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Event Notification Report for March 24, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2010 - 03/24/2010

** EVENT NUMBERS **


45695 45777 45778 45781 45784 45785 45786

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General Information or Other Event Number: 45695
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOE O'HARA
Notification Date: 02/12/2010
Notification Time: 10:45 [ET]
Event Date: 02/10/2010
Event Time: [EST]
Last Update Date: 03/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT DUE TO UNDERDOSE GREATER THAN 50%

The following was received from the Commonwealth of Massachusetts via e-mail:

"On 2/12/10, licensee reported to this Agency [Commonwealth of Massachusetts] the 2/11/10 discovery of a medical event that occurred on 2/10/10. The situation [was] described as two treatment fraction underdoses, delivered on the same day to the same patient, that differed from the prescribed dose, per fraction, by more than 50%. Initial indication [is] that [the] event was caused by [an] equipment software bug. Two fractions of 0.4 Gy were delivered on the first day of treatment. The prescription was for two treatments of 4 Gy per fraction per day for two days and one final 4 Gy treatment on the third day. [The] prescribing physician and equipment manufacturer [were] notified. This is a preliminary report; investigation [is] ongoing; more information to follow.

"The Agency considers this event OPEN and ONGOING."

* * * UPDATE FROM TONY CARPENITO TO JOE O'HARA VIA E-MAIL AT 1007 ON 2/17/10 * * *

"[The] equipment manufacturer found the software issue to be 'reproducible' and therefore may be classified as a 'potential' (patient) safety issue.

"[The] suspect portion of software will not be used again until [the] program [is] debugged and documented to be correct. [The] suspect portion of the software had not been used in the past by the licensee; no previous patients were affected."

The device has been identified as a Nucletron HDR V3, and the software program is named Oncentra.

Event docket #02-8893.

Notified R1DO(T. Jackson) and FSME EO(McIntosh)

* * * UPDATE FROM TONY CARPENITO TO HUFFMAN VIA E-MAIL AT 1448 ON 3/23/10 * * *

"The equipment manufacturer published a customer information bulletin describing the problem. The licensee submitted a formal follow-up report to this Agency [Commonwealth of Massachusetts] on 2/25/10. The licensee wrote that since the underdose could be made up there will be no effect on the treatment outcome. There is no radiation morbidity. Patient underdose on 2/10/10 was 90%. The Agency considers this matter to be closed."

Notified R1DO(Caruso) and FSME EO(Kock).

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: 45777
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: NUCOR-YAMATO STEEL
Region: 4
City: BLYTHEVILLE State: AR
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: KAYLA AVERY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/19/2010
Notification Time: 12:26 [ET]
Event Date: 03/17/2010
Event Time: [CDT]
Last Update Date: 03/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - DISCOVERY OF A SEALED SOURCE IN A LOAD OF SCRAP METAL

The following information was received via E-mail:

"The following are the findings of the Arkansas Department of Health, Radioactive Materials Program, concerning Event Number 03-10-01 involving an unknown radioactive source at Nucor-Yamato Steel in Blytheville, Arkansas. The Department was contacted on March 17, 2010 indicating that a sealed source had been discovered in a load of scrap metal. The isotope/activity of the sealed source is unknown at this time. It was also stated that survey readings were 50 mR/hr. Health Physicists from the Arkansas Department of Health went to Nucor-Yamato Steel. [Upon discovery], the cylinder-shaped source had been placed in a metal bucket and then put in a 55 gallon metal drum. Readings inside the barrel with the survey meter probe close to the source, the actual readings were 100-140 mR/hr. After all the shielding was in place, a survey was taken with the highest reading being 0.7 mR/hr at the surface of the drum, and the T.I. index [transport index] was 0.2 mR/hr. The drum containing the source was secured in the back of the state vehicle and transported to the Arkansas Department of Health, Radiation Control in Little Rock, Arkansas.

"The source is awaiting pickup by American Radiation Services for transport to their storage location in New Orleans, Louisiana. Further information and identification of the isotope and activity are pending the report from the vendor.

"The State of Louisiana has been notified."

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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: 45778
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: STRUCTURAL METALS, INC.
Region: 4
City: SEGUIN State: TX
County:
License #: LO-2188
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/19/2010
Notification Time: 12:50 [ET]
Event Date: 03/19/2010
Event Time: [CDT]
Last Update Date: 03/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED PROCESS GAUGE

The following information was received via E-mail:

"On March 19, 2010, at 1130 hours, the Agency [Texas Department of State Health Services] received a telephone call from the licensee [Structural Metals, Inc. DBA: CMC Steel Texas] stating that the shutter on one of their gauges was stuck. The gauge houses a Cobalt (Co)-60 source. The shutter stuck in the open position, [which is] the normal operating position. Dose rates taken in the area were normal, and the licensee has contacted a repair company to have the shutter fixed sometime next week. The licensee will not be using the gauge until it is fixed, and has agreed to update the Agency as information is received.

"Texas Incident #: I-8725"

* * * UPDATE ON 3/22/10 AT 1442 FROM TEXAS (ROBERT FREE) TO HUFFMAN * * *

The following information was received from the State of Texas via e-mail:

"A Co-60 gauge [was reported by the licensee to have been] damaged by molten steel during a pouring operation. The area was secured from personnel entry until the licensee authorized to conduct recovery operations arrives on site today to begin recovery operation. No model or serial number is available at this time. [The Texas Dept. of Health Radiation Branch] will provide an update as more complete information is available."

* * * UPDATE ON 3/22/10 AT 1744 FROM TEXAS (ROBERT FREE) TO HUFFMAN * * *

The following information was received from the State of Texas via e-mail:

"The event description should indicate that there was molten metal splashed or poured over the gauge. The gauge shutter mechanism remained open. The company, Structural Metals (CMC), did not know the status of the gauge until today. The gauge was recovered by a licensed contractor and the shielding was found to be intact. The only damage to the gauge was the mechanism used to open and close the shutter. The gauge will be repaired or replaced."

R4DO (Deese) and FSME EO (Luehman) notified.

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General Information or Other Event Number: 45781
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROTECHNICS
Region: 4
City: ALICE State: TX
County: JIM WELLS
License #: 03835
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 03/20/2010
Notification Time: 01:35 [ET]
Event Date: 03/19/2010
Event Time: 23:20 [CDT]
Last Update Date: 03/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
JIM LUEHMAN (FSME)
LANCE ENGLISH (ILTA)
MEXICO VIA FAX ()

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

Event Text

AGREEMENT STATE REPORT - THEFT OF LICENSED MATERIALS

The following information was received by e-mail:

"On March 19, 2010 at 2350 hours, the Agency [Texas Department of State Health Services-Radiation Branch] was notified by the licensee's Radiation Safety Officer (RSO) that 120 milliCuries of Iridium (Ir)-192 was stolen from one of their trucks parked at a Wal-Mart parking lot in Alice, Texas at about 2320 hours. The Ir-192 was contained in six, 20 milliliter vials each containing 20 millicuries (15 grams) of Ir-192 in the form of zero wash [isotope tracer]. Each vial was placed into a labeled lead pig and each pig was then shrink wrapped. The six pigs were then placed into a zip lock bag. The zip lock bag was placed into a tool box in the back of the pick up truck. The licensee stated that the employee had stopped at the Wal-Mart on their way to a job site in south Texas. The RSO stated that the tool box was not locked and other items were stolen from the tool box. The tool box did not have any labeling on it. The RSO stated that the employee did not perform a radiation survey of the pigs, but he estimated the dose rate to be about 100 millirem per hour on the outside of the tool box. Local law enforcement was notified of the theft. Additional information will be provided as it is received."

Texas Incident Number: I-8730

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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: 45784
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: BRADFORD ROBINSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/22/2010
Notification Time: 22:05 [ET]
Event Date: 03/22/2010
Event Time: 18:11 [MST]
Last Update Date: 03/23/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
RICK DEESE (R4DO)
ELMO COLLINS (R4)
RYAN LANTZ (R4)
BRIAN McDERMOTT (IRD)
ERIC LEEDS (NRR)
FREDERICK BROWN (NRR)
MARY ANN DOYLE (DHS)
GENE CANUPP (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO UNIDENTIFIED LEAKAGE GREATER THAN 10 GPM

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirement of 10CFR50.73.

"On March 22, 2010 at approximately 1756 MST, Palo Verde Nuclear Generating Station (PVNGS) Unit 1 identified a rising level and temperature trend in the Reactor Drain Tank (RDT). PVNGS Unit 1 was in Mode 1 (Power Operation) at 93% power with normal RCS temperature and pressure at the time of discovery. Containment temperature and humidity trends are normal. Technical Specification Limiting Condition for Operation 3.4.14 (RCS Operational Leakage), Condition 'A' was entered at 1811 due to unidentified leakage >10 gpm and the LCO allows 4 hours to restore leakage to <1 gpm. Also at 1811, a Notification of Unusual Event (NOUE) was declared due to unidentified leakage >10 gpm (MU5.1). PVNGS Unit 1 remains at power with all normal systems in operation; periodic pumping of the RDT is occurring.

"No automatic or manual reactor protection system or engineered safety features actuations occurred and none were required. There were no other component failures, testing or work in progress that contributed to the leak. The leak is located within the containment building, therefore there is no release of radioactivity to the environment and no impact to the health and safety of the public. There is no elevated RCS activity and heat removal is via normal steaming to the main turbine condenser. The electric grid is stable.

"Current plans are to enter containment and identify the source of leakage. State and Local authorities have been notified. The NRC Senior Resident Inspector has been notified."

The licensee notified the following state and local agencies: Maricopa County Sheriff, Arizona Department of Public Safety, Buckeye Police Department, Arizona Radiation Regulatory Agency, Arizona Division of Emergency Management, and the Maricopa County Emergency Management Agency.

* * * UPDATE FROM BRAD ROBINSON TO DONG PARK AT 0028 EDT ON 3/23/2010 * * *

At 2112 MST, the shift manager advised that the Pressurizer Main Spray Valve, 100E, packing leakage has been manually isolated. As of 2125 MST, the level trend in the RDT has stabilized. The licensee is working to verify the leakage rate, and remains in an Unusual Event. The plant remains stable in Mode 1 at 93% power.

The licensee has notified the NRC Resident Inspector, and the NRC Resident Inspector remains on site.

* * * UPDATE FROM BRAD ROBINSON TO DONG PARK AT 0121 EDT ON 3/23/2010 * * *

At 2146 MST, the licensee exited Technical Specification Limiting Condition for Operation 3.4.14, RCS Operational Leakage. At 2219 MST, the Unusual Event was terminated.

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Deese), NRR EO (Brown), IRD (McDermott), DHS (Moore), and FEMA (Canupp).

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Fuel Cycle Facility Event Number: 45785
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/23/2010
Notification Time: 09:20 [ET]
Event Date: 03/22/2010
Event Time: 09:30 [EDT]
Last Update Date: 03/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
70.74 APP. A - ADDITIONAL REPORTING REQUIREMENTS
Person (Organization):
MARK FRANKE (R2DO)
RAYMOND LORSON (NMSS)

Event Text

LOSS OF ONE OF TWO REQUIRED CONTINGENCY CONTROLS

"At approximately 0930 [EDT] on Monday, March 22nd, an operator noticed that a waste collection bag in the dry conversion area had torn away from its receptacle as it is designed to do when the mass of waste exceeds the specified threshold. The operator lifted the bag up and found it to be heavier than normal. The operator then transferred the bag to the decontamination area to sort through the contents and determine what had been placed in the bag per procedure. During the sorting process, the operator found two vacuum cleaner bags that contained uranium. Upon discovery of the vacuum bags, the operator promptly notified Nuclear Safety staff, who further notified Operations Management and the EHS Manager. Upon investigation it was determined that 8.7 kg of UO2 was present in the two vacuum bags, which is less than the criticality safety limit of 25kg UO2 specified in the Criticality Safety Analysis. As a result, no unsafe condition existed.

"Since uranium was placed directly into the waste collection receptacle, one of the administrative requirements for double contingency was violated. The second control functioned as designed and the mass of uranium within the waste collection receptacle was controlled to less than the safe mass limit. Therefore, this event resulted in a failure of an administrative requirement necessary to meet double contingency and is being reported per internal procedural requirements.

"As an immediate corrective action, the material was transferred into a favorable geometry 3-gallon can per procedure. In addition, a stand down of DCP operations was promptly performed to inform operators of the issue and retrain on the waste collection control requirements. All subsequent shifts have been briefed of the issue and retrained on the control requirements prior to returning to work.

"The double contingency controls required include (1) only contaminated items may be placed in a waste container. No uranium or containers with unknown uranium contents are allowed in the waste collection containers and (2) waste bags are designed to physically tear from their holders prior to accumulating greater than a safe mass in the bag. Material may not be placed in the bag after it has torn from the holder.

"Uranium was removed from the waste collection bag and placed into a 3-gallon can, which is a favorable geometry.

"Immediate corrective actions are complete. Investigation of the event and implementation of long term corrective actions are pending.

"At no time did an unsafe condition exist as the mass of uranium within the waste collection receptacle was less than the safe mass limit."

The licensee will notify NRC Region 2, and the North Carolina State Department of Radiation.

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Other Nuclear Material Event Number: 45786
Rep Org: WASHINGTON UNIVERSITY ST. LOUIS
Licensee: WASHINGTON UNIVERSITY ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUE LANGHORST
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/23/2010
Notification Time: 18:10 [ET]
Event Date: 02/04/2010
Event Time: [CDT]
Last Update Date: 03/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
LAURA KOZAK (R3DO)
ANDREA KOCK (FSME)

Event Text

EXTREMITY OVEREXPOSURE TO FINGERTIPS

The licensee's RSO reported that on March 9, 2010, a report was received from Landauer indicating that a technician that worked at the licensee's facility received a left hand ring dose of 11,900 millirem. The right hand ring dose was 4030 millirem. The licensee began an investigation into these readings and determined that the technician may have had a high extremity dose to the finger tips. After interviews with the technician and reconstruction of the event the licensee now believes that the technician may have received a dose between 50 rem and 400 rem over a 10 square-centimeter area of his fingertips as the result of improper handling of the radionuclide Bromine-76. The dose exposure to the fingertips was calculated using the Varskin computer code.

The technician was handling 32 millicurie vials of Bromine-76 between February 4 and February 5, 2010, related to research activities at Washington University. Normally, the vials would be handled with a long-handled tool with shielding. For reasons uncertain, the technician is believed to have directly handled the vials on several occasions. The technician has approximately six years of work-history with this type of activity.

The technician experienced no observable effects from the exposure. The technician has not worked with radioactive materials since mid-February. The Landauer whole-body deep dose badge reading for the period in question was 25 millirem.

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