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Event Notification Report for March 19, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/18/2014 - 03/19/2014

** EVENT NUMBERS **


49885 49886 49887 49892 49896 49897 49899 49927 49928

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Agreement State Event Number: 49885
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DE-RAY ENGINEERING, INC.
Region: 4
City: LAKEWOOD State: CO
County:
License #: CO 1097-01
Agreement: Y
Docket:
NRC Notified By: JIM GRICE
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/10/2014
Notification Time: 10:57 [ET]
Event Date: 03/10/2014
Event Time: 05:30 [MDT]
Last Update Date: 03/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The following was received from the State of Colorado via email:

"At appx. 5:30 MST on 3/10/14 the licensee's employee noticed that the window in his vehicle had been broken and the contents stolen. This included a CPN Model MC-1-DR portable nuclear gauge (Serial Number : MD10800432) containing two licensed sources (10 mCi Cs-137 and 50 mCi Am:Be).

"The vehicle was parked at the employees residence. The gauge was contained within a locked transport container. Although, the vehicle was locked there was no secondary tangible barrier preventing unauthorized removal of the gauge.

"The event was reported to the Wheatridge police on the morning of 3/10/14 and to the Colorado Department of Public Health and Environment at appx. 8:15 a.m. MST 3/10/14.

"The Colorado Department of Public Health and Environment received a follow up call at appx. 11:00 a.m. MST 3/10/14, indicating that the gauge was located by a member of the public and recovered by the licensee.

"The gauge was still in the locked transport container when it was recovered and there was no signs of damage to the case or indications that an attempt was made to open the case.

"A site visit will be conducted by a Colorado Department of Public Health and Environment inspector to interview staff and complete the investigation of the incident in the near future."

Event Report ID Number: CO14-I14-03

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: 49886
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: AMERICAN XRAY AND INSPECTION SERVICES, INC.
Region: 4
City: MIDLAND State: TX
County:
License #: 05974
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/10/2014
Notification Time: 11:14 [ET]
Event Date: 03/06/2014
Event Time: 15:45 [CDT]
Last Update Date: 03/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following was received from the State of Texas via email:

"On March 10, 2014, the Agency [State of Texas] received notice of a radiography source disconnect that occurred on March 6, 2014. The source was a 92.2 curie iridium-192 radiography source. The event occurred at a temporary field site just south of the border with New Mexico near Carlsbad, NM on the Texas side. No exposures to the public resulted from this event. No overexposures resulted from this event. The cause of the event is unknown at this time. The source was retrieved by the licensee. The licensee's initial report to the Agency [State of Texas] was later than 24 hours after the event. Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident #: I-9163

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Agreement State Event Number: 49887
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2885
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/10/2014
Notification Time: 12:21 [ET]
Event Date: 02/27/2014
Event Time: [EDT]
Last Update Date: 03/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 ADMINISTRATION TO LIVER

The following was received from New York City Bureau of Rad Health via email:

"[A] patient was receiving treatment of left lobe of liver with Y-90 Sir Spheres. Half way through the procedure the catheter became clogged. 30 mCi of Y-90 was prescribed, only 22.5 mCi was delivered. 7.5 mCi remained in the catheter. [The] initial report stated that treatment of right lobe of liver had been scheduled for April. [The] initial report stated that Physician decided to treat left lobe of liver with makeup dose of 7.5 mCi Y-90 at that time.

"[The] ORH [Office of Radiological Health] inspector stated that multiple attempts were made to flush the catheter without success. The catheter was removed and the remainder of the dose was administered at the date of the initial clog with a micro-catheter.

"[The] physician spoke to the vendor rep (company SureFire). [The] company stated that cause of the clog would be investigated when the Y-90 had decayed.

"[The] referring physician was notified.

"[This] incident is considered a reportable medical event because the administered dose differed from the prescribed dose by >20%.

"[The] hospital states that if any future incidents such as this equipment malfunction occurs, they will keep the patient in treatment position to determine by measurement if proper dosage was delivered. If measurements indicate that inadequate dosage was delivered, they will draw another dose to supplement the original administration until the appropriate dose is administered to the patient."

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: 49892
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ABINGTON MEMORIAL HOSPITAL
Region: 1
City: ABINGTON State: PA
County:
License #: PA-0055
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/11/2014
Notification Time: 09:40 [ET]
Event Date: 03/10/2014
Event Time: [EDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
FSME RESOURCES GROUP (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTIUM-90

The following information was provided by the State of Pennsylvania via email:

"Event type: [On March 10, 2014], A medical event involving the administration of yttrium-90 (Y-90) SirSpheres which is reportable under 10CFR35.3045(a)(3). Specifically, the licensee reported that an unintended organ received, as of yet, an undetermined dose during a prescribed treatment.

"Notifications: On March 10, 2014, the Department [PA Department of Environmental Protection] received notification about this medical event.

"Event Description: The patient underwent a Y-90 microsphere treatment. A gastric ulcer developed seemingly as a result of spheres migrating to the stomach.

"Cause of the Event: Non-target flow of microspheres through an aberrant hepatic arterial vasculature supplying the stomach.

"Actions: Details of the event are being developed. Further information will be given when received. The Department plans to do a reactive inspection."

PA Report ID NO: PA-140007

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: 49896
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: TRONOX LLC
Region: 4
City: HAMILTON State: MS
County:
License #: MS-149-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/11/2014
Notification Time: 13:40 [ET]
Event Date: 12/17/2013
Event Time: [CDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON FIXED INDUSTRIAL GAUGE WAS BROKEN IN THE OPEN POSITION

The following was received from the State of Mississippi via email:

"[The] shutter on Ohmart SH-F2 fixed gauge, (sealed source Ohmart Model A-2102, sealed source serial number 2597CG, source holder model SHF-2-45) was broken in the 'open' position. Source holder shielded, removed from location and transferred to source storage location where repairs could be made by Vega Americas. After repair, gauge returned to safe operation on 3/7/14."

The gauge contains 200 mCi of Cs-137.

Mississippi Report Number: MS-14001

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Agreement State Event Number: 49897
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: TRONOX LLC
Region: 4
City: HAMILTON State: MS
County:
License #: MS-149-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/11/2014
Notification Time: 14:00 [ET]
Event Date: 03/03/2014
Event Time: [CDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED INDUSTRIAL GAUGE

The following was received from the State of Mississippi via email:

"[The] licensee reported a stuck shutter on an Ohmart Model SH-F2 level gauge, Source Holder Model No. SH-F2-30, during maintenance work to repair the gauge detector. The failure was identified on 3/3/2014 by the licensee while preparing/isolating the gauge for work to be performed on the gauge detector. A Vega Americas service engineer was on site at the time to complete the repair of the shutter mechanism. The shutter failure was identified to be caused from age and oxidation."

The gauge contains 200 mCi of Cs-137.

Mississippi Event Report Number: MS-14002

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Agreement State Event Number: 49899
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PARADIGM CONSULTANTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 04875
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/11/2014
Notification Time: 21:43 [ET]
Event Date: 03/11/2014
Event Time: [CDT]
Last Update Date: 03/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email from the State of Texas:

"On March 11, 2014, the Agency [Texas Department of State Health Services] was notified of the theft of a Humboldt model 5001EZ moisture density gauge containing an americium-241 source and a cesium-137 source by the licensee. The licensee did not know the activity of the sources. The licensee stated a technician was working at a job site taking measurements every thirty minutes. The technician placed the gauge on the bed of their truck after taking a reading and left it there to talk to the site foreman. When they came back to the truck the gauge was missing. The technician and site foreman looked for the gauge, but did not find it. The technician notified his supervisor who notified the licensee's Radiation Safety Officer. The licensee stated they intend to notify the service providers they use of the theft. The licensee stated the operating rod for the cesium source was locked. Additional information will be provided as it is received in accordance with SA-300."

* * * UPDATE FROM TUCKER TO KLCO ON 3/12/14 AT 0908 EDT VIA EMAIL * * *

"On March 12, 2014 at 0745 [CDT], the Agency was notified by the licensee that the moisture density gauge had been recovered. The licensee had limited information on how the gauge was located and stated they will provide additional information as soon as it can be collected and verified. It did not appear to the licensee that any member of the general public received a significant exposure due to this event. Additional information will be provided to the HOO as it is received in accordance with SA-300."

Notified the R4DO(Farnholtz), FSME Events Resource via email and Mexico.

Texas Incident # I-9166

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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Power Reactor Event Number: 49927
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: TIMOTHY JONES
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2014
Notification Time: 17:09 [ET]
Event Date: 03/17/2014
Event Time: 10:18 [EDT]
Last Update Date: 03/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Shutdown 0 Cold Shutdown
4 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER HABITABILTY IMPACTED DUE TO LOSS OF AIR CONDITIONING

"At approximately 1018 EDT on March 17, 2014, during a check of facility equipment, the Technical Support Center (TSC) was found to be degraded due to the loss of the air conditioning (AC) system. Due to the loss of AC, TSC habitability is impacted.

"The emergency assessment function can be performed in the control room as addressed in emergency response procedures. This event is reported in accordance with 10 CFR 50.72(b)(3)(xiii).

"This condition is common to both units.

"Unrelated to this condition, Unit 3 is currently in the process of shutting down in preparation for a refueling outage.

"Unit 4 will remain Mode 1, 100% Power.

"The TSC AC system repairs are in progress."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE AT 0359 EDT ON 3/18/14 FROM PELL TO SNYDER * * *

The TSC AC system has been repaired and restored to service. The licensee will notify the NRC Resident Inspector.

Notified R2DO (O'Donohue).

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Power Reactor Event Number: 49928
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: BILL BALL
HQ OPS Officer: PETE SNYDER
Notification Date: 03/19/2014
Notification Time: 03:07 [ET]
Event Date: 03/18/2014
Event Time: 22:52 [CDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 35 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DUE TO FAILURE TO CONTROL MAIN TURBINE MOISTURE SEPARATOR LEVEL

"At 2252 on 03/18/2014, the Unit 3 reactor automatically scrammed due to a turbine trip from a high Main Turbine moisture separator level. Initial indications show the level controller for 3B2 Moisture Separator failed to adequately maintain level. Additionally local manual control attempts failed to restore moisture separator level. Main Steam Isolation Valves remained open with main turbine bypass valves controlling reactor pressure. Reactor feedwater pumps are in service to control reactor water level.

"Primary Containment Isolation System Groups 2, 3, 6 and 8 containment isolation and initiation signals were received. Upon receipt of these signals all required components actuated as required. Neither High Pressure Coolant Injection nor Reactor Core Isolation Cooling initiation signals were received.

"The reactor had been operating near 35% power during scheduled power ascension.

"This event is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"NRC Resident Inspector has been notified."

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