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Event Notification Report for February 19, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/18/2015 - 02/19/2015

** EVENT NUMBERS **


50351 50766 50776 50802 50804 50805 50810 50830

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Power Reactor Event Number: 50351
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNY HUNTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/07/2014
Notification Time: 20:00 [ET]
Event Date: 08/07/2014
Event Time: 17:07 [EDT]
Last Update Date: 02/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
REBECCA NEASE (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 90 Power Operation 90 Power Operation

Event Text

UNANALYZED CONDITION DUE TO DISCOVERY OF DEGRADED FIRE BARRIER WALLS

"During a fire inspection activity involving inspection of fire walls that serve as Appendix R barriers, degradation of some fire walls was identified that was sufficient to prevent these walls from meeting Appendix R requirements as 3-hour fire barriers. In the event of a postulated fire in the affected areas, both safe shutdown paths on the affected unit could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded conditions can be corrected.

"Condition Reports: 850802, 850819"

In addition to automatic fire protection features, the licensee has posted fire watches as a compensatory measure.

The licensee has notified the NRC Resident Inspector.


* * * UPDATE FROM STANLEY STONE TO DONALD NORWOOD AT 1814 EST ON 11/24/2014 * * *

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1023 - RPS MG Set Room and Fire Area 1015 - Annunciator Room. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity.

"Condition Report: 898908."

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Ehrhardt).


* * * UPDATE FROM KENNY HUNTER TO DANIEL MILLS AT 1758 EST ON 11/25/2014 * * *

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1016 - 600 Volt Switchgear Room 1C and Fire Area 1017 - 600 Volt Switchgear Room 1D. In the event of a postulated fire in the affected areas, both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity."

The licensee notified the NRC Resident Inspector.

Notified R2DO (Ernstes).


* * * UPDATE FROM SCOTT BRITT TO DONALD NORWOOD AT 1706 EST ON 12/4/2014 * * *

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, additional conditions were identified involving multiple fire barriers in the control building that affected both safe shutdown paths on Unit 1 and Unit 2 based on the respective inspection results. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised.

"Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report as required and will be documented in a revised LER at the end of the inspection activity."

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Freeman).


* * * UPDATE AT 1842 EST ON 12/12/2014 FROM G.S. GRIFFIS TO MARK ABRAMOVITZ * * *

"As part of the 'extent of condition' corrective action for the condition identified in EN# 50351, an inspection activity is in progress to inspect the remaining fire walls and associated penetrations for conditions similar to those reported on 08/07/2014. During this inspection, nonconformances of multiple fire barriers were identified that bring into question the functionality of the affected fire barriers that can compromise safe shutdown paths on Unit 1 and 2 based on the respective inspection results. Since additional time is required to further evaluate each nonconformance to conclusively determine if the nonconformance is sufficient to consider the barrier nonfunctional, interim conservative fire actions were taken by considering these fire barriers as nonfunctional. Based on this conservative conclusion, in the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations and fire walls in most of these same fire areas and will remain in place until the barrier(s) are repaired. Additional fire actions were taken as required to address the additional fire areas identified. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.

"Unit 1 is entering a planned outage due to unrelated activities."

Condition Report: 10000607

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Desai).


* * * UPDATE FROM STANLEY STONE TO DONALD NORWOOD AT 2315 EST ON 1/15/2015 * * *

"As part of the 'extent of condition' corrective action for the conditions identified in EN# 50351, an inspection activity was performed of a fire wall for conditions similar to those reported on 12/12/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1008 - Unit 1 AC Inverter Room and Fire Area 0001 to consider the barrier nonfunctional. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity."

Condition Report: 10013077

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Musser).

* * * UPDATE FROM JOHN MITCHELL TO JEFF HERRERA AT 2025 EST ON 1/21/2015 * * *

"During review and closeout of fire barrier and penetration seals work orders and surveillance procedures performed as part of the 'extent of condition' inspection activity initially described in Event # 50351, the following conditions were identified that in the event of a postulated fire in the respective fire areas listed both safe shutdown paths could be compromised.

"Unit 2 Control Bldg. el. 130', gap in the grout around conduit penetration between fire areas 2013 and 2015
"Unit 1 Reactor Bldg. el. 130', open conduit between fire areas 1203C and 1105

"Given this information the determination was made that this condition meets the reporting criteria of 10 CFR 50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in the Unit 2 fire area and will remain in place until the affected barrier areas are repaired. Compensatory measures were established for the Unit 1 areas and will remain in place until the affected barriers areas are repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. Subsequent similar condition(s) found when performing remaining inspections that meet the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.

"Condition Report 10015417
"Condition Report 10015437"

The licensee notified the NRC Resident Inspector.

Notified the R2DO (McCoy).

* * * UPDATE FROM G.S. GRIFFIS TO HOWIE CROUCH AT 1714 EST ON 2/4/15 * * *

"During the review of fire barrier surveillance procedures performed as part of the 'extent of condition' inspection activity for the event initially identified in EN# 50351, some degradation was observed on the east wall of fire area 2006. These nonconforming issues observed on the affected fire wall were identified as affecting both safe shutdown paths for Unit 2. Therefore, in the event of a postulated fire for the affected area, both safe shutdown paths on Unit 2 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures, in addition to portable fire protection equipment located in adjacent areas, ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this, and any subsequent similar condition(s) that meets the reporting requirements, will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."

CR 10021623

Notified R2DO (HAAG).

* * * UPDATE FROM JOHN MITCHELL TO DANIEL MILLS AT 1823 EST ON 2/18/15 * * *

"During performance of work package closeouts to support the 'extent of condition' inspection activity for the event initially identified in EN# 50351, the following fire barriers were identified as failing to meet the procedure acceptance criteria:
- Three penetrations separating Unit 1 Fire Areas 1013 and 0040
- A fire wall deficiency in the wall separating Unit 1 Fire Areas 1015 and 1013

"These nonconforming issues observed on the affected penetrations and fire wall were identified as affecting both safe shutdown paths for Unit 1. Therefore, in the event of a postulated fire for the affected area, both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10028364
"CR 10028366"

The NRC Resident Inspector has been notified. Notified R2DO (Rose).

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Agreement State Event Number: 50766
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: REED ENGINEERING GROUP, INC.
Region: 4
City: DALLAS State: TX
County:
License #: L04343
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 18:55 [ET]
Event Date: 01/26/2015
Event Time: [CST]
Last Update Date: 02/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

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

"On January 26, 2015, the licensee notified the Agency [State of Texas] that one of its technicians had left a temporary job site in Fort Worth and after traveling approximately 30 minutes toward another job site, he realized the tailgate was down [and the gauge was missing]. When he left the first site, he had left the Humboldt 5001EZ moisture/density gauge (SN: 3613), containing one 10 millicurie cesium-137 source and one 40 millicurie americium-241/beryllium source, on the tailgate and not secured in the back of the vehicle. The technician returned to the site and looked for the gauge. Other construction workers at the site did produce the carrying case and the lock that had been on it, the standard block, and the flattening plate but not the gauge. The licensee is notifying local law enforcement and will return to the site in the morning with reward offer. Further information will be provided as it is obtained in accordance with SA-300."

Texas Report Number: I-9272

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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Fuel Cycle Facility Event Number: 50776
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: KENNY KIRBY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/28/2015
Notification Time: 16:22 [ET]
Event Date: 01/09/2015
Event Time: 16:00 [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
ANTHONY MASTERS (R2DO)
JACK GUTTMANN (NMSS)
FUELS GROUP (OUO) (EMAI)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

UNANALYZED CONDITION WHILE CLEANING THE CATCH TRAY

"I. EVENT DESCRIPTION

"Scrap material resulting from various operations at B&W NOG-L's facilities is processed in the Low Level Dissolver (LLD) to reclaim as much of the uranium as possible. Since the material is scrap (e.g., filters, vacuum cleaner bags, etc.), it contains only small amounts of uranium bearing materials. On occasion during processing a slight amount of material will spill over the edge of the dissolver trays, filter bowls, or when hand-transferring material between the trays and filter bowls. These small spills collect on a large catch tray in the bottom of the enclosure. Periodically the catch tray is cleaned to limit the amount of material buildup. By procedure the solid material is to be scraped up and collected in a [less than or equal to] 2.5 liter container. During the cleanout the LLD process is shutdown.

"On January 9, 2015, the LLD process was shutdown and the enclosure was undergoing a routine cleanout. However on this occasion the operators scraped the material on the tray into several piles for subsequent collection into containers. The volume of most of the piles exceeded the 2.5 liter limit. However, the spacing between the piles was greater than the 15 inch limit, and the net weight of any single pile was less than the 7 kg limit for a 2.5 liter volume containing an unknown amount of U-235 . NDA [Non-Destructive Assay] measurements later determined the U-235 content of the piles ranged from 6.5 to 20.8 grams. There was no risk of a criticality accident. The accident scenarios for [less than or equal to] 2.5 liter containers of an unknown amount of U-235 were reviewed to analyze the event. At that point in time it was concluded the performance requirements of 10 CFR 70.61 were maintained.

"At 0900 EST on January 28, 2015, during discussion with the NRC as part of a regularly scheduled NCS inspection the applicability of these scenarios to the event came into question. The scenarios assume the material is containerized rather than in piles. Some of the IROFS [item relied on for safety] were therefore considered not available in this particular situation.

"II. EVALUATION OF THE EVENT

"The cleanup process as analyzed assumed the material was scraped up and collected in [less than or equal to] 2.5 liter containers. The scraping of the material into piles for subsequent collection into containers is a different process than what had been analyzed. The scenarios for the handling of materials containing an unknown amount of U-235 assume the material is containerized rather than in piles. Some of the IROFS credited in these scenarios were therefore not available for the collection of the material in piles. Although the as-found condition presented no safety concern, the scenarios as documented in the ISA [Integrated Safety Analysis] did not demonstrate the performance requirements of 10 CFR 70.61 were maintained.

"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event.

"Ill. NOTIFICATION REQUIREMENTS

"B&W is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.

"IV. STATUS OF CORRECTIVE ACTIONS

"An investigation of the root causes of this event is ongoing. Corrective actions will be determined as a result of the investigation."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM TONY ENGLAND TO JOHN SHOEMAKER AT 0908 EST ON 2/11/15 * * *

"I. EVENT DESCRIPTION

"On January 28, 2015 B&W NOG-L notified the NRC of an unanalyzed condition that occurred during the cleanup of residual solids from the Uranium Recovery Low Level Dissolver that failed to meet the performance requirements of 10 CFR 70.61. As part of the subsequent investigation of the event an Extent of Condition Review was performed. During the Extent of Condition Review of cleanup of residual solids from the High Level Dissolver, a similar potential condition was identified at 10:00 a.m. EST on February 10, 2015. A cleanup activity was not in process at the time of discovery.

"II. EVALUATION OF THE EVENT

"The Uranium Recovery High Level Dissolvers process scrap fuel materials. Undissolved residual solids collect in the Dissolvers' recirculation columns over time. These solids contain some amounts of U-235 that did not go into solution. The Dissolvers periodically undergo cleanup operations during inventory or contract changes. During this cleanout a small amount of solids are emptied from the horizontal recirculation columns onto drip pans and then transferred to a favorable volume less than or equal to 2.5 liter container. Although a cleanup was not in process at the time of the Extent of Condition Review, it could not be readily determined that the performance requirements of 10 CFR 70.61 would be met if a cleanup operation were to be performed. There was no immediate risk of a criticality or threat to the safety of workers or the public. No actual event occurred.

"Ill. NOTIFICATION REQUIREMENTS

"B&W is revising Event Report #50776 dated January 28, 2015. A potentially unanalyzed condition was identified that could not be demonstrated as meeting the performance requirements. B&W is making this 24 hr. report in accordance with 10 CFR 70, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.

"IV. STATUS OF CORRECTIVE ACTIONS

"An investigation of the root causes of this event is ongoing. Corrective actions will be determined as a result of the investigation. No cleanouts of the High Level Dissolvers' recirculation columns will occur until it can be demonstrated the performance requirements of 10 CFR 70.61 are met for this maintenance task."

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Nease), NMSS EO (Rahimi), Fuels Group, and NMSS Events Notification via email.

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Agreement State Event Number: 50802
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ACUREN INSPECTION INC.
Region: 3
City: DAYTON State: OH
County:
License #: 03320 99 0006
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: VINCE KLCO
Notification Date: 02/10/2015
Notification Time: 11:35 [ET]
Event Date: 02/10/2015
Event Time: 09:26 [EST]
Last Update Date: 02/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED

The following was received from the Ohio Bureau of Radiation Protection via email:

"A crew working near Cambridge, Ohio this morning experienced a source disconnect on a QSA Model 880D camera containing 60.5 Curies of Iridium-192, which occurred at 9:26 AM EST.

"The disconnect was discovered after a shot, when the crew's survey instrument indicated that the source was still exposed after the guide cable had been fully retracted. The cause for the source disconnect has not yet been determined.

"The area has been secured, roped off, and is under constant surveillance by the radiography crew. Two Acuren supervisors trained in source recovery are enroute from their Akron office. The customer has been advised and is cooperating in keeping all personnel away from the area.

"There has been no exposure to workers or members of the public from the disconnect.

"An ODH [Ohio Department of Health] Investigator is enroute to the site to observe recovery options."

The QSA Global Camera (Model: 880D; Serial number: 4192) contained an Ir-192 source of 60.5 Ci (Serial number:13665G)

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Non-Agreement State Event Number: 50804
Rep Org: BAYHEALTH MEDICAL CENTER
Licensee: BAYHEALTH MEDICAL CENTER
Region: 1
City: DOVER State: DE
County:
License #: 07-14850-01
Agreement: N
Docket:
NRC Notified By: ADAM HENRY
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/10/2015
Notification Time: 15:32 [ET]
Event Date: 07/24/2013
Event Time: [EST]
Last Update Date: 02/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL MISADMINISTRATION DURING IODINE 125 SEED IMPLANTATION

During a medical procedure to implant 70 Iodine-125 seeds (0.4 mCi each) into the prostate, 20 were implanted into the bladder. The 20 implanted into the bladder were recovered during the procedure. There was no effect to the patient. The patient and prescribing physician have been notified. The licensee is working on corrective actions to prevent a recurrence.

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: 50805
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: QSA GLOBAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-5934-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/10/2015
Notification Time: 17:17 [ET]
Event Date: 02/09/2015
Event Time: [CST]
Last Update Date: 02/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - RADIOACTIVE SHIPMENT DELIVERED TO THE WRONG LOCATION

The following information is an excerpt from a report received from the Louisiana Department of Environmental Quality via email:


"On 02/09/2015, the Director of Regulatory Affairs for QSA Global Notified the [Louisiana Department of Environmental Quality] LDEQ about an incident where the common carrier delivered a 'crate/container' of [Radioactive Materials] RAM to the Baton Rouge, LA address that was intended for Seoul, South Korea. The call was received approximately 9:00 am CST at the Department. The caller stated the shipment was Ir-192 wafers/disc that were to be assembled into radioactive sealed sources. [The Director of Regulatory Affairs for QSA Global] stated he believed the shipment involves Category #1 quantities that should be reported.

"The delivery error resulted in a partial shipment bound for Asia being delivered to the Corporation's Baton Rouge, LA location.

"One of the Asia bound containers was 'bound/attached' to the container destined for Baton Rouge location at the Memphis Hub belonging to the common carrier. The other container went on to Asia. The international paperwork would document the partial receipt of the first container and the other when it was delivered. The common carrier was notified of the incorrect delivery. The common carrier was to pick up the Asia container on 02/10/2015 at QSA Baton Rouge facility and take it to the common carrier terminal in Kenner, LA. Then the container would be forwarded to Asia from Kenner, LA.

"Three containers, each having radioactive material in excess of Category 1 quantities were being shipped from the QSA Global Burlington, MA facility. Two were addressed to Seoul, South Korea and one was being shipped to Baton Rouge, LA. The labeling on one of the Korean containers was not legible or missing and it was bound to the container going to Baton Rouge, LA. After the delivery was made to Baton Rouge and the shipment was being surveyed/assessed it was learned they had received a wrong container and was in excess of the licensed activity for Ir-192.

"The Baton Rouge facility was compliant for the IC principles and Radiation Safety procedures/aspects for the receipt activities. The Department, LDEQ, determined that it would grant an emergency verbal activity increase for this situation. This would hold the radioactive material safe and secure until the common carrier could retrieve the excess material. The NRC, Region IV, was made aware of this situation on 02/09/2015, and the circumstances involving the common carrier error. Region IV was told QSA Global Burlington was going to be making the proper notifications/reports to the regulatory agencies. This was the information provided by [The Director of Regulatory Affairs for QSA Global].

"However, on the morning of 02/10/2015, the NRC Region IV notified LDEQ that a report about this situation could not be located within his agency. [the Director of Regulatory Affairs for QSA Global] was notified and he was unaware the notifications had not been made. He stated he would look into the situation. A call was placed to the Baton Rouge facility around 9:00 am [EST]. At that time, it was learned the common carrier was at the Baton Rouge facility to retrieve the container of radioactive material and forward it to South Korea. At this time LDEQ is still waiting on [The Director of Regulatory Affairs for QSA Global]'s explanation for the notifications not being made.

"A fact finding discussion resulted in a plan of control and containment until the common carrier could take possession of the container.

"LDEQ considers this incident closed."

Louisiana Event Report ID No: LA15004

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Agreement State Event Number: 50810
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/11/2015
Notification Time: 12:27 [ET]
Event Date: 01/12/2015
Event Time: [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DURING CANCER TREATMENT

The following information was received from the New York State Department of Health Bureau of Environmental Radiation Protection via fax:

"[The New York State Department of Health] NYSDOH received telephone notification from a licensee reporting a therapy misadministration involving a patient undergoing treatment of vaginal cancer. The treatment involved the use of a GammaMedplus iX brachytherapy HDR remote afterloader utilizing an Iridium-192 radiation source. The patient was administered the treatment using a vaginal applicator for proper placement of the therapy source. However, the vaginal applicator was improperly placed within the organ, which resulted in the irradiation of healthy tissue and significantly less radiation to the cancer site. Three treatments were given to the patient by the same oncologist over a three week period. Each treatment was prescribed to provide approximately 600 to 700 centigray of absorbed radiation. Preliminary investigations show that the therapy equipment was functioning properly and the treatment plan was appropriate. The licensee is investigating the oncologist's procedures. A written report will be sent to [the New York State Department of Health] DOH within seven days with more detailed information."

NY Report #: NY-15-02

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: 50830
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: MARK L. GREER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/18/2015
Notification Time: 16:01 [ET]
Event Date: 02/18/2015
Event Time: 14:06 [EST]
Last Update Date: 02/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
RAY POWELL (R1DO)
JANE MARSHALL (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL SCRAM DUE TO RAPIDLY RISING REACTOR WATER LEVEL

"At 1406 [EST] Nine Mile Point Unit 2 inserted a manual scram due to rapidly rising reactor water level.

"The cause of the rapidly rising water prior to the manual scram is unknown and under investigation.

"Reactor water level is currently being maintained in normal control band post scram.

"The reactor scram is reportable in accordance with 10 CFR 50.72(b)(2)(iv)(B) as, 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical.'

"The NRC Resident has been notified."

All rods fully inserted. Nine Mile Point Unit 2 is in a normal electrical shutdown configuration. The licensee reported no impact on Unit 1.

The New York State Public Service Commission was also notified.

Page Last Reviewed/Updated Thursday, February 19, 2015
Thursday, February 19, 2015