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Event Notification Report for January 24, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/23/2013 - 01/24/2013

** EVENT NUMBERS **


48674 48675 48678 48694 48695 48696

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Agreement State Event Number: 48674
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: METHODIST UNIVERSITY HOSPITAL
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79027-H-15
Agreement: Y
Docket:
NRC Notified By: LAURA TURNER
HQ OPS Officer: VINCE KLCO
Notification Date: 01/15/2013
Notification Time: 12:45 [ET]
Event Date: 01/14/2013
Event Time: 12:15 [EST]
Last Update Date: 01/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
FSME_RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT- SOURCE STUCK IN A TRANSFER TUBE

The following information was received by email:

"On Monday, January 14, 2013, the [State of Tennessee] Division of Radiological Health received a report from Methodist University Hospital regarding a stuck HDR source. A patient was to be treated with the high dose rate remote afterloader (Nucletron model 105.999) on January 14th. The radiation source became stuck in the applicator/transfer tube at the beginning of treatment before reaching the patient. The physicists and physician followed the policy and procedure for removal of the source and tubing. The source was placed in a shielded container. A Nucletron engineer was notified by phone and arrived at 1600 CST, but was unable to dislodge the source from the transfer tube. The source and transfer tube will be sent back to Nucletron and replacements have been ordered. A written report is being prepared and will be sent to the Division of Radiological Health. Inspectors from the Memphis field office will follow-up on this incident and will continue to keep NRC informed of the status of our investigation."

Tennessee Event: TN-13-013

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Non-Agreement State Event Number: 48675
Rep Org: DEFENSE LOGISTICS AGENCY
Licensee: DEFENSE LOGISTICS AGENCY
Region: 1
City: NEW CUMBERLAND State: PA
County:
License #: 37-30062-01
Agreement: Y
Docket:
NRC Notified By: DAVID COLLINS
HQ OPS Officer: VINCE KLCO
Notification Date: 01/15/2013
Notification Time: 17:54 [ET]
Event Date: 01/14/2013
Event Time: [EST]
Last Update Date: 01/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN ROGGE (R1DO)
MICHAEL VASQUEZ (R4DO)
FSME EVENTS (EMAI)
GARY LANGLIE (ILTA)
MEXICO VIA FAX ()

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

Event Text

POTENTIAL THEFT OF PRESSURE INDICATOR CONTAINING SR-90 SOURCE

"An item was processed for shipment [from Norfolk, VA] to the manufacturer for repair and was delivered to a contracted carrier on 9 January 2013. The carrier notified the government representative on Monday, 14 January 2013, reporting that the subject material was involved in a police investigation for a potential theft in Riverside, CA. The government contractor reported the loss of freight to the depot who reported the incident to the DLA [Defense Logistics Agency] Distribution Radiation Safety Officer at 1503 hrs on 15 January 2013.

"DLA Distribution [Norfolk, VA] will work with all parties to obtain further information related to this incident and update the NRC as information becomes available."

The shipped item is a pressure indicator [NSN#6620-01-125-8904] containing a Sr-90 source (500 microCuries).

DLA Incident Number: 2013-DLA-001

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

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Agreement State Event Number: 48678
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120-78-0000
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/16/2013
Notification Time: 16:46 [ET]
Event Date: 01/15/2013
Event Time: [EST]
Last Update Date: 01/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MISPLACEMENT OF BRACHYTHERAPY SOURCE DURING MEDICAL TREATMENT

The following information was provided by the State of Ohio:

"The Ohio Department of Health Bureau of Radiation Protection was notified by the licensee RSO of a potential medical event. A patient was planned for a vaginal cylinder (HDR) procedure. Approved plan prescribed 4 Gy to target organ (vaginal canal) and 4.61 Gy to rectum. On the first of three fractions, the cylinder was inserted by the Authorized User (AU) in the rectum instead of the vaginal canal. The AU reviewed the film and approved the position for treatment. The physicist determined that the rectum received approximately 6.1 Gy (132% of the prescribed dose). At the time of this report it appears that the intended treatment target received less than 2 Gy (less than 50% of prescribed dose)."

The device used is a remote afterloader HDR manufactured by Nucletron, Model Microselectron S/N 31472, containing a single sealed source of 4.15 Ci Ir-192. The cause is identified as human error.

Item Number: OH130001

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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Non-Agreement State Event Number: 48694
Rep Org: NASA AMES RESEARCH CENTER
Licensee: NASA AMES RESEARCH CENTER
Region: 4
City: MOFFETT FIELD State: CA
County:
License #: 01-07845-04
Agreement: Y
Docket:
NRC Notified By: PATRICK MULDOON
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/23/2013
Notification Time: 13:10 [ET]
Event Date: 01/16/2013
Event Time: 12:07 [PST]
Last Update Date: 01/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

LEAKING NI-63 SOURCE

The following was excerpted from email received from NASA Ames:

"The source in question is a 5 mCi solid Ni-63 beta foil source located inside a Valco electron capture detector that was previously used for gas chromatograph. The leaking source in question was not in service at the time the contamination was found. The source was in storage awaiting disposal to a licensed facility."

"The radiation safety officer identified elevated contamination results for the source mentioned above during his review of the semi-annual sealed source inventory and leak test report which was conducted by the former health physics contractor in December 2012. All contamination levels were well below the NRC contamination threshold of .005 micro Curie at that time. The RSO directed the former health physics contractor to take a follow-up survey to verify the counts begin detected were actually Ni-63, bag the source, perform a survey of the immediate area where the source was being stored awaiting disposal, and prepare a report documenting the follow-up report and isotope identification prior to his termination with the end of his company's contract on December 31, 2012.

"On January 15, 2013, the new contract Health Physicist for NASA Ames Research Center, conducted a follow-up survey and leak test for the 5 mCi Ni-63 source. On January 16 the RSO confirmed that approximately 0.162 micro Curie (~36,000 dpm) beta contamination was distributed on the exterior surface of the electron capture detector. This value is in excess of the allowable leakage of 0.005 micro Curie (11,100 dpm) of contamination. The cause of the leaking source is not certain at this time. The source is approximately 23 years old so its possible age played a factor. The source has been in storage for a researcher who no longer had funding to continue using them in his research. It is stored in the RSO's radioactive materials storage facility for the last 6 years. During storage, the leak tests for the source continued to be conducted and all semi-annual leak tests never revealed any leaking contamination from the internal source.

"No persons are expected to have received any dose or exposure to radioactive materials as a result of this event. Ni-63 is a weak beta emitter and not capable of penetrating the dead layer of skin if in contact with the skin and is thus not an external radiation hazard. A general area contamination survey was also conducted in the immediate vicinity of where the source was stored. Contamination levels were all found to be near background levels in all locations confirming that there is no contamination event for the storage facility. The device has been in storage in a locked cabinet with access only to the RSO and Health Physics contractor during the period in which the leaking occurred so this makes the possibility of inadvertent personnel contamination remote. Required procedure for performing sealed source leak tests is to always wear disposable impermeable gloves. This would have prevented any personnel contamination."

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Fuel Cycle Facility Event Number: 48695
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: PHILIP OLLIS
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/23/2013
Notification Time: 15:00 [ET]
Event Date: 01/22/2013
Event Time: 15:30 [EST]
Last Update Date: 01/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
EUGENE GUTHRIE (R2DO)
KING STABLEIN (NMSS)

Event Text

UNANALYZED CONDITION - BASED ON ONGOING INTEGRATED ANALYSIS REVIEW

"During the ongoing Integrated Analysis (ISA) review, it was identified that a fire in labs adjacent to the Dry Scrap Recovery (DSR) area could impact the DSR. The existing masonry wall between DSR and the lab has several openings that are closed with plywood. With plywood in place, unicones (uranium storage containers) stored against the wall in DSR would not meet performance criteria for the accident sequence of a fire in the adjacent lab. The uranium containers have been removed from the storage area until the wall is upgraded to meet performance requirements. Other processes remain operational. A review has begun which will provide additional corrective actions, if required, and extent of condition."

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Power Reactor Event Number: 48696
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: MARK GREER
HQ OPS Officer: VINCE KLCO
Notification Date: 01/23/2013
Notification Time: 22:03 [ET]
Event Date: 01/23/2013
Event Time: 15:16 [EST]
Last Update Date: 01/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARC FERDAS (R1DO)

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

Event Text

CONCURRENT LOSS OF HIGH PRESSURE REACTOR MAKEUP SYSTEMS CAPABILITY

"On 1/23/2013 at 1516 [EST], Nine Mile Point 2 (NMP2) had a failure of a Reactor Building General Area temperature trip unit occur resulting in the closure of an isolation valve on the Reactor Core Isolation Cooling (RCIC) system steam supply line. Concurrent with this failure, the High Pressure Core Spray (HPCS) system was inoperable for planned surveillance testing. With both the RCIC and HPCS systems inoperable, NMP2 entered a Technical Specification Required Action to be in Mode 3 within 12 hours. At 1550, the HPCS system was restored to OPERABLE. Based on the concurrent loss of the high pressure reactor makeup capability of these two systems, it was determined that the condition is reportable under section 50.72(b)(3)(v) as the following safety functions were impacted: (A) Shutdown the reactor and maintain it in a safe shutdown condition; and (D) Mitigate the consequences of an accident.

"NMP2 remains in a stable condition at rated power. The offsite grid is stable with no restrictions or warnings in effect."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, January 24, 2013
Thursday, January 24, 2013