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Event Notification Report for July 11, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/10/2014 - 07/11/2014

** EVENT NUMBERS **


50251 50254 50255 50256 50257 50265 50266

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Agreement State Event Number: 50251
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: LONG ISLAND JEWISH MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: 75-2986-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/02/2014
Notification Time: 16:23 [ET]
Event Date: 07/02/2014
Event Time: 13:00 [EDT]
Last Update Date: 07/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION FOR TREATMENT OF PROSTATE CANCER

The following report was received from the New York City Office of Radiological Health (NYC ORH) via facsimile:

"Type of Incident: Underdose of Sm-153 administration IV for treatment of prostate cancer.

"Location of Incident: Long Island Jewish Medical Center. New York City Radioactive Materials License No. 75-2986-01

"Date and time of Incident: 07/02/14 at 1300 EDT.

"Date and time of Report to NYC ORH: 07/02/14 at 1530 EDT.

"Date of Investigation by ORH inspector: Inspection will be assigned no later than 24 hours from time of report to the Office of Radiological Health.

"Description of event: Patient was being injected with Samarium-153 intravenously [IV], in the arm for treatment of prostate cancer.

"In preliminary telephone report by hospital, RSO stated that administration was made into the skin, rather than IV as intended. Physician's prescription was for 100 microcuries (reporting RSO twice stated 'microcuries'). Of the prescribed 100 microcuries, it was estimated that only 39.2 microcuries was delivered. Procedure was stopped in the course of delivery.

"Reporting RSO at Medical Center stated that preliminary report would be sent by email later today. Letter with details to follow."

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: 50254
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: HALLIBURTON ENERGY SERVICES
Region: 3
City: DUNCAN State: OH
County:
License #: 31210990018
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/03/2014
Notification Time: 11:44 [ET]
Event Date: 06/28/2014
Event Time: [EDT]
Last Update Date: 07/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON MCCRAW (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED INDUSTRIAL GAUGES DAMAGED DURING FIRE

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

"On 6/29/14 at 1330 EDT, ODH [Ohio Department of Health] received a call that there was a fire at an oil well location in Hannibal, Ohio, Monroe County. A hydraulic line on a piece of drilling equipment failed, spilling hydraulic fluid onto a hot engine, igniting the fluid. The fluid continued to rapidly leak, which caused the fire to spread. When the fire department arrived on scene, the well pad was reported to be fully engulfed in flames. The drilling company has reportedly lost 20 vehicles in the fire. There were three density gauges on site, two (2) of which were mounted on equipment and one was mounted on the well. There were no detections of radiation at that time.

"On 6/30/14 two ODH inspectors were dispatched to the site to verify that the gauges were secure and had not suffered damage from the fire. Upon arrival the ODH inspectors were not allowed to go onto the drilling pad area because it is still being cleared of potentially explosive hazardous chemicals and unexploded ordinance (used in fracking process). The inspectors attended a meeting regarding status of the site and were briefed by representatives from Halliburton (the licensee). The gauges involved were two (2) Model 100-SD, containing 120 mCi of Cs-137 each, and one (1) Model 55-SD containing 66 mCi of Cs-137.

"Halliburton was able to conduct an initial visual inspection and survey of the gauges. They stated that there did not appear to be any significant visible damage and the devices appeared to be intact. They recorded readings of 0.5 mR/hr on contact for the Model 100-SD gauges, and 0.3 mR/hr on contact on for the Model 55-SD gauge. Wipe tests were taken by the licensee to check for leakage and the field survey indicated no contamination. The wipes were sent to a laboratory for further analysis. Licensee personnel will put up warning signs and barriers around the gauges once the site is safe for other than emergency operations. It is expected to be several days before the site is determined to be safe enough for any movement or removal of the devices.

"On 7/2/14 the licensee was granted permission from the site manager to remove the gauges. All three gauges were removed without incident, and appeared to be intact (although scorched on the exterior from the fire). There were no incidents during the removal and no radiation readings recorded above those originally reported. The three gauges were placed in over packs, with proper labels and shipping papers, and were sent to the Halliburton headquarters in Texas for further evaluation."

Ohio Reference Number: ODH 2014-017.

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Agreement State Event Number: 50255
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TERRACON CONSULTANTS INC
Region: 4
City: OLATHE State: KS
County:
License #: LA-5382-L01 A
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/03/2014
Notification Time: 16:46 [ET]
Event Date: 07/01/2014
Event Time: 14:30 [CDT]
Last Update Date: 07/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - TROXLER MOISTURE/DENSITY GAUGE RUN OVER BY BULLDOZER

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

"On July 2, 2014, the CRSO [Corporate Radiation Safety Officer], for Terracon Consultants (TCI) notified LDEQ [Louisiana Department of Environmental Quality] that a moisture density gauge being used at one of their projects was run over by a bulldozer.

"The source was left unattended when a bulldozer ran over the gauge and damaged the housing. They are conducting an investigation to determine the cause of the incident. It appears that it was human error.

"The sources were leak tested and TCI is waiting for the results of the test. The unit was surveyed and it appears the sources were not leaking. Results will be forwarded to NMED as an update when the information is obtained.

"All equipment involved is isolated and is not a threat to the public. There is no threat to TCI personnel and it appears to be safe.

"The damaged gauge was a Troxler, Model 3430, S/N 26346, loaded with 8 mCi of Cs-137 and 40 mCi of Am-241/Be. The gauge housing was damaged, but there was no indication the radioactive sources were compromised or leaking. The sources were isolated and leak tested."

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Agreement State Event Number: 50256
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: TALLAHASSEE MEMORIAL CANCER CENTER
Region: 1
City: TALLAHASSEE State: FL
County:
License #: 0416-2
Agreement: Y
Docket:
NRC Notified By: VICTOR GORETSKY
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/03/2014
Notification Time: 17:21 [ET]
Event Date: 06/26/2014
Event Time: [EDT]
Last Update Date: 07/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN BARTLEY (R2DO)
FSME EVENTS RESOURCE (EMAI)
AARON MCCRAW (R3DO)
RAY MCKINLEY (R1DO)

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

Event Text

AGREEMENT STATE REPORT - MISPLACED IODINE 125 SOURCE FOUND IN SHIPPING CASE

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

"A well chamber (HDR1000+, s/n A980392) was shipped to University of Wisconsin-Madison from Tallahassee Memorial Cancer Center Tallahassee FL. It arrived inside a case which also contained three source holders and an electrometer. An I-125 source was found on the bottom of the case on the foam inserts.

"Due to low exposure rate of the source (about two times background on contact) it was not detected by the monitoring system, but discovered visually. The UWADCL [University of Wisconsin Accredited Dosimetry Calibration Laboratory] received equipment on 6/26/2014. Calibration was completed on 7/2/2014. The shipper has been informed by phone and email."

Florida Incident #: FL14-062

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: 50257
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RAMMING PAVING COMPANY
Region: 4
City: AUSTIN State: TX
County:
License #: 04666
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/03/2014
Notification Time: 22:23 [ET]
Event Date: 07/03/2014
Event Time: 16:00 [CDT]
Last Update Date: 07/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
MEXICO (FAX)
FSME EVENT RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE/DENSITY GAUGE

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

"On July 3, 2014, the licensee notified the Agency [Texas Department of Health] that one of its technicians left the licensee's facility in Austin, Texas, to transport a Troxler Model 4640 moisture/density gauge containing an 8 milliCurie cesium-137 source to the licensee's facility in Buda, Texas. The technician failed to properly secure the gauge for transport. When the technician arrived in Buda, he found the tailgate on pickup was down and the gauge was missing. The licensee retraced the technician's route of travel and found a water jug that had also been in the back of the truck near the licensee's Austin facility, but the gauge was not located. The licensee reported that the device (source rod handle) was not locked. The licensee reported that there were no locks on the transport case lid. More information will be provided as it is obtained in accordance with SA-300."

* * * UPDATE FROM KAREN BLANCHARD TO VINCE KLCO ON 7/7/2014 AT 1144 EDT * * *

The following update was received by the State of Texas by email:

"Reporting criteria changed, as the only source in device (8 milliCurie cesium-137) is less than 1,000 times greater than Appendix C values and therefore does not meet 20.2201(a)(1)(i) immediate reporting criteria. The incident does meet 20.2201(a)(1)(ii) and further information will be provided in accordance with SA-300."

Notified the R4DO (Kellar) and FSME Event Resource via email.

Texas Incident # I-9211

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Power Reactor Event Number: 50265
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WESLEY CONKLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/10/2014
Notification Time: 09:17 [ET]
Event Date: 07/10/2014
Event Time: 04:45 [CDT]
Last Update Date: 07/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
ANTHONY MASTERS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 98 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"At 0445 [CDT] on July 10, 2014, Browns Ferry Unit 2 initiated actions to commence a reactor shutdown to comply with TS LCO 3.0.3. TS LCO 3.0.3 was entered at 0355 [CDT] and was required due to the 'C' Emergency Diesel Generator becoming inoperable after isolating a leak on the Emergency Equipment Cooling Water System. Currently, a 7 day TS LCO Action 3.5.1.A is in effect due to ongoing scheduled Core Spray Loop I maintenance outage. The declaration of inoperability of the equipment supported by the 'C' Emergency Diesel Generator, Core Spray Loop II, along with the redundant Core Spray system inoperable for maintenance resulted in TS LCO 3.0.3 for Unit 2. TS LCO 3.0.3 requires actions to be initiated within one hour; to place the unit in MODE 2 within 10 hours; MODE 3 within 13 hours; and MODE 4 within 37 hours.

"This event requires a 4 hour report lAW 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'

"Actions were taken to restore the Core Spray System to Operable status and LCO 3.0.3 was exited at 0735 [CDT] on July 10, 2014.

"The NRC Resident Inspector has been notified.

"This event was entered into the Corrective Action Program."

Browns Ferry Unit 2 had reduced power to 98% when LCO 3.0.3 was exited, the power reduction was suspended, and preparations are being made to return power to 100%. There is no impact on Units 1 or 3.

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Power Reactor Event Number: 50266
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMANN
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/10/2014
Notification Time: 13:29 [ET]
Event Date: 07/10/2014
Event Time: 08:38 [CDT]
Last Update Date: 07/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (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

Event Text

HIGH RANGE SHIELD BUILDING VENT STACK GAS MONITOR REMOVED FROM SERVICE FOR MAINTENANCE

"At 0830 CDT on July 10, 2014, 2R-50 High Range Shield Building Vent Stack Gas Monitor was removed from service for planned maintenance. 2R-50 was planned for an out of service time of approximately 8 hours. The clearance order associated with the work isolated the flow path to the sample pump. Subsequent to the execution of the clearance order, it was discovered that the flow path to the alternate sample pump was also unavailable inhibiting the ability to implement compensatory measures. With 2R-50 rad monitor sample pump out of service and no alternate sampling available, timely classification of two Emergency Action Levels (EALs), SAE (Notification of Site Area Emergency) and General Emergency classifications would not be achievable. This results in a Loss of Emergency Assessment Capability while 2R-50 is out of service. This is a reportable condition in accordance with 10 CFR 50.72(b)(3)(xiii).

"Unit 2 Shield Building Ventilation Stack is also monitored by the Shield Building Vent Gas Monitor, 2R-22, which is used for the same purpose in NUE (Notification of Unusual Event) and Alert classifications. 2R-22 is being monitored and is indicating normal values. There are no radioactive leaks that will impact the Shield Building as evidenced by normal readings on 2R-22 prior to removing 2R-50 from service. This planned maintenance will not result in the unplanned release of radioactivity to the environment and will not adversely affect the safe operation
of the plant or health and safety of the public.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Friday, July 11, 2014
Friday, July 11, 2014