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Event Notification Report for June 24, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/23/2014 - 06/24/2014

** EVENT NUMBERS **


49734 50199 50201 50204 50205 50220 50221 50222

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Agreement State Event Number: 49734
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CENTRAL ARKANSAS RADIATION THERAPY INSTITUTE INC
Region: 4
City: CONWAY State: AR
County:
License #: ARK-0654-0220
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/17/2014
Notification Time: 11:41 [ET]
Event Date: 01/15/2014
Event Time: 18:00 [CST]
Last Update Date: 06/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PROSTATE SEED IMPLANT MISADMINISTRATION

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

"Central Arkansas Radiation Therapy Institute, Inc. (CARTI), ARK-0654-02200, reported a medical event involving a patient treated for prostate cancer. The treatment plan included implanting 128 I-125 brachytherapy seeds (6 seeds were not implanted), containing a total activity of 1.592 GBq (43.036 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14,400 cGy. It appears that approximately 40 of the total number of seeds were implanted into the prostate gland. The seeds were implanted on December 31, 2013. On January 15, 2014, the patient returned to the facility for a post implant CT scan. The scan showed that the implanted seeds, although in an appropriate pattern, were placed outside the intended target.

"The State performed an on-site review on January 16, 2014, of the event and discussed the initial details of the event.

"The licensee is continuing to investigate the cause and is preparing a written report.

"The State is continuing to investigate and will update this report when the report is received from the licensee.

"This event is reportable under 10 CFR 35.3045 of the NRC Regulations and RH-8800 of the Arkansas State Board of Health Rules and Regulations for Control of Sources of Ionizing Radiation."

State Event Report Number: AR-2014-001

* * * UPDATE PROVIDED VIA EMAIL BY STEVE MACK TO JEFF ROTTON AT 1557 EDT ON 06/23/2014 * * *

"Doses: The D90 for the prostate pre-plan was 167.86 Gy and the D90 for the prostate post-plan is 25.31 Gy.

"Estimated mean doses to other organs and tissues were, Seminal Vesicles 13.99 Gy, Rectum 45.80 Gy, Bladder 3.89 Gy, and the Penile Bulb 185.24 Gy.

"Root cause of the event: The licensee stated: 'the facts of the case lead us to believe that the complexity of the patient anatomy contributed to anatomical misidentification by the attending urologist, i.e. mistaking the penile bulb with the prostate gland.'

"Corrective Actions

"Multiple corrective actions were implemented including: (1) Centralizing prostate seed implant programs to fewer facilities under the Radioactive Material License, (2) At those facilities continuing to perform prostate seed implants, ensure consistent adherence to the seed implant procedural and policies at each facility, (3) Re-evaluation of the prostate seed implant procedures by the radiation oncologists, (4) Require quality assurance documents on the ultrasound equipment utilized for prostate seed implants, and (5) Require training and proficiency records for operating room staff assisting with prostate seed implants.

"Manufacturer and model number of the seeds: The seeds used during this misadministration were Oncura, OncoSeed, Model 6711, containing 0.336 mCi of I-125. Thirty-four (34) seeds of 128 were implanted into the prostate.

"The Department [Arkansas Department of Health] considers this event to be closed."

Notified R4DO (Allen) and FSME Resources 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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Non-Agreement State Event Number: 50199
Rep Org: US ARMY
Licensee: US ARMY
Region: 1
City: ABERDEEN State: MD
County:
License #: SUB 834
Agreement: Y
Docket:
NRC Notified By: JEREMY FORD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 06/13/2014
Notification Time: 08:27 [ET]
Event Date: 06/12/2014
Event Time: 16:00 [EDT]
Last Update Date: 06/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE (EMAI)
GLENN DENTEL (R1DO)

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

Event Text

LOST DEPLETED URANIUM PROJECTILE

The licensee was conducting a test fire exercise at the Ford Farms section of the Aberdeen Test Center when a depleted uranium penetrator projectile went off it's intended flight path, exited the building, and landed in an area near the facility designated to receive test rounds. Ford Farms is an indoor hard target test facility. There were no injuries or projected dose to workers or the public. No additional effort will be made to recover the projectile because the projectile landed in a historic impact area of Aberdeen containing various other unexploded ordinance.

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: 50201
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: PORT LAVACA State: TX
County:
License #: L00051
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/16/2014
Notification Time: 11:43 [ET]
Event Date: 06/16/2014
Event Time: [CDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTERS

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

"On June 16, 2014, the Agency [State of Texas] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting routine maintenance checks, the shutter on two Ohmart-Vega Model SHD source holders containing 250 millicuries of cesium-137 failed to shut. A third SHD source holder shutter appeared to shut but there was no change in the radiation level as expected. The RSO has contacted a vendor to inspect and repair the gauges. The gauges are normally open. There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident: I-9204

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Agreement State Event Number: 50204
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ANSUL INC/TYCO FIRE PROTECTION PRODUCTS
Region: 3
City: MARINETTE State: WI
County:
License #: 704087
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/16/2014
Notification Time: 16:40 [ET]
Event Date: 06/13/2014
Event Time: [CDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK VALOS (R3DO)
FSME EVENT RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"During an inventory on June 13, 2014, the licensee determined a total of 6 tritium exit signs were not accounted for at the facility. One 20 Ci SRB Technologies sign and five 11.5 Ci Safety Light Corporation signs were missing. Three of the signs are known to have been removed during a previous remodeling and are presumed to have been disposed of with the waste. The three other signs are missing from their normal locations. Maintenance staff have been alerted to the missing items and told to look for them in the storage areas. Additional training is being developed that will require any person who removes an exit sign, regardless of type, to return it to the Environmental, Health, and Safety Department for review prior to disposing. A plan is also in place to remove all tritium exit signs from the facility and replace with electrically wired signs. The Wisconsin Radiation Protection Section is continuing to monitor the situation."

Event Report ID: WI 140007

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: 50205
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: HOQUE & ASSOCIATES INC
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-431
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/16/2014
Notification Time: 18:58 [ET]
Event Date: 06/16/2014
Event Time: [MST]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME EVENT RESOURCE (EMAI)
MEXICO (FAX)
ILTAB (EMAI)

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 from the State of Arizona via email:

"On June 16, 2014, the Agency [State of Arizona] was notified of the theft of a Troxler Model 3450 Moisture-Density gauge Serial Number 533, from a locked box on a pickup truck parked in a secure area of the licensee facility. Other equipment was also stolen from the truck. The locks and one hasp and a gate lock were ground off. The theft occurred over the June 14 -15 weekend.

"The investigation into this event is ongoing.

"The AZ Governor's Office, FBI, US NRC, and the states of CA, NV, CO, and NM are being notified of this event."

First Notice: 14-014

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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Power Reactor Event Number: 50220
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOHN DEVENNEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/23/2014
Notification Time: 09:20 [ET]
Event Date: 06/23/2014
Event Time: 09:00 [EDT]
Last Update Date: 06/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRICE BICKETT (R1DO)

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

LOSS OF COMMUNICATIONS DUE TO PLANNED MAINTENANCE

"A planned maintenance evolution at the Oyster Creek Nuclear Generating Station has removed the dedicated phone line between Emergency Response Facilities and the NARS line from service and will be rendered non-functional during the course of the work activities. Expected out of service time is approximately 82 hours from 0900 [EDT] 6/23/14 to 1900 [EDT] 6/26/14.

"If an emergency is declared requiring the use of emergency communication phone circuits a proceduralized alternative method will be used.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) for planned maintenance that impacts the emergency communications capability. An update will be provided when the dedicated phone line between Emergency Response Facilities and the NARS line has been restored to normal operation."

The licensee has notified the NRC Resident Inspector

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Power Reactor Event Number: 50221
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: BRAIN JOHNSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/23/2014
Notification Time: 17:02 [ET]
Event Date: 06/23/2014
Event Time: 11:07 [CDT]
Last Update Date: 06/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (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

EMERGENCY DIESEL GENERATOR AUTO START DUE TO DEGRADED BUS VOLTAGE SIGNAL

"At 1107 [CDT] on 6/23/14, Safeguards Bus 15 received a degraded voltage signal that resulted in the bus load shed and the automatic start of the D1 Emergency Diesel Generator (EDG). Bus 15 re-energized to normal voltage after the source breaker from D1 [EDG] automatically closed. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) for valid actuation of the D1 EDG.

"The initiating condition appears to be a failure of the automatic voltage tap changer on the 10-Bank transformer which affected voltage to the normal offsite power supply to the 1R transformer and Safeguards Bus 15.

"Currently Bus 15 is powered from offsite via the CT-11 transformer and D1 [EDG] has been shutdown.

"When Bus 15 power supply was transferred from D1 [EDG] to CT-11 transformer, a lockout was received on D1 [EDG] due to reverse power. Unit 1 is in TS [Technical Specification] 3.8.1 Condition D for one path inoperable and one EDG inoperable.

"At no time during the event were the health and safety of the public challenged. The redundant AC power supply train (Bus 16 and D2 EDG) remained operable and Bus 16 remained powered from offsite power.

"The Senior Resident Inspector has been notified."

TS 3.8.1 Condition D requires that the one inoperable offsite power path or the D1 EDG be returned to operable status by 2334 CDT or be in Mode 3 in 6 hours. Unit 2 is not affected by this issue.

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Power Reactor Event Number: 50222
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DAVID RENN
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/23/2014
Notification Time: 19:55 [ET]
Event Date: 06/23/2014
Event Time: 15:40 [CDT]
Last Update Date: 06/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ROBERT HAAG (R2DO)

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 93 Power Operation 93 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

REPORTABLE SMALL OIL SPILL INTO U.S. WATERS

"On 06/23/2014 at approximately 1540 [CDT], it was reported that an oil sheen was visible in the fore bay. Upon further investigation it was determined that a high cold water channel level had caused diesel fuel oil to wash free from an oil drain device from the channel diesel fire pump into the fore bay. This oil spill is reportable to the EPA (National Response Center) under 40CFR112. Notification to the National Response Center was made at 1551 [CDT]. Notification number is 1086840.

"A total of 1 to 2 gallons were reported to enter US waters. The source of leak into the fore bay and cold water channel has been stopped. All reportable oil spillage has been contained in the fore bay (considered US waters).

"Additional notifications have been made to Alabama Emergency Management."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, June 24, 2014
Tuesday, June 24, 2014