Event Notification Report for December 10, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/09/2014 - 12/10/2014
Agreement State
Event Number: 50669
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KOURY GEOTECHNICAL SERVICES
Region: 4
City: CHINO State: CA
County:
License #: 6449-19
Agreement: Y
Docket:
NRC Notified By: ANDREW TAYLOR
HQ OPS Officer: HOWIE CROUCH
Licensee: KOURY GEOTECHNICAL SERVICES
Region: 4
City: CHINO State: CA
County:
License #: 6449-19
Agreement: Y
Docket:
NRC Notified By: ANDREW TAYLOR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/11/2014
Notification Time: 13:25 [ET]
Event Date: 12/10/2014
Event Time: 00:00 [PST]
Last Update Date: 12/11/2014
Notification Time: 13:25 [ET]
Event Date: 12/10/2014
Event Time: 00:00 [PST]
Last Update Date: 12/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
HEATHER GEPFORD (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE
The following information was obtained from the State of California via email:
"On December 10, 2014, the Assistant Radiation Safety Officer of Koury Geotechnical Services contacted the Radiologic Health Branch Brea office regarding a moisture density gauge that was run over by a construction vehicle at a construction site at 6500 Atlantic Avenue in Long Beach. The gauge was a CPN Model MC1-DRP gauge, S/N MD30901675 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was in use as the Cs-137 source was extended approximately 8 inches in the soil at the time of the incident. The source rod has been damaged. The electrical body was also damaged but there was no evidence that the protective shield or the Am:Be-241source was damaged. The Long Beach Fire Department was notified and responded to the incident. Fire Department personnel did a visual inspection and radiation survey of the area and noted that the area was secured at least 50 feet from the gauge and noted that the dose rates at this boundary were at background. Long Beach Hazmat then arrived to take control of the area from the Fire Department. After assessing the situation they contacted Los Angeles County Radiation Management to assist in placing the sources in a safe condition. Thomas Gray and Associates (California materials license number 2105) was also contacted to assist in remediating the damaged gauge. The Health Physicist from Los Angeles County, with assistance from the Thomas Gray technician, was able to place the Cs-137 source into the shielded position and verified that the shutter block was in the proper position. A visual inspection of the body was performed and indicated that there was no damage to the shielding. Wipes were taken on the body of the gauge then tested using a survey meter with a geiger-mueller pancake probe. The wipes were at background indicating that the sources were not leaking. An MCA [multi-channel analyzer] was used to verify that both the Cs-137 and AmBe-241 sources were present. The gauge body was placed in the transport case along with the rest of the gauge parts then turned over to the Koury technician to take to Maurer Technical Services (California radioactive license 6163) to be shipped to the manufacturer so that it can be repaired or the sources recycled.
"The investigation is on-going and any citations will be determined at a later date."
CA Report No.: 5010-121014
The following information was obtained from the State of California via email:
"On December 10, 2014, the Assistant Radiation Safety Officer of Koury Geotechnical Services contacted the Radiologic Health Branch Brea office regarding a moisture density gauge that was run over by a construction vehicle at a construction site at 6500 Atlantic Avenue in Long Beach. The gauge was a CPN Model MC1-DRP gauge, S/N MD30901675 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was in use as the Cs-137 source was extended approximately 8 inches in the soil at the time of the incident. The source rod has been damaged. The electrical body was also damaged but there was no evidence that the protective shield or the Am:Be-241source was damaged. The Long Beach Fire Department was notified and responded to the incident. Fire Department personnel did a visual inspection and radiation survey of the area and noted that the area was secured at least 50 feet from the gauge and noted that the dose rates at this boundary were at background. Long Beach Hazmat then arrived to take control of the area from the Fire Department. After assessing the situation they contacted Los Angeles County Radiation Management to assist in placing the sources in a safe condition. Thomas Gray and Associates (California materials license number 2105) was also contacted to assist in remediating the damaged gauge. The Health Physicist from Los Angeles County, with assistance from the Thomas Gray technician, was able to place the Cs-137 source into the shielded position and verified that the shutter block was in the proper position. A visual inspection of the body was performed and indicated that there was no damage to the shielding. Wipes were taken on the body of the gauge then tested using a survey meter with a geiger-mueller pancake probe. The wipes were at background indicating that the sources were not leaking. An MCA [multi-channel analyzer] was used to verify that both the Cs-137 and AmBe-241 sources were present. The gauge body was placed in the transport case along with the rest of the gauge parts then turned over to the Koury technician to take to Maurer Technical Services (California radioactive license 6163) to be shipped to the manufacturer so that it can be repaired or the sources recycled.
"The investigation is on-going and any citations will be determined at a later date."
CA Report No.: 5010-121014
Power Reactor
Event Number: 50666
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: BOB PAGE
HQ OPS Officer: JEFF ROTTON
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: BOB PAGE
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/10/2014
Notification Time: 17:13 [ET]
Event Date: 12/10/2014
Event Time: 13:44 [EST]
Last Update Date: 12/10/2014
Notification Time: 17:13 [ET]
Event Date: 12/10/2014
Event Time: 13:44 [EST]
Last Update Date: 12/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BINOY DESAI (R2DO)
BINOY DESAI (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 |
INADVERTENT LOSS OF VITAL INDICATION DURING MAINTENANCE
"On December 10, 2014, at 1344 [EST], channel 1 of Refueling Water Storage Tank (RWST) level indication failed low during maintenance activities on channel 2. At that time, operators entered abnormal procedure 1-AP-3, 'Loss of Vital Indication, on Unit 1.' Additionally, Technical Specification (TS) 3.0.3 was entered due to 2 channels inoperable that affect Recirculation Spray (RS) pump auto-start capability. Had a Containment Depressurization Actuation (CDA) occurred during the time that both channels were inoperable, accident mitigation would have been adversely impacted. At 1356, both level indications returned to normal. At 1417, channel 2 was declared Operable and TS 3.0.3 was cleared. At 1439, channel 1 was declared Operable.
"Therefore, this 8-hour report is being made per 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function due to the RS pump auto-start concern."
Technicians inadvertently went to the incorrect channel (Channel 1) during planned maintenance activity of Channel 2, causing the loss of both channels simultaneously for a short period of time.
The licensee has notified the NRC Resident Inspector and will be notifying the Louisa County Administrator.
"On December 10, 2014, at 1344 [EST], channel 1 of Refueling Water Storage Tank (RWST) level indication failed low during maintenance activities on channel 2. At that time, operators entered abnormal procedure 1-AP-3, 'Loss of Vital Indication, on Unit 1.' Additionally, Technical Specification (TS) 3.0.3 was entered due to 2 channels inoperable that affect Recirculation Spray (RS) pump auto-start capability. Had a Containment Depressurization Actuation (CDA) occurred during the time that both channels were inoperable, accident mitigation would have been adversely impacted. At 1356, both level indications returned to normal. At 1417, channel 2 was declared Operable and TS 3.0.3 was cleared. At 1439, channel 1 was declared Operable.
"Therefore, this 8-hour report is being made per 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function due to the RS pump auto-start concern."
Technicians inadvertently went to the incorrect channel (Channel 1) during planned maintenance activity of Channel 2, causing the loss of both channels simultaneously for a short period of time.
The licensee has notified the NRC Resident Inspector and will be notifying the Louisa County Administrator.
Agreement State
Event Number: 50673
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: UNIVERSITY OF MARYLAND HELEN DENT CANCER CENTER
Region: 1
City: OLNEY State: MD
County:
License #: MD-31-310-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: HOWIE CROUCH
Licensee: UNIVERSITY OF MARYLAND HELEN DENT CANCER CENTER
Region: 1
City: OLNEY State: MD
County:
License #: MD-31-310-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/12/2014
Notification Time: 14:40 [ET]
Event Date: 12/10/2014
Event Time: 00:00 [EST]
Last Update Date: 12/12/2014
Notification Time: 14:40 [ET]
Event Date: 12/10/2014
Event Time: 00:00 [EST]
Last Update Date: 12/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
MARYLAND AGREEMENT STATE REPORT - MISADMINISTRATION OF I-125 SEEDS DURING PROSTATE THERAPY
The following information was obtained from the State of Maryland via email:
"Post implant CT determined that all seeds missed the prostate and were deposited in an unintended area of soft tissue at the base of the patient's penis. A medical determination has been made to not remove the seeds due to the difficulty of removal. The patient will be followed over the next two weeks to determine whether damage to the urethra has occurred. The licensee states that the patient has been informed.
"Preliminary root cause evaluation is that the Medical Center's ultrasound unit used to guide insertion is 12 years old and has a poor (grainy) display. No defect with the Mick applicator has been determined.
"The Maryland Radiation Program will conduct an on-site investigation of this incident."
The patient was administered 53 seeds at a nominal 0.36 mCi I-125 per seed manufactured by Best Industries. Intended dose to the prostate was 108 Gy.
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.
The following information was obtained from the State of Maryland via email:
"Post implant CT determined that all seeds missed the prostate and were deposited in an unintended area of soft tissue at the base of the patient's penis. A medical determination has been made to not remove the seeds due to the difficulty of removal. The patient will be followed over the next two weeks to determine whether damage to the urethra has occurred. The licensee states that the patient has been informed.
"Preliminary root cause evaluation is that the Medical Center's ultrasound unit used to guide insertion is 12 years old and has a poor (grainy) display. No defect with the Mick applicator has been determined.
"The Maryland Radiation Program will conduct an on-site investigation of this incident."
The patient was administered 53 seeds at a nominal 0.36 mCi I-125 per seed manufactured by Best Industries. Intended dose to the prostate was 108 Gy.
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.