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Event Notification Report for September 23, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/22/2014 - 09/23/2014

** EVENT NUMBERS **


50451 50453 50458 50460 50478 50480

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Agreement State Event Number: 50451
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: AMERICAN X-RAY AND INSPECTION SERVICES INC.
Region: 4
City: MIDLAND State: TX
County: REEVES
License #: 05974
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/12/2014
Notification Time: 10:42 [ET]
Event Date: 09/11/2014
Event Time: 12:00 [CDT]
Last Update Date: 09/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (E-MA)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK OUTSIDE THE CAMERA

The following information was received via e-mail:

"On September 11, 2014, at 1241 hours [CDT], the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that one of their radiography crews reported they were unable to fully retract a 46 curie iridium - 192 source into a SPEC 150 exposure device. The RSO stated the radiographers had completed an exposure and cranked the source back to the exposure device. The radiographer picked up their dose rate meter and observed the reading was 30 millirem an hour. The radiographer also observed that the locking mechanism had not tripped. The radiographer contacted the RSO. An individual qualified to perform source retrieval was sent to the scene. The radiographer did not approach the exposure device. The RSO stated the source retrieval person should reach the location in about an hour. Awaiting information from RSO. Update will be provided in accordance with SA-300."

Texas Report #: I-9232

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Non-Agreement State Event Number: 50453
Rep Org: NOVELIS
Licensee: NOVELIS
Region: 1
City: FAIRMONT State: WV
County:
License #: 47-13348-02
Agreement: N
Docket:
NRC Notified By: MICHAEL ROSSANA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/12/2014
Notification Time: 16:30 [ET]
Event Date: 09/12/2014
Event Time: 11:30 [EDT]
Last Update Date: 09/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOUCE (EMAI)

Event Text

FIXED GAUGE SHUTTER STUCK IN CLOSED POSITION

The licensee RSO (Radiation Safety Officer) reported that the shutter on a fixed gauge was stuck in the closed position. An authorized technician was able to repair the shutter and the gauge has been returned to service. There were no exposures involved with this event. The gauge is an ABB/IRMS, source model S18 containing a Y-90 300 mCi source. This report is being made per 10CFR30.50(b)(2)(i).

* * * UPDATE FROM MICHAEL ROSSANA TO JOHN SHOEMAKER AT 1250 EDT ON 9/13/14 * * *

The licensee RSO reported that around 0000 EDT on 9/13/14, an electrician performing routine checks found the gauge shutter stuck in the open position. The technician who performed maintenance on the previous day had caused the shutter to stick in the open position because of a mis-positioned screw. Repairs were completed and the gauge shutter is now functioning normally. This gauge is scheduled to be replaced during the upcoming Christmas shutdown. There were no exposures involved with this event.

Notified R1DO (Jackson) and FSME Events Resource via email.

* * * UPDATE FROM MICHAEL ROSSANA TO JOHN SHOEMAKER AT 1224 EDT ON 9/15/14 * * *

The following report was received from the Novelis Corporation RSO via email;

"This email serves as [the licensee's] formal notification to follow up the two telephone notifications made by [the licensee's RSO] on September 12, 2014. Both occurrences were related to shutter failures on the same thickness gauge. These notifications were made to satisfy the NRC Regulation 10 CFR 30.50 reporting requirement.

"On Friday, September 12, 2014, at approximately 1300 [EDT], the shutter on the Novelis Fairmont #1 Mill thickness gauge failed in the closed position. An employee who has received non-routine maintenance training per NUREG-1556, Volume 4, Appendix G & N, took it upon himself to remove the side of the gauge and perform an investigation and repair the stuck shutter. It was determined that the pneumatic cylinder for the shutter was not functioning properly and replaced. A radiation survey was performed and the surrounding area was taped off with caution tape. There was no over exposure to radiation. The gauge was put back into service at approximately 1400 [EDT] that same afternoon.

"On the same night, Friday, September 12, 2014, at approximately 2330 [EDT], the shutter on the same thickness gauge failed again. This time the shutter failed in the open position. Once the shutter was determined to be in the open position, the foreman on shift notified [the RSO]. [The RSO] spoke with the shift electrician and had him perform a radiation survey and tape off the area with caution tape. The shift electrician has received non-routine maintenance training per NUREG-1556, Volume 4, Appendix G & N. [The RSO] was on site at approximately 0030 [EDT] Saturday morning, September 13, 2014. [The RSO] verified that the shutter was in the open position by performing a radiation survey. Additionally, the light identifying the shutter position was RED indicating the shutter was open. The same individual that replaced the pneumatic cylinder was on site and he investigated the failure. It was determined that the shutter appeared to be on a bind and the screws that hold the pneumatic cylinder in place were adjusted and the shutter was free to move as intended.

"With the side off of the gauge, next to the shutter assembly, at 6 inches, the measured mR/H was approximately 1 mR/h. Directly beside the shutter mechanism approximately 2 mR/h was measured. The employee worked for about 30 minutes to adjust the shutter mechanism. During this repair, there was no over exposure to radiation."

Notified R1DO (Lilliendahl) and FSME Events Resource via email.

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Agreement State Event Number: 50458
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/15/2014
Notification Time: 15:12 [ET]
Event Date: 08/06/2014
Event Time: [EDT]
Last Update Date: 09/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)
FSME PART 21 (EMAI)
BILLY DICKSON (R3DO)
MICHAEL VASQUEZ (R4DO)

Event Text

AGREEMENT STATE REPORT - MANUFACTURING DEFECT RESULTING IN EQUIPMENT TO NOT PERFORM AS DESIGNED

The following information was provided by the Commonwealth of Massachusetts via email:

"On 9/15/2014, Massachusetts Radiation Control Program (MA RCP) was notified by licensee (QSA Global, Inc.) in accordance with 105 CMR 120.142(B)(2) of manufacturing defect of a model 95020 radiographic guide tube resulting in equipment that failed to function as designed. The licensee reported that its customer (Team Industrial Services of South Roxana, Illinois) informed the licensee on 8/6/2014 that the end stop of the guide tube had come off during a radiographic exposure performed 7/25/2014, that the source was able to be returned to the shielded/stored position in the exposure device using normal retraction with the control assembly, and that there was no excessive personnel exposure related to the part failure.

"The licensee reported that its examination of the model 95020 assembly failed part showed that the end fitting had not been swaged to the guide tube housing as is required by the design.

"The licensee reported that upon learning of the part failure, it immediately performed a visual inspection of all guide tube and control assemblies accepted into stock for distribution and that there were no other instances of unswaged fitting or improper manufacture identified for accepted stock. Licensee further reported that it believes that the instance to be an isolated occurrence and that no other assemblies containing this defect remain in the field.

"Licensee reported that manufacturer failed to swage end stop fitting to guide tube and manufacturer failed to perform pull test of end stop fitting to guide tube and check connection for slip using inspection gauge.

"Licensee reported that corrective actions include changes that will be implemented in the production process to increase inspection and review of quality critical operational steps to ensure this type of manufacturing defect is not accepted and released to customers in the future.

"Model 95020 guide tubes are approved for use with QSA Global, Inc. model 880 series radiographic exposure devices described by Sealed Source and Device Registration No. MA-1059-D-334-S.

"Licensee reported that it conducted a review to determine if this type of condition had occurred previously and identified one instance from 2012 where a different model guide tube, model 48906, had not been properly swaged and tested prior to distribution to an international customer.

"MA RCP plans to perform inspection to include evaluation for any generic implications."

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Agreement State Event Number: 50460
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: SHERTECH PHARMACY
Region: 1
City: SPARTANBURG State: SC
County:
License #: 531
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/15/2014
Notification Time: 17:55 [ET]
Event Date: 09/15/2014
Event Time: [EDT]
Last Update Date: 09/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - IODINE 131 SPILL IN PHARMACY

The following information was provided by the State of South Carolina via email:

"Shertech Pharmacy (SC Radioactive Material License No. 531) in Spartanburg, SC, reported a spill of 100mCi of I-131. A pharmacist dropped the iodine vial on the pharmacy floor. Most of the contamination was on the floor and the shoes of the pharmacist. The Radiation Safety Officer and pharmacist began clean-up procedures. Clothes and shoes were placed in zip lock bags. The floor was cleaned with Radiac wash and the cleaning items were placed in zip lock bags. Activated charcoal was placed on the floor. The four individuals present did take Lugol's solution. Zip lock bags containing the contaminated items were placed in the fume hood. No contamination was found on the skin of any of the individuals involved. Readings of 0.6 mR/hr are measured outside of the closed room. The licensee will perform bioassays at 24, 48, and 72 hours on the four individuals present during the spill and clean up. The primary contamination appeared to be on the shoes themselves."

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Power Reactor Event Number: 50478
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: FRED POLLAK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/22/2014
Notification Time: 09:34 [ET]
Event Date: 09/22/2014
Event Time: 10:00 [EDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (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 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"On September 22, 2014, at 1000 EDT, the Technical Support Center (TSC) will be unavailable due to pre-planned maintenance impacting the TSC ventilation envelope. The TSC is expected to be restored to operational status on September 23, 2014.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures, and the TSC staff will assemble at a preplanned alternate location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the loss of an emergency response facility (ERF). An update will be provided once the TSC has been restored to operational status. The NRC Resident Inspector has been notified."

The maintenance is expected to be completed within 36 hours.

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Part 21 Event Number: 50480
Rep Org: QUALTECH NP
Licensee: QUALTECH NP
Region: 1
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JIM TUMLINSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/22/2014
Notification Time: 17:17 [ET]
Event Date: 09/22/2014
Event Time: [CDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MEL GRAY (R1DO)
MARVIN SYKES (R2DO)
NICK VALOS (R3DO)
JAMES DRAKE (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 NOTIFICATION - DISCREPANCY BETWEEN QUALIFICATION REPORT AND INSTALLATION INSTRUCTIONS

The following information was obtained from the vendor via facsimile:

"To whom it may concern:

"This letter is issued to provide notification of a documentation defect concerning QualTech NP Generation 3 Quick Disconnect Connectors (Gen 3 QDC). Specifically, there is a discrepancy concerning o-ring replacement between the 1/2 Inch Gen 3 QDC Qualification Report (EGS-TR-23009-14, through Revision B) and the Instructions for Installation (EGS-TR-23066-04, Revision Original), the 3/4 Inch Gen 3 QDC Qualification Report (EGS-TR-23067-01, Revision A) and the 1-1/2 Inch Gen 3 QDC Qualification Report (EGS-TR-23068-01, Revision A).

"Section 5.0 of the 1/2 Inch Qualification Report (EGS-TR-23009-14, through Revision B) states in part that 'whenever the connector is disconnected after one week or more installed service, the used o-ring must be discarded and a new o-ring installed prior to reconnection.' Contrary to this requirement, Section 9.0 of the Instructions for Installation (EGS-TR-23066-04, Revision Original) states in part that, 'whenever the QDC is disconnected after one week or more installed service, it is recommended that the o-ring be discarded and a new o-ring installed prior to reconnection. This action, while not mandatory, will maintain the o-ring seal in a superior condition' and Section 6.0 of both the 3/4 Inch Qualification Report (EGS-TR-23067-01, Revision A) and 1-1/2 Inch Qualification Report (EGS-TR-23068-01, Revision A) states in part that, 'whenever the connector is disconnected after one week or more, it is recommended that the used o-ring be discarded and a new o-ring installed prior to reconnection.'

"To prevent confusion and inconsistency between the 1/2 Inch Qualification Report (EGS-TR-23009-14), the 3/4 Inch Qualification Report (EGS-TR-23067-01), the 1-1/2 Inch Qualification Report (EGS-TR-23068-01) and the Instructions for Installation (EGS-TR-23066-04), the documents have been revised to require that the o-ring must be discarded and a new o-ring installed prior to reconnection. The new revision level of each document is as follows:
- EGS-TR-23067-01, Revision B - 3/4 Inch Qualification Report
- EGS-TR-23068-01, Revision B - 1-1/2 Inch Qualification Report
- EGS-TR-23066-04, Revision A - Instructions for Installation

"The revised Qualification Reports and the Instructions for Installation have been or will be distributed to all customers who have received 1/2 Inch, 3/4 Inch, and/or 1-1/2 Inch Gen 3 QDC connectors.

"Should any Gen 3 QDC connectors be currently installed in service, it is required that a determination be made as to whether or not the connector has been disconnected after one week of installed service and if the o-ring was replaced. If the o-ring was replaced, no further action is required. If the connector was disconnected and the o-ring was not replaced, the o-ring must be discarded and a new o-ring installed.

"QualTech NP will provide replacement o-rings, free of charge, to customers who identify replacement o-rings are required for Gen 3 QDC connectors that have been installed in service.

"As a point of interest, please note that this notification does not apply to the original EGS QDC connectors (Gen 1 QDC). QualTech/EGS QDC connectors certified to Qualification Reports PEI-TR-880701-04, Revision A (1/2 Inch Gen 1 QDC), EGS-TR-913601-01. Revision B (3/4 Inch Gen 1 QDC) and/or EGS-TR-913602-01, Revision B (1-1/2 Inch Gen 1 QDC) are not impacted by this notification as these Qualification Reports require the o-ring be discarded and replaced if the connector is disconnected after one week of installed service.

"If you require additional details or would like to discuss this further please contact the undersigned or Tony Gill (QualTech NP Quality Assurance Manager) at 256-924-7438 (office), 256-426-4558 (mobile) or tgill@curtisswright.com.

"Jim Tumlinson
Products Engineering Manager
QualTech NP, Huntsville Operations
Curtiss-Wright Corporation
256-924-7429 (office)
256-425-8037 (mobile)
jtumlinson@curtisswright.com"

Page Last Reviewed/Updated Tuesday, September 23, 2014
Tuesday, September 23, 2014