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Event Notification Report for April 10, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/09/2014 - 04/10/2014

** EVENT NUMBERS **


49946 49981 49983 49986 49989 50013 50015 50017

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 49946
Rep Org: BOZEMAN DEACONESS HOSPITAL
Licensee: BOZEMAN DEACONESS HOSPITAL
Region: 4
City: BOZEMAN State: MT
County:
License #: 25-10994-04
Agreement: N
Docket:
NRC Notified By: KARI CANN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/21/2014
Notification Time: 17:53 [ET]
Event Date: 09/09/2008
Event Time: [MDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

THREE MEDICAL MISADMINISTRATION INCIDENTS

During a recent review of historical records, it was determined that three medical misadministration incidents had occurred. Two of these incidents occurred on September 9, 2008 and the third incident occurred on September 30, 2008.

The patients were being treated for prostate cancer and were receiving I-125 brachytherapy. Two patients were each prescribed a source activity of 0.269 mCi but received 0.341 mCi. The third patient was prescribed 0.340 mCi but received 0.439 mCi.

The patients have been followed elsewhere for the last few years. The licensee will assess the patients as soon as they are available. The licensee is in the process of notifying the patients of the misadministrations.

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.

* * * RETRACTION AT 0835 ON 4/9/14 FROM KARI CANN TO PETE SNYDER * * *

The RSO for the hospital has reevaluated this report and has determined, in consultation with NRC Region IV, that due to a lack of complete information this report is retracted. If later, when more complete information is available it is determined that a report needs to be made it will be made at that time.

Notified R4DO (Drake) and FSME EVENT RESOURCE (email).

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Non-Agreement State Event Number: 49981
Rep Org: PATRIOT ENGINEERING AND ENVIRONMENT
Licensee: PATRIOT ENGINEERING AND ENVIRONMENT
Region: 3
City: TERRE HAUTE State: IN
County:
License #: 13-32725-01
Agreement: N
Docket:
NRC Notified By: KENNETH SULLIVAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/01/2014
Notification Time: 11:50 [ET]
Event Date: 04/01/2014
Event Time: 07:30 [EDT]
Last Update Date: 04/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVE PASSEHL (R3DO)
FSME EVENTS RESOURE (EMAI)
ILTAB (EMAI)

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

Event Text

THEFT OF SEAMAN MODEL C-200 NUCLEAR DENSITY GAUGE

A technician for Patriot Engineering and Environmental, Inc. took possession of a Seaman Model C-200 (Serial # L-102) nuclear density gauge on the evening of 3/31/2014 for use at a jobsite the next day. He secured the gauge in the back of his pickup truck with a chain and 3 padlocks. Two of the padlocks secured the gauge to the bed of the pickup truck and the third padlock secured the wrapped chain to the device. Between 0100 EDT and 0730 EDT on the morning of 4/1/2014, the gauge was stolen from the back of the pickup truck. Indianapolis Metro Police Department was contacted and they are investigating. The gauge contains 4.5 mCi of Radium 226 (Source Serial # B8633)

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: 49983
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BIG STATE X-RAY
Region: 4
City: ODESSA State: TX
County:
License #: L02693
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/01/2014
Notification Time: 15:47 [ET]
Event Date: 11/12/2013
Event Time: 09:30 [CDT]
Last Update Date: 04/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - CAMERA FAILED TO RETRACT SOURCE PROPERLY

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

"On March 26, 2014, the Agency [State of Texas - Department of State Health Services] received information that a source disconnect had occurred in November of the previous year. A subsequent report from the licensee received April 1, 2014 indicates that the disconnect occurred on November 12, 2013 at a temporary field site just west of Wink, Texas. The drive cable had become worn, allowing the source to be pushed out without being fully engaged with the pigtail. The source was pushed out of the guide tube but did not retract when the drive cable was cranked in. The camera was a QSA Model 880D S/N D6125, source QSA Global model A424-9 Ir-192 at 66.7 Ci, S/N 99589B. The source was recovered without further incident by attaching another drive cable. No exposure to the public resulted form this event. Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident Number: I-9174

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Agreement State Event Number: 49986
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GREATER BALTIMORE MEDICAL CENTER
Region: 1
City: BALTIMORE State: MD
County:
License #: 005-002-03
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/02/2014
Notification Time: 14:25 [ET]
Event Date: 04/01/2014
Event Time: 09:00 [EDT]
Last Update Date: 04/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - BROKEN I-125 SEED DURING IMPLANTATION

The following information was received from the State of Maryland via email:

"This is a synopsis of an I-125 seed breaking during an implant procedure at GBMC [Greater Baltimore Medical Center]. We [GMBC] will be meeting as a team to discuss corrective action and how to avoid something like this happening again.

"An I-125 implant was performed at GBMC Hospital on Tuesday, April 1, 2014. 78 Bard I-125 seeds, activity 0.319 mCi/seed, were ordered for the procedure, 71 seeds were used, and 70 seeds were confirmed after the procedure on CT evaluation in Radiation Oncology. The unused seeds (7.5 seeds) were returned to Radiation Oncology and recorded as per policy and procedure.

"The chief physicist and dosimetrist were called to Cysto at approximately 0900 EDT when the case was completed to [the attending physician's] satisfaction. Upon entry of the Cysto room [the attending physician] informed the physics staff that a seed had jammed in the Mick applicator and he had to use force to continue and complete the case.

"On arrival, the physics staff surveyed the patient 1 meter above the umbilicus and found 1.7 mR/hr reading using Model 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). The patient was removed from the OR and sent to recovery room.

"Upon additional survey of the room, it was discovered that a seed was fractured, when a portion of the seed was found on the sterile table. At that time, a thorough and complete area survey was performed. The reading was found to be 1.2 mR/hour on the table, trash, and blood drain. [A staff member] was called to bring an additional survey meter (Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13). All contaminated items were collected for proper storage in the hot lab in Radiation Oncology. All staff and personnel involved in the case were thoroughly monitored and cleared using 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). After the removal of the contaminated items the Cysto room was thoroughly monitored and clear of radiation contamination.

"The patient was then brought down to the Radiation Oncology department where a CT scan was performed to ensure seed count. VeriSeed program was used to confirm that the patient was implanted with 70 seeds.

"[The Chief Medical Physicist] contacted Bard to discuss the shattered seed. It was suggested that radiation oncology staff be monitored for thyroid uptake. Bioassay studies were thereby performed and the results were found to match background readings.

"On Wednesday, April 2, 2014, the patient's recovery area was scanned using Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13. A reading of 300 CPM was recorded. The background was also recorded to be 300 CPM. "

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Agreement State Event Number: 49989
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: INTERNATIONAL PAPER COMPANY
Region: 4
City: QUEEN CITY State: TX
County:
License #: 01686
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/02/2014
Notification Time: 17:21 [ET]
Event Date: 04/02/2014
Event Time: [CDT]
Last Update Date: 04/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON TWO NUCLEAR GAUGES

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

"On April 2, 2014, the licensee notified the Agency [Texas Department of Health] that earlier that morning, while it was doing lockouts on fixed nuclear gauges in preparation for the annual shutdown of its facility, the handles on two shutters broke. The handles sheared their roll pins. The two gauges are mounted on digesters and are used for level control. The licensee was able to close one of the shutters, but the other shutter remains stuck in the open position. There is no exposure risk to any person. The licensee contacted a service company and arrangements have been made for the company to come on-site and make repairs next week.

"Device #1 Information: Kay Ray, Model 7063, 1.5 curies cesium-137 (original activity in 1972)
"Device #2 Information: Kay Ray, Model 7063P, 1.0 curie cesium-137 (original activity in 1972)

"Further information will be provided per SA-300 as it is obtained."

Texas Incident #: I-9175

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Part 21 Event Number: 50013
Rep Org: UNITED CONTROLS INTERNATIONAL
Licensee: UNITED CONTROLS INTERNATIONAL
Region: 1
City: NORCROSS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KORINA LOOFT
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 13:37 [ET]
Event Date: 03/25/2014
Event Time: [EDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
RAY POWELL (R1DO)
MALCOLM WIDMANN (R2DO)
JAMES DRAKE (R4DO)
NRR PART 21 GROUP (EMAI)

Event Text

PART 21 - POTENTIAL DEFECT IN GENERAL ELECTRIC SB1 SWITCHES AND HEA RELAYS

The following is an excerpt from a fax received from United Controls International (UCI):

"The purpose of this letter is to provide the NRC with a report in general conformity of the requirements of 10CFR Part 21.21. On March 19, 2013, United Controls Issued an Interim letter regarding a discovered manufacturing change in the contact assembly of General Electric SBM series switches. Since 2009, the manufacturing process of the contact assembly of the SBM switch contacts has changed to have the whole assembly (contact holder and contact tip) tin plated. This was discovered while investigating an SBM switch that failed at a customer site due to high contact resistance across closed contacts. The finding that there was a manufacturing process change in the SBM switches lead to further discussions and evaluations regarding equipment of similar design. General Electric SB1 series switches and HEA series relays use the same contact arrangement design as the SBM series switches. The contact assemblies of the SB1 switches and HEA relays are subject to the same tin plating process of the contact assembly as previously reported on the SBM series switches.

"At this time, UCI is unable to evaluate if this manufacturing change may have an adverse effect on the capability of the General Electric SB1 switches and GE HEA relays to perform in their intended safety related application.

"UCI will notify the affected Utilities to our findings."

The affected Part Number, Utility, Order Number and Quantity is listed below:

Part Number 12HEA61B23SX2; Utility CFE; Order 700372018; Quantity 3
Part Number 12HEA61C236X2; Utility FPL Turkey Point; Order 02260642-34; Quantity 2
Part Number 12HEA61C237; Utility OPPD; Order 180520; Quantity 4
Part Number 12HEA61C238X2; Utility OPPD; Order 180520; Quantity 3
Part Number 12HEA61C237; Utility OPPD; Order 185929; Quantity 2
Part Number 12HEA61C237X2; Utility OPPD; Order 188314; Quantity 2
Part Number 12HEA63C239X2; Utility FPL St. Lucie; Order 02260642-41; Quantity 8
Part Number HEA61C234X2; Utility Antung; Order PP100204; Quantity 2
Part Number HEA61C244X2; Utility OPPD; Order 179664; Quantity 5
Part Number HEA61C241X2; Utility OPPD; Order 179664; Quantity 2
Part Number HEA63C239X2; Utility FPL St. Lucie; Order 02260642-103; Quantity 3
Part Number 12HEA61C238X2; Utility OPPD; Order 194686; Quantity 4
Part Number 16SB1BB339STS2P; Utility Duke Oconee; Order 156606; Quantity 11
Part Number 165BlFB2C85SWM2Y; Utility Nextera Seabrook; Order 2259825-3; Quantity 1
Part Number 16SB1LB2C01LSM2P; Utility CFE; Order 700327408; Quantity 3

Utility CFE is the Comisi¢n Federal de Electricidad (Mexico) and Utility Antung is located in Taiwan.

"If you have any questions or wish to discuss this matter or this report, please contact:

Jim Garrison
Engineering Manager, Seismic and Equipment Qualification
JGarrison@unitedcontrols.com
770-496-1406 X 103"

The 10CFR Part 21.21 received on March 19, 2014 is EN #49940.,

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Part 21 Event Number: 50015
Rep Org: QUALTECH NP
Licensee: QUALTECH NP
Region: 1
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MATTHEW THELEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 15:21 [ET]
Event Date: 04/09/2014
Event Time: [CDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MALCOLM WIDMANN (R2DO)
JAMES DRAKE (R4DO)
NRR PART 21 GROUP (EMAI)

Event Text

PART 21 - POTENTIAL DEFECT IN GENERAL ELECTRIC TYPE CR120AD CONTROL RELAYS

The following information was received via fax:

"This letter is being issued by QualTech NP, Huntsville, AL, to provide an initial notification to the Nuclear Regulatory Commission and Nebraska Public Power District [NPPD] Cooper Nuclear Station concerning a potential defect in General Electric Type CR120AD control relays. A failure analysis revealed that the most likely initiator of the failure was a flaw or defect in the start wrap of the magnet wire. The flaw created an arc that involved windings directly beneath the start wrap which resulted in an open circuit on the coil windings. This failure is classified as infant mortality, which is similar to the failure mode identified in the 10 CFR part 21 30 day report (accession number 9706190261) dated June 12, 1997 submitted by GPU Nuclear.

"Investigation of documents dating back to 1997 revealed that the manufacturer issued an informal recommendation to detect infant mortality in these relays by performing burn-in testing and mechanical cycle aging of the relay. QualTech NP, in conjunction with NPPD, determined that the risk of infant mortality can be mitigated by subjecting these relays to a 100 hour burn-in and performance of 100 mechanical cycles prior to installation.

"It has been confirmed that only two orders, with two units each, for this particular relay are affected. Both orders have been shipped to Nebraska Public Power District as requested by purchase orders 4500149953 and 4500142705. All subject relays shall be subjected to a 100 hour bum-in and exposed to 100 mechanical cycles or returned to QualTech NP for replacement.

"Additional details will be provided in the formal written report. Please contact Matthew Thelen at 256-924-7441 (office) or mthelen@curtisswright.com for additional information.

"Matthew Thelen
Project Manager
QualTech NP Huntsville Operations
a business unit of Curtiss-Wright Flow Control Company
http://qualtechnp.cwfc.com"

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Part 21 Event Number: 50017
Rep Org: BALDOR ELECTRIC CO.
Licensee: BALDOR ELECTRIC CO.
Region: 1
City: FLOWERY BRANCH State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES THIGPEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 15:19 [ET]
Event Date: 03/19/2014
Event Time: [EDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MALCOLM WIDMANN (R2DO)
PATTY PELKE (R3DO)
NRR PART 21 GROUP (EMAI)

Event Text

PART 21 - POTENTIAL DEFECT IN MOTORS SHIPPED TO DTE ELECTRIC COMPANY

The following is excerpted from a report received by fax:

"NUCLEAR NONCONFORMANCE REPORT

"1. CUSTOMER: DTE Electric Company, P.O. BOX 44440, DETROIT Ml 48244

"2. PURCHASE ORDER: 4700670925 - QTY 2

"3. PART/COMPONENT NAME: AC MOTORS

"4. PART/COMPONENT#: B1038686-010 T1/DTE P/N 100309425 and B1038686-010 T2/DTE P/N 100309425

"5. QUANTITY ON HAND - 1 SHIPPED- 2

"6. LOCATION OF ALL UNITS: Motor in service at DTE, Enrico Fermi Power Plant 2 (Qty 1) and at Baldor Gainesville Motor Plant (Qty 1)

"7. DATE NONCONFORMANCE ASCERTAINED: March 13, 2014

"8. DESCRIPTION OF DEFECT/NONCONFORMANCE: This is a reportable 10CFR21 notification because we believe it is possible that the B1038686-010 T1, 1E motor shipped by Baldor Electric, contains a design where the shaft journal is not long enough to allow the proper fit between the motor shaft and the o-ring of the inpro seal rotating element.

"The motor (Bl038686-010 T2) returned for evaluation under RA310488951 was in response to the inpro seal separating. Upon inspection Baldor has determined the shaft journal is not long enough to allow the proper fit between the motor shaft and the o-ring of the in pro seal rotating clement.

"9. CORRECTIVE ACTION TAKEN: Baldor has notified DTE Electric Company's Quality Assurance of our findings. Through them we have initiated replacement of the motor identified as located at DTE, Enrico Fermi Power Plant 2.

"A review was completed by design engineering to determine this design issue has only occurred for the Specification ID B1038686, of which Baldor has only shipped the 2 motors identified above. The design of the shaft/inpro seal fit has been completed to correct the issue.

"10. ANY ADVICE RELATED TO DEFECT/NONCONFORMANCE: Separation of the rotating element from the in pro seal obviously reduces the full effectiveness of the in pro seal. However, if this were to occur, the motor is still functional. Baldor has confirmed the motor with a failed inpro seal as received is still equivalent to IP55. Grease from the DE bearing will still be retained as intended, and water ingress into the motor would only occur if sprayed directly. Baldor recommends continued use of B1038686-010T1 until the next outage unless direct spray is expected. B1038686-010T2, which is currently in Baldor's possession, will be repaired by changing the rotating assembly. Baldor has notified DTE that we will be manufacturing a complete motor per the revised bill of material to replace B1038686-010T1 which is currently in service.

"11. INDIVIDUAL COMPLETING THIS REPORT: James Thigpen, QA Manager, Baldor Electric, Gainesville, GA 30506, April 09, 2014"

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