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Event Notification Report for November 8, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/07/2011 - 11/08/2011

** EVENT NUMBERS **


47396 47402 47405 47407 47408 47410 47411 47418

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Agreement State Event Number: 47396
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: UNKNOWN
Region: 1
City: UNKNOWN State: NY
County: UNKNOWN
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2011
Notification Time: 11:11 [ET]
Event Date: 10/13/2011
Event Time: 12:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received by facsimile:

"NYS Incident 935 - On 10/31/2011 a NY radioactive materials licensee reported a diagnostic misadministration which occurred on 10/13/2011 and discovered on 10/28/2011. A patient undergoing diagnostic imaging of the thyroid using Iodine-123 was administered 4.21 mCi instead of the intended 400 uCi. The estimated dose to the patient's thyroid is 58 rem.

"This is a preliminary 24 hour notification report.

"The facility is performing an investigation and root cause analysis.

"Telephone communications with the facility [and the State of New York] are ongoing.

"The facility is required to submit a written report within 15 days."

New York Event: NY-11-25

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: 47402
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ALL STAR METALS LLC
Region: 4
City: BROWNSVILLE State: TX
County:
License #: 02239
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/02/2011
Notification Time: 16:45 [ET]
Event Date: 11/01/2011
Event Time: [CDT]
Last Update Date: 11/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER STUCK CLOSED

The following information was received via fax:

"On November 2, 2011, the Agency [Texas Department of Health] was notified by a general licensee that the shutter on a NITON XLp818 nuclear gauge containing 30 milliCuries of americium (Am) - 241 used for metal analysis was stuck in the closed position. The gauge appeared to have suffered an impact locking the shutter closed. The screen displays this error. The licensee has sent gauge to the manufacturer for repairs. The serial number is #7625. There is no exposure since the shutter failed in the closed position. The investigation in to this incident is ongoing. Further details will be provided in accordance with SA 300."

Texas report: I-8896

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Agreement State Event Number: 47405
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: USX IRVIN
Region: 1
City: WEST MIFFLIN State: PA
County:
License #: PA-G0309
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/03/2011
Notification Time: 12:33 [ET]
Event Date: 11/02/2011
Event Time: 03:00 [EDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - THICKNESS GAUGE WARNING LIGHTS LOST POWER

The following was received from the Commonwealth of Pennsylvania via facsimile:

"A licensee's thickness gauge warning lights lost power. The problem was found to be in the wiring circuitry to the gauge. Repairs were made to wiring with the shutter remaining closed throughout the event. No radiation exposure to personnel ensued. The device is identified as: Manufacturer (AccuRay), Model (U-3), Serial # (771353031), isotope (Americium-241, Activity (1000 mCi).

"Repairs were made to the wiring. A 30-day licensee report is expected. The department plans to do a reactive inspection."

PA Event #: PA110034

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Agreement State Event Number: 47407
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CUMBERLAND COAL RESOURCES
Region: 1
City: WAYNESBURG State: PA
County:
License #: PA-G0153
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/03/2011
Notification Time: 14:24 [ET]
Event Date: 11/01/2011
Event Time: 15:00 [EDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SHUTTER ACTUATOR FAILED TO CLOSE SHUTTER

The following was received from the Commonwealth of Pennsylvania via facsimile:

"During the monthly shutter test, the licensee recognized the actuator that controls the shutter failed on both gauges. The handle that connects the actuator to the shutter snapped on both, rendering the shutter inoperable and in an open position, which is the normal operating position. A service provider was contacted to make necessary repairs. No exposure have been reported and none are expected. The device is identified as: Manufacturer (BSI Instruments), Model (7224), Serial # (ED355A), Isotope (Co-60), Activity (100 mCi), and Model (7440), Serial # (2498-11-87), Isotope (Cesium-137), Activity (20 mCi).

"A service provider has been contacted and they are planning on making repairs as soon as parts are available. A departmental reactive inspection is planned to investigate this event further."

PA Report #: PA110035

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Agreement State Event Number: 47408
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: LIXI, INC
Region: 3
City: HUNTLEY State: IL
County:
License #: IL-01339-01
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 14:29 [ET]
Event Date: 11/03/2011
Event Time: [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK VALOS (R3DO)
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - GADOLINIUM SOURCE LOST

The following report was received via e-mail:

"On November 3, 2011, at approximately 9:30AM, a 709.36 mCi Gadolinium-153 sealed source was discovered to be missing from the back of a LIXI, Inc. employee's RV in Phoenix, Arizona. The source was last seen on Monday, October 31st at approximately 8PM in Abilene, Texas.

"The investigation into this event is ongoing.

"The U.S. NRC, AZ governor's office, Texas, and Illinois have been notified."

Arizona Report: 11-012

* * * UPDATE ON 11/3/2011 AT 1541 FROM AUBREY GODWIN TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"At 11:45AM, the licensee was notified that the source was left at the PepsiCo in Abilene, Texas. The licensee is flying back to Texas to pick up the source at approximately 7:30PM tonight.

"The U.S. NRC, AZ Governor's Office, Texas, and Illinois have been notified."

Notified the R4DO (Gaddy) and FSME (Camper).

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: 47410
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EQUISTAR CHEMICAL LP
Region: 4
City: PASADENA State: TX
County:
License #: 01854
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 16:10 [ET]
Event Date: 11/02/2011
Event Time: [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER STUCK OPEN

The following was received via email:

"On November 3, 2011, the Agency [Texas Department of Health] was notified by the licensee that the shutter on an Ohmart Vega model SH-F1A containing 50 milliCuries of cesium - 137 failed to close during the required maintenance check done on November 2, 2011. The gauge shutter is stuck in the open position, which is the normal operating position for the gauge and does not pose an increased exposure risk to any individual. The licensee stated that the pin attaching the operating handle to the shutter operating arm was found broken. They had not determined when the pin was broken. On November 3, 2011, the license determined that they could not repair the gauge. The vessel the gauge is attached to is not accessed during system operation. The licensee stated that they were in the process of contacting the manufacturer for repairs or replacement of the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-8897

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Agreement State Event Number: 47411
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EQUISTAR CHEMICALS LP
Region: 4
City: PASADENA State: TX
County:
License #: 01854
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/03/2011
Notification Time: 16:23 [ET]
Event Date: 11/02/2011
Event Time: [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER STUCK OPEN

The following was received via email:

"On November 3, 2011, the agency [Texas Department of Health] was notified by the licensee that the shutter on an Ohmart Vega model SH-F2 containing 500 milliCurie of cesium-137 failed to close during the required maintenance check done on November 2, 2011. The gauge shutter is stuck in the open position, which is the normal operating position for the gauge and does not pose an increased exposure risk to any individual. The licensee stated that the pin attaching the operating handle to the shutter operating arm was found broken. They had not determined when the pin was broken. On November 3, 2011, the licensee determined that they could not repair the gauge. The reactor vessel the gauge is attached to is not accessed during system operation. The licensee stated that they were in the process of contacting the manufacturer for repairs or replacement of the gauge. Additional information will be provided as it is received in accordance with SA-300"

Texas Report: I-8898

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Non-Agreement State Event Number: 47418
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: KUPARUK OIL FIELD State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/06/2011
Notification Time: 13:04 [ET]
Event Date: 11/05/2011
Event Time: 22:00 [YST]
Last Update Date: 11/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

RADIOGRAPHY CAMERA SOURCE LOCK MALFUNCTION

A radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunction of the locking system on an INC IR-100 exposure device.

After completing radiography activities, the source was cranked in however, the source was still 1/4 to 1/2 inch from the fully retracted position. There were no abnormal readings observed and the key was turned to the locked position. The crew has been trained for this type of situation. They dismantled the lock, cleaned it, rebuilt it, and retracted the source to its fully retracted position.

Exposure Device: Industrial Nuclear IR-100
Device S/N: 6774
Source S/N: 70129B
Source Activity: 80 curies
Source Type: Ir192

There was no exposure from this event.

* * * UPDATE AT 1548 EST ON 11/7/2011 FROM KEENAN REMELE TO MARK ABRAMOVITZ * * *

The following report was received via fax:

"On November 5th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6774).

"During the shift, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated.

"The 2 mR/hr boundary was reconfirmed and the Foreman and Supervisor were notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the Permanent Storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service.

"Exposure Device: Industrial Nuclear IR-100
Device S/N: 6774
Source S/N: 70129B
Source Activity: 63.4 curies
Source Type: Ir-192
Source Model # QSA 87703"

There was no exposure to the crew or the general public during this incident.

Notified the R4DO (Hay) and FSME (Camper).

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