United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 27, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2012 - 11/27/2012

** EVENT NUMBERS **


48513 48515 48516 48519 48520 48521 48536 48537

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Agreement State Event Number: 48513
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL
Region: 1
City: BURLINGTON State: MA
County:
License #: MA 12-8361
Agreement: Y
Docket:
NRC Notified By: MICHAEL WHALAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/16/2012
Notification Time: 20:06 [ET]
Event Date: 11/15/2012
Event Time: [EST]
Last Update Date: 11/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE ()
DENNIS ALLSTON (ILTA)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IRIDIUM-192 SOURCE MISSING DURING SHIPMENT

A representative from the Massachusetts Radiation Control Program called to report information he had received concerning a missing Iriduim-192 Category 3 source shipment that was being imported to QSA Global in Burlington, Massachusetts from Australia. The shipment had cleared customs at JFK and was being stored at a warehouse near JFK (Air Menzies Aviation). On the evening of 11/15/12, the package was scheduled to be picked up at the warehouse, however, it could not be found. At this point the shipment is considered missing. QSA currently believes that the package is simply misplaced at this time. QSA and the carrier continue to search for the package.

* * * UPDATE FROM M. WHALAN TO P. SNYDER ON 11/26/12 AT 0819 EST * * *

The source was found by the licensee at an alternate location.

Notified R1DO (Dwyer), ILTAB (Hahn) and FSME Event Resource (Email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 48515
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: S&ME ENGINEERING
Region: 3
City: VALLEY VIEW State: OH
County:
License #: 3121025006
Agreement: Y
Docket:
NRC Notified By: CHUCK McCRACKEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/17/2012
Notification Time: 13:45 [ET]
Event Date: 11/16/2012
Event Time: 16:40 [EST]
Last Update Date: 11/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE ()

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER DENSITY GAUGE

The following information is a summary of a report received from the Ohio Bureau of Radiation Protection:

A Troxler nuclear density gauge was being used on an Ohio Earthwork Project in Riley Township, Ohio. The gauge technician set the gauge on the ground and left it unattended while preparing for testing. A bulldozer moved over the location where the gauge had been set down without realizing the gauge was there.

The isotopes in this unit are 8 millicuries of cesium 137 and 40 millicuries of Am-241/Be.

The damaged unit was a Troxler Model Number 3430, Serial Number 21036. The source serial number for the Cs 137 is 75-2465 and the source serial number for the Am-241:Be is 47-16507

The licensee dispatched a contractor (Solutient Technologies) to the jobsite. Solutient identified that no leakage occurred, that the sources are intact and in their protective housing. The sources were placed in a 5 gallon steel drum and the remainder of the gauge was placed in a 30 gal steel drum and deemed suitable for transport. These containers were removed from the site on Saturday, November 17, 2012 and returned to the licensee's Cleveland office.

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Non-Agreement State Event Number: 48516
Rep Org: ACUREN USA
Licensee: ACUREN USA
Region: 4
City: PRUDHOE BAY State: AK
County:
License #: 42-32443-01
Agreement: N
Docket:
NRC Notified By: ROBERT JEFFERSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/17/2012
Notification Time: 14:50 [ET]
Event Date: 11/16/2012
Event Time: 14:00 [YST]
Last Update Date: 11/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE ()

Event Text

RADIOGRAPHY CAMERA SOURCE CONTROL CABLE BREAKAGE

The following is a summary of a report provided by the licensee to the NRC Operations Center:

The licensee could not fully retract a radiography camera source into the shielded position (Sentinel Delta 880D, Serial # 87400B). It was determined that the control assembly cable had broken approximately three inches from the source connector. The source assembly was gravity fed from the guide tube onto the ground and then shielded by reverse placement into another Sentinel exposure device. A serviceable control assembly was then connected to the original exposure device and the control cable routed through the device and guide tube, then connected to the source. The source was then retracted into the original device without incident.

Corrective actions taken and planned to prevent reoccurrence: Remove 100% of control assemblies from service and complete a thorough inspection. Perform a safety stand down with all radiographers and assistants for review of daily equipment inspections.

The four individuals involved in this event received exposures of 95 mR; 48 mR; 20 mR; and 20 mR respectively.

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Agreement State Event Number: 48519
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: LAKE CUMBERLAND REGIONAL HOSPITAL
Region: 1
City: SOMERSET State: KY
County:
License #: 202-123-26
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/19/2012
Notification Time: 11:03 [ET]
Event Date: 06/03/2011
Event Time: [CST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENTS INVOLVING PROSTATE SEED IMPLANTS

The following information was obtained from the Commonwealth of Kentucky via fax:

"KY RHB [Radiation Health Branch] was notified via e-mail by the Medical Physicist of the facility of two past medical events. The medical events involved two patients treated for prostate cancer with I-125 and Pd-103 seeds for which the Medical Physicist had developed the treatment plans. The Radiation Oncologist and the Urologist, who performed the procedures determined the dose delivered to the target organ based on D90 was less than 80% using the Variseed Treatment Planning software. The Radiation Oncologist who contoured the prostate and determined the post implant D90 doses, was not aware that a D90 less than 80% of the prescribed dose was a medical event that required reporting to the Radiation Health Branch. The patient treated on 6/3/11 was treated with 101 Bard STM1251, I-125 seeds (0.37 mCi/seed) monotherapy and received a D90 of 76.7%. The intended dose to the prostate was 145Gy and the administered dose was 111.2Gy. The second patient was treated on 4/12/12 with 73 seeds of Theraseed Model 200, Pd-103 (1.1 mCi/seed) as a part of a boost therapy to IMRT [Intensity Modulated Radiation Therapy]. This patient received a post implant D90 of 68.3%. The intended dose to the prostate was 90Gy and the administered dose was 61Gy. The Medical Physicist discovered these two medical events after performing an audit of the facility's permanent implant prostate brachytherapy program since its inception for a total of 71 patients. The State will continue to keep NRC informed of the status of our investigation.

"KY Event Report ID No: KY120013"

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: 48520
Rep Org: OAKWOOD MEDICAL CENTER
Licensee: OAKWOOD MEDICAL CENTER
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: ZUBIN BHARUCHA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/19/2012
Notification Time: 13:00 [ET]
Event Date: 09/18/2012
Event Time: [EST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BILLY DICKSON (R3DO)
FSME EVENTS RESOUCE ()

Event Text

PATIENT RECEIVED LESS THAN PRESCRIBED DOSE FOLLOWING BRACHYTHERAPY TREATMENT

On 9/18/12, a patient at the Oakwood Medical Center was administered a brachytherapy treatment of the prostate. 72 Iodine-125 seeds were implanted at the time. On a post-implant study on 11/18/12, it was determined that D90 dose for the treatment was 68.3%. The study indicated that the anterior prostate was somewhat "cold." There was some evidence of seed migration. The physician has been notified. The underdose is not expected to have any significant impact on the patient.


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: 48521
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PHYSICIAN RELIANCE LP
Region: 4
City: FORT WORTH State: TX
County:
License #: 05545
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/19/2012
Notification Time: 12:53 [ET]
Event Date: 01/05/2012
Event Time: [CST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME RESOURCES (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL PROSTATE THERAPY UNDERDOSE

"On November 16, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that a potential medical event occurred. On January 5, 2012, a patient received an Iodine-125 prostate seed implant of 63 seeds (0.475 mCi/seed). The implant was completed as planned and verification films were taken and confirmed that the implant appeared normal and no concerns were expressed during or immediately after the implant procedure. In late August or early September, a post plan was created for evaluation. 63 seeds were localized by a staff physicist and sometime after or during the post plan analysis, the staff physicist noticed the seed placement appeared inconsistent with the pre-plan. The staff physicist informally notified the Chief Physicist and a Senior Radiation Oncologist who each viewed the plan and concluded that further evaluation was needed. The implant appeared shifted inferior to the prostate. The final determination is that all of the parameters of the implant (activity per seed, total activity, seed distribution, etc.) were all consistent with the pre-plan except that the center of the seed distribution and the center of the prostate were separated by a couple of centimeters and the most inferior seed was approximately 3.5 cm inferior to the apex of the prostate. The licensee has been contacted to report prescribed dose, actual dose, and percent of dose received. Additional information will be provided IAW SA-300."

Texas Incident# I-9014

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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Power Reactor Event Number: 48536
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: TYLER HALYE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/26/2012
Notification Time: 17:29 [ET]
Event Date: 11/26/2012
Event Time: 10:29 [EST]
Last Update Date: 11/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (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

Event Text

LOSS OF ASSESSMENT CAPABILITY- RADIATION MONITOR INOPERABLE FOR PRE-PLANNED MAINTENANCE

"This is a non-emergency notification. At 1029 EST on November 26, 2012, radiation monitor RM-1 WV-3546-1, Waste Processing Building Wide Range Gas Monitor was declared inoperable for pre-planned maintenance. This monitor is the only monitor credited in the EALs for monitoring a gaseous release from the Waste Processing Building.

"This radiation monitor is necessary for accident assessment and is credited for Emergency Action Level (EAL) classification in the Harris Nuclear Plant Emergency Plan. Inability to classify an EAL due to an out of service monitor is considered a loss of accident assessment capability and Is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2. This condition does not affect the health of safety of the public or the operation of the facility. An alternative method for sampling and determination of activity levels has been implemented."

The licensee stated that the radiation monitor was returned to service at 1728 EST on 11/26/12.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48537
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE JOHNSTON
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/27/2012
Notification Time: 00:02 [ET]
Event Date: 11/26/2012
Event Time: 19:30 [EST]
Last Update Date: 11/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

DEGRADED CONDITION DUE TO PINHOLE LEAK IN REACTOR HEAD SPRAY LINE

"Pinhole leak discovered on a Reactor Head Spray line weld during Nuclear Steam Supply System Leak Test.

"Oyster Creek Nuclear Generating Station is currently in the Shutdown Condition executing Refueling Outage 1R24, which includes Nuclear Steam Supply System (NSSS) Leak Testing, prior to startup.

"At 1930 on 11/26/2012, a pinhole leak was discovered on a Reactor Head Spray Class 1 piping weld. The leak was discovered during the NSSS Leak Test, while the Reactor was in the Shutdown Condition. The leak is on a flange to piping weld on the Reactor Head Spray system upstream of the N-7B nozzle. Water was found to be weeping from the pinhole leak (approximately 2 to 3 drops per minute).

"The cause is under investigation and corrective action plans are being developed.

"The leak has been evaluated by Exelon and determined to meet the criteria for reporting identified in NUREG-1022: Welding or material defects in the primary coolant system that cannot be found acceptable under ASME Section XI, IWB-3600, 'Analytical Evaluation of Flaws,' or ASME Section XI, Table IWB-3410-1, 'Acceptable Standards.'"

The NRC Resident Inspector has been informed.

Page Last Reviewed/Updated Tuesday, November 27, 2012
Tuesday, November 27, 2012