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Event Notification Report for June 16, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/15/2010 - 06/16/2010

** EVENT NUMBERS **


45949 45996 45999 46000 46001 46002 46008

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General Information or Other Event Number: 45949
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: WEATHERFORD INTERNATIONAL LIMITED
Region: 4
City: WILLISTON State: ND
County: WILLIAM
License #: 33-46901-01
Agreement: Y
Docket:
NRC Notified By: DAN HARMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 05/24/2010
Notification Time: 12:05 [ET]
Event Date: 05/21/2010
Event Time: 13:00 [MDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
ANGELA MCINTOSH (FSME)
CHUCK CAIN (R4)

Event Text

AGREEMENT STATE REPORT- CALIBRATION SOURCE NOT RETURNED TO ITS STORAGE HOLDER

The following information was received by e-mail:

"About 0930 Weatherford International, LTD. (ND Lic # 33-45901-01) reported that at about 1500, May 21, 2010, in Williston, Williams County, ND, a well logging tool was [returned to] the truck with the calibration source still in the tool. The calibration source is Cs-137, strength about 55.5 GBq. This error was discovered about 1500, May 21, 2010. The source, when in the tool is highly collimated, restricting significant potential dose to a limited volume. The dosimeter badges for those working in the vicinity of the truck and those in an adjacent office have been sent in to Landauer for analysis. Drawings and estimated doses will be forwarded to NRC as soon as received from Weatherford.

"ND Incident #: ND10003"

* * * UPDATE FROM NORTH DAKOTA (HARMAN) TO HUFFMAN (VIA E-MAIL) ON 6/15/10 * * *

The information below is a summary of a report provided from Weatherford to the State of North Dakota.

"On May 21, 2010, a 1.5 Ci [55.5 GBq] Cs-137 source was placed into a logging tool for calibrations. After calibrations were complete, the tool containing the source was placed into a logging truck and left for approximately 24 hours, potentially exposing two Well Logging Supervisors, one District Manager and one Well Logging Assistant.

"On May 22, 2010 at approximately 1400 (MDT), one of the Well Logging Supervisors, while trying to perform after [job] calibrations for the job which he had returned, noted high gamma ray background readings and, using a survey meter, began searching the area looking for a reason why the background readings were higher than normal. At approximately 1600 (MDT), he began searching the shop and noted that the readings as he approached logging truck were extremely high. He and the Well Logging Assistant removed the density logging tool from the wireline unit and found that the density source was still in the tool. At this point, the 1.5 Ci Cs-137 source had been in the tool loaded on logging truck for 24 hours.

"The facility employs twelve individuals, of which eight were not present at the facility during the period of 1600 on May 21, 2010 and 1600 May 22, 2010. On May 24, 2010, the dosimeters for the [two Well Logging Supervisors, the Well Logging Assistant,] one spare located in the office, one control and an employee's dosimeter, which was left on the desk, were sent to Landauer for analysis. It should be noted that one of the Well Logging Supervisors was not wearing his dosimeter during the incident.

"The incident was reconstructed and surveys were taken to aid in identifying the possibility of excess exposure to the District Manager and the Well Logging Supervisor that were not wearing dosimeters.

"The incident investigation uncovered many procedural issues including failure to document the removal of radioactive material (RAM) from storage (i.e., utilization records), failure to properly secure storage areas, failure to properly return RAM to storage and failure to establish a radiation area during calibration procedures. Because of not following proper procedures, [personnel actions were taken for one of the individuals involved]. [In addition], written corrective action has been given to one of the Well Logging Supervisors for not wearing a dosimeter while on duty and failure to notify management of an improperly secured storage area. All facility employees have been given a verbal corrective action on radiation procedures.

"Although there were many procedural violations, after analysis of the dosimeters and incident reconstruction surveys, Weatherford has no reason to believe an overexposure incident has taken place. "

Based on event reconstruction and available dosimeter readings, it is believed that none of the four employees exposed by this event received in excess of 18 mRem total effective dose equivalent.

R4DO (Powers) and FSME EO (Watson) notified.

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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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General Information or Other Event Number: 45999
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MEDICAL COLLEGE OF WISCONSIN
Region: 3
City:  State: WI
County:
License #: 079-1104-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: JOE O'HARA
Notification Date: 06/10/2010
Notification Time: 11:18 [ET]
Event Date: 06/10/2010
Event Time: [CDT]
Last Update Date: 06/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY DOSE RECEIVED WAS GREATER THAN 20% OF PRESCRIBED DOSE

The following was received from the State via fax:

"On June 9, 2010, the Radiation Safety Officer (RSO) reported that earlier that day a patient undergoing an intravascular brachytherapy procedure was administered a dose to the coronary artery exceeding the prescribed dose by more than 20%. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 18.4 Gy; the dose delivered was 23 Gy. The treatment device is a Novoste Beta-Cath intravascular brachytherapy device containing Sr-90. The overdose was identified during the post-planning for the procedure. The treatment time for this procedure is based on the measured diameter of the coronary artery. Depending on the diameter, one or three treatment times is selected; in this case the wrong treatment time was selected. The RSO stated that this treatment time is supposed to be independently reviewed and approved on the written directive, which is to be signed by the authorized user. The written directive was not signed by the authorized user prior to administration. [Wisconsin] DHS inspectors will investigate this medical event on June 11, 2010."

Event Report No.: WI100008

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: 46000
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NRG TEXAS POWER LLC
Region: 4
City: THOMPSON State: TX
County:
License #: L02063
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2010
Notification Time: 12:15 [ET]
Event Date: 06/10/2010
Event Time: [CDT]
Last Update Date: 06/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE MALFUNCTIONS

"On June 11, 2010 at 1100 Central Daylight Time, the Agency, [Texas Department of Health,] was notified by the licensee that the shutters on six gauges failed in the open position. Three of the gauges were manufactured by Berthold [Model 7400D] and each contained 30 millicuries of Cesium (Cs) - 137 (S/N's: 2423, 2425, 2426). The other three gauges were manufactured by Ohmart/VEGA [Model SHD] and each contained 150 millicuries of Cs-137 (S/N's: 74452, 74453, 73491). The licensee stated that dose rates taken in the area were normal, since the shutters failed in their normal operating positions. The licensee has contacted the manufacturer to schedule a repair of the gauges. The Agency reminded the licensee to request an exemption to continue to use the gauges while their shutters are awaiting repair so that that the licensee would not violate a condition of their license."

A contractor is making arrangements for the gauges to be repaired by their manufacturers.

Texas Incident No: I-8753

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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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General Information or Other Event Number: 46002
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TEAM INDUSTRIAL SERVICES INC.
Region: 4
City: HUTCHINSON State: KS
County:
License #: 21-B875
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2010
Notification Time: 17:21 [ET]
Event Date: 06/11/2010
Event Time: 16:00 [CDT]
Last Update Date: 06/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANDREW MAUER (FSME)
JULIO LARA (R3DO)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY CAMERA SOURCE

At approximately 1600 CDT local time, a Kansas Licensee, Team Industrial Services Inc., reported that they had a radiography camera source become stuck during source retraction. While they were retracting the source, the stand tipped and resulted in the guide tube being bent such that the source could not be fully retracted. The licensee was able to secure the area easily since the shot was being conducted in a vault. Personnel exited the area and the licensee contacted their corporate RSO in Hammond, Indiana. There is no concern by the licensee of any over-exposure.

The State, after talking with the licensee's corporate RSO, authorized recovery by a person on-site who is listed under the NRC license in Indiana.

The State is expediting reciprocity paperwork to recognize the source recovery.

Kansas # KS-100005.

* * * UPDATE FROM DAVE WHITFILL TO STEVE SANDIN AT 1848 EDT ON 6/11/10 * * *

At 1725 CDT the source was successfully retracted. Notified R4DO (Powers) and FSME (Mauer).

* * * UPDATE FROM DAVE WHITFILL TO BILL HUFFMAN AT 1716 EDT ON 6/14/10 * * *

The State of Kansas provided the following additional details on this event via facsimile:

"Equipment involved: QSA Global model 880D exposure device s/n D3027, Iridium 192 s/n 59219B, 26.6 curies, with associated equipment including drive mechanism, guide tube. And a tungsten collimator.

"Description of incident: At approximately 3:15 pm, the magnetic stand used during the exposure set up fell at the conclusion of a radiographic exposure and impacted the source guide tube causing it to crimp and preventing the source assembly from returning to the fully shielded position within the exposure device.

"Actions taken to resolve: The exposures were conducted within a shielded room thereby providing radiation attenuation and enhancing control of the area during incident remediation activities. There were no exposures to unmonitored persons or members of the general public. The Radiographer immediately contacted emergency response personnel within Team Industrial Services, Inc. including the Corporate Radiation Safety Officer. The CRSO performed a preliminary assessment of the event and contacted Kansas Department of Health and Environment. A retrieval plan was developed and discussed with on site personnel. The plan used involved the placement of additional shielding (including available steel and bags of welding flux) at the source location using an overhead crane. This reduced the radiation levels to the point that the radiographer could approach the location of the crimp and remove the crimp by applying pressure using large adjustable pliers (i.e. channel-lock type). He then retracted the source into the fully shielded position within the exposure device, surveyed, and locked the device. The exposure for the complete activity including the radiographic operations was 120 mrem for the radiographer and 75 mrem for the assistant radiographer as registered on their assigned direct reading dosimeters.

"Corrective Actions taken: The damaged guide tube was immediately removed from service. An inspection of the device and drive assembly, including the drive cable and source assembly, will be conducted to determine if any damage occurred before releasing for continued use. An investigation into the use of the magnetic stand will be conducted to try to determine the problems associated with the use of this type of source positioning device."

Notified R4DO (Powers), R3DO (Kunowski), and FSME (Mauer).

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General Information or Other Event Number: 46008
Rep Org: TENNESSEE VALLEY AUTHORITY
Licensee: TENNESSEE VALLEY AUTHORITY
Region: 1
City: KNOXVILLE State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN CASEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/15/2010
Notification Time: 09:44 [ET]
Event Date: 06/14/2010
Event Time: 11:18 [EDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)

Event Text

NON-LICENSED SUPERVISOR FITNESS FOR DUTY

A non-licensed employee supervisor had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to TVA nuclear plants has been terminated. Contact the Headquarters Operations Officer for additional details.

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