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Event Notification Report for November 7, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/06/2014 - 11/07/2014

** EVENT NUMBERS **


50335 50572 50575 50576 50578 50583 50584 50597 50598 50600

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Agreement State Event Number: 50335
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: ECO RECYCLING
Region: 1
City: BROCKTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ANTHONY CARPENITO
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/01/2014
Notification Time: 11:22 [ET]
Event Date: 09/12/2012
Event Time: [EDT]
Last Update Date: 11/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - ALPHATRON IONIZATION VACUUM GAUGE FOUND IN LOAD OF SCRAP METAL

The following information was obtained from the Commonwealth of Massachusetts via email:

"On 9/12/12, a scrap metal load shipped by ECO Recycling of Brockton, MA, was rejected by Metal Recycling of Providence, RI, for triggering the site's radiation detectors. The highest vehicle radiation reading was < 0.2 mR/hr. The vehicle returned to Brockton where, on 9/13/12, one device (described as an Alphatron ionization vacuum gauge containing approximately 500 microCuries Radium-226 manufactured by National Resources of Newton, MA approximately 40 years ago) was located and removed from the load by an independent consultant and isolated in secure storage on-site in Brockton for future disposition. The consultant indicated < 0.5 mR/hr readings in accessible areas near the storage container. The original owner not determined. The device continues to be secured at Brockton site as of 8/1/14.

"The Agency [Massachusetts Radiation Control Program] considers this event to still be OPEN."

Event Docket #: 19-1408

* * * UPDATE AT 1441 EDT ON 9/2/2014 FROM TONY CARPENITO TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"9/12/14 Update - Agency conducted on-site inspection 8/1/14. No significant change to previously reported information. Agency [Massachusetts Radiation Control Program] review ongoing.

"The Agency considers this matter to still be OPEN."

Notified the R1DO (Ferdas) and FSME Event Resources (via e-mail).

* * * UPDATE ON 10/7/14 AT 1512 EDT FROM ANTHONY CARPENITO TO DONG PARK * * *

The following was received from the Commonwealth of Massachusetts via email:

"ECO Recycling in process of soliciting / collecting quotes from waste brokers for proper disposal.

"Agency review ongoing. Agency considers this event to still be OPEN."

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

* * * UPDATE ON 11/6/14 AT 1151 EDT FROM ANTHONY CARPENITO TO DONG PARK * * *

The following was received from the Commonwealth of Massachusetts via email:

"ECO Recycling continuing process of soliciting / collecting quotes from waste brokers for proper disposal.

"Agency review ongoing. Agency considers this event to still be OPEN."

Notified R1DO (Gray), FSME Events Resource, and NMSS Events Resource via email.

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Agreement State Event Number: 50572
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: TEAM INDUSTRIAL SERVICES
Region: 1
City: PITTSBURG State: PA
County:
License #: PA-1176
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2014
Notification Time: 12:37 [ET]
Event Date: 10/28/2014
Event Time: [EDT]
Last Update Date: 10/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
FSME EVENTS RESOURCE (EMAI)
JACK GUTTMANN (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE CAN NOT BE RETRACTED

The following information was received from the Commonwealth of Pennsylvania via email:

"The Department's [PA Department of Radiation Protection] Southwest Office informed the Central Office of this event on October 28, 2014. This event is reportable to the Department within 24-hours per 10 CFR 30.50(b)(2), and within 30 days as per 10 CFR 34.101(a)2.

"While radiographing a pipe in the field, a crew had an incident where the camera fell and crimped the guide tube, and the source could not be retracted. The area was immediately secured after the event, and recovery operation initiated. The recovery was completed within two hours. Using long handled pliers under lead sheets, the licensee was able to un-crimp the guide tube and retract the source back into the camera. The readings with the lead sheets in place were in the range of 10 to 15 milli-roentgen per hour (mR/h). Electronic dosimetry readings of those involved with the recovery were provided to the Department [Radiation Protection], with no whole body results above 40 mR.

"Camera Information:
Model: AEA / QSA 880 Delta
Serial#: D12920

"Source Information:
Model: AEA / QSA A424-9
Serial #: 11088G
Isotope: lr-192
Activity: 99 Ci

"CAUSE OF THE EVENT: The camera was not tied down to the pipe, it slid off the supporting structure, fell, and crimped the guide tube.

"ACTIONS: The licensee was able to un-crimp the guide tube and retract the source back into the camera. The Department plans a reactive inspection."

PA Event Report ID No.: PA140022

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Agreement State Event Number: 50575
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CAPITAL ULTRASONICS, LLC
Region: 4
City: WALKER State: LA
County:
License #: LA-15838-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/29/2014
Notification Time: 14:35 [ET]
Event Date: 09/11/2014
Event Time: [CDT]
Last Update Date: 10/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENTS RESOURCE (EMAI)
JACK GUTTMANN (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE CANNOT BE RETRACTED

The following information was provided by the State of Louisiana via fax:

"On September 12, 2014, LA DEQ [Louisiana Department of Environmental Quality] received a notification from the [licensee] Radiation Safety Officer [RSO]. [The RSO] stated a crew was making exposures at a fab shop [in Walker, LA] at approximately 1730 CDT. The exposure device was on an I-beam when the device slid off of the beam onto the front guide tube outlet connection. The radiographer realized the source could not be retracted back into the shielded position.

"The lead radiographer contacted the RSO and received instructions on how to secure/shield the area from potential/unnecessary exposures. An assistant RSO, was dispatched to the site to perform the retrieval and he arrived approximately 1830 CDT. [The assistant RSO] was able to retract/shield the source when he removed the crimped drive cable. The source retrieval was completed approximately 1920 CDT. The crew members exposures were both less than 30 mrem and the assistant RSO's exposure was less than 100 mrem.

"The exposure device and associated equipment (crank out control and source guide tube) were shipped to QSA Global for a materials evaluation. The equipment was evaluated and passed the quality assurance requirements for Type B radiography equipment. The male connector on the source guide tube was replaced and was returned to the customer. The equipment involved in the incident and returned to the customer after the repair and evaluation: QSA 880 Delta, s/n D9829. QSA source model A424-9, Ir-192 source, s/n 16863C with an activity of 69 Ci. QSA control model SAN88225R and a Swivel End Stop QSA GST TAN48906.

"[The licensee] is Departmental [LA DEQ] approved and licensed to perform source retrievals."

License No.: LA-15838-Lol, AI#s. 12540; 165525.

Louisiana Event Report ID No.: LA-140010

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Agreement State Event Number: 50576
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: INEOS ABS CORPORATION
Region: 3
City: ADDYSTON State: OH
County:
License #: 31201310002
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2014
Notification Time: 15:45 [ET]
Event Date: 10/28/2014
Event Time: 15:30 [EDT]
Last Update Date: 10/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
JACK GUTTMANN (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURES FOR NON-OCCUPATIONAL WORKERS

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

"At 1530 EDT on 10/28/14, an INEOS Supervisor noticed that the indicator for the High-High Level gauge for the tank in the DIN1 reactor showed that the gauge was in the open position. The gauge shutter was closed immediately upon this discovery. The level gauge contains a 1 Ci Cs-137 source (assay date 1993).

"The open shutter could have caused exposures to non-occupational workers who were working in the area performing cleaning and maintenance. The tank had been emptied for cleaning and contractors have been entering the tank for maintenance. Workers would have passed through the beam while using the access ladder to gain entry to the tank to perform their work. At the time of the original notification by the licensee, it was unknown how many individuals might have been exposed and for how long. The licensee was advised to take prompt action to determine the exposure to the individuals and it was recommended that he contact a CHP Health Physics Consultant as soon as possible.

"ODH [Ohio Department of Health] responded on 10/29/14. Investigation determined that work actually began on 10/26/14 and that five (5) individuals were involved, all non-occupational workers. Any exposure would have been primarily from passing through beam on access ladder enroute to work in tank, which was taking place approximately 25 feet below the beam inside the tank. There was one (1) individual who was performing a maintenance task in or near the beam for approximately 15 minutes at a distance of approximately 12 inches from the gauge.

"Licensee has contacted a local gauge manufacturer which has experienced staff available to assist with dose reconstruction.

"Information on gauge and source model/type/serial number not available at time of this entry. More information to follow as available.

"Initial investigation would indicate that exposures may exceed allowances for non-occupational workers, but not at a level that would result in serious health issues."

Ohio Item Number: OH140012

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Agreement State Event Number: 50578
Rep Org: NV DIV OF RAD HEALTH
Licensee: UNIVERSITY OF NEVADA , LAS VEGAS
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-13-0305-01
Agreement: Y
Docket:
NRC Notified By: ADRIAN HOWE
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2014
Notification Time: 19:12 [ET]
Event Date: 10/28/2014
Event Time: 16:15 [PDT]
Last Update Date: 10/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
JACK GUTTMANN (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - FIRE IN RADIOCHEMISTRY LAB CAUSES CONTAMINATION OF FUME HOOD

"On October 28, 2014 at 1615 PDT, a fire started in a fume hood in radiochemistry lab MSM 173 hood 2 [located at the University of Nevada, Las Vegas]. The researcher was working with uranium, which is pyrophoric. The fire damaged a container of used pipettes containing Tc-99 (maximum of 150 microCi), which resulted in contamination of the fume hood. The damage to the container and loss of integrity of the licensed material resulted in this report.

"The lab was immediately closed and surveys performed. There were no personnel or airborne contamination detected. The two HEPA filters for the fume hood exhaust prevented a release to the environment. The [licensee] issued a Stop Work order for all radiochemistry labs and initiated an investigation and will follow-up with additional reports to the Nevada Radiation Control Program."

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Non-Agreement State Event Number: 50583
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-30957-01
Agreement: Y
Docket:
NRC Notified By: RICHARD PICCOLO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 17:15 [ET]
Event Date: 10/29/2014
Event Time: 13:30 [EDT]
Last Update Date: 10/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BRICE BICKETT (R1DO)

Event Text

STUCK SOURCE IN A VARIAN HIGH DOSE RATE AFTERLOADER

Staff at the New Milford Cancer Center in New Milford, CT were performing their daily quality assurance checks on their Varian Medical Systems high dose rate (HDR) afterloader when the 7.2 Ci (estimated) Ir-192 source became stuck in the safe position. New Milford contacted the vendor who dispatched a support team to investigate.

The Varian RSO surveyed the area and found the dose rate at 5 cm was 1.5 mR/hr which was within normal parameters with the source in the shielded position. While attempting to free the source, it became stuck outside of the shielded position. Dose rates increased to 20 mR/hr at the entrance to the maze, 280 mR/hr at the turn (approximately 15 feet from the HDR) and 5.4 R/hr at 0.5 meters. The service manager was able to use the emergency hand crank to return the source to its shielded position. During the retrieval, the RSO received 9 mR while the service manager received 27 mR.

Based on past issues and current symptoms, Varian technicians replaced the drive mechanism and will be installing a new source wire.

Once all repairs are made, the HDR will be placed into service with the Varian team on hand during the first post-maintenance use.

Varian, an NRC licensee, is making this report since New Milford Cancer Center (license number 0617892-01) did not exceed any reporting thresholds due to this event.

The vendor has notified R1 (Modes). See similar events in Event Notifications 46695 and 46758.

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Non-Agreement State Event Number: 50584
Rep Org: BEAUMONT HEALTH SYSTEM
Licensee: BEAUMONT HOSPITAL ROYAL OAK
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 18:17 [ET]
Event Date: 10/30/2014
Event Time: 10:00 [EDT]
Last Update Date: 10/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)

Event Text

PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

"This is a notification of a medical event that occurred on October 30, 2014 at 1000 EDT in which the Y-90 SIR-Sphere dose delivered to the patient's posterior portion of the right lobe of the liver was more than the prescribed dose by 20 percent or more (10 CFR 35.3045). This patient had a dual administration, with the correct dose administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy). The medical event occurred before this, when the patient who was prescribed a dose of 0.39 GBq (64.5 Gy) was administered a dose that was 20.5% more than the prescribed dose. The posterior portion of the right lobe of the liver was administered 0.47 GBq (77.5 Gy), which was the intended dose for the anterior portion of the right lobe of the liver. The total dose to the right lobe of the liver (both posterior and anterior portions) was 0.90 GBq (142 Gy) compared to the planned dose of 0.91 GBq (143.6 Gy). Our color coding procedure failed to prevent this error. The radiopharmacy staff had applied the green colored dot to the QMP [Quality Management Program] and Dose Planning Forms appropriate for the posterior portion of the right lobe. The medical physicist applied the green colored dot to the checklist intended for the anterior portion of the right lobe rather than to the checklist intended for the posterior portion of the right lobe. The error was not caught during the time out prior to the dose administration. Upon completion of the first of the dual administrations, the medical physicist identified and reported the error to the authorized user and RSO. A time out was called and the decision was made to prepare a new Y-90 SIR-Sphere dosage for the anterior portion of the right lobe in accordance with the written directive. The correct dose was then administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy).

"To prevent this from occurring, the color coding procedure was revised by the Radiopharmacy and modeled after their blood labeling process. The check list was revised to instruct the medical physicist that 'If dual administration case, verify correct color dots on QMP form, dose plan, and checklist.' Before a dual administration case is started, the dose planning page with the correct corresponding color dot will be pulled from the paperwork and placed in the control room. This allows the AU [authorized user], physicist, and remaining team (techs, nurses) to see the plan clearly. Once the physician (AU) gains access to the first treatment site, they will give the verbal notice to the physicist, so they can assemble the corresponding dose. With the finished assembly in place table side, the AU and physicist will verify the dose intended for the location. As it pertains to this case, the physician would say, 'We are in the posterior right lobe, the dosage is 0.52 GBq and is labeled with the orange dot, correct?' The QMP was revised to include these revised procedures. No adverse effect is expected for the patient. Both the patient and the referring physician were notified on October 30, 2014."

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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Power Reactor Event Number: 50597
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RYAN MEREMA
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/06/2014
Notification Time: 04:30 [ET]
Event Date: 11/05/2014
Event Time: 19:38 [CST]
Last Update Date: 11/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
DAVE PASSEHL (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

SIX UNIT 2 CONTROL ROD DRIVE HYDRAULIC CONTROL UNITS INOPERABLE

"Six (6) U2 CRD [Control Rod Drive] HCU [Hydraulic Control Unit] accumulators were identified with riser brackets that were installed incorrectly. This issue impacts U2 CRD HCU accumulators only. The incorrect riser bracket installation could challenge the ability of the CRD hydraulic control unit to perform its design function during a seismic event.

"Identified U2 control rods associated with HCU accumulators that had riser brackets installed incorrectly were declared inoperable. This condition has been corrected since initial identification, restoring all control rods to operable status. Reference IR 2407342.

"This notification is made pursuant to 10CFR 50.72(b)(3)(v) regarding the reportability of multiple failures that could have prevented fulfillment of a safety function.

"The NRC Resident Inspector will be notified."

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Power Reactor Event Number: 50598
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEPHEN SEILHYMER
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/06/2014
Notification Time: 13:41 [ET]
Event Date: 11/05/2014
Event Time: 16:25 [CST]
Last Update Date: 11/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVE PASSEHL (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - LICENSED OPERATOR IN VIOLATION OF THE FITNESS FOR DUTY POLICY

A licensed operator has been found in violation of the Northern States Power Minnesota Fitness for Duty Policy. The individual's access to the plant has been suspended and the operator has been removed from duty. The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 50600
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROBERT WARNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/06/2014
Notification Time: 18:22 [ET]
Event Date: 11/06/2014
Event Time: 11:16 [MST]
Last Update Date: 11/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
GEOFFREY MILLER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 20 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO DROPPED CONTROL ELEMENT ASSEMBLY

"On November 6, 2014 at 1116 Mountain Standard Time (MST), Control Element Assembly (CEA) 15 dropped fully into the core while all other CEAs remained fully withdrawn. Limiting Condition for Operation (LCO) 3.1.5 Condition A was entered for one CEA misaligned from its group which requires restoration of the CEA within 2 hours. An initial power reduction was performed upon receipt of the deviation in accordance with technical specifications. The CEA could not be aligned within 2 hours and LCO 3.1.5 Condition C was entered at 1316 MST which requires entry into Mode 3 within 6 hours. Power reduction continues as necessary to comply with technical specifications.

"No major equipment was inoperable prior to the event that contributed to the event. No emergency classification was required per the Emergency Plan. No automatic essential safety feature actuations occurred and none were required. The Emergency Diesel Generators did not start and were not required. Safety related buses remain energized. The offsite power grid is stable. Other LCOs were entered as required by technical specifications."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY RYAN LANE TO JEFF ROTTON AT 0012 EST ON 11/07/2014 * * *

"Efforts to repair the CEA control system and realign CEA 15 with the other CEAs in its regulating group were unsuccessful. Shutdown of Unit 2 was completed at 1636 [MST] in accordance with normal operating procedures to comply with the shutdown requirements of LCO 3.1.5 Condition C. Unit 2 is currently stable in Mode 3 with the reactor coolant system at normal operating temperature and pressure. All equipment responded as expected with the exception of steam generator # 2 economizer feedwater regulating valve which remained 3 percent open. The economizer feedwater isolation valves to both steam generators were manually closed to isolate the economizer feedwater flow paths. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event.

"The NRC Resident Inspector has been informed of the Unit 2 shutdown."

Notified R4DO (Miller)

Page Last Reviewed/Updated Friday, November 07, 2014
Friday, November 07, 2014