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Event Notification Report for January 20, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/16/2015 - 01/20/2015

** EVENT NUMBERS **


50723 50724 50727 50728 50729 50731 50743 50744

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Non-Agreement State Event Number: 50723
Rep Org: US ARMY
Licensee: WOMACK ARMY MEDICAL CENTER
Region: 1
City: FT BRAGG State: NC
County:
License #: 32-04054-04
Agreement: Y
Docket:
NRC Notified By: KACEY MCGEE
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/08/2015
Notification Time: 11:34 [ET]
Event Date: 12/11/2014
Event Time: [EST]
Last Update Date: 01/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
DON JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

UNINTENDED DOSE TO FETUS

On December 11, 2014, a patient was receiving a thyroid ablation treatment containing 97 mCi of I-131. A pregnancy test performed prior to the treatment was negative. On December 29, 2014, the patient reported to the medical center that it had been determined that she was pregnant on the day of the treatment, and that the gestational age of the fetus was determined to be 4 weeks at the time of the thyroid ablation treatment.

The US ARMY Fort Bragg Radiation Safety Officer was notified of this event on January 5, 2015 by the authorizing physician of the exposure to the fetus via email. The calculated dose to the uterus was 20.43 Rad. The expected impact to the fetus was determined to be either miscarriage or no effect. The medical center is performing a root cause analysis to determine any potential corrective actions. The licensee will ensure the patient has been notified of the potential medical consequences to the fetus of this treatment.

* * * UPDATE AT 1510 EST ON 01/12/15 FROM KACEY McGEE TO S. SANDIN * * *

The patient was informed by the medical staff on 12/31/14. The root cause investigation is on-going.

Notified R1DO (Burritt) and NMSS Events Notification (email).

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Agreement State Event Number: 50724
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: THERAGENICS
Region: 1
City: BUFORD State: GA
County:
License #: GA 885-5
Agreement: Y
Docket:
NRC Notified By: JOEL MIMS
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/08/2015
Notification Time: 13:13 [ET]
Event Date: 11/12/2014
Event Time: [EST]
Last Update Date: 01/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED IN STRAND LAB

The following information was provided by the State of Georgia via facsimile:

"Theragenics was packing radioactive seeds for transport to customer when one of the seeds was lost in the strand lab and could not be found. This was an Iodine 125 seed manufactured by Medi-Physics, model Oconoseed 6711. At the time of production the seed had a radioactivity of 0.696 mCi, but by the time of the report had decayed to 0.492 mCi radioactivity.

"On November 12, 2014, licensee personnel were filling an order for stranded seeds when a seed could not be accounted for. After searching the lab area continually and personnel when they left the lab (portal monitor scanning), the seed still has not been found. The licensee made a report via phone notification of the missing seed on December 12, 2014.

"License has conducted refresher training for employees who work in the lab areas. An emphasis was noted on handling technique, especially during mid-late October through November, when the change in weather and humidity have traditionally resulted in an increase of seed-handling errors, i.e., seeds 'popping' out of tweezers during manipulation. Additionally, the strand lab is scheduled for its semi-annual cleaning (per General Lab Practice) on December 19-20, 2014. During that process, crews will look for this seed and the one that was reported missing from September 2014."

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: 50727
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/09/2015
Notification Time: 13:40 [ET]
Event Date: 01/08/2015
Event Time: [EST]
Last Update Date: 01/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - GAUGE FAILED TO FUNCTION AS REQUIRED

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

"During a daily routine maintenance inspection [at the Edgar Thomson Plant in Braddock, PA], the licensee observed that the Berthold moisture analyzer gauge was at an odd angle when compared to the chute that it was attached. A mounting bracket had broken causing the gauge to become dislodged. An area survey check was performed and determined no elevated radiation readings. The shutter was placed into the closed position and a service provider was notified. The gauge was then removed by the service provider and transported to their warehouse to determine the repair method. The licensee is also awaiting a response from the manufacturer.

"Manufacturer: Berthold Technologies, Isotope: Am-241, Activity: 300 mCi

"CAUSE OF THE EVENT: The bracket had broken allowing the device to shift. The device was still in place but not completely flush with the chute.

"ACTIONS: The device was removed from the site without incident and transported to the service provider's warehouse for repair. The Department plans a follow-up inspection with the licensee. More information will be provided when received."

PA Event Report ID NO: PA150001

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Non-Agreement State Event Number: 50728
Rep Org: NOVELIS
Licensee: NOVELIS
Region: 1
City: FAIRMONT State: WV
County:
License #: 47-13348-02
Agreement: N
Docket:
NRC Notified By: DOUG ROSSANA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/09/2015
Notification Time: 14:14 [ET]
Event Date: 01/09/2015
Event Time: [EST]
Last Update Date: 01/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DON JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

GAUGE SHUTTER OPERATED SLOWLY IN THE CLOSE DIRECTION

On December 18-19, 2014, Operations personnel detected a local indicating light showing the gauge shutter in the open position. Control room indication and local area surveys indicated the gauge shutter was closed. During the annual Christmas maintenance shutdown, a gauge contractor was onsite and the licensee requested that the suspect gauge shutter be investigated. On January 3, 2015, the gauge technician changed sensors for shutter open/close indication noticed slow operation of the shutter in the close direction. The technician made adjustments to the gauge shutter so that it would slide freely. The technician also recommended routine lubrication to prevent this issue in the future.

The gauge contains 300 mCi Sr-90 source. Gauge serial number 3737622, Source serial number S432-A. No adverse personnel exposures are expected as a result of this event.

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Non-Agreement State Event Number: 50729
Rep Org: ELKHART GENERAL HOSPITAL
Licensee: ELKHART GENERAL HOSPITAL
Region: 3
City: ELKHART State: IN
County:
License #: 13-18879-01
Agreement: N
Docket:
NRC Notified By: WILLIAM MOEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/09/2015
Notification Time: 14:18 [ET]
Event Date: 01/08/2015
Event Time: 10:00 [EST]
Last Update Date: 01/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

PATIENT RECEIVED WRONG FORMULATION OF TECHNETIUM RADIOPHARMACEUTICAL

A patient who was to be given a myocardial stress profusion exam was incorrectly given a 160 mCi dose of technetium pertechnetate [instead of prescribed Tc-99m sestamibi]. The cause of the incident was the medical technologist deviated from established procedures. There is no expected adverse impact on the patient as a result.

The patient and physician have been informed.

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: 50731
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: MEADWESTVACO TEXAS LLP
Region: 4
City: SILSBEE State: TX
County: JASPER
License #: L01095
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: VINCE KLCO
Notification Date: 01/12/2015
Notification Time: 13:37 [ET]
Event Date: 01/12/2015
Event Time: 11:00 [CST]
Last Update Date: 01/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

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

"On January 12, 2015, the licensee notified the Agency [Texas Department of State Health Services] that during routine fixed nuclear gauge inspections and shutter checks, it discovered that the shutter on one of its Ronan Model SA1-C5 gauges, containing a 300 millicurie cesium-137 source (SN: 6409GK), was stuck in the open position. [The event occurred at the licensee site located in Evadale, Texas.] This gauge normally operates with the shutter in the open position. The gauge is mounted on a vessel that the licensee does not enter. There is no risk of exposure to any individual. The licensee is contacting the manufacturer to schedule repair. Further information will be provided as it is obtained in accordance with SA-300.

Texas Incident: I-9266

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Power Reactor Event Number: 50743
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DOUG PETERSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/19/2015
Notification Time: 02:30 [ET]
Event Date: 01/18/2015
Event Time: 21:31 [CST]
Last Update Date: 01/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HIRONORI PETERSON (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

LOSS OF NORMAL TECHNICAL SUPPORT CENTER POWER

"At 2131 CST on January 18, the Duane Arnold Energy Center [DAEC] Technical Support Center (TSC) Normal Power was lost when a single phase to the T4 '36KV-12.5KV DAEC SITE TRANSFORMER' was lost due to a blown primary side fuse. Automatic power transfer occurred to maintain power to the TSC from the TSC Emergency Diesel Generator (EDG) which automatically started. The TSC remained functional throughout the incident.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(xiii) due to the loss of an emergency assessment capability. An update will be provided once the normal power supply has been restored."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 50744
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PIERCE C. MOORE
HQ OPS Officer: VINCE KLCO
Notification Date: 01/19/2015
Notification Time: 14:24 [ET]
Event Date: 01/19/2015
Event Time: 11:00 [CST]
Last Update Date: 01/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID PROULX (R4DO)

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

MISSILE DOOR MISALIGNED RESULTS IN A REDUCTION IN ACCIDENT MITIGATION

"The missile door (door 33012) protecting Class 1E Engineered Safety Features (ESF) buses NB01/NB02 switchgear rooms was discovered misaligned on its hinge and stuck partially open and not capable of being closed. The missile door has since been repaired and closed. Technical Specification (TS) 3.8.9, 'Distribution Systems- Operating,' was declared not met and Condition F entered when the immediate operability determination identified that buses NB01 and NB02 were inoperable. Condition F of TS 3.8.9 requires immediate entry into Limiting Condition for Operation (LCO) 3.0.3. LCO 3.0.3 was entered at 1100 CST and subsequently exited when the missile door was repaired at 1118 CST. The unit was in and still is in MODE 1 at 100% power. No actions were initiated to commence a unit shut down. The NRC resident inspector was contacted regarding this event. All systems functioned as expected."

Page Last Reviewed/Updated Tuesday, January 20, 2015
Tuesday, January 20, 2015