Event Notification Report for January 26, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/25/2015 - 01/26/2015
EVENT NUMBERS
5076550766507675075950770
Agreement State
Event Number: 50765
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: FLORIDA BUREAU OF RADIATION SERVICES
Region: 1
City: ATLANTA State: GA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Licensee: FLORIDA BUREAU OF RADIATION SERVICES
Region: 1
City: ATLANTA State: GA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 17:09 [ET]
Event Date: 01/26/2015
Event Time: 00:00 [EST]
Last Update Date: 01/26/2015
Notification Time: 17:09 [ET]
Event Date: 01/26/2015
Event Time: 00:00 [EST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
BARRY WRAY (ILTA)
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
BARRY WRAY (ILTA)
AGREEMENT STATE REPORT - STOLEN DOSE CALIBRATOR SOURCES
The following report was received from the State of Georgia via email:
"Georgia Radioactive Materials Program discovered through a Law Enforcement List Server that 2 Co-57 sources and 1 Cs-137 source (what appear to be Dose Calibrator Sources as indicated in the example photo provided by LE) were stolen from a vehicle at or around Atlanta Hartsfield Airport.
"Activities of the sources are: The 2 Co-57 are 2.47 mCi and .365 mCi sources. The Cs-137 is a .232 mCi source.
"The individual transporting the sources was from Florida [Florida Department of Radiation Services]. Florida Radiation Control has been notified and Atlanta FBI has been notified.
"Updates to follow when more information is available."
State of Georgia Event Report 1-26-2015.
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 report was received from the State of Georgia via email:
"Georgia Radioactive Materials Program discovered through a Law Enforcement List Server that 2 Co-57 sources and 1 Cs-137 source (what appear to be Dose Calibrator Sources as indicated in the example photo provided by LE) were stolen from a vehicle at or around Atlanta Hartsfield Airport.
"Activities of the sources are: The 2 Co-57 are 2.47 mCi and .365 mCi sources. The Cs-137 is a .232 mCi source.
"The individual transporting the sources was from Florida [Florida Department of Radiation Services]. Florida Radiation Control has been notified and Atlanta FBI has been notified.
"Updates to follow when more information is available."
State of Georgia Event Report 1-26-2015.
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
Agreement State
Event Number: 50766
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: REED ENGINEERING GROUP, INC.
Region: 4
City: DALLAS State: TX
County:
License #: L04343
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN SHOEMAKER
Licensee: REED ENGINEERING GROUP, INC.
Region: 4
City: DALLAS State: TX
County:
License #: L04343
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 18:55 [ET]
Event Date: 01/26/2015
Event Time: 00:00 [CST]
Last Update Date: 02/18/2015
Notification Time: 18:55 [ET]
Event Date: 01/26/2015
Event Time: 00:00 [CST]
Last Update Date: 02/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TOM ANDREWS (R4DO)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)
TOM ANDREWS (R4DO)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)
AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE
The following report was received from the State of Texas via email:
"On January 26, 2015, the licensee notified the Agency [State of Texas] that one of its technicians had left a temporary job site in Fort Worth and after traveling approximately 30 minutes toward another job site, he realized the tailgate was down [and the gauge was missing]. When he left the first site, he had left the Humboldt 5001EZ moisture/density gauge (SN: 3613), containing one 10 millicurie cesium-137 source and one 40 millicurie americium-241/beryllium source, on the tailgate and not secured in the back of the vehicle. The technician returned to the site and looked for the gauge. Other construction workers at the site did produce the carrying case and the lock that had been on it, the standard block, and the flattening plate but not the gauge. The licensee is notifying local law enforcement and will return to the site in the morning with reward offer. Further information will be provided as it is obtained in accordance with SA-300."
Texas Report Number: I-9272
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 report was received from the State of Texas via email:
"On January 26, 2015, the licensee notified the Agency [State of Texas] that one of its technicians had left a temporary job site in Fort Worth and after traveling approximately 30 minutes toward another job site, he realized the tailgate was down [and the gauge was missing]. When he left the first site, he had left the Humboldt 5001EZ moisture/density gauge (SN: 3613), containing one 10 millicurie cesium-137 source and one 40 millicurie americium-241/beryllium source, on the tailgate and not secured in the back of the vehicle. The technician returned to the site and looked for the gauge. Other construction workers at the site did produce the carrying case and the lock that had been on it, the standard block, and the flattening plate but not the gauge. The licensee is notifying local law enforcement and will return to the site in the morning with reward offer. Further information will be provided as it is obtained in accordance with SA-300."
Texas Report Number: I-9272
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
Power Reactor
Event Number: 50767
Facility: MILLSTONE
Region: 1 State: CT
Unit: [] [] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WAYNE HARRELSON
HQ OPS Officer: STEVE SANDIN
Region: 1 State: CT
Unit: [] [] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WAYNE HARRELSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/27/2015
Notification Time: 00:24 [ET]
Event Date: 01/26/2015
Event Time: 16:50 [EST]
Last Update Date: 01/27/2015
Notification Time: 00:24 [ET]
Event Date: 01/26/2015
Event Time: 16:50 [EST]
Last Update Date: 01/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
CHRISTOPHER CAHILL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
TURBINE BUILDING STACK VENTILATION RADIATION PROCESS MONITORS REMOVED FROM SERVICE
Normal and High Range Ventilation Process Radiation Monitors (3HVR*RE10A/B) were removed from service due to low process flow affecting sample flow. The cause of the low process flow is unknown and under investigation at this time. Maintenance was performed yesterday, 1/26/15, including a successful calibration.
Action taken includes placing temporary sampling in service and estimating process flow. A priority one work package has been issued with repairs in progress.
The licensee informed the State of Connecticut, Waterford Township Police and the NRC Resident Inspector.
Normal and High Range Ventilation Process Radiation Monitors (3HVR*RE10A/B) were removed from service due to low process flow affecting sample flow. The cause of the low process flow is unknown and under investigation at this time. Maintenance was performed yesterday, 1/26/15, including a successful calibration.
Action taken includes placing temporary sampling in service and estimating process flow. A priority one work package has been issued with repairs in progress.
The licensee informed the State of Connecticut, Waterford Township Police and the NRC Resident Inspector.
Power Reactor
Event Number: 50759
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DANIEL MILLER
HQ OPS Officer: DANIEL MILLS
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DANIEL MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/26/2015
Notification Time: 05:04 [ET]
Event Date: 01/26/2015
Event Time: 03:55 [CST]
Last Update Date: 01/27/2015
Notification Time: 05:04 [ET]
Event Date: 01/26/2015
Event Time: 03:55 [CST]
Last Update Date: 01/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED PREVENTATIVE MAINTENANCE
"At 0355 [CST] on Monday, January 26, 2015, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system was removed from service for planned preventative maintenance activities on the TSC air handling unit, air compressor units, and TSC air filtration unit. During the maintenance, the TSC Ventilation will be shut down. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 38 hours. Contingency plans are in place so that if an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning (EP) procedures and checklists. If radiological or environmental conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with station procedures.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM RYAN SEARS TO JOHN SHOEMAKER AT 2012 EST ON 1/27/15 * * *
"At 1740 CST on January 27th, 2015, Dresden TSC Ventilation was restored. The Dresden TSC Ventilation is functional at this time.
"The NRC Resident Inspector has been notified."
Notified the R3DO (Dickson).
"At 0355 [CST] on Monday, January 26, 2015, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system was removed from service for planned preventative maintenance activities on the TSC air handling unit, air compressor units, and TSC air filtration unit. During the maintenance, the TSC Ventilation will be shut down. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 38 hours. Contingency plans are in place so that if an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning (EP) procedures and checklists. If radiological or environmental conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with station procedures.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM RYAN SEARS TO JOHN SHOEMAKER AT 2012 EST ON 1/27/15 * * *
"At 1740 CST on January 27th, 2015, Dresden TSC Ventilation was restored. The Dresden TSC Ventilation is functional at this time.
"The NRC Resident Inspector has been notified."
Notified the R3DO (Dickson).
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 50770
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CANCER CENTER OF GAITHERSBURG MARYLAND
Region: 1
City: GAITHERSBURG State: MD
County:
License #: 31-385-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOHN SHOEMAKER
Licensee: CANCER CENTER OF GAITHERSBURG MARYLAND
Region: 1
City: GAITHERSBURG State: MD
County:
License #: 31-385-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2015
Notification Time: 14:49 [ET]
Event Date: 01/26/2015
Event Time: 14:30 [EST]
Last Update Date: 03/26/2015
Notification Time: 14:49 [ET]
Event Date: 01/26/2015
Event Time: 14:30 [EST]
Last Update Date: 03/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following report was received from the State of Maryland via email:
"On 1/27/15 at 0830 EST, [Maryland Department of the Environment (MDEP) personnel] discussed preliminary findings [with the licensee] regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO [Radiation Safety Officer]. The initial notification came to [the Maryland] RHP [Radiological Health Program] on 1/26/15 at 1600 EST.
"The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878.
"The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR [High Dose Rate].
"The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose.
"[The Licensee] stated no history of previous medical incidents.
"The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray.
"Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur.
"The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed.
"Present at the therapy - Oncologist, Medical Physicist, and Therapist.
"[The Medical Physicist] stated that the licensee will re-examine all quality assurance oversight for HDR therapies.
"Preliminary consideration for corrective actions: All new treatment plans will be given new identities [and] the licensee will explore ways to delete previous treatment plans.
"The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day.
"[The Medical Physicist] was informed that RHP will investigate the incident."
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.
* * * UPDATE FROM ALAN JACOBSON TO JEFF HERRERA ON 01/28/2015 AT 0828 EST * * *
The following information was provided by the State of Maryland via email:
The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci.
Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email).
* * * EVENT RETRACTED AT 1205 EDT ON 3/26/2015 BY RAY MANLEY TO MARK ABRAMOVITZ * * *
This event is retracted because the dose delivered matched the written directive. Due to a software error, the dose was reported as double the actual dose. The patient, doctor and NMED have been notified.
Notified the R1DO (Jackson) and NMSS Events Resource (via e-mail)
The following report was received from the State of Maryland via email:
"On 1/27/15 at 0830 EST, [Maryland Department of the Environment (MDEP) personnel] discussed preliminary findings [with the licensee] regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO [Radiation Safety Officer]. The initial notification came to [the Maryland] RHP [Radiological Health Program] on 1/26/15 at 1600 EST.
"The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878.
"The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR [High Dose Rate].
"The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose.
"[The Licensee] stated no history of previous medical incidents.
"The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray.
"Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur.
"The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed.
"Present at the therapy - Oncologist, Medical Physicist, and Therapist.
"[The Medical Physicist] stated that the licensee will re-examine all quality assurance oversight for HDR therapies.
"Preliminary consideration for corrective actions: All new treatment plans will be given new identities [and] the licensee will explore ways to delete previous treatment plans.
"The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day.
"[The Medical Physicist] was informed that RHP will investigate the incident."
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.
* * * UPDATE FROM ALAN JACOBSON TO JEFF HERRERA ON 01/28/2015 AT 0828 EST * * *
The following information was provided by the State of Maryland via email:
The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci.
Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email).
* * * EVENT RETRACTED AT 1205 EDT ON 3/26/2015 BY RAY MANLEY TO MARK ABRAMOVITZ * * *
This event is retracted because the dose delivered matched the written directive. Due to a software error, the dose was reported as double the actual dose. The patient, doctor and NMED have been notified.
Notified the R1DO (Jackson) and NMSS Events Resource (via e-mail)