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Event Notification Report for November 9, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/08/2011 - 11/09/2011

** EVENT NUMBERS **


47404 47405 47407 47408 47409 47410 47411 47415 47417 47421 47422

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Agreement State Event Number: 47404
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: EASTERN REGIONAL MEDICAL CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0980
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOE O'HARA
Notification Date: 11/03/2011
Notification Time: 10:29 [ET]
Event Date: 11/02/2011
Event Time: 15:50 [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 - UNDERDOSAGE OF Y-90 THERASPHERES

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

"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 63%, which is reportable under 10CFR35.3045(a)(1)(ii).

"Notifications: On November 2, 2011, at 1550, the Department's Southeast Regional Office received notification via phone message about the ME.

"Event Description: A patient who was being treated with MDS Nordion Y-90 TheraSpheres, received only 37% of the intended dose based on the before and after survey readings of the TheraSphere accoutrements (5.8mR/hr vs. 3.8mR/hr). The licensee is in the process of notifying the patient. No more information is available at this time.

"Cause of the Event: The licensee suspects that procedural changes led to the problem. Nordion recently changed the procedure to clamp the priming line with a hemostat because the original clamp is hard to manipulate. This was their first procedure using the hemostat.

"Actions: Nordion has been contacted. The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection."

Event Report ID No. PA 110033

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: 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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Hospital Event Number: 47409
Rep Org: BARNES-JEWISH HOSPITAL
Licensee: BARNES-JEWISH HOSPITAL
Region: 3
City: ST LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/03/2011
Notification Time: 15:05 [ET]
Event Date: 11/02/2011
Event Time: 14:00 [CDT]
Last Update Date: 11/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NICK VALOS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL DOSE LESS THAN INTENDED DUE TO A LEAKING CONNECTOR

The patient had a written directive to receive 81 mCi of Sm-153 (Quadramet) as a whole body exposure for bone metastases. The administered dose was 29 mCi with the rest leaking out of a connector onto the tubing and absorbent pads. Any residual contamination was cleaned up. Both the doctor and patient were notified of the underdose and a follow-on treatment has been scheduled for next week.

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: 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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Agreement State Event Number: 47415
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: VALLEY INDUSTRIAL X-RAY & INSPECTION SERVICES
Region: 4
City: BAKERSFIELD State: CA
County:
License #: 4182-15
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/04/2011
Notification Time: 18:49 [ET]
Event Date: 11/03/2011
Event Time: 16:00 [PDT]
Last Update Date: 11/04/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILS TO RETRACT

The following report was received via e-mail:

"Valley Industrial X-ray and Inspection Services radiographers were unable to retract an Ir-192 source assembly into its fully shielded position and secure it in this position. The device is an Industrial Nuclear Co, Model IR-100 s/n 4100 camera which contained 49 Ci of Ir-192. Emergency procedures were enacted by evacuating the area 200 yards around the exposure device and calling the RSO for assistance. Radiation safety personnel were able to retract the source into the shield and the device was secured by 1600 [PDT]. The licensee removed the Ir-192 source from the camera and placed it into a spare shield. The IR-100 camera (without a source assembly) was sent to Industrial Nuclear Co. in San Leandro, CA for evaluation. No personnel overexposure occurred due to this event. RHB [Radiologic Health Branch] is following up with the licensee as to the cause of the event."

California Report: 5010-110311

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Agreement State Event Number: 47417
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TGR GEOTECHNICAL, INC
Region: 4
City: SANTA ANA State: CA
County:
License #: 7196-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/05/2011
Notification Time: 18:56 [ET]
Event Date: 11/04/2011
Event Time: 16:30 [PDT]
Last Update Date: 11/05/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
LARRY CAMPER (FSME)
JIM WHITNEY (ILTA)
MEXICO ()

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

Event Text

AGREEMENT STATE REPORT - THEFT OF A MOISTURE DENSITY GAUGE

"On 11/4/2011, at 1630, the licensee reported to [State of California] Radiologic Health Branch [RHB], Brea (and by voice mail to Sacramento) the theft of one of its portable nuclear gauges, a Troxler, Model 3440, # 34646. The theft took place from the licensee's permanent storage location, sometime in the last six weeks. The gauge was in the authorized permanent storage area and had not been used at a temporary job location for two years. The RSO stated that some employees had been recently laid off and may have been disgruntled. There was no evidence of tampering with the storage location locks. The gauge contained 0.3 GBq (9 mCi) of Cs-137 and 1.48 GBq (44 mCi) of Am-241/Be. The RSO was instructed to notify the local low enforcement agency to report the theft and place a reward notice in the local newspaper. The RSO will be providing a written report and supporting documentation to RHB within 30 days. RHB is initiating an investigation."

California Report: 5010-110411

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: 47421
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: THOMAS OLIVER
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/08/2011
Notification Time: 16:53 [ET]
Event Date: 11/08/2011
Event Time: 07:55 [EST]
Last Update Date: 11/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GEORGE HOPPER (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 REPORT INVOLVING A NON-LICENSED SUPERVISOR

A non-licensed supervisor (contractor) tested positive for alcohol. The contractor had not entered the protected area after reporting to work. The contractor had his badge pulled and his access to the site was terminated.

Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 47422
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIM MILLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/08/2011
Notification Time: 17:18 [ET]
Event Date: 11/08/2011
Event Time: 17:18 [EST]
Last Update Date: 11/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEORGE HOPPER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 81 Power Operation 81 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"On November 8, 2011, at 1718 EST, the Technical Support Center (TSC) will be unavailable due to pre-planned maintenance to maintain the Technical Support Center and Emergency Response Data Acquisition and Display System ventilation system. The TSC is expected to be restored to available status at approximately 2300 on November 10, 2011.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures, and the TSC staff will relocate to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility (ERF). An update will be provided once the TSC has been restored to normal operation. The NRC Resident Inspector has been notified."

The TSC ventilation will be out of service for two days for ducting modifications and flow testing.

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