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Event Notification Report for June 15, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/14/2010 - 06/15/2010

** EVENT NUMBERS **


45988 45991 45993 45995 45996 46001 46005 46006 46007

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General Information or Other Event Number: 45988
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ONCOLOGY HEMATOLOGY CONSULTANTS PA
Region: 4
City: FT. WORTH State: TX
County:
License #: TX-5919
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/08/2010
Notification Time: 17:15 [ET]
Event Date: 06/08/2010
Event Time: [CDT]
Last Update Date: 06/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - MEDICAL EVENT

On June 8, 2010, the State of Texas was notified by the licensee that during routine chart review, they determined that over a six month period, five patients received 30% to 50% less than prescribed dose. All the patients underwent High Dose Rate Brachytherapy using a Ir-192 Gammamed device. The licensee is still investigating an evaluating patient outcomes due to the under dosages. It is unknown whether the patients and their prescribing physicians were notified.

Texas Incident No.: I-8751

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: 45991
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: SULPHUR State: LA
County:
License #: L01774
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/09/2010
Notification Time: 12:26 [ET]
Event Date: 03/11/2010
Event Time: [CDT]
Last Update Date: 06/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILED TO RETRACT

"On June 9, 2010 the Incident Investigation Program was notified via email by the Nuclear Regulatory Commission that the licensee had experienced a failure to retract a radiography source that had occurred on March 11, 2010 somewhere in Texas. A radiography crew out of Sulphur, Louisiana was working in Beaumont, Texas, when the 96 Curie, Iridium 192 radiography source became stuck during the crew's 6th exposure (approximately 1250 Central Daylight Time). The two person radiography team then extended their barricade to about 350 feet from the source. The crew notified their sight representative, as well as the Site Radiation Safety Officer of the Sulphur, Louisiana office. While one of the radiographers verified the 2mR/hr boundary with a survey meter, the other stood behind a large pump at the plant and repeatedly tried to crank the source back into the camera. After approximately 7 minutes, the radiographer was able to return the source to the camera. The radiography crew verified the source local in the shielded position with their survey meter. According to the report submitted by the Louisiana Site RSO (LARSO), no members of the public or workers were overexposed. Later that same day, the LARSO met with the radiographers. The LARSO subsequently sent the radiographers' TLD badges to be read on Friday March 12, 2010. The results were returned on Monday, March 15, 2010. According to the report by the LARSO, it was determined that one of the radiographers received 55mR and the other 210 mR as a result of this event.

"On March 15, 2010 the crank out assembly was sent to the manufacturer (QSA Global) for inspection and repair. QSA determined that the bearing assembly in the pistol control crank had come apart. Part of the bearing assembly had worked its way into and lodged into the drive gear assembly. The piece of the bearing assembly then caused a tooth of the drive gear assembly to break off. The tooth was large enough to become jammed between the drive gear and the drive cable in the pistol control. This caused the pistol to malfunction. QSA repaired the assembly and all defective parts were replaced, and the assembly passed all tests.

"On June 9, 2010 the Texas Department of State Health Services contacted the Radiation Safety Officer (RSO) for the Texas licensee. The RSO stated that she would submit a report to the State of Texas as soon as possible."

Texas Incident Number I-8752.

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General Information or Other Event Number: 45993
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AMERICAN ENGINEERING LABORATORIES, INC.
Region: 4
City: WHITTIER State: CA
County:
License #: 5775-36
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/09/2010
Notification Time: 16:07 [ET]
Event Date: 06/09/2010
Event Time: [PDT]
Last Update Date: 06/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)
ILTAB VIA EMAIL ()
MEXICO VIA FAX ()

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

Event Text

CALIFORNIA AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE MISSING

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

"On June 8, 2010, [the licensee] contacted RHB-Brea [Radiation Health Branch] about a moisture density gauge (CPN MC-3 M39099120, 10 mCi Cs-137, 50 mCi Am:Be-241) that was missing from their facility since approximately June 3, 2010. The facility was searched with no sign of the missing gauge and all operators were questioned and were instructed to search their residences for the gauge. None of the individuals could find the gauge, none of them could recall using the gauge recently and could not recall if they may have used or misplaced the gauge. A review of the gauge log indicated that gauge had been logged incorrectly and that two individuals were logging in the same gauge at the same day and times, preventing a proper accounting of the whereabouts of their gauge. [The licensee] was notified that a police report must be filed, a reward offered, and a written report must be provided to RHB within 30 days.

"At this time, the incorrect use of the gauge in/out log is the only root cause identified though it appears that other factors are likely to also be a potential root cause of this incident. While the investigation is ongoing, the licensee will be cited for failing to maintain control of the gauge and failing to properly log the use of their gauges. Further citations will be deferred until the 30-day report has been received or further infractions have been identified by RHB during our investigation. Also, corrective actions will be verified from the 30-day report or from our investigation. "

California Report: 5010-060810

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

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General Information or Other Event Number: 45995
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: THE SHAW GROUP, INC.
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: CALIF 7704-30
Agreement: Y
Docket:
NRC Notified By: MARIO A. BETTOLO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/09/2010
Notification Time: 17:38 [ET]
Event Date: 05/20/2010
Event Time: [MDT]
Last Update Date: 06/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)

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

Event Text

UTAH AGREEMENT STATE REPORT - TWO MISSING TRITIUM EXIT SIGNS

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

"Two tritium exit signs were purchased and installed between March 2004 and October of 2005 by Shaw Environmental, Inc., as part of a contract with the United States Army Corp of Engineers [performing] renovation of military recruiting centers. Shaw is conducting an inventory of all tritium exit signs purchased and installed under this contract and identified that the listed signs are not located where installation records indicated that they were installed."

"Manufacturer: SRB Technologies, Inc.; Model: BetaLux-E, each contains 10 Ci of H-3, Serial Numbers 000102 ([previously located at] 175 S. Main St., Salt Lake City, UT) and C000108 ([previously located at] 545 E. 4500 St., Ste. E-125, Salt Lake City, UT)"

This is the third report of missing tritium exit signs discovered during Shaw Environmental, Inc.'s inventory effort. See EN #45972 and EN #45885.

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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General Information or Other Event Number: 45996
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: WALLA WALLA CLINIC
Region: 4
City: WALLA WALLA State: WA
County:
License #: MO23
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: PETE SNYDER
Notification Date: 06/09/2010
Notification Time: 18:36 [ET]
Event Date: 06/08/2010
Event Time: [PDT]
Last Update Date: 06/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - WRONG DOSE

The following information was received via e-mail:

"On June 8, 2010 at approximately 9:45 am, a patient scheduled for a 30 mCi TC-99m Myoview cardiac scan was mistakenly administered a 27.1 mCi Tc-99m Medronate bone dose. The mistake was discovered shortly after the administration of the dose when the technician noticed the name on the dose did not match that of the patient. The bone scan patient and cardiac patient had very similar sounding last names, which contributed to the error. The patient was notified of the error when he returned for his cardiac scan 45 minutes after injection. The actual bone scan patient was sent home without any scan and was not injected with any dose because they caught the error before he arrived for scanning."

Event No.: WA 100041

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Fuel Cycle Facility Event Number: 46001
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: CHERYL GOFF
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2010
Notification Time: 14:56 [ET]
Event Date: 06/11/2010
Event Time: 09:45 [EDT]
Last Update Date: 06/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
REBECCA NEASE (R2DO)
CHRISTOPHER REGAN (NMSS)
FUELS GROUP ()

Event Text

UNANALYZED ACCUMULATION OF MATERIAL IN THE URANIUM RECOVERY AREA

"Maintenance was being performed on a dissolver enclosure in the Uranium Recovery Facility. Part of the maintenance activities included the spraying of water on the interior surfaces of the enclosure to reduce contamination. A small quantity of this water leaked into an adjoining pass-through glove box, which also had loose contamination on its interior surfaces. As a result, approximately 1 liter of solution with a concentration of approximately 26 grams 235U per liter accumulated on the floor of the pass-through glove box. The amount of uranium mass within the accumulated solution was much less than the minimum amount required for criticality. There was no immediate risk or threat to the safety of workers or the public as a result of this event.

"An evaluation is currently being performed on this event.

"BWXT is making this 24 hour report in accordance with 10 CFR 70.61, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of [10 CFR] 70.61.

"The dissolver system is shutdown pending further investigation."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46005
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/13/2010
Notification Time: 15:00 [ET]
Event Date: 06/14/2010
Event Time: 03:00 [EDT]
Last Update Date: 06/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAMELA HENDERSON (R1DO)

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

PLANNED MAINTENANCE ON TSC EMERGENCY VENTILATION SYSTEM

"On June 14, 2010 at 0300 hours, Limerick Generating Station will apply a clearance to inspect and repair Fire Suppression Equipment associated with the Onsite Technical Support Center (TSC) Emergency Ventilation System and perform corrective maintenance associated with MD-1 (Outside Air Damper). During the time that the clearance is applied, the TSC Ventilation System will not be available to be restored in a time period required to staff and activate the TSC Emergency Response Organization. This work is expected to be completed on June 16, 2010.

"If an emergency is declared requiring TSC activation, the TSC will be staffed and activated using emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature. Radiological or other conditions. If relocation becomes necessary, the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable Site procedures.

"This notification is being made in accordance with 10CFR50.72(b}(3)(xiii) due to the Loss of an Emergency Response Facility (ERF) because of the Unavailability of the Emergency Ventilation System. The NRC Resident Inspector has been informed."

* * * UPDATE FROM BROILLET TO HUFFMAN AT 2206 EDT ON 6/14/10 * * *

The TSC Emergency Ventilation System was returned to service at 2150 EDT on 6/14/10. The licensee has informed the NRC Resident Inspector. R1DO (Holody) notified.

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Power Reactor Event Number: 46006
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LEE GRZECK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/14/2010
Notification Time: 16:07 [ET]
Event Date: 06/14/2010
Event Time: 13:05 [EDT]
Last Update Date: 06/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)

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 - NON-LICENSED CONTRACT SUPERVISOR

A non-licensed contract security supervisor tested positive for an illegal substance on a random fitness-for-duty test. The supervisor's access to the plant has been denied. A review of the individual's work history is being performed.

The NRC Senior Resident Inspector has been informed. Contact the HOO for additional details

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Other Nuclear Material Event Number: 46007
Rep Org: CARRO & CARRO ENTERPRISES INC.
Licensee: CARRO & CARRO ENTERPRISES INC.
Region: 1
City: CIALES State: PR
County:
License #: PR2005-02
Agreement: N
Docket:
NRC Notified By: JUAN CARRO
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/14/2010
Notification Time: 19:30 [ET]
Event Date: 06/10/2010
Event Time: 12:00 [EDT]
Last Update Date: 06/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DANIEL HOLODY (R1DO)
ANDREW MAUER (FSME)
ILTAB via email ()

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

Event Text

MISSING SEAMAN MOISTURE DENSITY GAUGE

Carro & Carro Enterprises Inc. reported that a Seaman Model C-300 Moisture Density Gauge containing a 4.5 mCi Radium-226 source was discovered missing from a temporary job location in San Juan, Puerto Rico on Thursday, June 10th. A search was conducted on Friday with negative results. A police report was filed on Monday, June 14th, and a reward offered in two local newspapers.

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

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