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Event Notification Report for March 28, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2014 - 03/28/2014

** EVENT NUMBERS **


49930 49931 49936 49939 49963 49966

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Agreement State Event Number: 49930
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: TRIAD ISOTOPES
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NY STATE
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/19/2014
Notification Time: 15:08 [ET]
Event Date: 03/18/2014
Event Time: [EDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
JULIO LARA (R3DO)
FSME EVENTS RESOURCE ()

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

Event Text

AGREEMENT STATE NOTIFICATION - FOUND DEPLETED URANIUM SHIELD

The following was received from the State of New York via fax:

"On 3/18/2014 NYC sanitation workers clearing a vacant lot in Queens discovered one depleted uranium (DU) shield and the remains of 3 to 4 plastic outer-packs from Mallinckrodt manufactured Mo/Tc radiopharmaceutical generators. Information on the packaging indicates the generators were supplied to NYS Licensee C5413 Triad Isotopes in 2013. Discussions with Triad Isotopes on 3/19/2014 indicate that Mallinckrodt contacted them in October 2013 regarding a shipment of 5 spent generators being returned from Triad to Mallinckrodt via their contractor MDS [that] did not make it to Mallinckrodt in Missouri. The DU shield is being secured by NYC while waiting to be picked up by Triad. NRC Region 3 has been contacted. NYS Incident #1055"

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: 49931
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: CONFIDENTIAL
Region: 1
City: CONFIDENTIAL State: NY
County:
License #: CONFIDENTIAL
Agreement: Y
Docket:
NRC Notified By: FAX
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/19/2014
Notification Time: 16:03 [ET]
Event Date: 03/04/2014
Event Time: [EDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF IODINE-125 SOLUTION DURING BRACHYTHERAPY

The following information was received via facsimile:

"A patient was prescribed 50 Gray to be delivered to a brain tumor bed via a GliaSite balloon inflated with 200 mCi of I-125 saline solution implanted for 66 hours. Upon removal of the balloon on March 7, 2014, it was discovered that the balloon had not inflated and no dose to the tumor bed had been delivered.

"A three position stopcock was incorrectly positioned at the time of inflation and the I-125 saline solution was diverted to another syringe rather than to the balloon. All material is accounted for and is being held for DIS. The three position stopcock is not part of the vendor's kit.

"Corrective Actions: In-service by the vendor scheduled, revision of policies and procedures to include verification of balloon via medical imaging post-infusion, and in-service to staff on new policies and procedures."

NYS Incident: #1054

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: 49936
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL CORPORATION
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-1280
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/20/2014
Notification Time: 12:35 [ET]
Event Date: 02/13/2014
Event Time: [EDT]
Last Update Date: 03/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - COLLIMATOR BLOCK BROKEN OFF OF THE SHUTTER ASSEMBLY

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

Notifications: The [Pennsylvania Bureau of Radiation Protection] Department's Central Office was informed of this event on March 19, 2014. This event is reportable within 24-hours per 10 CFR 30.50(b)(2).

"Event Description: During a routine monthly inspection of the gauge, [the licensee] discovered that the collimator block had broken off of the shutter assembly. The collimator block was found lying in the quarter inch steel box that the gauge is housed in to protect it from the operating conditions on the battery. The cause of this event is still being investigated. Radiation surveys performed indicated no employees were exposed as a result of this event.

"Manufacturer: Thermo Measure Tech
Model: 5204
Serial Number: B392
Isotope: Cs-137
Activity: 4 Ci

"CAUSE OF THE EVENT: Unknown at this time.

"ACTIONS: The broken shutter mechanism was removed and replaced by a licensed service provider. The shutter mechanism was tested and confirmed as operating properly. The [State of PA] Department plans a reactive inspection.

"Media attention: None at this time."

PA Event Report ID No: PA140009

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Agreement State Event Number: 49939
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: INOVA FAIRFAX HOSPITAL
Region: 1
City: FALLS CHURCH State: VA
County:
License #: 610-116-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/20/2014
Notification Time: 17:31 [ET]
Event Date: 03/11/2012
Event Time: [EDT]
Last Update Date: 03/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - ERROR IN DOSE CALCULATION AND UNDERDOSE ADMINISTRATION

The following was received from the Commonwealth of Virginia via fax:

"Event description: On March 18, 2014, the licensee identified an error in a dose calculation for high dose rate (HDR) treatments administered to a patient on March 11-12. The initial report from the licensee indicates the patient was administered two out of a total of six prescribed fractionated doses. An error was made in planning the correct dwell position for the two fractions. The administered dose differed from the prescribed dose (was less than) by more than 20 percent. The licensee plans to correct for the underdose during the remaining fractions. The licensee is investigating if the dose to tissues other than the treatment site may have met the definition of a medical event."

Virginia Event Report ID No.: VA-14-0002

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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Power Reactor Event Number: 49963
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: CHRIS ROJAS
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/27/2014
Notification Time: 09:42 [ET]
Event Date: 03/27/2014
Event Time: 01:51 [CDT]
Last Update Date: 03/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
BILLY DICKSON (R3DO)

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

Event Text

FAILURE OF SECONDARY CONTAINMENT DOOR INTERLOCK

"At 0151 [CDT] on March 27, 2014, indication was received in the Control Room that two Secondary Containment doors, in the 2/3 Diesel Generator Interlock, were opened simultaneously. An equipment operator, in the field at the time of the event, reported that while opening the reactor building side interlock doors, individuals were able to open the diesel side interlock doors. The interlock mechanism preventing both doors from operating simultaneously did not operate as expected.

"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2, since two doors in a singular access opening were allowed to open. As a result, entry into Technical Specification 3.6.4.1 Condition A was made due to Secondary Containment being inoperable. The doors were open for approximately 5 seconds and were immediately secured. Secondary Containment differential pressure was maintained throughout the event.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(C) as a condition that could have prevented the fulfillment of a safety function.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49966
Facility: MILLSTONE
Region: 1 State: CT
Unit: [1] [2] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: PATRICK ANHALT
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/28/2014
Notification Time: 08:43 [ET]
Event Date: 03/27/2014
Event Time: 12:00 [EDT]
Last Update Date: 03/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

FITNESS FOR DUTY VIOLATION

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