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Event Notification Report for November 7, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/06/2013 - 11/07/2013

** EVENT NUMBERS **


49483 49484 49485 49488 49499 49507 49509 49510

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Non-Agreement State Event Number: 49483
Rep Org: AIR FORCE MASTER MATERIAL LICENSE
Licensee: AIR FORCE MASTER MATERIAL LICENSE
Region: 1
City: FORT MEADE State: MD
County:
License #: 42-23539-01AF
Agreement: Y
Docket: 30-28641
NRC Notified By: MAJOR EDWARD KELLY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/29/2013
Notification Time: 13:50 [ET]
Event Date: 10/17/2013
Event Time: 08:00 [EDT]
Last Update Date: 10/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES DRAKE (R4DO)
MATTHEW HAHN (ILTA)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LOST GENERAL LICENSE DEVICE CONTAINING A NICKEL 63 SOURCE

"On January 20, 2012, leak tests were conducted on all [Air Force] BE's [Bioenvironmental Engineering] APDs [air particulate detectors] with the expectation of disposing them to AFRRAD [Air Force Radioactive Recycling and Disposal]. The APDs were placed in storage at the BE office (Bldg 3423) awaiting sample results and direction from AFRRAD. At the time, AFRRAD had a backlog in workload and were not receiving GLDs [general license devices]. During a GLD program review on Oct.17, 2013, BE determined that the GLD, a Smith's Detection APD-2000 (ECN: 0300069, SN: 4150) was missing and likely disposed via DRMO [Defense Reutilization and Marketing Office]. A records search commenced immediately.

"In April 2013, a SSgt [Staff Sergeant] at 779 AMDS/SGPB began the equipment turn-in process on a GLD, a Smith's Detection APD-2000 (ECN: 0300069, SN: 4150). The GLD was turned over to 779 MDSS/MERC by another SSgt, via AF Form 601 and radiation leak sampling data for the item. Upon receipt of the GLD, MERC then turned it over to 779 MDSS/SGSM. On April 24, 2013, the GLD was removed from the BE Flight's Defense Medical Logistics Standard Support (DMLSS) account, and identified for 'turn-in to DRMO'.

"The SSgt [at 779 AMDS/SGPB], contacted the Defense Logistics Agency (DLA) warehouse at Ft. Meade on Oct. 23, 2013 [and] visited them in an effort to retrieve the missing GLD. DLA [Defense Logistics Agency] records management was overhauled shortly after the item was turned in, thus records relating to the GLD from the warehouse were unable to be furnished. Bioenvironmental Engineering's radiation detection equipment, a SAM940 & Victoreen 451P, were used but [the search] was unsuccessful in locating the GLD at the warehouse. DLA warehouse management has been instructed to immediately notify 779 AMDS/SGPB should the GLD be discovered at their location."

The licensee considers the device un-retrievable and has contacted NRC R4 (Cook).

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

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Agreement State Event Number: 49484
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNIVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DARREN PERRERO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/30/2013
Notification Time: 14:36 [ET]
Event Date: 10/29/2013
Event Time: [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE ()

Event Text

ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE TO A PATIENT

The following report was received from the Illinois Emergency Management Agency via e-mail:

"On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated.

"As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days."

The cause of this event was equipment failure.

Illinois Item Number: IL13032

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.

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Agreement State Event Number: 49485
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: ALLWEST TESTING & ENGINEERING
Region: 4
City: HAYDEN State: ID
County:
License #: 11-27637-01
Agreement: N
Docket: 03035139
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/30/2013
Notification Time: 14:21 [ET]
Event Date: 10/27/2013
Event Time: 11:25 [MST]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PORTABLE MOISTURE DENSITY GAUGE DAMAGED AT WORKSITE

The following report was received from the North Dakota Department of Health via e-mail:

"A portable moisture/density gauge possessed by ALLWEST Testing & Engineering, LLC of Hayden, Idaho containing a 10 mCi Cesium-137 sealed source and a 50 mCi Americium-241:Beryllium sealed source was crushed by a piece of heavy equipment (excavator bucket) at a temporary job site located southwest of Dickinson, North Dakota. The portable gauge user had failed to maintain constant surveillance of the gauge. Upon observing the heavy equipment running into the gauge, the user flagged down the heavy equipment operator to halt his activity. The operator lifted the bucket off the gauge and set it to the side. The gauge user instructed the operator to relocate to an area approximately 150 feet from the damaged gauge. Subsequently, he phoned his immediate supervisor and the Radiation Safety Officer (RSO) for guidance. An area at an approximate distance of 150 feet in three directions from the damaged gauge was roped off with 'Caution Radiation' tape. The fourth direction (east) consisted of a large hill of soil not readily accessible.

"1:02 PM (MST): The gauge user placed a call to the ND State Radio emergency response number to report the event.

"1:08 PM (MST): ND State Radio personnel notified the Stark County Emergency Manager (SCEM) who in turn notified the Southwestern District Health Unit Executive Officer (HUEO).

"1:10 pm (MST): The HUEO notified the ND Department of Health Radiation Control Program Manager (RCPM) of the event. The RCPM informed the HUEO the gauge should remain in place until radiation surveys had been performed and the site evaluated by his department.

"2:17 pm (MST): The HUEO and the SCEM were present at the event site. They met with the gauge user and the Westcon, Inc. HSE Coordinator for a briefing of the event. The HUEO performed an initial radiation survey using a calibrated SE International, Inc. Model Radiation Alert Inspector survey instrument (SN 35756). The survey was performed beginning at the outer boundary moving inwards toward the damaged gauge. The reading at a distance of 4 feet from the source was 0.063 mR/hr. The background reading was 0.013 mR/hr. The HUEO and SCEM instructed the gauge user to leave the gauge in place and wait for North Dakota Department of Health personnel to be on site the next morning to evaluate the site. Visual assessment of the gauge showed evidence of the two source housings to be physically intact.

"October 28, 2013:

"6:00 am (MST): As instructed by ALLWEST Testing & Engineering's RSO, the gauge user relocated the damaged gauge and associated fragments to the gauge transport case. The case was secured in the box of his pickup truck.

"9:00 am (MST): North Dakota Department of Health (NDDoH) personnel were on site to perform interviews, radiation surveys and evaluation of the site. Radiation surveys were performed by the NDDoH using a calibrated Ludlum Model 19 microR meter (SN 270378) and a Canberra Dineutron neutron meter (SN 18327). The background readings were 12 microR/hr and 0.027 mR/hr respectively. The highest gauge shipping container surface readings were 3.1 mR/hr (gamma) and 0.09 mR/hr (neutron). Surveys of the pathway from the initial impact of the bucket to the gauge's final resting spot revealed background readings. A leak test of the gauge was performed and shipped via overnight express for analysis. The leak test results demonstrated no leakage. The gauge was transported by licensee personnel back to their Idaho office to make arrangements for final disposal.

"Throughout the event, the gauge user had not worn personnel dosimetry. Exposure calculations will be performed by the RSO."

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Agreement State Event Number: 49488
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GB BIOSCIENCES CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: 03521
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2013
Notification Time: 15:46 [ET]
Event Date: 10/29/2013
Event Time: [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER STUCK IN THE OPEN POSITION

The following information was obtained from the State of Texas via email:

"On October 30, 2013, the Agency [Texas Department of Health] was notified by the licensee that while conducting routine maintenance checks on a Texas Nuclear model 5196 nuclear gauge containing a 20 milliCurie cesium137 source, the shutter was found stuck in the open position. The licensee lubricated the operating shaft and attempted to close and reopen the shutter. While attempting to reopen the shutter, the operating rod for the shutter broke. The licensee determined the gauge is in the open position, which is the normal operating position for the gauge. The licensee has contacted the gauge manufacturer and will either repair or replace the gauge. No individual received any additional exposure as a result of this event. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."

Texas Incident #: I-9132

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Power Reactor Event Number: 49499
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: SCOTT CIESFLEWICZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/04/2013
Notification Time: 09:15 [ET]
Event Date: 11/04/2013
Event Time: 07:28 [CST]
Last Update Date: 11/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTINE LIPA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled

Event Text

PLANNED MAINTENANCE ON THE PARTICULATE, IODINE, AND NOBLE GAS RADIATION MONITOR

"On November 4, 2013 at 0728 CST, the Kewaunee Power Station rendered the Auxiliary Building SPING [Particulate, Iodine, and Noble Gas] Radiation Monitor Mid and Hi ranges non-functional for planned maintenance. The Emergency Response Organization (ERO) has been notified of the Auxiliary Building SPING non-functionality.

"Work will be performed with high priority on a continuous schedule. The Auxiliary Building SPING is expected to be restored to functional at 1800 CST on November 6, 2013.

"This condition is being reported in accordance with 10CFR50.72(b)(3)(xiii) as an event that results in a major loss of emergency assessment capability (unable to sufficiently identify and classify an Emergency Action Level for off-site radiation conditions). The NRC Resident Inspector has been notified."


* * * UPDATE FROM GARY AHRENS TO DANIEL MILLS AT 1437 EST ON 11/06/13 * * *

The planned maintenance is complete and the Radiation Monitor was returned to service on 11/6/13 at 1010 CST.

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Duncan).

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Power Reactor Event Number: 49507
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: PETE SNYDER
Notification Date: 11/06/2013
Notification Time: 03:26 [ET]
Event Date: 11/06/2013
Event Time: 00:58 [CST]
Last Update Date: 11/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTINE LIPA (R3DO)

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 N 0 Defueled 0 Defueled

Event Text

R-21 CIRCULATING WATER DISCHARGE RADIATION MONITOR PLANNED OUTAGE

"When transferring power supplies to a non-safety related cooling tower bus for planned outage maintenance, R-21, the Circulating Water Discharge Radiation Monitor was removed from service at 0058 [CST] and returned to service at 0111 [CST]. There is no installed backup for R-21 which has an emergency response function to provide indication of gaseous liquid effluent release to the environment. This monitor has no compensatory measure that will allow timely classification of two NUE (Notification of Unusual Event) and Alert classifications when out of service. This resulted in a loss of emergency assessment capability while R-21 was out of service.

"There are no radioactive leaks that impact the Circulating Water System.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 49509
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MIKE WEISE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2013
Notification Time: 16:48 [ET]
Event Date: 11/06/2013
Event Time: 10:28 [EST]
Last Update Date: 11/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES NOGGLE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 98 Power Operation 98 Power Operation

Event Text

STACK RADIATION MONITORS REMOVED FROM SERVICE FOR PREPLANNED MAINTENANCE

"The Millstone Station stack radiation monitor, RM-8169, was removed from service for preplanned maintenance at 1028 [EST] and returned to service at 1513 [EST].

"The Unit 2 high range stack radiation monitor, RM-8168, was removed from service for preplanned maintenance at 1543 [EST] and will be removed from service for approximately 3 days."

The licensee has notified the NRC Resident Inspector and applicable state and local authorities.

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Power Reactor Event Number: 49510
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JEREMY SHARKEY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2013
Notification Time: 22:12 [ET]
Event Date: 11/06/2013
Event Time: 08:00 [EST]
Last Update Date: 11/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JAMES NOGGLE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

PROHIBITED ITEM FOUND IN THE PROTECTED AREA

"On November 6, 2013, at approximately 0800 hours [EST], a 40 oz. beer bottle containing what was believed to be 20 oz. of alcohol (beer) was discovered in the vicinity of the dilution plant trash raking system inside the protected area. The bottle was discovered during a routine tour and the finding was immediately reported to supervision. Based on the location of the bottle, the weathered condition of the bottle, and interviews with maintenance personnel who observed the bottle falling from the trash rake, it is known that the source of the bottle was the intake canal. The bottle was retrieved during automated raking evolutions and fell from the trash rake while the rake was in-transit to the dumpster. This report is submitted pursuant to 10 CFR 26.719 (b)(1) based on the presence of alcohol in the protected area."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, November 07, 2013
Thursday, November 07, 2013