDEP/BRP believes this ME is reportable under 10CFR35.3045, and may be an Abnormal Occurrence (AO). The state will perform a reactive inspection next week, and coordinate with NRC Region I; because of their ongoing evaluation of pre-April 2008 brachytherapy implants at U Penn, and at the Philadelphia VA hospital.

"Cause of the event: A new ultrasound unit that was used to place the I-125 seeds may have been malfunctioning.

"Actions: There is a reactive inspection scheduled to investigate this apparent ME at U Penn on March 2, 2010. PaDEP/BRP will also ask U Penn to evaluate the need for FDA notification regarding the ultrasound unit."


Event Report ID Number: PA100002

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: 45733
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: ACUREN INSPECTIONS
Region: 4
City: DORCHESTER State: NE
County:
License #: KS RECIPROSIT
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/27/2010
Notification Time: 13:46 [ET]
Event Date: 02/26/2010
Event Time: 18:40 [CST]
Last Update Date: 02/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LYDIA CHANG (FSME)
RYAN LANTZ (R4DO)

Event Text

AGREEMENT STATE - POTENTIAL OVEREXPOSURE DURING RADIOGRAPHY

A representative of the State of Nebraska has received preliminary information about a radiography incident that may have resulted in overexposures. The incident occurred during radiography of elevated piping at a pumping station. The radiographer and a contactor operating an aerial lift bucket had just completed a radiography shot on some overhead piping. The assistant radiographer was in a different location and had supposedly retracted the source into its safe position. Because the radiographer had his alarming rate meter under his clothing, and because there was significant ambient noise in the work area, the radiographer did not immediately hear that his rate meter was alarming as he and the aerial lift operator approached the radiography camera guide tube to set up for the next shot. When the radiographer heard the alarm, he checked his pocket dosimeter and found it off-scale. The radiographer had the assistant re-perform the source retraction and was subsequently able to confirm that the source was now fully retracted into the camera's safe position.

Based on initial estimates by the radiographer, his worst case exposure could be as high as 7.1 REM. The best case scenario would put his exposure around 200 mREM. The aerial lift operator, who is not a radiation worker, is believed to have exposures less than the radiographer. The radiographer's TLD has been sent for immediate processing by Landauer.

The State should have an inspector at the site on 2/28/10. This report will be updated and more details provided after the State completes its initial inspection.

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General Information or Other Event Number: 45736
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: DAKOTA GASIFICATION COMPANY
Region: 4
City: BEULAH State: ND
County:
License #: 33-15327-01
Agreement: Y
Docket:
NRC Notified By: LOUISE ROEHRICH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/01/2010
Notification Time: 11:48 [ET]
Event Date: 02/16/2010
Event Time: [MST]
Last Update Date: 03/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER FOUND STUCK CLOSED ON PROCESS GAUGE

During the semi-annual inspection of the gasification facility's process gauges, a gauge was found with its shutter stuck closed. The gauge had not been used since the last licensee inspection so there would have been no indication from operation of the facility that there was a problem. The gauge was a Berthold Model P-2608-100 containing a 5 millicurie Co-60 source. The licensee has determined that the gauge is not really needed to support the process and has contacted Berthold to come to the facility and remove the gauge and take possession of it. The licensee has inactivated the gauge and, with the shutter stuck closed, considers that there is no risk to personnel.

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Other Nuclear Material Event Number: 45743
Rep Org: ARCELORMITTAL
Licensee: ARCELORMITTAL
Region: 3
City: EAST CHICAGO State: IN
County: LAKE
License #: 13-03086-03
Agreement: N
Docket:
NRC Notified By: RYAN HILL
HQ OPS Officer: VINCE KLCO
Notification Date: 03/03/2010
Notification Time: 17:30 [ET]
Event Date: 12/07/2009
Event Time: [EST]
Last Update Date: 03/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN GIESSNER (R3DO)
MARK DELLIGATTI (FSME)

Event Text

UNABLE TO FULLY CLOSE A FIXED GAUGE SHUTTER

During operation, the shutter for a fixed gauge had a build up of dust. When the shutter failed to close completely, the licensee called the manufacturer for repairs. After cleaning of the fixed gauge, the shutter closed satisfactorily. The fixed gauge is a K-Ray, model number 7064P, serial number 8318 with a Cs-137, 5 Curie source.

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