Event Notification Report for March 15, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/14/2016 - 03/15/2016
EVENT NUMBERS
517985179951804517915179251793
Agreement State
Event Number: 51798
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: HESEK & KEPES RADIATION ONCOLOGY
Region: 1
City: PLANT CITY State: FL
County:
License #: 4302-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DANIEL MILLS
Licensee: HESEK & KEPES RADIATION ONCOLOGY
Region: 1
City: PLANT CITY State: FL
County:
License #: 4302-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 17:33 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/17/2016
Notification Time: 17:33 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following was received from Florida via email:
"On Tuesday March 15, 2016, a patient being treated for skin cancer on the right side of his mandible using a Valencia applicator was treated using the plan time from another patient who is being treated for the left leg also using a Valencia applicator. The short fall difference in time was 8.2 seconds, meaning that the patient treated for the right mandible was given 3.2% less radiation than what was correctly calculated for.
"As a plan of action, the patient as well as the attending physician will be notified of the occurrence, and a 'time-out' policy will be implemented for all HDR [high does rate brachytherapy] treatments to ensure that the correct patient, date of birth, patient number, plan number, date of the plan, and treatment location are being treated prior to the actual treatments. A policy will be formally drafted to this effect and placed into the departmental policy and procedures manual.
"[The prescribing physician] will decide whether or not to make up the short fall in the treatment dose after consultation with the patient."
Florida Incident # FL16-043
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 was received from Florida via email:
"On Tuesday March 15, 2016, a patient being treated for skin cancer on the right side of his mandible using a Valencia applicator was treated using the plan time from another patient who is being treated for the left leg also using a Valencia applicator. The short fall difference in time was 8.2 seconds, meaning that the patient treated for the right mandible was given 3.2% less radiation than what was correctly calculated for.
"As a plan of action, the patient as well as the attending physician will be notified of the occurrence, and a 'time-out' policy will be implemented for all HDR [high does rate brachytherapy] treatments to ensure that the correct patient, date of birth, patient number, plan number, date of the plan, and treatment location are being treated prior to the actual treatments. A policy will be formally drafted to this effect and placed into the departmental policy and procedures manual.
"[The prescribing physician] will decide whether or not to make up the short fall in the treatment dose after consultation with the patient."
Florida Incident # FL16-043
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.
Agreement State
Event Number: 51799
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ALPHA-OMEGA SERVICES, INC.
Region: 4
City: VINTON State: LA
County:
License #: LA-10025-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DANIEL MILLS
Licensee: ALPHA-OMEGA SERVICES, INC.
Region: 4
City: VINTON State: LA
County:
License #: LA-10025-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 17:28 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 03/17/2016
Notification Time: 17:28 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - RADIOACTIVE SOURCE SHIPMENT IN EXCESS OF LICENSED QUANTITY
The following was received from Louisiana via email:
"On 03/16/2016, the RSO for A&O [Alpha Omega] called in a report of a HDR [high does rate brachytherapy] source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025.
"[The RSO] was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care.
"A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at [1700 EDT] on 03/15/2016 to report the error.
"The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier"
A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated.
Louisiana incident # LA-160005
The following was received from Louisiana via email:
"On 03/16/2016, the RSO for A&O [Alpha Omega] called in a report of a HDR [high does rate brachytherapy] source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025.
"[The RSO] was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care.
"A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at [1700 EDT] on 03/15/2016 to report the error.
"The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier"
A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated.
Louisiana incident # LA-160005
Agreement State
Event Number: 51804
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENN STATE HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: PA-0127
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DANIEL MILLS
Licensee: PENN STATE HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: PA-0127
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/18/2016
Notification Time: 11:43 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/18/2016
Notification Time: 11:43 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following was received from Pennsylvania via email:
"On March 15, 2016 a written directive for 18.1 mCi of yttrium-90 (Y-90) was written by the authorized user (AU) and referring physician for this procedure. The entire content of the syringe was injected and the residual activity in the vial measured 13.3 mCi, or 73.5% of the prescribed dose. No harm is expected to the patient.
"A different AU wrote the initial written directive based on incorrect dose calculation. The discrepancy was not realized until after the administration was completed.
"A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt."
PA Incident # PA160010
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 was received from Pennsylvania via email:
"On March 15, 2016 a written directive for 18.1 mCi of yttrium-90 (Y-90) was written by the authorized user (AU) and referring physician for this procedure. The entire content of the syringe was injected and the residual activity in the vial measured 13.3 mCi, or 73.5% of the prescribed dose. No harm is expected to the patient.
"A different AU wrote the initial written directive based on incorrect dose calculation. The discrepancy was not realized until after the administration was completed.
"A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt."
PA Incident # PA160010
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.
Agreement State
Event Number: 51791
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: GEOTEST ENGINEERING, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: L02735
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVEN VITTO
Licensee: GEOTEST ENGINEERING, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: L02735
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/15/2016
Notification Time: 10:36 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 03/15/2016
Notification Time: 10:36 [ET]
Event Date: 03/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 03/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (FAX)
ILTAB (EMAI)
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (FAX)
ILTAB (EMAI)
AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE
The following information was obtained from the State of Texas via email:
"On March 15, 2016, the licensee notified the Agency [Texas Department of State Health Services] that one of its technicians had stopped by an apartment complex on his way to a temporary job site and had left a Troxler model 3430 moisture/density gauge (SN: 63944) secured with 2 chains in the back of the company truck while he went inside an apartment. When he returned to his vehicle, he found that the chains had been cut, the transport case was on the ground near the vehicle, and the gauge had been removed. The licensee's radiation safety officer reported that the insertion rod on the gauge was locked and the technician had the key. The RSO notified local law enforcement and searched the immediate area. They will continue and expand their search for the gauge. The gauge contained a 40 milliCurie americium-241 source and an 8 milliCurie cesium-137 source. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: I-9386
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 information was obtained from the State of Texas via email:
"On March 15, 2016, the licensee notified the Agency [Texas Department of State Health Services] that one of its technicians had stopped by an apartment complex on his way to a temporary job site and had left a Troxler model 3430 moisture/density gauge (SN: 63944) secured with 2 chains in the back of the company truck while he went inside an apartment. When he returned to his vehicle, he found that the chains had been cut, the transport case was on the ground near the vehicle, and the gauge had been removed. The licensee's radiation safety officer reported that the insertion rod on the gauge was locked and the technician had the key. The RSO notified local law enforcement and searched the immediate area. They will continue and expand their search for the gauge. The gauge contained a 40 milliCurie americium-241 source and an 8 milliCurie cesium-137 source. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: I-9386
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: 51792
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/15/2016
Notification Time: 15:14 [ET]
Event Date: 03/15/2016
Event Time: 06:49 [CDT]
Last Update Date: 03/15/2016
Notification Time: 15:14 [ET]
Event Date: 03/15/2016
Event Time: 06:49 [CDT]
Last Update Date: 03/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
ROBERT ORLIKOWSKI (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Refueling |
IDENTIFIED PRESSURE BOUNDARY LEAKAGE
"During a scheduled refueling outage, an inspection of containment components revealed a suspected through wall leak on 1CV-200B, Letdown Orifice 'B' Outlet Control. Non-destructive engineering inspection has been completed and determined that an indication exists.
"10 CFR 50.2(2)(i) defines the reactor coolant pressure boundary as being connected to the reactor coolant system, up to and including the outermost containment isolation valve in system piping which penetrates primary reactor containment. 1CV-200B is isolable from the Reactor Coolant System (RCS) by a single motor operated valve, 1RC-427, Reactor Coolant Loop 'B' Leg to CVCS Letdown Isolation valve.
1CV-200B is located inside of containment between 1RC-427 and the two containment isolation valves for the letdown line, 1CV-371 and 1CV-371A. Based on the definition provided in 10 CFR 50.2, the condition is considered pressure boundary leakage and is considered reportable under 10 CFR 50.72(b)(3)(ii).
Unit 1 is currently in Mode 6. Repairs for the condition are being determined.
The NRC Resident Inspector has been notified.
"During a scheduled refueling outage, an inspection of containment components revealed a suspected through wall leak on 1CV-200B, Letdown Orifice 'B' Outlet Control. Non-destructive engineering inspection has been completed and determined that an indication exists.
"10 CFR 50.2(2)(i) defines the reactor coolant pressure boundary as being connected to the reactor coolant system, up to and including the outermost containment isolation valve in system piping which penetrates primary reactor containment. 1CV-200B is isolable from the Reactor Coolant System (RCS) by a single motor operated valve, 1RC-427, Reactor Coolant Loop 'B' Leg to CVCS Letdown Isolation valve.
1CV-200B is located inside of containment between 1RC-427 and the two containment isolation valves for the letdown line, 1CV-371 and 1CV-371A. Based on the definition provided in 10 CFR 50.2, the condition is considered pressure boundary leakage and is considered reportable under 10 CFR 50.72(b)(3)(ii).
Unit 1 is currently in Mode 6. Repairs for the condition are being determined.
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 51793
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ECS-FLORIDA, LLC
Region: 1
City: TAMPA State: FL
County:
License #: 3440-3
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: HOWIE CROUCH
Licensee: ECS-FLORIDA, LLC
Region: 1
City: TAMPA State: FL
County:
License #: 3440-3
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/15/2016
Notification Time: 19:43 [ET]
Event Date: 03/15/2016
Event Time: 07:25 [EDT]
Last Update Date: 03/15/2016
Notification Time: 19:43 [ET]
Event Date: 03/15/2016
Event Time: 07:25 [EDT]
Last Update Date: 03/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
FLORIDA AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE
The following information was obtained from the State of Florida via email:
"[A licensee] employee left the shop this morning at 7:25 a.m. [EDT] in a pick up truck. The soil moisture density gauge was locked but not chained and locked to bed of pick up truck. [The] employee drove about one mile to [the] job site and upon arrival realized the gauge was missing. Multiple employees retraced the route to try and find the gauge but could not find it. The RSO [Radiation Safety Officer] notified local law enforcement and fire department. The RSO noted the gauge is an InstroTek 1955 Explorer 3500, sources serial number is CZ6000; 267-14 and estimated current activity is 40 mCi of Am241 and 10 mCi of Cs137. Incident report from RSO to follow."
Florida Incident Number: FL16-040
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 information was obtained from the State of Florida via email:
"[A licensee] employee left the shop this morning at 7:25 a.m. [EDT] in a pick up truck. The soil moisture density gauge was locked but not chained and locked to bed of pick up truck. [The] employee drove about one mile to [the] job site and upon arrival realized the gauge was missing. Multiple employees retraced the route to try and find the gauge but could not find it. The RSO [Radiation Safety Officer] notified local law enforcement and fire department. The RSO noted the gauge is an InstroTek 1955 Explorer 3500, sources serial number is CZ6000; 267-14 and estimated current activity is 40 mCi of Am241 and 10 mCi of Cs137. Incident report from RSO to follow."
Florida Incident Number: FL16-040
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