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Event Notification Report for December 29, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/24/2014 - 12/29/2014

** EVENT NUMBERS **


50680 50682 50683 50684 50689 50692 50693 50694 50695 50704 50705

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Non-Agreement State Event Number: 50680
Rep Org: MIDWEST TESTING
Licensee: MIDWEST TESTING
Region: 3
City: OVERLAND State: MO
County:
License #: 24-24619-02
Agreement: N
Docket:
NRC Notified By: JOE HONICH
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/16/2014
Notification Time: 09:21 [ET]
Event Date: 12/16/2014
Event Time: 07:42 [CST]
Last Update Date: 12/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
NEIL OKEEFE (R4DO)
AARON MCCRAW (R3DO)
NMSS EVENTS (EMAI)
ILTAB (EMAI)

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

Event Text

LOST HUMBOLDT 5001EZ DENSITY GAUGE

A trailer containing a Humboldt 5001EZ Density gauge was found missing/stolen by a technician staying at the Holiday Inn Express in Oklahoma City, OK. The gauge was chained and locked to the trailer. The licensee reported that there have been no press or media inquiries and no rewards are currently being considered for the return of the density gauge. The licensee was performing work in OK under reciprocity.

The gauge is a Humboldt 5001EZ model, Serial Number: 3309 containing 10 mCi of Cs-137 and 40 mCi of Am-241/Be.

The local police department and the State of Oklahoma were notified.

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: 50682
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ACUREN INSPECTION, INC. D/B/A WIT PIPELINE
Region: 3
City: SUPERIOR State: WI
County:
License #: 133-2008-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/16/2014
Notification Time: 13:44 [ET]
Event Date: 12/12/2014
Event Time: [CST]
Last Update Date: 12/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON MCCRAW (R3DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

WISCONSIN AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was obtained from the State of Wisconsin via email:

"The licensee reported that a radiography crew working at a temporary jobsite on the night of December 12, 2014, had a failure of a drive cable mechanism on a QSA Global Model 880D radiography camera. The drive cable severed, and the radiography crew was unable to retract the source into the camera. The crew re-established boundaries and maintained appropriate surveillance of the area. An individual who is licensed to perform source retrievals responded to the jobsite and was able to retract the source into the safe position in the camera. Direct-reading dosimeters did not indicate any exposures exceeding regulatory limits. The licensee has sent permanent record dosimetry for emergency processing, and the licensee has sent the failed equipment to QSA for analysis.

"The Wisconsin Radiation Protection Section will provide updates through NMED after receiving the licensee's written report."

Wisconsin Event Report ID No.: WI140014

* * * UPDATE FROM MEGAN SHOBER TO JOHN SHOEMAKER AT 1213 EST ON 12/17/14 * * *

The following information was obtained from the State of Wisconsin via email:

"The drive cable in question broke near the junction between the cable and the metal ball on the end of the cable. On December 17, 2014, the licensee submitted a report of the radiographer's permanent record dosimetry. Exposures from the source retrieval were less than regulatory limits.

"Because the radiography crew and equipment involved in this incident are based in Illinois, the Wisconsin Radiation Protection Section notified the Illinois Emergency Management Agency."

Notified R3DO (McCraw) and NMSS Events Notification (via email).

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Agreement State Event Number: 50683
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: COVANTA
Region: 1
City: NEWARK State: NJ
County:
License #: 506859
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/16/2014
Notification Time: 15:36 [ET]
Event Date: 12/15/2014
Event Time: 15:00 [EST]
Last Update Date: 12/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following report was received from the State of New Jersey via fax:

"Event Description: [The licensee] is a trash-to-steam facility and uses generally and specifically - licensed fixed gauges as level indicators. One of their registered, generally licensed gauges was found to be damaged during the 6-month shutter check. The damage appears to be a result of impact and the plunger needed to close the shutter is inoperable. The gauge is a Berthold Model LB 7440 L, S/N 838-3-90, containing 50 mCi of Cs-137. The gauge is in a fairly inaccessible area of the plant, and personnel do not work in the area. No overexposures are thought to have occurred at this time. An investigation is being performed and a 30-day report will be provided."

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Agreement State Event Number: 50684
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: IBA MOLECULAR
Region: 1
City: TOTOWA State: NJ
County:
License #: 452369
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/16/2014
Notification Time: 16:16 [ET]
Event Date: 12/16/2014
Event Time: 13:40 [EST]
Last Update Date: 12/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (EMAI)
PATRICIA MILLIGAN (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MARISSA BAILEY (NMSS)
PAMELA HENDERSON (NMSS)
DUNCAN WHITE (NMSS)

Event Text

AGREEMENT STATE REPORT - INDIVIDUAL EXCEEDS OCCUPATIONAL DOSE LIMIT OF 50 REM TO THE SKIN

The following report was received from the State of New Jersey via fax:

"Event Description: [The licensee,] IBA is a PET [Positron Emission Tomography] manufacturer and radiopharmacy. When the dosimetry reports for November 2014, were reviewed, it was noted that one individual exceeded the 20.1201(a)(2)(ii) occupational dose limit of 50 rem to the skin of an extremity. This was caused by a November dose of greater than 46 rem to the left extremity, bringing the year to-date dose to greater than 62 rem. The licensee is investigating this unusual November dose and will be preparing a written report. The individual has been removed from work with radioactive materials and the dosimeter for December has been sent in early for processing."

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Non-Agreement State Event Number: 50689
Rep Org: NATIONAL INST OF STANDARDS & TECH
Licensee: NATIONAL INST OF STANDARDS & TECH
Region: 1
City: GAITHERSBURG State: MD
County: MONTGOMERY
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: TOM O'BRIEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/17/2014
Notification Time: 14:28 [ET]
Event Date: 11/20/2014
Event Time: [EST]
Last Update Date: 12/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DONNA JANDA (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
DARYL JOHNSON (ILTA)

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

Event Text

LOST AM-241 SOURCE

While conducting an inventory, the licensee was unable to locate a Standard Reference Material Electro-Plated AM-241, 0.079 uCi source that is used for calibration. It is believed the source may have been disposed as radioactive waste or transferred to another facilty. The licensee will continue searching for the missing source.

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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Non-Agreement State Event Number: 50692
Rep Org: AIR FORCE MEDICAL SUPPORT AGENCY
Licensee: AIR FORCE MEDICAL SUPPORT AGENCY
Region: 4
City: TRAVIS AFB State: CA
County:
License #: 42-23539-01/A
Agreement: Y
Docket:
NRC Notified By: DANIEL SHAW
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2014
Notification Time: 12:57 [ET]
Event Date: 12/16/2014
Event Time: 18:00 [PST]
Last Update Date: 12/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

PRESCRIBED DOSE CHANGED BY UNAUTHORIZED USER

"On 16 December 2014, at 1800 [PST], a patient was prescribed to receive 8-12 mCi of I-123 MIBG [metaiodobenzylguanidine]. The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC [Officer-in-Charge] changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. [The Nuclear Medicine OIC] is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that [the Nuclear Medicine OIC] meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee).

"Location: Travis AFB, David Grant USAF Medical Center"

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: 50693
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: CHRISTUS SAINT VINCENT HOSPITAL
Region: 4
City: SANTA FE State: NM
County:
License #: MI 485-04
Agreement: Y
Docket:
NRC Notified By: VICTOR DIAZ
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/18/2014
Notification Time: 12:45 [ET]
Event Date: 12/17/2014
Event Time: 14:00 [MST]
Last Update Date: 12/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED MORE THAN PRESCRIBED DOSE

A patient received 150 mCi instead of the 30 mCi of I-131 that was prescribed for thyroid ablation treatment. The cause of the overdose was the patient was misidentified. The patient and prescribing physician has been informed. No adverse health effects are expected.

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: 50694
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: JANX INTEGRITY GROUP
Region: 1
City: PENNSAUKEN State: NJ
County:
License #: 507152
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2014
Notification Time: 14:47 [ET]
Event Date: 12/17/2014
Event Time: 15:55 [EST]
Last Update Date: 12/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following report was received from the State of New Jersey via fax:

"A source disconnect occurred during normal radiography operations. The exposure device was a SPEC 150 containing 29 Ci of lr-192. The operators immediately adjusted perimeter barriers and notified their RSO. A source retrieval team arrived in an hour and were able to successfully return the source to its shielded position within another hour. No overexposures were received. Direct reading dosimeters showed no exposure to the radiography team, and a dose of 33 mR and 5 mR were received by the source retrieval two-person team. The event was reported to be caused by operator error in failing to assure that the source tube was securely connected to the camera."

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Agreement State Event Number: 50695
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: TRICAN WELL SERVICE
Region: 1
City: MILL HALL State: PA
County:
License #: PA-G0076
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/19/2014
Notification Time: 12:19 [ET]
Event Date: 12/18/2014
Event Time: [EST]
Last Update Date: 12/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILURE

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

"Notifications: The [Pennsylvania] Department [Bureau of Radiation Protection] was notified on 12/18/2014 of a shutter malfunction. This event is reportable within 24-hours per 10 CFR 30.50(b)(2).

"Event Description: An operator tried to open the shutter handle, and it was hard to move. When the shutter did move, it spun freely and was put in the open position but no activity was observed. However, when the shutter was placed in the closed position activity was seen, thus verifying a malfunction.

"Manufacturer: Berthold Technologies
Model: LB8010
Serial Number: 10204
Isotope: Cs-137
Activity: 20 mCi

"Cause of the event: Unknown at this time, possible sheared roll pin.

"Action: Berthold, the manufacturer, was called to fix the damaged shutter handle. The [Pennsylvania] Department [Bureau of Radiation Protection] plans to follow-up with the licensee and the manufacturer. More information will be provided when received.

"Event Report ID No: PA140024"

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Power Reactor Event Number: 50704
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANIEL PIPKIN
HQ OPS Officer: DANIEL MILLS
Notification Date: 12/25/2014
Notification Time: 12:41 [ET]
Event Date: 12/25/2014
Event Time: 08:37 [CST]
Last Update Date: 12/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 85 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM

"At 0837 [CST] on 12/25/14, a loss of Reactor Protection System (RPS) 'B' occurred which resulted in a Division 2 RPS half SCRAM. This occurred concurrent with a Division 1 RPS half SCRAM which had been inserted for LCO 3.3.1.1 Action 'A' due to issues with the #2 turbine control valve RPS logic on 12/23/14. This resulted in a full RPS actuation and Reactor SCRAM. During the SCRAM, a reactor water Level '8' occurred which tripped the running reactor feed pump. Reactor water level peaked at 56 inches. This Level '8' is under investigation. Once reactor water level lowered below 51 inches the Level '8' signal was reset, and the team attempted to start the 'C' reactor feed water pump.

"The 'C' reactor feed pump failed to start upon attempt. The 'A' reactor feed pump was then started successfully. The startup feed regulating valve failed to open in automatic or manual mode, resulting in an RPV Level '3' signal (lowering to 8.1 inches). The operators manually aligned the 'C' feed water regulating valve and restored reactor water level to normal band. The plant is stable in Mode 3 pending investigation."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 50705
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: WILLIAM STANG
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/29/2014
Notification Time: 03:40 [ET]
Event Date: 12/28/2014
Event Time: 20:23 [CST]
Last Update Date: 12/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

TWO INOPERABLE EMERGENCY DIESEL GENERATORS

"While the 12 Emergency Diesel Generator (EDG) was inoperable for performance of the monthly surveillance, adjustments were inadvertently made to 11 EDG which made it inoperable. As a result, Technical Specification [TS] 3.8.1 Condition E, for both EDG's inoperable was entered. Monticello has subsequently restored 12 EDG to an operable status within the 2 hour TS LCO [Limiting Condition for Operation] completion timer requirement. The station remained in a safe condition during this discovery with 12 EDG available at all times. The plant continues to operate in a normal condition with no initiating events present. The health and safety of the public was not impacted as a result of this condition.

"The NRC Resident Inspector has been notified."

EDG 12 was restored to operable status at 2214 CST and EDG 11 will remain inoperable until a surveillance test is performed to start the EDG and restore the local governor control idle speed to the correct setting.

The licensee will be notifying the Minnesota State Duty Officer.

Page Last Reviewed/Updated Monday, December 29, 2014
Monday, December 29, 2014