Event Notification Report for October 15, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/14/2014 - 10/15/2014
Agreement State
Event Number: 50548
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY ASSOCIATES
Region: 4
City: GLENDALE State: AZ
County:
License #: AZ 07-639
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: JEFF ROTTON
Licensee: ARIZONA ONCOLOGY ASSOCIATES
Region: 4
City: GLENDALE State: AZ
County:
License #: AZ 07-639
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/17/2014
Notification Time: 12:16 [ET]
Event Date: 10/15/2014
Event Time: 10:30 [MST]
Last Update Date: 10/17/2014
Notification Time: 12:16 [ET]
Event Date: 10/15/2014
Event Time: 10:30 [MST]
Last Update Date: 10/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK HAIRE (R4DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)
MARK HAIRE (R4DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MOVEMENT OF TREATMENT CYLINDER
"At approximately 1030 [MST] on October 15, 2014, the Agency [Arizona Radiation Regulatory Agency] was informed that the licensee had a medical event involving a High Dose Rate afterloader containing a 4.641 curie Iridium-192 source. A patient was receiving the third of three fractions involving a vaginal cylinder. When the Physicist entered the room after the treatment had concluded, he noticed that the cylinder had fallen out of the vaginal canal and was lying on the treatment table. The patient was unaware of the cylinders' position, but remembers feeling an 'oozing sensation' at the beginning of the treatment. The treatment time was for 431.3 seconds and the total prescribed dose for the fraction was 600 centigray and the total dose for all three fractions was 1800 centigray. The patient was also receiving external beam therapy at a rate of 200 centigray for 26 fractions, for a total dose of 5200 centigray. The patient received the last fraction on October 16th.
"The Agency is investigating the event.
"The Governor's office is being notified of this event."
Arizona First Notice Event No.: 14-025
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.
"At approximately 1030 [MST] on October 15, 2014, the Agency [Arizona Radiation Regulatory Agency] was informed that the licensee had a medical event involving a High Dose Rate afterloader containing a 4.641 curie Iridium-192 source. A patient was receiving the third of three fractions involving a vaginal cylinder. When the Physicist entered the room after the treatment had concluded, he noticed that the cylinder had fallen out of the vaginal canal and was lying on the treatment table. The patient was unaware of the cylinders' position, but remembers feeling an 'oozing sensation' at the beginning of the treatment. The treatment time was for 431.3 seconds and the total prescribed dose for the fraction was 600 centigray and the total dose for all three fractions was 1800 centigray. The patient was also receiving external beam therapy at a rate of 200 centigray for 26 fractions, for a total dose of 5200 centigray. The patient received the last fraction on October 16th.
"The Agency is investigating the event.
"The Governor's office is being notified of this event."
Arizona First Notice Event No.: 14-025
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.
Power Reactor
Event Number: 50540
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAMON FEGLEY
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAMON FEGLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/15/2014
Notification Time: 22:23 [ET]
Event Date: 10/15/2014
Event Time: 17:00 [EDT]
Last Update Date: 10/15/2014
Notification Time: 22:23 [ET]
Event Date: 10/15/2014
Event Time: 17:00 [EDT]
Last Update Date: 10/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID AYRES (R2DO)
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 |
APPENDIX R UNANALYZED CONDITION AFFECTING THE TURBINE DRIVEN AUX FEEDWATER PUMP
"WBN U1 [Watts Bar Nuclear Unit-1] Appendix R (APP R) procedures do not include all the required operator manual actions to ensure manual control of the Unit 1 Turbine Driven Auxiliary Feed (TDAFW) Pump during a fire in room 713-A1A or 737-A1A. The current APP R procedure includes actions to transfer the Unit 1 TDAFW Pump to local control, but does not account for the potential loss of 125 VDC or 120 VAC to the Unit 1 TDAFW pump controls.
"Without procedural guidance to transfer the 120 VAC and 125 VDC supplies, the operation of the Unit 1 TDAFW pump may not be completed within the required time. Failure to take all the required actions to control the Unit 1 TDAFW Pump places WBN Unit 1 in an unanalyzed condition.
"WBN has instituted a fire impairment for the affected rooms and established an hourly roving fire watch.
"The NRC Resident Inspector has been notified of this condition."
The affected components are the trip throttle valve and the local control panel. Procedures should be in place by 10/16/2014 to rectify this situation.
"WBN U1 [Watts Bar Nuclear Unit-1] Appendix R (APP R) procedures do not include all the required operator manual actions to ensure manual control of the Unit 1 Turbine Driven Auxiliary Feed (TDAFW) Pump during a fire in room 713-A1A or 737-A1A. The current APP R procedure includes actions to transfer the Unit 1 TDAFW Pump to local control, but does not account for the potential loss of 125 VDC or 120 VAC to the Unit 1 TDAFW pump controls.
"Without procedural guidance to transfer the 120 VAC and 125 VDC supplies, the operation of the Unit 1 TDAFW pump may not be completed within the required time. Failure to take all the required actions to control the Unit 1 TDAFW Pump places WBN Unit 1 in an unanalyzed condition.
"WBN has instituted a fire impairment for the affected rooms and established an hourly roving fire watch.
"The NRC Resident Inspector has been notified of this condition."
The affected components are the trip throttle valve and the local control panel. Procedures should be in place by 10/16/2014 to rectify this situation.
Agreement State
Event Number: 50541
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ELG METALS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02275
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Licensee: ELG METALS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02275
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/16/2014
Notification Time: 12:12 [ET]
Event Date: 10/15/2014
Event Time: 00:00 [CDT]
Last Update Date: 10/16/2014
Notification Time: 12:12 [ET]
Event Date: 10/15/2014
Event Time: 00:00 [CDT]
Last Update Date: 10/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
MEXICO (FAX)
JAMES RUBENSTONE (NMSS)
ILTAB (EMAI)
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
MEXICO (FAX)
JAMES RUBENSTONE (NMSS)
ILTAB (EMAI)
AGREEMENT STATE REPORT - STOLEN X-RAY FLUORESCENCE DEVICE
The following was received from the State of Texas via email:
"On October 15, 2014, the Agency [State of Texas] received a call from the licensee reporting that a Thermo Niton device model number XLP-818 containing 30 millicuries of americium-241 had been stolen. The device and a portable x-ray device were discovered missing from a locked cabinet on October 13, 2014. After initiating an investigation and searching for the devices, the licensee is confident that both devices were locked up in a cabinet on Friday, October 10, 2014 and went missing the following Monday morning. The licensee stated they did not believe any individual would receive any exposure due to this event. The licensee investigation is in progress. Additional information will be provided as it is received in accordance with SA 300."
Texas Incident #: I-9244
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
The following was received from the State of Texas via email:
"On October 15, 2014, the Agency [State of Texas] received a call from the licensee reporting that a Thermo Niton device model number XLP-818 containing 30 millicuries of americium-241 had been stolen. The device and a portable x-ray device were discovered missing from a locked cabinet on October 13, 2014. After initiating an investigation and searching for the devices, the licensee is confident that both devices were locked up in a cabinet on Friday, October 10, 2014 and went missing the following Monday morning. The licensee stated they did not believe any individual would receive any exposure due to this event. The licensee investigation is in progress. Additional information will be provided as it is received in accordance with SA 300."
Texas Incident #: I-9244
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