Event Notification Report for May 29, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/28/2015 - 05/29/2015
EVENT NUMBERS
5110551110511115110351100
Non-Agreement State
Event Number: 51105
Rep Org: MISTRAS GROUP
Licensee: MISTRAS GROUP
Region: 4
City: PRUDHOE BAY State: AK
County:
License #: 12-16559-02
Agreement: N
Docket:
NRC Notified By: JEREMY DUNNING
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: MISTRAS GROUP
Region: 4
City: PRUDHOE BAY State: AK
County:
License #: 12-16559-02
Agreement: N
Docket:
NRC Notified By: JEREMY DUNNING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/30/2015
Notification Time: 15:39 [ET]
Event Date: 05/29/2015
Event Time: 22:10 [YDT]
Last Update Date: 05/30/2015
Notification Time: 15:39 [ET]
Event Date: 05/29/2015
Event Time: 22:10 [YDT]
Last Update Date: 05/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
WAYNE WALKER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
WAYNE WALKER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RADIOGRAPHY SOURCE STUCK IN GUIDE TUBE
"The equipment supporting the collimator, guide tube, and extension tube fell from a height of 9 feet causing the guide tube to become entangled in the piping below. [The guide tubes fell on equipment below and the short radius bends prevented source retrieval.]
"Equipment Involved:
7 foot flexible guide tube Serial Number GT060
7 foot flexible extension tube serial number EXT-15
Exposure device model: Sentinel Delta 880D, serial # D11876
Isotope: Ir-192, source Serial Number 17211G
Source Activity: 102.3 Ci
35 foot Control Assembly S/N 16681
"Place: Salt Water Treatment Plant, Central Operating Area, Prudhoe Bay, Alaska
"Actions taken to establish normal operations: The radiographer extended his restricted area and contacted the plant operator to inform him of the situation. He and the assistant radiographer then maintained security of the restricted area throughout the duration of the event. At no time did any member of the public enter the restricted area. The Radiation Safety Officer was contacted by the radiographer and arrived on the scene at 2320 hours [AKDT]. Remote handling tools were used to untangle the guide tube and extension tube. Once the equipment was properly laid out the source was retracted to the shielded position using the control assembly.
"Corrective actions taken and planned to prevent reoccurrence: Retrain personnel on setup techniques with an increased focus on the stabilization of equipment.
"Qualifications [and dose] of personnel involved in incident:
(1) IRRSP card holder, dose received, 7mR
(2) Assistant Radiographer, dose received, 17mR
(3) IRRSP card holder, dose received, 2mR
(4) Jeremey A. Dunning, Site Radiation Safety Officer, IRRSP card holder, Source Retrieval trained by LAMCO & Associate February 25, 2011, dose received, 23mR (Dosimeter)"
"The equipment supporting the collimator, guide tube, and extension tube fell from a height of 9 feet causing the guide tube to become entangled in the piping below. [The guide tubes fell on equipment below and the short radius bends prevented source retrieval.]
"Equipment Involved:
7 foot flexible guide tube Serial Number GT060
7 foot flexible extension tube serial number EXT-15
Exposure device model: Sentinel Delta 880D, serial # D11876
Isotope: Ir-192, source Serial Number 17211G
Source Activity: 102.3 Ci
35 foot Control Assembly S/N 16681
"Place: Salt Water Treatment Plant, Central Operating Area, Prudhoe Bay, Alaska
"Actions taken to establish normal operations: The radiographer extended his restricted area and contacted the plant operator to inform him of the situation. He and the assistant radiographer then maintained security of the restricted area throughout the duration of the event. At no time did any member of the public enter the restricted area. The Radiation Safety Officer was contacted by the radiographer and arrived on the scene at 2320 hours [AKDT]. Remote handling tools were used to untangle the guide tube and extension tube. Once the equipment was properly laid out the source was retracted to the shielded position using the control assembly.
"Corrective actions taken and planned to prevent reoccurrence: Retrain personnel on setup techniques with an increased focus on the stabilization of equipment.
"Qualifications [and dose] of personnel involved in incident:
(1) IRRSP card holder, dose received, 7mR
(2) Assistant Radiographer, dose received, 17mR
(3) IRRSP card holder, dose received, 2mR
(4) Jeremey A. Dunning, Site Radiation Safety Officer, IRRSP card holder, Source Retrieval trained by LAMCO & Associate February 25, 2011, dose received, 23mR (Dosimeter)"
Agreement State
Event Number: 51110
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WESTINGHOUSE ELECTRIC COMPANY, LLC
Region: 1
City: MADISON State: PA
County:
License #: PA-1053S
Agreement: Y
Docket:
NRC Notified By: JOSEPH M MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Licensee: WESTINGHOUSE ELECTRIC COMPANY, LLC
Region: 1
City: MADISON State: PA
County:
License #: PA-1053S
Agreement: Y
Docket:
NRC Notified By: JOSEPH M MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 06/01/2015
Notification Time: 14:10 [ET]
Event Date: 05/29/2015
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2015
Notification Time: 14:10 [ET]
Event Date: 05/29/2015
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - TRANSPORTED PACKAGE EXCEEDS EXTERNAL RADIATION LIMITS
The following report was received from the Commonwealth of Pennsylvania via email:
"The Department [Pennsylvania Department of Environmental Protection] was notified on May 29, 2015, after the close of business, of a package received by the licensee that exceeded the external radiation limits. This event is reportable immediately per 20.1906(d)(2).
"On Friday May 29, 2015, a package was received at the Madison location of Westinghouse. Receipt surveys determined that the package containing 'tri-nuc filters' exceeded the contact dose rate of 200 mR/hr as noted in 10 CFR 71.47. Confirmatory instruments used indicated a dose rate of around 300 mR/hr on contact (75 mR/hr at one foot, and 16 mR/hr at three feet). No removable contamination is present. The package was shipped from Westinghouse's European service center in Belgium. They maintain that the package met all transportation requirements prior to departure. It is believed that either the package shielding or material may have shifted during transport. No exposures in excess of regulatory limits are expected.
"The Department [Pennsylvania Department of Environmental Protection] plans a reactive inspection and the facility is preparing a full report. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA150016
The following report was received from the Commonwealth of Pennsylvania via email:
"The Department [Pennsylvania Department of Environmental Protection] was notified on May 29, 2015, after the close of business, of a package received by the licensee that exceeded the external radiation limits. This event is reportable immediately per 20.1906(d)(2).
"On Friday May 29, 2015, a package was received at the Madison location of Westinghouse. Receipt surveys determined that the package containing 'tri-nuc filters' exceeded the contact dose rate of 200 mR/hr as noted in 10 CFR 71.47. Confirmatory instruments used indicated a dose rate of around 300 mR/hr on contact (75 mR/hr at one foot, and 16 mR/hr at three feet). No removable contamination is present. The package was shipped from Westinghouse's European service center in Belgium. They maintain that the package met all transportation requirements prior to departure. It is believed that either the package shielding or material may have shifted during transport. No exposures in excess of regulatory limits are expected.
"The Department [Pennsylvania Department of Environmental Protection] plans a reactive inspection and the facility is preparing a full report. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA150016
Agreement State
Event Number: 51111
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UTAH STATE UNIVERSITY
Region: 4
City: LOGAN State: UT
County:
License #: UT0300159
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: UTAH STATE UNIVERSITY
Region: 4
City: LOGAN State: UT
County:
License #: UT0300159
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/01/2015
Notification Time: 18:49 [ET]
Event Date: 05/29/2015
Event Time: 18:00 [MDT]
Last Update Date: 06/01/2015
Notification Time: 18:49 [ET]
Event Date: 05/29/2015
Event Time: 18:00 [MDT]
Last Update Date: 06/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JACK WHITTEN (R4DO)
DAVEY TOTTERER (ILTA)
NMSS_EVENTS_NOTIFIC (EMAI)
JACK WHITTEN (R4DO)
DAVEY TOTTERER (ILTA)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - POLONIUM 210 SOURCE MISSING
"Loss of control of source: Data Control Device (DCD) containing a 500 microCurie Po-210 source was transferred from the Utah State University campus by an unnamed researcher. The source was removed and was transported to a city in India. The RSO [Radiation Safety Officer] is currently making efforts to locate the researcher in India and verify the source is under his control."
This event occurred on 5/29/2015 and was reported to the state at 1300 MDT on 6/1/2015.
Utah Report: UT150002
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
"Loss of control of source: Data Control Device (DCD) containing a 500 microCurie Po-210 source was transferred from the Utah State University campus by an unnamed researcher. The source was removed and was transported to a city in India. The RSO [Radiation Safety Officer] is currently making efforts to locate the researcher in India and verify the source is under his control."
This event occurred on 5/29/2015 and was reported to the state at 1300 MDT on 6/1/2015.
Utah Report: UT150002
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: 51103
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS GARRISON
HQ OPS Officer: JOHN SHOEMAKER
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS GARRISON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/29/2015
Notification Time: 20:17 [ET]
Event Date: 05/29/2015
Event Time: 12:30 [EDT]
Last Update Date: 06/12/2015
Notification Time: 20:17 [ET]
Event Date: 05/29/2015
Event Time: 12:30 [EDT]
Last Update Date: 06/12/2015
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):
KATHLEEN O'DONOHUE (R2DO)
KATHLEEN O'DONOHUE (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SUPPORT CENTER VENTILATION SYSTEM OUT OF SERVICE DUE TO DISCOVERED CONDITION
"This is non-emergency eight hour notification for a loss of Emergency Assessment Capability.
"This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility.
"A condition impacting functionality of the TSC [Technical Support Center] Ventilation system was discovered on 05/29/2015 at 1230 [EDT]. The issue involves a loss of cooling capability of the TSC ventilation system due to a failed relay. Maintenance will begin repairs at 0700 [EDT] on 05/30/2015. Estimated time to repair is unknown at this time.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Coordinator will relocate the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team will be notified of the condition and the possible need to relocate during an emergency. This condition does not affect the health and safety of the public or station employees. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector will be notified."
* * * UPDATE FROM AARON MICHALSKI TO DANIEL MILLS AT 1557 EDT ON 6/12/15 * * *
The TSC ventilation system has been returned to service. The licensee will notify the NRC Resident Inspector.
Notified R2DO (Guthrie).
"This is non-emergency eight hour notification for a loss of Emergency Assessment Capability.
"This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility.
"A condition impacting functionality of the TSC [Technical Support Center] Ventilation system was discovered on 05/29/2015 at 1230 [EDT]. The issue involves a loss of cooling capability of the TSC ventilation system due to a failed relay. Maintenance will begin repairs at 0700 [EDT] on 05/30/2015. Estimated time to repair is unknown at this time.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Coordinator will relocate the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team will be notified of the condition and the possible need to relocate during an emergency. This condition does not affect the health and safety of the public or station employees. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector will be notified."
* * * UPDATE FROM AARON MICHALSKI TO DANIEL MILLS AT 1557 EDT ON 6/12/15 * * *
The TSC ventilation system has been returned to service. The licensee will notify the NRC Resident Inspector.
Notified R2DO (Guthrie).
Agreement State
Event Number: 51100
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-27
Agreement: Y
Docket:
NRC Notified By: BRANDON JURAN
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-27
Agreement: Y
Docket:
NRC Notified By: BRANDON JURAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/29/2015
Notification Time: 16:26 [ET]
Event Date: 05/29/2015
Event Time: 10:30 [CDT]
Last Update Date: 05/29/2015
Notification Time: 16:26 [ET]
Event Date: 05/29/2015
Event Time: 10:30 [CDT]
Last Update Date: 05/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTINE LIPA (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CHRISTINE LIPA (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL TREATMENT TO INCORRECT LOBE OF THE LIVER
"The Minnesota Department of Health was notified on May 29, 2015, by a representative from Abbott Northwestern Hospital of a Medical Event. A patient was given 23.62 mCi of Y-90 TheraSpheres with an intended dose of 125.3 Gy to segment 4 of the liver. The 125.3 Gy dose was unintentionally given to the right lobe of the liver (segments 1, 5, 6, 7, and 8). The licensee was planning on treating the right lobe in the future. The patient and referring physician will be notified on May 29, 2015. The Minnesota Department of Health will follow-up with the licensee early next week."
Minnesota Event: MN150003
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 Minnesota Department of Health was notified on May 29, 2015, by a representative from Abbott Northwestern Hospital of a Medical Event. A patient was given 23.62 mCi of Y-90 TheraSpheres with an intended dose of 125.3 Gy to segment 4 of the liver. The 125.3 Gy dose was unintentionally given to the right lobe of the liver (segments 1, 5, 6, 7, and 8). The licensee was planning on treating the right lobe in the future. The patient and referring physician will be notified on May 29, 2015. The Minnesota Department of Health will follow-up with the licensee early next week."
Minnesota Event: MN150003
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.