Event Notification Report for May 17, 2012

STUCK OPEN SHUTTER ON SEALED SOURCE GAUGE

The following report was received via email.

"During an unannounced health, safety, and security inspection conducted on July 12, 2012 at SSAB Iowa, Inc. the Agency [Iowa Department of Public Health] discovered that the licensee had a shutter fail open on an EG & G Berthold, model LB 300 MLT, serial number 1739-10-05 containing approximately 50 millicuries of Cobalt-60. This failure occurred on May 17, 2012 while the device was measuring the level of molten metal in a caster. On May 22, 2012 a contractor arrived on site and repaired the shutter. Cause of failure appears to have been binding due to the extreme heat conditions of the castor. Precautions were taken to ensure that no individual received a radiation dose and normal operations continued until the shutter was repaired."

Iowa Event Report # IA 120003

MEDICAL EVENT - PATIENT INJECTED WITH WRONG RADIOPHARMACEUTICAL AND QUANTITY

A patient scheduled for a lymphoscintigraphy procedure was incorrectly injected with 25 milliCuries of Tc-99M Medronate instead of the prescribed 3 milliCuries of Tc-99 Sulphur Colloid. The cause of the event was human error. The patient and physician have been notified. The physician believes there will be no long term adverse effects due to this error. In order to prevent reoccurrence, the nuclear medicine staff will add this event to staff training to ensure that staff double check the label and the dosage and drug. Other options are still being assessed.

The licensee also notified NRC Region 3 (Bob Gattone).

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.

EMERGENCY OPERATIONS FACILITY NON-FUNCTIONAL DUE TO FAILED RETURN FAN

"At 0438 [CDT] on Thursday, May 17, the Callaway Plant Emergency Operations Facility (EOF) was declared non-functional when the building's return fan was found not running. Loss of the EOF return fan, results in an inability to maintain a positive pressure on the facility. Efforts are underway to return this fan to service.

"If an emergency is declared requiring EOF activation while the EOF is non-functional, EOF emergency response personnel will report to their backup locations in accordance with Callaway Plant emergency planning procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the unavailability of an emergency response facility.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM BRANDON LONG TO JOHN SHOEMAKER ON 05/17/12 AT 1704 EDT * * *

At 1330 (CDT) on 05/17/12, the Callaway Plant EOF was been returned to service.

The licensee will notify the NRC Resident Inspector. Notified R4DO (Powers).

AREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The State of California submitted the following information via email:

"On May 17, 2012, at 1126 [PDT], [the licensee Assistant Radiation Safety Officer] ARSO of Ninyo and Moore, contacted the California Emergency Management Agency with a report of a theft of a Troxler Model 3430 moisture/density gauge, S/N 38771 (9 mCi Cs-137, 44 mCi Am:Be-241) in Moreno Valley, CA. This occurred between 1000 and 1030 [PDT]. The ASRO stated that the gauge operator arrived at the construction site and unlocked and opened the tailgage/hatch on their Nissan Armada SUV and then walked away approximately 15 feet to speak with the site manager to find out where to make the measurements. The gauge was still inside the gauge transport case with two locks and a trigger lock. The case was tied down to the inside of the vehicle, but was not secured to the frame of the vehicle. While the gauge operator was speaking with the site manager, an older model black sedan (make and model unknown and did not have a license plate) stopped next to SUV and an unknown individual exited the sedan, grabbed the gauge case out of the SUV, placed the gauge case in the sedan and then left the scene before anyone could stop the theft. The gauge operator then contacted their office to report the theft. The Moreno Valley Police and Cal EMA were also notified. The Moreno Valley Police then arrived to investigate (Police report #MZ121380120).

"At approximately 1215 [PDT], [the California State Department of Public Health, Senior Health Physicist] spoke with the ASRO about the incident. [The ASRO] confirmed the information in the previous paragraph. [The ASRO] also stated that the measurements were to be taken of the asphalt/concrete of the sidewalk on the side of the road, which allowed the public easy access to the vehicles at the site. When asked about the security of the gauge, [the ASRO] stated that the gauge case had two locks and a the gauge had a handle lock. The gauge case was tied down inside the vehicle, but was not locked or secured otherwise. During transport, the tailgate is locked, securing the gauge inside the SUV. When asked if the vehicle had an alarm, [the ASRO] stated that he was not sure, but the vehicle did have a Lojack tracking device installed. The ASRO was informed that a written report was required within 30 days and that a newspaper ad with a reward and description of the stolen item be placed in a local paper. The ASRO was also informed that the gauge operator should be writing a statement and that the most current leak test should be submitted to [State] office. [The ASRO] stated that his [Radiation Safety Officer] RSO was currently working on those items. When asked if anyone had attempted to search the immediate area in an attempt to locate the gauge or the vehicle, [the ASRO] stated that they were going to have some of their employees search the local neighborhood in the afternoon.

"The licensee will be cited for leaving the gauge unattended. Any other citations will be deferred until the licensee has submitted the 30-day report and the investigation has been completed by this office. As of the time of this report, the gauge has not been recovered."

California Incident 5010 Number - 051712

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

AGREEMENT STATE - POOL IRRADIATOR ROOF PLUG SENSOR FAULT

"The RSO [Radiation Safety Officer] for the licensee said that an Assistant RSO called him after a [pool irradiator] roof plug fault had occurred and the source rack dropped to the shielded position. It was confirmed that the roof plug and roof cap were still in place, but the plug sensor located between the cap and plug had failed. There are two sensors that alarm if the plug was removed. One sensor is located inside the vault and the second sensor is between the cap and plug. The second sensor is the one that failed. The plant is installing a new sensor, located on the cap of the roof plug that will alarm if the roof cover is removed dropping the source rack."

Nebraska State Report No. - NE-09-00X

FITNESS FOR DUTY

A licensed operator employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access has been suspended. Contact the Headquarters Operations Officer for additional details.