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Event Notification Report for December 27, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/26/2013 - 12/27/2013

** EVENT NUMBERS **


49403 49649 49654 49655 49656 49658 49677

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Agreement State Event Number: 49403
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: IBA MOLECULAR NORTH AMERICA, INC
Region: 1
City: HAVERHILL State: MA
County:
License #: 41-0618
Agreement: Y
Docket:
NRC Notified By: EDWARD SALOMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 10/02/2013
Notification Time: 18:31 [ET]
Event Date: 10/02/2013
Event Time: 17:15 [EDT]
Last Update Date: 12/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOUCE (E-MA)

Event Text

AGREEMENT STATE REPORT - LEAKING CESIUM-137 CALIBRATION SOURCE

The Massachusetts Radiation Control Program provided the following report via facsimile:

"[The Massachusetts Radiation Control Program] Agency received a call from the licensee [stating] that a Cs-137 dose calibrator sealed source was leaking. This sealed source [has been] stored for a long time. [The] licensee performed a leak test today on the sealed source before the sealed source was going to be used. The leak test results indicated that [the source] was leaking and the activity reported was 0.3 microCuries of activity, which is above the regulatory reporting limit of 0.005 microCuries.

"The licensee provided the following information about the sealed source: original activity: 251 microCuries; Manufacture Date: 9/01/2011; and Source lD # 743-16-17. The leaking sealed source was never used and it was returned to storage for disposal. There was no personnel contamination or area contamination from this leaking source.

"The licensee will file a report to the Agency within 5 days of this leak test."

* * * UPDATE ON 11/04/13 AT 1128 EST FROM MASSACHUSETTS RADIATION CONTROL PROGRAM * * *

The Massachusetts Radiation Control Program provided the following information via e-mail:

A Licensee letter to Agency [Massachusetts Radiation Control Program] dated 10/7/13 contained updated source manufacture date and original activity information and confirmed contact made with manufacturer to arrange for return shipment of source for eventual disposal. On 11/4/13, upon Agency inquiry, the licensee stated that arrangements for return of source to manufacturer were progressing.

The original source strength was revised to 241 microCuries as of 9/01/03. The revised leak test results were 0.357 microCuries of activity.

The Agency considers this matter to still be OPEN pending confirmed return of source to manufacturer.

The R1DO (Noggle) notified. A copy of this update was provided to FSME Events Resource via e-mail.

* * * UPDATE AT 1159 EST ON 12/26/2013 FROM TONY CARPENITO TO MARK ABRAMOVITZ * * *

The Massachusetts Radiation Control Program provided the following information via e-mail:

"Source returned to manufacturer 12/12/13. The Agency [Massachusetts Radiation Control Program] considers this matter CLOSED.

"Additional Information: Model# RV-137; Manufacture Date 9/01/01; Original Activity 0.000251 Ci."

Notified the R1DO (Dwyer) and FSME Events (via e-mail).

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Agreement State Event Number: 49649
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN-KETTERING CANCER CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 12:22 [ET]
Event Date: 11/21/2013
Event Time: [EST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - HDR BRACHYTHERAPY SOURCE PLACED INCORRECTLY

"Description of incident: HDR brachytherapy treatment of the bronchial, tracheal area. The source was placed incorrectly, resulting in underdose to intended treatment area.

"An additional treatment fraction will be prescribed to compensate for underdose to intended treatment area. Underdose was discovered on 1st of 3 fractions, prior to delivery of 2nd fractions.

"Sequelea: No adverse effects expected as a result of medical event, since the patient is terminally ill.

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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Non-Agreement State Event Number: 49654
Rep Org: U. S. ARMY
Licensee: U. S. ARMY
Region: 1
City: FORT BRAGG State: NC
County:
License #: 21-32838-01
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 13:50 [ET]
Event Date: 12/13/2013
Event Time: 09:30 [EST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
KENNETH RIEMER (R3DO)
FSME EVENTS RESOURCE (EMAI)
BARRY WRAY (ILTA)

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

Event Text

STOLEN CHEMICAL AGENT MONITORS

The US Army in Warren, Michigan, reported that 3 improved chemical agent monitors were stolen from a storage facility at Fort Bragg, NC. Each of the 3 detectors contained a sealed 15 mCi Ni-63 source. The detectors were stored in building N-5342 and the locks on the building, storage area, and storage locker were damaged. The Fort Bragg Criminal Investigation Unit is conducting an investigation.

The US Army has also notified NRC Region 3.

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: 49655
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA DAVIS
Region: 4
City: SACRAMENTO State: CA
County:
License #: 1334
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 15:31 [ET]
Event Date: 12/18/2013
Event Time: [PST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)
BARRY WRAY (ILTA)
ANTHONY DIMITRIADIS (R1DO)

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

Event Text

AGREEMENT STATE REPORT - LOST MATERIAL SHIPMENT

An outgoing shipment of a Strontium (Sr-82, 23.6 mCi; Sr-85, 54 mCi) Generator, from the University of California Davis to Los Alamos, NM, cannot be located by the shipping company. Shipment tracking shows the items last seen in Memphis, TN. It is suspected the shipment is only temporarily misplaced due to holiday shipping traffic and the shipping company is continuing attempts to locate the shipment.

California Report #121713.

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

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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Agreement State Event Number: 49656
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: GE HEALTHCARE
Region: 3
City: ARLINGTON HEIGHTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/18/2013
Notification Time: 14:09 [ET]
Event Date: 12/16/2013
Event Time: [CST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (E-ma)
BARRY WRAY (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST VIAL OF THALLIUM-201

"The Radiation Safety Officer at GE Healthcare (Mediphysics) [IL-01109-01] Arlington Heights, IL called the Agency [IL Emergency Management Agency] on December 18, 2013 to report an incident concerning an over pack shipment intended for their pharmacy in Atlanta, Georgia. On Sunday December 15, a package containing 12 shielded vials of TL-201, 31 milliCi each, was transferred to Delta Airlines Freight services at Chicago's O'Hare international airport for shipping to Atlanta. The package arrived at Atlanta's Hartsfield International Airport the next day and was unloaded. However during the trip from the air plane cargo hold to the freight hub, the package tumbled off the conveyance and was broken open. This occurred on Sunday night, December 16. That night and the next morning a 3rd party contractor hired by the airlines/airport collected the vials and its packaging and placed the material into an over pack and secured the drum until it could be claimed by GE Healthcare. Based on the description and measurements performed by the company which were provided to GE Healthcare, it appeared none of the glass vials within their shielded containers were broken. As such it was determined that the vials were to be repackaged and forwarded to the pharmacy for evaluation. When repackaging at the freight hub was attempted by the GE Atlanta pharmacist on Tuesday, December 17, it was confirmed that no contamination was present on the packaging or the interior containers, however, it became clear that only 11 of the 12 vials were present in the salvage drum, contrary to the contractor's initial assertions. GE Healthcare contacted the Georgia agreement state program regarding the matter. The contractor is conducting additional visual and radiological surveys of the tarmac and freight hub. As of today (12/18/13), calculations show that a single vial contains approximately 16 milliCi of TL-201. If intact and still shielded as the other vials which were found, GE Healthcare estimates that the vial would have a dose rate of approximately 350 microR/hr at one foot.

"A report on the matter from GE Healthcare is anticipated. They have indicated that they would keep us appraised of developments as this matter moves forward. The Agency has been in touch with a representative of the Georgia program regarding potential additional actions to recover the vial. Given the 72 hour half life of the material, there will be no TL-201 present within the next 30 days. Also given that no contamination was detected on the packaging and the other 11 containers of Tl-201 were found intact, there is reason to assume the missing container was still intact at the time of the accident and the search is being conducted accordingly."

Illinois Event Number: IL13036

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: 49658
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DOMTAR A.W., LLC
Region: 4
City: ASHTOWN State: AR
County:
License #: ARK-0354-0312
Agreement: Y
Docket:
NRC Notified By: KAYLA AVERY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 17:06 [ET]
Event Date: 12/18/2013
Event Time: [CST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MULTIPLE STUCK SHUTTERS AT A PAPER MILL PLANT

The following report was received via email:

"The following are the preliminary findings of the Arkansas Department of Health, Radioactive Materials Program, involving multiple stuck shutters at a paper mill plant.

"An onsite inspection of this licensee was conducted on December 17, 2013. During this inspection, it was discovered that since 2008, multiple shutters were found to have been stuck open and were not able to be locked out. Based on the records reviewed at the time of inspection, it appears that there were a total of 17 gauges with stuck shutters since May 2010. It appears at this time that all but nine (9) of these gauges have been repaired, dismounted and/or disposed. Currently, these nine gauges (9) are still in use with the shutters stuck in the open position. In accordance with RH-1502.f.2. (equivalent 10 CFR 30.50(b)(2)), each stuck shutter event should have been reported to the State of Arkansas within 24 hours. The licensee failed to notify the State of Arkansas of all of these events.

"The information concerning the 17 gauges is as follows:

Radionuclide Manufacturer Model # Activity

Cesium-137 Berthold LB 7440 50 mCi
Cesium-137 Berthold LB7440 100 mCi
Cesium-137 Berthold LB 7440 30 mCi
Cesium-137 Berthold LB 7440 250 mCi
Cobalt-60 Berthold LB 300L 0.2 mCi
Cobalt-60 Berthold LB 300L 0.5 mCi
Cobalt -60 Berthold LB 300L 0.19 mCi
Cobalt-60 Berthold LB 300L 0.7 mCi
Cobalt-60 Berthold LB 300L 4.14 mCi
Cobalt-60 Berthold LB 300L 0.46 mCi
Cobalt-60 Berthold LB 300L 1.8 mCi
Cobalt-60 Berthold LB 300L 1.51 mCi
Cesium-137 Berthold LB 330 24 mCi
Cobalt-60 Berthold LB 300L 1.8 mCi
Cobalt-60 Berthold LB 300L 0.46 mCi
Cobalt-60 Berthold LB 300L 1.51 mCi
Cobalt-60 Berthold LB 300L 0.22 mCi

"The licensee is in the process of submitting additional records. Information related to the gauge serial numbers and event date will be provided in another update. The Department is continuing to investigate and will provide updates as information is received."

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Power Reactor Event Number: 49677
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JIM VAUGHN
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/26/2013
Notification Time: 16:29 [ET]
Event Date: 12/26/2013
Event Time: 13:01 [EST]
Last Update Date: 12/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 65 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO BLOWN FUSE

"On December 26, 2013 at 1301 EST, Nine Mile Point Unit 1 (NMP1) commenced a reactor shutdown in accordance with Technical Specification (TS) 3.2.7.c as a result of Main Steam Isolation Valve (MSIV) 111 being declared inoperable due to a surveillance test failure when power was lost to the control circuit. The cause of the power loss was a blown fuse due to a short in the test circuitry. TS 3.2.7.c requires that a normal orderly shutdown be initiated within one hour and have the reactor in cold shutdown condition within ten hours. The blown fuse was replaced, test circuit isolated, power to the control circuit restored and MSIV 111 was declared operable at 1549 EST. Power ascension is in progress."

Post maintenance operability test have been completed and the surveillance will be completed at a later time.

The licensee has notified the NRC Resident Inspector and the State of New York.

Page Last Reviewed/Updated Friday, December 27, 2013
Friday, December 27, 2013