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Event Notification Report for November 26, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/25/2013 - 11/26/2013

** EVENT NUMBERS **


49542 49549 49555 49579

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Non-Agreement State Event Number: 49542
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARDS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/15/2013
Notification Time: 13:27 [ET]
Event Date: 11/14/2013
Event Time: 13:50 [EST]
Last Update Date: 11/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

Y-90 MICROSHPERE DOSE LESS THAN PRESCRIBED

"On the afternoon of 11/14/2013, a patient was scheduled for a Y-90 microsphere radioembolization treatment at Indiana University Medical Center under NRC License 13-02752-03. The treatment consisted of two separate doses of Y-90 for which two separate written directives were prepared. Segment 4 of the patient's liver was prescribed a dosage of 27.0 mCi, and the right lobe of the liver was prescribed a dosage of 88.0 mCi. At 13:50 on 11/14/2013, following measurement of the remaining activity after injection of the Y-90 microspheres, it was determined that a dose of 19.5 mCi was delivered to segment 4 (72.2% of the intended dose). Shortly thereafter, at 14:06, a dose of 87.5 mCi of Y-90 was delivered to the right lobe (99.4% of the intended dose).

"Both procedures appeared to proceed in accordance with standard operating procedures, and no abnormalities were identified during the procedure by the Interventional Radiology Physician or the Health Physicist supporting the procedure. Following the procedure, personnel and area surveys were performed using an SE International GM meter and no contamination of personnel, the room or equipment was identified. The container holding residual activity from the segment 4 treatment has been set aside for decay and further analysis.

"As the activity delivered to segment 4 of the liver meets the criteria in 10 CFR 35.3045(a)(1) and 10 CFR 35.3045(a)(1)(i), a report to the NRC Operations Center shall be made in accordance with 10 CFR 35.3045(c). The attending physician and patient will be contacted in accordance with 10 CFR 35.3045(e)."

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: 49549
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NICHOLS ALUMINUM ALABAMA
Region: 1
City: DECATUR State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/18/2013
Notification Time: 11:30 [ET]
Event Date: 11/14/2013
Event Time: [CST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

FIRE DAMAGE OF A GENERAL LICENSED DEVICE

"On the afternoon of November 15, 2013 at 1530 CST, the Alabama Office of Radiation Control was notified that on November 14, 2013 a coal bed fire occurred at Nichols Aluminum Alabama in Decatur, AL. This fire occurred in the vicinity of a general licensed radioactive material device causing damage to the device. The device was identified as an Accuracy model 7000M, serial number 4084600. The device contained a Sr-90 sealed source model USS-18, source serial number LB-650 with an original activity of 11.1 milliCurie. Initial action taken by the company was to restrict access around the device at a 100 feet radius. A consultant from Phillips Group evaluated the radiation hazard on November 16, 2013 taking radiation measurements and a leak test of the device. Preliminary test indicate that the sealed source capsule remained intact with no leakage. The device shutter could not be completely closed but the device has been secured and presents no hazard to workers. The general licensee plans to contract with the manufacturer to package and dispose of the device. The written report from the general licensee is pending."

Alabama Incident #13-52

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Agreement State Event Number: 49555
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: HALES SAND AND GRAVEL
Region: 4
City: RICHFIELD State: UT
County:
License #: UT 2100441
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/18/2013
Notification Time: 18:05 [ET]
Event Date: 11/14/2013
Event Time: 15:47 [MST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following was received via facsimile from the Utah Division of Radiation Control:

"The Operations Manager of Hales Sand and Gravel reported to the Division of Radiation Control that one of the licensee's gauge operators was at a temporary job site to perform soil moisture density measurements on November 14, 2013. After taking a moisture density measurement, the gauge operator left the gauge sitting on the ground while he walked away to talk to the roller operator. The gauge was left in the backing up path of Hales Sand Gravel's grader (heavy equipment) and was run over.

"After everyone was cleared out of the area, the Radiation Safety Officer of Jones & Demille Engineering was contacted to provide a survey instrument. At the time of the incident the radioactive sources were in the safe shielded position. After the gauge was run over, the gauge was broken into two pieces; the source rod was separated from the shielding block but was still in one piece. Upon arrival, the Radiation Safety Officer verified that the radioactive sources were still intact and attached to the source rod.

"The Radiation Safety Officer added additional shielding to the source rod to prevent the sources from becoming detached. The Radiation Safety Officer then put the damaged gauge and its pieces into the transportation container. After the gauge was loaded in the truck and removed from the job site, the Radiation Safety Officer performed a survey of the area the accident occurred at to verify that no contamination was present. No contamination was found, and the gauge was returned to its storage area in Elsinore, Utah.

"On November 15, 2013, the Division of Radiation Control's inspector arrived at Hales Sand and Gravel's facility at approximately 1230 [MST]. The inspector interviewed personnel involved in the accident and collected statements. The inspector took photographs of the damaged gauge, collected wipe tests, and took surveys of the damaged gauge. The inspector also visited the site of the accident to perform a contamination survey. No readings were distinguishable from background.

"Gauge information: Troxler 3430, s/n 31986"

Event Report ID Number: UT 130004

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Part 21 Event Number: 49579
Rep Org: ABB INC
Licensee: ABB INC
Region: 1
City: FLORENCE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAY LAVRINC
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/25/2013
Notification Time: 14:52 [ET]
Event Date: 11/25/2013
Event Time: [EST]
Last Update Date: 11/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DAN SCHROEDER (R1DO)
FRANK EHRHARDT (R2DO)
HIRONORI PETERSON (R3DO)
GREG PICK (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT - PRIMARY CLOSE LATCH FAILED TO MEET SPECIFICATION IN K-LINE CIRCUIT BREAKERS

The following is a summary of a fax received from ABB Inc.:

"[ABB Inc. is reporting a] failure to comply with specifications associated with primary close latch, part number 716611K02, used in K-Line 225 to 2000 amp continuous current low voltage electrically operated Model 7 circuit breakers. It does not affect previous models of these same breakers that have not been upgraded to include the interlocking primary and secondary close latches. It does not affect manually operated K-Line breakers or K3000/4000 circuit breakers."

Page Last Reviewed/Updated Tuesday, November 26, 2013
Tuesday, November 26, 2013