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Event Notification Report for January 23, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/22/2015 - 01/23/2015

** EVENT NUMBERS **


50735 50736 50738 50748 50749 50751 50752

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Agreement State Event Number: 50735
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: MEDWELL HILL
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2015
Notification Time: 16:15 [ET]
Event Date: 01/14/2015
Event Time: 13:47 [EST]
Last Update Date: 01/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ANTHONY HSIA (NMSS)
PAM HENDERSON (MSTR)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - TWO CATEGORY 2 IRIDIUM SOURCES UNACCOUNTED FOR DURING SHIPMENT

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

QSA Global (Shipper) initially provided notification to the Commonwealth of Massachusetts of the following:

"On Tuesday, January 13, 2015, QSA was notified by the customer a routine shipment of two Ir-192 sources from QSA Global, Inc. to Huntington Testing and Technology did not arrive as expected. They (HT&T) contacted the carrier and were told that the shipment could not be located. A trace was initiated. This trace is still actively being pursued by [the carrier's representative] and as of the writing of this email, the shipment is suspected of being at a US Postal Service facility in Charleston, SC."

QSA Global subsequently provided notification to the Commonwealth of Massachusetts of the following:

"Please be advised that QSA has received notification by [the carrier's representative] that the shipment to Huntington Test and Technologies reported missing has been located and physically verified in Memphis, TN at the [shipper's] hub. Additional information will be forthcoming in a followup 30 day report. "

The two Iridium-192 sources are 102.8 Ci (SN: 14381G) and 102.7 Ci (SN: 14382G), respectively shipped in an SC-650L Source Changer (SN: 202). The shipment has no indication of tampering and is currently enroute to HT&T.

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: 50736
Rep Org: SAINT VINCENTS MEDICAL CENTER
Licensee: SAINT VINCENTS MEDICAL CENTER
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-00843-03
Agreement: N
Docket:
NRC Notified By: SHAWN MATTHEWS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/15/2015
Notification Time: 12:00 [ET]
Event Date: 01/14/2015
Event Time: 13:30 [EST]
Last Update Date: 01/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ART BURRITT (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

MEDICAL EVENT INVOLVING A Y-90 SIR-SPHERE UNDER DOSE

Notification of a medical event that occurred on January 14, 2015 at 1330 EST, in which the Y-90 SIR-Sphere dose delivered to the patient's liver was less than the prescribed dose. The intended dose to the patient was 22 mCi, however the catheter disconnected during administration, resulting in a spill on the table which caused the underdose to the patient. It is estimated the patient received only 11.5 mCi or approximately 52% of intended dose and there was no harm to the patient.

The patient and prescribing physician have been informed and a follow-up treatment is planned. There was no contamination or exposure to other personal.

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: 50738
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KAISER PERMANENTE MEDICAL CENTER - ANTIOCH
Region: 4
City: Antioch State: CA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: KENT PENDERGAST
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/15/2015
Notification Time: 15:36 [ET]
Event Date: 01/07/2015
Event Time: [PST]
Last Update Date: 01/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (NMSS)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED EXCEEDED 50 REM

The following information was provided by the State of California Department of Public Health - Radiological Health Branch (RHB) via email:

"On 01/14/15, RHB received an email from the RSO reporting a Medical Event. On 1/7/15 a patient was scheduled for a thyroid uptake scan. Instead of the prescribed dose of 300 microcuries of Sodium Iodide 123, 3.69 mCi [3690 microcuries] of the isotope was administered to the patient. Due to quality of the scan, the error was noted. An initial calculation performed on 1/8/15 indicated target organ [dose] exceeding 50 rem. On 1/9/14, another calculation performed by the consulting physicist using patient's actual measured uptake values, the target organ [dose] was deemed less than 50 rem and it was decided to be non-reportable. On 1/13/15, the chief of Nuclear Medicine reviewed the reference source and contacted the same physicist to review his calculations, and the physicist realized that he made an error in calculations, and informed the facility that the organ dose exceeded 50 rem. On 1/14/15, the Kaiser Medical Physicist confirmed the [dose] to be 53.6 rem to the thyroid, and the RSO notified RHB of the Medical Event. RHB will be following up on this matter."

CA Event Report Number: 011415

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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Fuel Cycle Facility Event Number: 50748
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: MICHAEL TESTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/21/2015
Notification Time: 18:32 [ET]
Event Date: 01/21/2015
Event Time: 10:40 [EST]
Last Update Date: 01/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(4) - FIRE/EXPLOSION
Person (Organization):
GERALD MCCOY (R2DO)
TIM MCCARTIN (NMSS)
BERNARD STAPLETON (IRD)
FUELS GROUP (EMAI)

Event Text

UNPLANNED FIRE IN BUILDING 110 R&D LABORATORY VENTILATION HOOD

"During calcining of a water-rinsed polypropylene cartridge filter, flames were observed at the top of the furnace door. The flames were contained in ventilation hood H-103. The flames lasted for 5-10 minutes, always limited to the top of the furnace door. The glass in the sash for hood H-103 broke, most likely from the heat of the flame. The glass is spider-webbed, but contained in the sash. The testing in the hood has been stopped and the hood and furnace have been tagged out of service.

"There were no actual consequences due to this event. Potential consequences could have involved worker exposure and/or environmental releases."

The licensee notified the NRC Resident Inspector.

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Research Reactor Event Number: 50749
Facility: TEXAS A&M (AGN)
RX Type: 0.005 KW AGN-201 #106
Comments:
Region: 4
City: COLLEGE STATION State: TX
County: BRAZOS
License #: R-23
Agreement: Y
Docket: 05000059
NRC Notified By: CHRIS CROUCH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2015
Notification Time: 13:31 [ET]
Event Date: 01/21/2015
Event Time: [CST]
Last Update Date: 01/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
DUANE HARDESTY (NRR)
PATRICK ISAAC (NPR)
ALEXANDER ADAMS (NPR)
KEVIN HSEUH (NPR)

Event Text

VIOLATION OF TECHNICAL SPECIFICATION AT RESEARCH AND TEST REACTOR FACILITY

The following information was obtained from the licensee via email:

"Notification of Reportable Occurrence at the Texas A&M University AGN 201M Reactor: Transgression of Technical Specification 5.3 Reactor Room, Reactor Control Room, Accelerator Room (item d).

"During a review of the AGN 201M reactor facility boundary, it was discovered that the facility was not in compliance with Technical Specification 5.3.d. More specifically, the reactor control console is located in the reactor room contrary to the specification. This specification reads: 'The reactor room, reactor control room, and accelerator room are separate rooms in the Zachry Engineering Center, constructed with adequate shielding and other radiation protective features to limit doses in restricted and unrestricted areas to levels no greater than permitted by 10 CFR 20, under normal operating conditions, and to a level below criterion 19, Appendix A, 10 CFR 50 recommendations under accident conditions.'

"On April 2, 1984, a memo was sent to the Texas A&M University Reactor Safety Board (RSB) Chairman requesting the control console be moved to the reactor room. In this memo, it was noted that a submittal of changes to the security plan and emergency plan would be required to the Nuclear Regulatory Commission (NRC). Approval for this modification was authorized by the RSB on April 20, 1984. The reactor control console was relocated to the reactor room on September 20, 1984. The University subsequently submitted the revised security plan and emergency plan to the NRC, dated October 11, 1984. Upon review of the changes, the NRC agreed with the changes to the emergency plan and requested further review at Headquarters for implementation of the new security plan. The University then requested a license amendment on September 2, 1985 for implementation of the revised security plan. This amendment (No. 13) was issued on November 5, 1985.

"It appears Technical Specification 5.3.d was not taken into account during the process of moving the control console to its current location in 1984. Currently the AGN 201M is not operating in accordance with Confirmatory Action Letter EA-2013-154, limiting the impact to the health and safety of facility personnel.

"Prior to restoration of reactor operations, this issue will be addressed and an appropriate solution will be implemented. Solutions are being investigated to return the facility to compliance."

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Power Reactor Event Number: 50751
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JUSTIN EASTMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2015
Notification Time: 18:31 [ET]
Event Date: 01/22/2015
Event Time: 18:13 [EST]
Last Update Date: 01/22/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GERALD MCCOY (R2DO)
VICTOR MCCREE (R2RA)
JENNIFER UHLE (NRR)
BERNARD STAPLETON (IRD)
MICHELE EVANS (NRR)

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

NOTIFICATION OF UNUSUAL EVENT DECLARED DUE TO TOXIC GAS IN THE SECURITY DIESEL BUILDING

At 1801 EST, the control room received multiple fire alarms in the control room. At 1803, site security notified the control room of the presence of smoke in the security diesel building. At 1813, the licensee declared a Notification of Unusual Event due to the presence of toxic gas in the security diesel building on the battery/UPS side of the building. The fire suppression (NOVEC) system had discharged. Both the Technical Support Center and the Operations Support Center were fully manned.

The site fire brigade made entry into the building and saw no evidence of fire but they did see and smell an acrid odor from an apparent electrical fire as well as the presence of the NOVEC fire suppressant. Offsite assistance was requested but not required to mitigate the event. Investigation of the cause of the toxic gas is under investigation. At this time, no security equipment is affected.

Both the Technical Support Center and the Operations Support Center were fully manned.

The licensee notified the State of North Carolina, New Hanover and Brunswick counties, and the NRC Resident Inspector.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA National Watch Center (email) and Nuclear SSA (email).

* * * UPDATE FROM BRUCE HARTSOCK TO MARK ABRAMOVITZ AT 1936 EST ON 1/22/15 * * *

At time 1923 EST, the Notification of Unusual Event was terminated after normal access to the security diesel building was restored. The cause of the event is under investigation.

The licensee notified the State of North Carolina, New Hanover and Brunswick counties, and the NRC Resident Inspector.

Notified R2DO (McCoy), IRD (Stapleton), NRR (Evans), DHS SWO, FEMA Operations Center, DHS NICC, FEMA National Watch Center (email) and Nuclear SSA (email).

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Power Reactor Event Number: 50752
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BOB MARTIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/22/2015
Notification Time: 18:51 [ET]
Event Date: 01/22/2015
Event Time: 17:45 [EST]
Last Update Date: 01/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RAY MCKINLEY (R1DO)

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

UNANALYZED HEAT EXCHANGER LINEUP COULD EXCEED DESIGN BASIS TEMPERATURES

"On 1/20/15, it was determined that a certain line up of component cooling heat exchangers and shutdown cooling heat exchangers could exceed the design basis temperatures for the component cooling water system following a design basis accident. Although not a safety concern at this time because of low ultimate heat sink temperatures (which cools component cooling water), in the past the ultimate heat sink temperatures have been high enough to create this condition. This particular heat exchanger line up was unanalyzed in that the ultimate heat sink temperature limits were not known until 1/22/15. This issue has been entered into the corrective action program.

"A review of Control Room logs for 2014 showed that in 1 instance for Unit 1 and 1 instance for Unit 2, the Units were in an unanalyzed lineup with ultimate heat sink temperature greater than the maximum now calculated. During these instances, both Units had an unanalyzed condition that had potential to significantly degrade plant safety and is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, January 23, 2015
Friday, January 23, 2015