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Event Notification Report for June 17, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/16/2014 - 06/17/2014

** EVENT NUMBERS **


49895 50064 50135 50179 50181 50203

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Part 21 Event Number: 49895
Rep Org: ASCO VALVE INCORPORATED
Licensee: ASCO VALVE INCORPORATED
Region: 1
City: AIKEN State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB ARNONE
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/11/2014
Notification Time: 13:00 [ET]
Event Date: 03/11/2014
Event Time: [EDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - SCRAM SOLENOID PILOT VALVE NOT EXHAUSTING PROPERLY

The following was excerpted from a fax received from ASCO Valve, Inc.:

"Problem Description

"GE Hitachi Nuclear Energy (GEH) customer Energy Northwest reported that an ASCO scram solenoid pilot valve (SSPV) Catalog number HVL266000010J 115/60, GE-H part number 107E6022P014, serial number A272718-054, CRD-SPV-118/1043 did not exhaust properly. The valve had been installed in Energy Northwest's Columbia facility for approximately 7 months and had been cycled 60-70 times. Energy Northwest's internal investigation revealed the pilot head assembly spring was not in the groove of the associated core.

"Conclusion

"Various tests were performed to rule out possible manufacturing non-conformances in the spring or core. The successful completion of these tests has established that when the spring is properly installed on the core, the spring will not come off in service. We have not yet identified any other conditions that could cause the spring to come off the core, except for improper assembly.

"This configuration of spring and core design was used on the original 090405 scram valve. There has not been any design change to this core assembly since its inception in 1959. This spring/core assembly makes up the bulk of ASCO core solenoid offering. It is used across all of ASCO valve ranges in the Commercial, Nuclear, Military, and Petrochemical markets. ASCO has supplied over 10 million valves to these markets over the entire product offering. This Includes over 50,000 Nuclear Qualified Valves. With the exception of the 1994 and 2012 events, a review of ASCO return records found no other cases of this condition where a spring disengaged from the core.

"Since ASCO does not have adequate knowledge of the actual installations and operating conditions of these valves, it was not able to be determined if this could create a 'Substantial safety hazard' as defined in 10 CFR Part 21. This information is intended to provide interim investigation results.

"If you have any questions, you can contact Bob Arnone at 803-641-9395."

* * * UPDATE FROM LARS GACAD TO JOHN SHOEMAKER VIA FACSIMILE ON 6/16/14 AT 0855 EDT * * *

"Closure and Conclusion: Various tests were performed to rule out possible manufacturing non-conformances in the spring or core. The successful completion of these tests has established that when the spring is properly installed on the core, the spring will not come off in service. We have not yet identified any other conditions that could cause the spring to come off the core, except for improper assembly.

"This configuration of spring and core design was used on the original 090405 scram valve. There has not been any design change to this core assembly since its inception in 1959. This spring/core assembly makes up the bulk of ASCO core solenoid offering. It is used across all of ASCO valve ranges in the Commercial, Nuclear, Military, and Petrochemical markets. ASCO has supplied over 10 million valves to these markets over the entire product offering. This includes over 50,000 Nuclear Qualified Valves. With the exception of the 1994 and 2012 events, a review of ASCO return records found no other cases of this condition where a spring disengaged from the core. Since ASCO does not have adequate knowledge of the actual installations and operating conditions of these valves. It was not able to be determined if this could create a 'substantial safety hazard' as defined in 10 CFR Part 21. This information is intended to provide interim investigation results.

"If you have any questions, you can contact Bob Arnone at 803-641-9395."

Notified R4DO (Hay) and Part 21 Group via email.

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Agreement State Event Number: 50064
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: ELEKTA, INC.
Region: 1
City: NORCROSS State: GA
County:
License #: GA 1153-2
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/28/2014
Notification Time: 10:20 [ET]
Event Date: 04/24/2014
Event Time: [EDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
MARK HAIRE (R4DO)
FSME EVENTS RESOURSE (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT

The following information was received via E-mail:

"On the evening of April 24, 2014 Elekta, (Georgia license - GA 1153-2) working under a Nebraska reciprocity general license, was installing the initial source (9.98 curies of lr-192) into the new Flexitron unit at Saint Francis Medical Center (Nebraska Radioactive Material License # 08-09-01) in Grand Island, Nebraska. During the upload procedure, the source did not completely retract into the safe and became hung-up on the in-drive. The device gave an error stating the source was detached from the cable. Following the manufacturer's recommended emergency procedures, the engineer entered the room to investigate the issue and determined the source cable needed to be cut to remove it from the stuck source drive. The Field Service Engineer (FSE) then quickly cut the exposed source cable and, using pliers, manually inserted the source into the transport container. However, due to the fact that the source cable was short, he could not get it completely into the center of the shielded transport container. The exposure rate at one meter from the transport container was 200 mR/hour. The facility physicist and FSE insured the door to the treatment room was sealed and marked so no one could enter overnight.

"The following morning, April 25, 2014, work began to construct temporary shielding made of lead bricks on a trolley in order to transport the container to the facility hot lab. Additionally, arrangements were made with Elekta's source manufacturer to acquire a type A container of the proper size to house and ship the source transport container to their facility, thus removing it from St. Francis premises.

"Elekta's Radiation Safety Officer failed to notify the State of Nebraska Radioactive Material's Program in a timely manner. The incident occurred after business hours and Friday April 25, 2014 was a State holiday (Arbor Day). No call was made to the emergency call number for the State and the information was only obtained by the Nebraska Program Manager by a series of e-mails and a voicemail after 0800 CDT on Monday, April 28, 2014."

Item Number: NE14003

* * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *

The following information was received via email:

"On April 29, 2014, a special Type A container from Alpha Omega Services (AOS) arrived on site and the source was packaged in it for shipment. On May 1, 2014, source was shipped to AOS. On May 7, 2014, the source was received at AOS facility for safe decay storage before shipping back to Mallinckrodt.

"On May 21 & 22, 2014, the HDR unit involved in the incident was shipped back to Nucleotron B. V. in the Netherlands for investigations. No results as of June 16, 2014."

Notified R4DO (Hay), R1DO (Welling) and FSME Event Resource via email.

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Agreement State Event Number: 50135
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NEBRASKA METHODIST HOSPITAL
Region: 4
City: LINCOLN State: NE
County:
License #: 01-07-02
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/23/2014
Notification Time: 16:05 [ET]
Event Date: 05/22/2014
Event Time: [CDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISCALCULATION

The following was received from the State of Nebraska via fax:

"At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem."

Nebraska Item Number: NE140004

* * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *

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

"In a letter dated June 3, 2014, the RSO/Medical Physicist from Nebraska Methodist Hospital updated the information for this incident. The implanted dose was 184 Gray. The dose to the organ at risk (rectum) is as follows: Only a small percentage of the entire organ (rectum) was imaged and contoured, in the plan that was 12cc. An estimate of the increased dose ranges from 16 Gray in the highest dose regions comprising 90% of the contoured volume and 27 Gray in the highest dose regions comprising 30% of the contoured volume.

"The patient was informed within 24 hours of the discovery of the misadministration."

Notified R4DO (Hay) and FSME Event Resource via email.

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: 50179
Rep Org: ALABAMA RADIATION CONTROL
Licensee: HEALTH IMAGING SERVICES
Region: 1
City: CULLMAN State: AL
County:
License #: RML 1370
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/06/2014
Notification Time: 18:30 [ET]
Event Date: 06/06/2014
Event Time: 16:10 [CDT]
Last Update Date: 06/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)
PAMELA HENDERSON (FSME)

Event Text

AGREEMENT STATE REPORT - FIRE AT A NUCLEAR MEDICINE FACILITY

The following is a summary of an email received from the State of Alabama:

A fire was reported at a nuclear medicine facility in Cullman, AL at around 1610 CDT. The Nuclear Medicine Tech at Health Imaging Services stated that she had gathered the 2 e-vials (286.8 microCuries of Ba-133, and 195.4 microCuries of Cs-137), PET waste box, and a rod source and took these materials to the Coleman Regional Medical Center [CRMC] for storage. An individual at the Alabama Emergency Management Agency [AEMA] stated that fire personnel had access to radiation survey equipment, and that the incident appeared to be a structure fire and not a radiation event. The Nuclear Medicine Tech at Health Imaging Services stated that she was able to retrieve her survey meter, but it was not functioning properly. She stated that one rod source remained in the scanner (about 1 milliCurie Ge-68), and that the scanner appeared to not be compromised. The Nuclear Medicine Tech at Health Imaging Services stated that she and the RSO from CRMC would return to perform radiation surveys with a properly functioning survey meter later this evening. All sources appeared to be accounted for, except for the rod in the scanner, and appropriate surveys are to be performed later.

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Agreement State Event Number: 50181
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: NEWPAGE WISCONSIN SYSTEMS
Region: 3
City: WISCONSIN RAPIDS State: WI
County:
License #: 141-1258-01
Agreement: Y
Docket:
NRC Notified By: LAUREN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/09/2014
Notification Time: 16:55 [ET]
Event Date: 06/07/2014
Event Time: 17:00 [CDT]
Last Update Date: 06/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENT RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - STUCK PROCESS GAUGE SHUTTER

The following information was received via e-mail:

"On Sunday, June 8th, 2014, the Wisconsin Radiation Protection Section received notice from the mill [NewPage Wisconsin Systems] Radiation Safety Officer (RSO) for the Wisconsin Rapids facility that the licensee had a gauge with a stuck shutter. The stuck shutter was discovered on Saturday, June 7th at 5:00 pm [CDT]. The device is an Ohmart model A-2102 (serial number M-3212) fixed gauge originally containing 100 mCi of Cs-137. The facility is currently shut down for maintenance. VEGA Americas, Inc. has been called for immediate repairs. The mill RSO stated that the gauge was in the normal operating position and did not pose a radiation safety hazard. The gauge has been roped off from personnel. Personnel are not allowed inside the chip chute since it is in the path of the radiation beam between the broken source and its detector.

"The Wisconsin Radiation Protection Section will continue to monitor the situation."

Wisconsin Event: WI140006

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Power Reactor Event Number: 50203
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPCINSKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/16/2014
Notification Time: 13:38 [ET]
Event Date: 06/16/2014
Event Time: 10:27 [CDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NICK VALOS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO HYDRAULIC OIL SPILL

"At approximately 1027 CDT on June 16, 2014, Xcel Energy notified the Minnesota State Duty Officers that a hydraulic hose on a cement truck failed and spilled approximately 15 gallons hydraulic oil to grade at a building site for the new Site Administrative Building. The hydraulic oil spill did not enter the storm drain system or any water ways. The site is in the process of cleaning up the spill.

"There is no impact to public health and safety or the environment due to this incident.

"This event is reportable per 10 CFR 50.72(b)(2)(xi), an event related to protection of the environment for which a notification to other government agencies has been made.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Tuesday, June 17, 2014
Tuesday, June 17, 2014