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Event Notification Report for January 31, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/30/2013 - 01/31/2013

** EVENT NUMBERS **


43068 48395 48469 48470 48691 48692 48693

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General Information Event Number: 43068
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NINYO AND MOORE
Region: 4
City: SAN JACINTO State: CA
County:
License #: 5073-30
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: PETE SNYDER
Notification Date: 12/29/2006
Notification Time: 16:13 [ET]
Event Date: 12/28/2006
Event Time: 18:30 [PST]
Last Update Date: 01/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
KEITH McCONNELL (NMSS)
ILTAB (via e-mail) ()
MEXICO CNSNS ()

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

Event Text

AGREEMENT STATE REPORT - THEFT OF A TROXLER MOISTURE DENSITY GAUGE

"On December 29, 2006, at 11:10 am, the licensee contacted the California [Radiologic Health Branch] RHB to report the theft of a Troxler, Model 3430 moisture/density gauge (S/N 38217) containing a nominal 10 millicuries Cs-137 and nominal 40 millicuries Am-241. When the licensee initially reported, they had been informed by their technician that the gauge (secured by two locking cables in the truck bed) had been stolen at 11:00 am on December 29, 2006, while the technician was having lunch at a restaurant in Fontana, CA. Subsequently, during the police investigation, the technician acknowledged that the gauge had actually been stolen out of his truck, sometime the night previously (i.e., between about 6:30 pm December 28, 2006 and 8:00 am December 29, 2006), while the truck was parked in front of his home in San Jacinto, CA.

"The licensee prohibits their technicians from taking the gauges home overnight, and intends to take disciplinary action against the technician in this regard. The San Jacinto police have also been contacted, and the licensee intends to place a reward notification in the local press in the San Jacinto area. RHB will continue to follow up on this matter."

* * * UPDATE FROM DONELLE KRAJEWSKI TO CHARLES TEAL ON 1/30/13 AT 1351 EST * * *

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

"On Monday, January 28, 2013, the Border Patrol notified us, the Texas Department of State Health Services (DSHS), that a trailer had caused the radiation monitor to alarm at its checkpoint in Sierra Blanca, TX (approximately 90 miles east of El Paso on I-10).

"The individual pulling the trailer stated he was moving to Texas from California. The source of radiation was identified as being a Troxler moisture/density gauge. [The individual] stated that he had purchased the gauge as a tool for finding underground pipe at a swap-meet in Beaumont, CA, back in late August/early September of 2012 (he paid $125 or $150 for it). He stated he had not used the gauge he had only opened the case and looked at it and then put it in his storage shed where it remained until he packed up to move. The gauge was detained by one of our Agency [DSHS] inspectors and [the individual] willingly surrendered it.

"Gauge information:

"Troxler Model 3430
"SN: 38217

"It, and the case, are in very good condition. Based on isotope identification by Border Patrol and the DSHS inspector, it appears that the cesium-137 and the americium-241/beryllium sources are still in the gauge."

Notified R4DO (Walker), Mexico, and FSME Event Resource via email.


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.

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Power Reactor Event Number: 48395
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/10/2012
Notification Time: 00:32 [ET]
Event Date: 10/03/2012
Event Time: 18:15 [PDT]
Last Update Date: 01/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DON ALLEN (R4DO)

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

UNANALYZED FIRE PROTECTION DEFICIENCIES

"On 10/9/12, at 16:30 PDT control room operators were questioned whether recently identified fire protection program deficiencies should have been reported to the NRC.

"On October 3 and October 8, 2012, DCPP [Diablo Canyon Power Plant] staff reviewing NFPA 805 Nuclear Safety Capability Assessment (NSCA) Variance From Deterministic Requirements (VFDRs) identified fire areas that neither conformed to Appendix R requirements nor had established, proceduralized and practiced compensatory measures in place. The issues were identified in the DCPP corrective action program and compensatory measures were established in accordance with the DCPP fire protection program requirements.

"Event: 10/3/12 Fire areas containing cables associated with startup transformers 1-2 and 2-2 could result in loss of startup power and also prevent the emergency diesels from performing their Appendix R safe shutdown function.

"Event: 10/8/12 Fire areas containing reactor coolant pump (RCP) breakers could result in loss of RCP seal cooling and prevent the credited local manual trip of the RCPs, contrary to the specified method of performing the Appendix R safe shutdown function.

"Event: 10/8/12 Fire areas containing cables for the ventilation systems of the 480V switchgear, DC panels, and battery chargers could require unproceduralized use of portable fans to maintain adequate cooling of the electrical equipment necessary to perform the Appendix R safe shutdown function.

"Operators established fire watches as compensatory measures as required by the DCPP fire protection program requirements.

"The above late notification of discovery of the unanalyzed conditions has been entered into the DCPP corrective action program.

"NRC Resident Inspector has been notified."

*****UPDATE AT 0028 EDT ON 11/01/12 FROM GLENN GOELZER TO S. SANDIN*****

"This is an update to EN #48395 reported on October 10, 2012, at 0032 EDT.

"During the NRC's Fire Protection Triennial Inspection the NRC identified that several Alternate Compensatory Measures (ACMs) were not in the current post-fire procedure CP M-10. The ACMs address potential Appendix R non-conformance issues identified via the initiative to convert the DCPP fire protection program to NFPA 805. PG&E has established compensatory measures for all the identified areas in accordance with the DCPP fire protection program requirements.

"[The] NRC Resident Inspector has been notified."

Notified R4DO (Deese).

* * * UPDATE FROM D. BAHNER TO V. KLCO ON 11/30/12 AT 1618 EST * * *

"This is an update to EN #48395 reported on October 9, 2012, at 2132 PST.

"During the ongoing evaluation of the issues previously identified in this event notification, PG&E [Pacific Gas & Electric] has concluded that a fire in the fire areas containing cables associated with startup transformers 1-2 and 2-2 would not result in loss of startup power or prevent the emergency diesels from performing their Appendix R safe shutdown function. This issue was reported as an unanalyzed condition. However, it is analyzed and controlled in plant procedure CP M-10, 'Fire Protection of Safe Shutdown Equipment.' PG&E retracts the initial event documented on October 3, 2012, thus making the date on which the first unanalyzed condition was discovered October 8, 2012. Therefore, PG&E will submit the 60-day Licensee Event Report by December 7, 2012.

"The NRC Resident Inspector has been notified."

Notified the R4DO(Whitten).

* * * UPDATE AT 1944 EST ON 1/30/13 FROM KLINE TO TEAL* * *

"This is an update to EN #48395 reported on October 9, 2012, at 2132 PDT.

"On October 31, 2012, at 2128 PDT, PG&E provided an update to this event notification identifying that several alternate compensatory measures (ACMs) were not in plant procedure, CP M-10, 'Fire Protection of Safe Shutdown Equipment.' PG&E has evaluated this further and concluded that ACMs had been adequately implemented in CP M-10, and therefore retracts the EN update of [November 1, 2012 at 0028 EDT].

"NRC resident inspector has been notified."

Notified R4DO (Walker).

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Agreement State Event Number: 48469
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/03/2009
Event Time: [EDT]
Last Update Date: 01/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

The following information was provided by the State of Georgia via email:

"Licensee contacted the Department [Georgia Radioactive Materials Program] via telephone on 8/12/09 reporting that a patient who underwent a nuclear cardiology treadmill stress test on 8/3/09 resulted in an embryo/fetus exposure greater than 500 mRem. The Department received a report from the licensee on 8/14/12 describing that prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/10/09. Isotopes and activity administered to the patient were as follows: Tc-99m 28.2 mCi & Tl-201 3.62 mCi with a Total Activity of 31.82 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

* * * UPDATE FROM TRAVIS CARTOSKI TO VINCE KLCO ON 1/30/13 AT 0943 EST* * *

The following information was excerpted from a received facsimile:

"[The update is concerned with] the radiopharmaceutical dose administration that a female patient recently received at the testing facilities. It was subsequently determined that this patient was 4 months pregnant. The patient received two dose administrations, one dose of Tc-99m - Myoview for the Stress Myocardial Perfusion scan and one dose of Tl-201 as Thallous Chloride for the Rest Myocardial Perfusion scan. The patient received 28.2 mCi of Tc-99m-Myoview and 3.62 mCi of TI-201.

"The dose to the conceptus was approximately 1.97 Rad. Determination of dose is limited by patient habitus and physiology."

Notified the R1DO (Bellamy) and FSME Resources.

Report: GA-2009-12i

NMED# 090811

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Agreement State Event Number: 48470
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/17/2009
Event Time: [EDT]
Last Update Date: 01/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

The following information was provided by the State of Georgia via email:

"Licensee informed the Department [Georgia Radioactive Materials Program] via written correspondence dated 8/28/09 that a patient who underwent a nuclear cardiology treadmill stress test on 8/17/09 resulted in an embryo/fetus exposure greater than 500 mRem. Prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/27/09. Isotopes and activity administered to the patient were as follows: Tc-99m 26.9 mCi & Tl-201 5.38 mCi with a Total Activity of 32.28 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

* * * UPDATE FROM TRAVIS CARTOSKI TO VINCE KLCO ON 1/30/13 AT 0943 EST * * *

The following information was excerpted from a received facsimile:

"[The update is concerned with] the radiopharmaceutical dose administration that a female patient recently received at testing facility. It was subsequently determined that this patient was 9 weeks pregnant. The patient received two dose administrations, one dose of Tc-99m - Myoview for the Stress Myocardial Perfusion scan and one dose of TI-201 as Thallous Chloride for the Rest Myocardial Perfusion scan. The patient received 26.9 mCi of Tc-99m-Myoview and 5.38 mCi of TI-201.

"The dose to the conceptus was approximately 2.53 Rad. Determination of dose is limited by patient habitus and physiology."

Notified the R1DO(Bellamy) and FSME Resources via email.

Report: GA-2009-18i

NMED# 090812

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Agreement State Event Number: 48691
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: PATIENT CARE INFUSION, LLC
Region: 4
City: TEMPE State: AZ
County:
License #: AZ-7-572
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: VINCE KLCO
Notification Date: 01/22/2013
Notification Time: 13:10 [ET]
Event Date: 01/21/2013
Event Time: [MST]
Last Update Date: 01/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS (EMAI)

Event Text

AGREEMENT STATE REPORT- PHARMACEUTICAL DISTRIBUTION FAILED QUALITY CONTROL TESTING

The following information was received by email:

"This First Notice constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received WITHOUT verification or evaluation, and is basically all that is known by the [Arizona Radiation Regulatory] Agency Staff at this time.

"At approximately 0830 [MST on 1/22/13], the Agency was notified by PCI [Patient Care Infusion], the Licensee, that yesterday [1/21/13] they distributed a pharmaceutical that failed the quality control testing. Several licensees reported to them they were receiving improper data from patients injected with the material. A total of 9 licensees were shipped the radiopharmaceutical and the licensee estimates as many as 13 patients may have received the deficient material. Additionally, a like number were scheduled to receive the material but did not receive the material.

"The Licensee is preparing the 30 day written report of this event.

"The Agency continues to investigate this event."

Arizona First Notice: 13-003

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Agreement State Event Number: 48692
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: ST. FRANCIS HEALTH CENTER
Region: 4
City: TOPEKA State: KS
County:
License #: 19-B272-04
Agreement: Y
Docket:
NRC Notified By: DAVID J. WHITFILL
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/23/2013
Notification Time: 11:00 [ET]
Event Date: 01/23/2013
Event Time: 06:22 [CST]
Last Update Date: 01/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)
KING STABLEIN (NMSS)

Event Text

AGREEMENT STATE REPORT - VEHICLE ACCIDENT DURING TRANSPORT OF RADIOPHARMACEUTICALS

The following preliminary information was provided by the State of Kansas via fax:

"Rollover accident involving transport of radiopharmaceuticals. Initial report received at 06:22 A.M. [CST]. Condition of driver unknown. Accident location: 2.5 miles north of US 69 and 47 junction, close to Arma, KS. Preliminary information indicates shipment was Tc-99m. Max contact 0.04 mR/h, no damage to packages. Personnel from St. Francis are on site. Driver was taken to the hospital."

Kansas Item Number: KS130001

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Agreement State Event Number: 48693
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/23/2013
Notification Time: 12:31 [ET]
Event Date: 01/22/2013
Event Time: [CST]
Last Update Date: 01/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EMAIL RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following information was provided by the State of Texas via email:

"On January 22, 2013, the Agency [State of Texas] was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew performing radiography operations at a field location experienced a source disconnect. The crew was using an INC IR 100 exposure device containing a iridium - 192 source. The crew had performed nine or ten exposures and was moving the camera to the next location when they discovered the source was still in the guide tube. A source recovery team was sent to the location and the source was returned to the exposure device and locked in the fully shielded position. The RSO did not know how the crew discovered the source was still in the guide tube. The RSO stated that the self reading dosimeter of the radiographer who moved the exposure device was reading off scale and that his personnel dosimeter was being sent to the dosimetry processor for immediate processing. The RSO stated that the radiographer did not perform a post exposure radiation survey prior to moving the camera and that the radiographer stated that their alarming dosimeter did not alarm. The RSO stated that he did not know how long or how close the radiographer was to the source while they were moving the exposure device. The RSO stated that the radiographer has been removed from all duties involving exposure to radiation. The RSO stated that no other individual received an exposure of concern. The RSO stated that the device would be returned to the manufacturer for inspection. The licensee is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9035

* * * UPDATE ON 1/25/2013 AT 1305 EST FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"On January 25, 2013, the RSO stated the dosimetry processor reported the dose received by the individual who relocated the exposure device was 791 millirem DDE [deep dose equivalent]. The RSO stated that their investigation into the event is ongoing. Additional information will be provided as it is received in accordance with SA - 300."

Notified the R4DO (Okeefe) and FSME Events Resource.

Page Last Reviewed/Updated Thursday, January 31, 2013
Thursday, January 31, 2013