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Event Notification Report for April 7, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/06/2011 - 04/07/2011

** EVENT NUMBERS **


46225 46718 46719 46725 46731 46735

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Non-Agreement State Event Number: 46225
Rep Org: IDAHO STATE UNIVERSITY
Licensee: IDAHO STATE UNIVERSITY
Region: 4
City: POCATELLO State: ID
County:
License #: 1127380-01
Agreement: N
Docket:
NRC Notified By: RICHARD BREY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/02/2010
Notification Time: 15:45 [ET]
Event Date: 09/02/2010
Event Time: [MDT]
Last Update Date: 04/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)
DARYL JOHNSON (ILTA)
CANADA (FAX)

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

Event Text

MISPLACED BUTTON SOURCES

On 9/2/2010, the licensee concluded that they were unable to account for two (2) Pu-239 solid sources that are about the size of a quarter each. Each source is estimated to weight about 1 gm with a source strength of 60 milliCuries and is in a non-dispersible form. The licensee noted that these sources were missing as a result of a normal inventory and leak test procedure on 8/19/10. Since that time the licensee has conducted an intensive search for the material both visually and using detection instrumentation but was unable to locate the material.

The licensee discovered that the lost sources were last checked out of their storage location as part of a group of 10 such sources in April 2010. In July 2010 records indicate that only 8 of 10 sources were checked out since only 8 were available at the time.

The licensee has restricted access to the sources and implemented additional controls for being able to check out the sources that include using a two man rule.

* * * UPDATE AT 1727 EST ON 2/11/11 FROM BREY TO HUFFMAN * * *

As of 2/11/11 at approximately 1710 EST, the licensee has formally declared the two plutonium button sources lost. The licensee stated that following extensive searching the sources are considered lost. The licensee notes that it has been in contact with responsible staff at NRC Region 4 and that the NRC had sent inspectors to the facility on October 4 and October 18, 2010. The licensee will continue to stress an awareness of the missing sources to personnel and emphasize continued vigilance for finding the sources. The licensee has not reached any conclusion as to what happened to the lost sources.

R4DO (Clark), FSME (McConnell), and ILTAB (Hahn) notified.

* * * UPDATE FROM RICHARD BREY TO JOE O'HARA AT 1705 EDT ON 4/6/11 * * *

The two missing plutonium sources have been found inside a source vault mixed in with other radioactive materials in storage for decay purposes.

Notified R4DO(O'Keefe), FSME(Michalak), and ILTAB(Johnson).

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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Agreement State Event Number: 46718
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK-001-02110
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/01/2011
Notification Time: 16:03 [ET]
Event Date: 03/16/2011
Event Time: [CDT]
Last Update Date: 04/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE

The following was received from the State of Arkansas via email:

"On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient.

"The facility has contacted the manufacturer of the administration device.

"On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event.

"Conditions requiring reporting of this event:

"The dose differs from the prescribed dose by more than 50 rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy.

"Arkansas Event Number: 03-11-03"

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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Agreement State Event Number: 46719
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 33136
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/01/2011
Notification Time: 16:24 [ET]
Event Date: 04/01/2011
Event Time: [EDT]
Last Update Date: 04/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - I-131 ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE

The following was received from the State of Florida via email:

"A patient was scheduled to receive a 150 mCi dose of I-131 for thyroid cancer therapy treatment on 3/31/11. The dose was two 75 mCi capsules. Only one pill was taken. The other pill was discovered sticking on the bottom of the vial on 4/1/11 (capsules are sticky and the label around the vial prevented direct observation of the capsule from the side). Patient was under dosed by 50%. The tech failed to ensure that both pills were taken. The physician has been notified and he will notify the patient. The patient will be redosed to bring the dose up to prescription. The dosing procedure will be changed to require the tech to verify that the vial is empty. Licensee will submit a written report. Any further action on this incident is referred to Radioactive Materials. This office will take no further action on this incident."

Florida Incident Number: FL 11-028

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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Fuel Cycle Facility Event Number: 46725
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: BARRY COLE
HQ OPS Officer: PETE SNYDER
Notification Date: 04/05/2011
Notification Time: 12:01 [ET]
Event Date: 04/05/2011
Event Time: 11:49 [EDT]
Last Update Date: 04/05/2011
Emergency Class: ALERT
10 CFR Section:
70.32(i) - EMERGENCY DECLARED
Person (Organization):
MARVIN SYKES (R2DO)
ABY MOHSENI (NMSS)
VICTOR MCCREE (R2)
LAWRENCE KOKAJKO (NMSS)
VONNA ORDAZ (NMSS)
WILLIAM GOTT (IRM)
TAB BEACH (DHS)
ERWIN CASTO (FEMA)
NICK THREAT (EPA()
STU BAILEY (DOE)

Event Text

ALERT DECLARED DUE TO ACID LEAK GREATER THAN THE 40 CFR LIMIT

The licensee secured their process after an acid leak greater that the 40 CFR limit developed at a piping joint. The leak consisted of a mixture of hydrofluoric and nitric acid. A licensee response team was dispatched to the site of the leak to evaluate the condition.

No injuries resulted and there were no evacuations nor health and safety consequences at the site.

Additionally notified USDA (R. Jones), HHS (J. Dennis) and Fuels OUO Group.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM DONNA MILLER TO PETE SNYDER AT 1241 EDT ON 4/5/11 * * *

The licensee exited the emergency condition at 1237 EDT on 4/5/11. The spill is contained and no longer poses any threat to employees or the environment.

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Power Reactor Event Number: 46731
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES SHAW
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/06/2011
Notification Time: 02:44 [ET]
Event Date: 04/06/2011
Event Time: 04:00 [EDT]
Last Update Date: 04/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT DALEY (R3DO)

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

TECHNICAL SUPPORT CENTER VENTILATION SYSTEM OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"At 0400 EDT on Wednesday, April 6, 2011, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems will be removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance is scheduled to be completed by 1600 EDT on Wednesday, April 6, 2011.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DEAN BRUCK TO DONG PARK ON 4/6/11 AT 1514 EDT * * *

"The TSC ventilation system maintenance was completed satisfactorily and the system was restored to service at 1455 EDT."

Notified R3DO (Daley).

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Power Reactor Event Number: 46735
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MIKE SLABY
HQ OPS Officer: PETE SNYDER
Notification Date: 04/06/2011
Notification Time: 21:20 [ET]
Event Date: 04/06/2011
Event Time: 15:30 [EDT]
Last Update Date: 04/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JOHN CARUSO (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

Event Text

DEGRADED FIRE BARRIER

"During walk downs for a planned site modification on April 6, 2011 at 1530 EDT, two degraded fire barrier seals were identified in the wall between the Auxiliary Building Basement and the Charging Pump Room. The wall is listed as an Appendix R wall between Fire Area (FA) ABBM and FA CHG. The wall separates redundant safe shutdown equipment.

"Two cylindrical six inch penetrations through the wall did not contain the required material to conform to a 3-hour fire rated barrier. This has been identified as a missing fire barrier such that the required degree of separation for redundant safe shutdown trains is lacking.

"A fire watch was established as a compensatory measure on 4/6/11. The discovery of this non-compliance is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified of this event."

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