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Event Notification Report for February 19, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/18/2014 - 02/19/2014

** EVENT NUMBERS **


49761 49811 49812 49815 49816 49817 49837 49838 49840

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Agreement State Event Number: 49761
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: POLAR CORPORATION
Region: 1
City: WORCESTER State: MA
County:
License #: G0118
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2014
Notification Time: 16:21 [ET]
Event Date: 01/23/2014
Event Time: [EST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING DEVICE CONTAINING AMERICIUM-241

The following information was obtained from the Commonwealth of Massachusetts via email:

"Immediate report in accordance with 105 CMR 120.281(A)(1) of missing device containing a 100 millicurie americium-241sealed source.

"After [a] billing inquiry by Massachusetts Radiation Control Program [the Program] [to] the licensee about generally licensed devices registered with [the] Program, the licensee reported on January 23, 2014 that one Industrial Dynamics Co., LTD Model FT-12 device [a fill level gauge], S/N 102282, containing a 100 millicurie americium-241 sealed source, cannot be located or is missing.

"The licensee informed the Program that the device is obsolete and has been out of service for about 15 years and may have been returned to manufacturer or might be in storage at licensee's facilities. The licensee informed [the] Program that it is making the effort of contacting a person that may have known about the device and is conducting a search of it's storage facilities.

"The Program notified the licensee of it's responsibility for providing [a] written report in accordance with the requirements of 105 CMR 120.281(B).

"Root cause and corrective actions are not known at this time and the Program intends to make site visit.

"This event remains open."

* * * UPDATE FROM ANTHONY CARPENITO TO CHARLES TEAL ON 2/18/14 AT 0828 EST * * *

The following information was obtained from the Commonwealth of Massachusetts via email:

"The Commonwealth of Massachusetts performed an on-site inspection on 2/17/14. Licensee has been in contact with the gauge manufacturer and has been searching numerous potential storage locations on licensee's property which covers multiple city blocks to determine possible long ago return to manufacturer or possible long-term on-site storage. There is no change in status and the device is still missing. The investigation is ongoing and the event remains OPEN."

Massachusetts Event Number: 14-1155

Notified R1DO (Krohn) and FSME Event Resource via email.

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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Non-Agreement State Event Number: 49811
Rep Org: US ARMY 20TH CBRNE COMMAND
Licensee: US ARMY 20TH CBRNE COMMAND
Region: 1
City: ABERDEEN State: MD
County:
License #: 19-31127-01
Agreement: Y
Docket:
NRC Notified By: SCOTT DAVIDSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/10/2014
Notification Time: 14:26 [ET]
Event Date: 02/10/2014
Event Time: [EST]
Last Update Date: 02/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ROBERT DALEY (R3DO)
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)
NICK TAYLOR (R4DO)

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

Event Text

SOURCE LOST DURING SHIPMENT

"A shipment of licensed material was shipped from our CBRNE Analytical and Remediation Activity, CARA, located in Pine Bluff, AR on 3 February 2014 was not received by the consignee, Frontier Technology Corporation, 1641 Burnett Drive, Xenia, OH 45385, [Ohio license # - 03214290000]

"The source, a 1.3 mCi Frontier Model 100 Cf-252 source Serial Number 4151, was shipped in a DOT Spec 7A Type A container. The transportation index on the package was 2.

"This was one of two items shipped from CARA, Pine Bluff, AR [scheduled to arrive on February 10, 2014]. The second source, serial number 4152, was received by Frontier Technology Corporation today along with an unrelated package containing what appeared to be environmental samples in a combination package."

Common Carrier has not claimed that they have lost physical control.

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: 49812
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: QUALSPEC, LLC., DBA TC INSPECTION LLC
Region: 4
City: RODEO State: CA
County:
License #: 5299-07
Agreement: Y
Docket:
NRC Notified By: KENT PENDERGAST
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/10/2014
Notification Time: 16:53 [ET]
Event Date: 02/09/2014
Event Time: 00:30 [PST]
Last Update Date: 02/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENT RESOURCES (EMAI)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LEFT UNATTENDED

The following Agreement State report was received via email:

"[The California Department of Health, Radiologic Health Branch] RHB Richmond received an incident report from the Qualspect Manager, via an email that a radiography camera had been left unattended. On February 9, 2014, between 0030 and 0245 [PST], Qualspect employees were conducting a radiography operation using [a camera containing an] Ir-192 104 Curie [source], camera s/n 4850, at the Valero Benicia Refinery. During the operation a few Qualspect rope [access] employees were in the area, their presence distracted the two radiographers thinking that another radiographer was in the area, so they left to process film. While the film was being processed, the camera was [left] dangling at 2 feet from the floor and unattended. A Valero Benicia Refinery employee discovered the suspended camera and brought it to the Qualspect employees' attention. Shortly thereafter, the Qualspect employees took possession of the camera."

The California RHB considers this a major event and is conducting an investigation. There were no personnel overexposures.

California Report #021014

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49815
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2014
Notification Time: 17:37 [ET]
Event Date: 01/24/2014
Event Time: [EST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING UNINTENDED DOSE

"During a liver radio embolization procedure with Y-90 SIRTEX Sir-Spheres on January 24, 2014 an unanticipated shunting occurred and was identified during the procedure. The procedure for the right liver lobe was stopped when the shunting was identified. The licensee runs contrast between vial doses to verify proper delivery of the microspheres. After imaging of the patient, the licensee determined on January 27, 2014 that the unintended dose to the gastric fundus was 11 Gray. The licensee reported the medical event to ODH BRP [Ohio Department of Health - Bureau of Radiation Protection] by telephone on February 11, 2014 at 3:30pm [EST].

"The referring physician and patient were notified on January 24, 2014. The patient is asymptomatic (no adverse effects) and is currently receiving medical monitoring."

Ohio Report #: OH140002


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: 49816
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS GROUP, INC.
Region: 4
City: BENICIA State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/11/2014
Notification Time: 18:03 [ET]
Event Date: 02/09/2014
Event Time: 10:35 [PST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LEFT UNATTENDED

The following Agreement State report was received via email:

"On February 10, 2014, [the California Department of Health, Radiologic Health Branch] RHB Richmond received a call from the MISTRAS Group RSO, indicating that a radiographer had inadvertently left behind a radiography camera when he drove off the parking lot at the Chevron Richmond Refinery. On February 9, 2014, at 1035 [PST] after the radiographer finished radiography using IR100 Camera containing 31 Curies Ir-192, s/n 6614, he left the radiography camera on the bumper of the truck; later, assuming that he left the camera inside the truck, he drove off and the camera fell onto the pavement. According to the radiographer, the camera was left unattended for a short period of time. Later, a Chevron Richmond employee noticed the camera in the parking lot and contacted the Chevron facility Manager. Chevron management contacted Mistras RSO and he drove to the refinery and took possession of the camera."

California Report #: 021014

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49817
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS GROUP, INC.
Region: 4
City: BENICIA State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/11/2014
Notification Time: 18:40 [ET]
Event Date: 02/09/2014
Event Time: 06:00 [PST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following Agreement State report was received via email:

"On February 10, 2014, [the California Department of Health, Radiologic Health Branch] RHB Richmond received a call from MISTRAS Group, Inc. RSO, regarding a source disconnect. On February 9, 2014, at 0600 [PST], during radiography at Chevron Refinery, using IR-100 camera, containing 31 Curies, Ir-192, s/n 6614, the source pigtail connector became disconnected from the drive cable. Following good health physics practices, the RSO retrieved and secured the source into the shielded position. Exposures to personnel [were] less than 50 millirem for this event."

California Report #: 021114

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Power Reactor Event Number: 49837
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: E. MICHAEL SOCHA
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/18/2014
Notification Time: 11:55 [ET]
Event Date: 02/18/2014
Event Time: 07:28 [EST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (R1DO)

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

Event Text

RADIATION MONITORS WILL BE REMOVED FROM SERVICE FOR PRE-PLANNED MAINTENANCE

"The four Main Steam Line Radiation Monitors 3MSS*RE75, 3MSS*RE76, 3MSS*RE77 and 3MSS*RE78 along with Terry Turbine Aux Feedwater Steam Exhaust Radiation Monitor 3MSS*RE79 will be removed from service to support a scheduled design change.

"This condition is reportable per 10CFR50.72(b)(3)(xiii).

"This equipment is expected to be restored to service within 72 hours."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 49838
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: SCOTT AREBAUGH
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/18/2014
Notification Time: 13:18 [ET]
Event Date: 02/18/2014
Event Time: 09:44 [CST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
HIRONORI PETERSON (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

Event Text

MOMENTARY LOSS OF SECONDARY CONTAINMENT

"At 0944 CST, on February 18, 2014, both doors in the Secondary Containment Airlock were opened concurrently. The doors being open at the same time caused a failure to meet SR 3.6.1.4.2 to verify that either the outer door(s) or the inner door(s) in each Secondary Containment access opening are closed. The identified condition caused Secondary Containment to be considered inoperable per TS LCO 3.6.1.4. Upon discovery, immediate action was taken to close the doors. This action allowed SR 3.6.4.1.2 to be met, and restored Secondary Containment to operable status.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(v)(C).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49840
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MARK S. SMITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/18/2014
Notification Time: 22:15 [ET]
Event Date: 02/18/2014
Event Time: 18:20 [CST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
HIRONORI PETERSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

MOMENTARY LOSS OF SECONDARY CONTAINMENT

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(C), Event or Condition that could have prevented fulfillment of a Safety Function needed to Control the Release of Radioactive Material. An employee entered a secondary containment [airlock] interlock and identified that both doors of the interlock opened simultaneously when the door on the reactor building side was opened. The employee immediately secured both doors in the interlock and notified the Main Control Room Supervisor. Both doors in the interlock were open for approximately 3 seconds. With both doors open, TS SR 3.6.4.1.2 was not met. This rendered secondary containment inoperable per TS 3.6.4.1. Reactor Building differential pressure, as observed in the Main Control Room, has remained less than -0.25 inches H2O at all times. Initial investigation determined that a mechanical interlock for the doors was malfunctioning. Administrative controls have been put in place to ensure the doors remain closed pending repairs to the mechanical interlock."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014