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Event Notification Report for February 23, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/20/2015 - 02/23/2015

** EVENT NUMBERS **


50814 50818 50819 50820 50821 50823 50836 50839 50841 50842

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Agreement State Event Number: 50814
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALLEGHENY GENERAL HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/12/2015
Notification Time: 10:38 [ET]
Event Date: 02/10/2015
Event Time: [EST]
Last Update Date: 02/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE ADMINISTRATION OF Y-90 MICROSPHERES

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"Notifications: The Department [Pennsylvania Department of Environmental Protection] was notified of this event on Wednesday, February 11, 2015. It is immediately reportable as per 10 CFR 35.3045(a)(1)(i).

"Event Description: A patient was receiving Y-90 Sirtex Sirspheres when the administering device failed and a portion of the dose was lost in the apparatus. The patient received 10.4 mCi, or 58% of the prescribed 17.82 mCi dose.

"Cause of the event: The device came apart during the procedure and the remainder of the dose was contained in the packaging.

"Actions: The Department plans a reactive inspection."

Pennsylvania Event Report ID No: PA150004

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: 50818
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RESURRECTION MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01034-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/13/2015
Notification Time: 10:43 [ET]
Event Date: 11/21/2014
Event Time: [CST]
Last Update Date: 02/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
PATRICIA MILLIGAN (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING HIGH DOSE RATE AFTERLOADER

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

"Licensee reported that while following up with a patient who had undergone radiation treatments following surgical removal of a breast tumor, redness, pain and swelling were occurring near the catheter insertion site. It was determined that the intended dose had been delivered with the connector end of the applicator interface identified as the reference location instead of the tip of the applicator as planned in the treatment. As a result, the 10 fractions of 340 cGy each were offset by over 4 cm for all the dwell positions within the applicator. The treatments were conducted with a strut adjusted volume implant (SAVI) applicator following an accelerated partial breast irradiation treatment regime. The catheter insertion site is estimated as having received a dose of over 13,000 R. The patient received medical treatment for the damaged tissue which would not heal. The Agency [Illinois Emergency Management Agency] is conducting an investigation into the matter to determine if the event is isolated or if other similar treatments may have had associated errors. Additional precautions have been taken by the licensee to prevent future occurrences including changing treatment planning systems, implementing additional quality assurance procedures and involving additional personnel to verify plans before treatment commences.

"This event was reported to the US NRC Operations Center on February 13, 2015 and assigned event number 50818.

"This item remains open pending additional investigation results."

The HDR source was 6.95 Ci of Ir-192. As a result of the damage to the tissue, a mastectomy was performed.

IL Report Number: IL15001

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: 50819
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: GALLATIN STEEL COMPANY
Region: 1
City: GHENT State: KY
County:
License #: 201-557-56
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/13/2015
Notification Time: 13:58 [ET]
Event Date: 08/15/2014
Event Time: [CST]
Last Update Date: 02/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON BERTHOLD MLT300 FIXED GAUGE

The following information was received from the Commonwealth of Kentucky:

"On 8/15/14, Gallatin Steel discovered a problem with the source holder (serial number 6596) on a Berthold MLT300 fixed gauge. The gauging device contained 27 mCi of Co-60, serial# 165-02-13. The source holder was closed and locked, removed from service, placed in storage, and service was scheduled with Berthold service group. On 8/20/14 Radiametrics Technologies shutter-checked, surveyed and leak tested the device. The shutter was found to be stuck in the closed position which was caused by the lifting mechanism. Excessive wear on the lifting mechanism caused it to indent the edge of the shutter and the top plate causing an inoperable condition. The shutter was repaired and rechecked for proper operation and no problems were found. On 2/13/14 Gallatin Steel sent the KY RHB [Kentucky Radiological Health Branch] notification of the event. Corrective actions include repair of the gauge, and service/inspection of the lifting device every 6 months. Gallatin Steel informed all personnel involved, including Berthold Service Group, of the incident and the notification requirements to the KY RHB."

Kentucky Event ID: KY150001

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Agreement State Event Number: 50820
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: JOSHUA E. DAEHLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/13/2015
Notification Time: 14:35 [ET]
Event Date: 02/13/2015
Event Time: 12:35 [EST]
Last Update Date: 02/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
SCOTT MOORE (NMSS)
LAURA DUDES (NMSS)
BERNARD STAPLETON (IRD)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Category 1 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - CAT 1 IRIDIUM-192 SHIPMENT LOST/FOUND DURING TRANSIT

The following information was received from the Commonwealth of Massachusetts:

"QSA Global reported that [the common carrier] has initiated a trace of the shipment or packages to find the missing materials.

"Abstract:

"At 12:35 p.m. February 13th, the licensee (QSA Global, Inc.) made a telephone notification to the Massachusetts Radiation Control Program.

"At 9:30 a.m. February 13th, QSA Global, Inc. was notified by [the common carrier] that a shipment of 6 packages was missing and that [the common carrier] had initiated a trace on the shipment or packages.

"QSA Global reported [the common carrier] stated that the packages were last observed by [the common carrier] to be at [their] facility on Thursday, February 12th.

"The total activity of all 6 packages was reported by QSA Global to be 73,000 curies of lridum-192.

"QSA Global described the packages to each be Model 702 bulk shipping containers. Two of the packages each contain four Model 849 special form capsules and four of the packages each contain three Model 849 special form capsules. All special form capsules contain iridium-192 wafers. QSA Global reported that it was not certain whether or not the six packages were together or separated at the [common carrier] facility.

"QSA Global reported that the shipment originated from the Netherlands and was intended for delivery to their QSA Global's Burlington, MA facility.

"The reporting requirement is immediate. 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C."

* * * UPDATE AT 1515 EST ON 02/13/15 FROM JOSHUA E. DAEHLER TO S. SANDIN * * *

"The Agency (Massachusetts Radiation Control Program) was notified at 3:15 p.m. today by our licensee (QSA Global, Inc.) that the iridium-192 missing sources had been located at [common carrier hub] and are under their control .

Notified NMSS (Dudes), IRD (Stapleton), R1DO (Powell) and NMSS Event Notification via email.

Notified the following Federal Agencies: DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, NICC Watch Officer, USDA Ops Center, EPA EOC, FDA EOC, FEMA NWC (email), Nuclear SSA (email) and, DNDO-JAC (email).

* * * UPDATE AT 1428 EST ON 02/17/15 FROM EDWARD SALOMON VIA EMAIL * * *

"The licensee (QSA Global, Inc.) notified our Agency [Massachusetts Radiation Control] (email message, dated 2/16/2015) that the formerly missing packages were physically delivered to their QSA Global, Inc. facility in Burlington , MA on Monday, 2/16/2015.

"The Agency considers this matter to still be OPEN pending follow-up report from licensee. The licensee is expected to file a written report to our agency within 30 days of the immediate notification related to 105 CMR 1281 (A)(1), an immediate report."

Notified R1DO (Powell) and NMSS Events Notification via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 1" LEVEL OF RADIOACTIVE MATERIAL

Category 1 sources, if not safely managed or securely protected would be likely to cause permanent injury to a person who handled them, or were otherwise in contact with them, for more than a few minutes. It would probably be fatal to be close to this amount of unshielded material for a period of a few minutes to an hour. These sources are typically used in practices such as radiothermal generators, irradiators and radiation teletherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 50821
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ISOAID
Region: 1
City: PORT RICHEY State: FL
County:
License #: NONE
Agreement: Y
Docket:
NRC Notified By: KELLIE L. ANDERSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/13/2015
Notification Time: 14:46 [ET]
Event Date: 02/13/2015
Event Time: 13:40 [EST]
Last Update Date: 02/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - ONE I-125 SEED LOST/RECOVERED DURING SHIPMENT

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

"[The common carrier] was delivering 2 packages from CA to Isoaid in Port Richey (they dispose of the used material sent in by customers). The boxes at some point fell out of the truck and they were not discovered missing until the driver reached Isoaid. It is not known the exact time this [occurred], the phone call to the BRC [Bureau of Radiation Control] was at 1:40 pm. They did locate them but one package was run over and (1) I-125 seed was missing from the box. As of 2:35 pm they have found the missing seed."

Florida Incident No.: FL15-008

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: 50823
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MARSHFIELD CLINIC
Region: 3
City: MARSHFIELD State: WI
County:
License #: 141-1162-01
Agreement: Y
Docket:
NRC Notified By: LAUREN JAMES
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/13/2015
Notification Time: 17:34 [ET]
Event Date: 02/13/2015
Event Time: [CST]
Last Update Date: 02/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE UNIT FAILED TO FUNCTION AS DESIGNED

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

"On Friday, February 13, 2015, the Wisconsin Radiation Protection Section received notice from the Radiation Safety Officer (RSO) of Marshfield Clinic that their Leksell Gamma Knife Perfexion gamma stereotactic radiosurgery unit failed to function as designed. The Gamma Knife unit became stuck open and staff had to manually retract the patient bed and close the shielding doors on the unit. It is not believed that the patient received a dose higher than was planned but it is unknown if it is a medical event at this time.

"The Wisconsin Radiation Protection Section will conduct an investigation on Monday, February 16, 2015 and provide updates through NMED."

WI Event ID: WI150001

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Power Reactor Event Number: 50836
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHEL CICCONE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/20/2015
Notification Time: 00:49 [ET]
Event Date: 01/19/2015
Event Time: 20:18 [EST]
Last Update Date: 02/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY POWELL (R1DO)

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

Event Text

HIGH ENERGY LINE BREAK BOUNDARY DOOR NOT LATCHING

"A High Energy Line Break (HELB) boundary door was discovered not latching. HELB boundary affects both trains of safety related [480V] switchgear and was not operable for approximately seven minutes. [The licensee] entered the technical specification action statement, restored the door to functional, and exited the technical specification action statement."

The licensee notified the NRC Resident Inspector, the State of Connecticut and local officials.

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Power Reactor Event Number: 50839
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN TUITE
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/21/2015
Notification Time: 12:46 [ET]
Event Date: 02/21/2015
Event Time: 10:32 [EST]
Last Update Date: 02/21/2015
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):
STEVE ROSE (R2DO)

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

Event Text

MANUAL REACTOR TRIP INSERTED DUE TO RAPID LOSS OF MAIN CONDENSER VACUUM

"On February 21, 2015 at 10:32 EST, Watts Bar Nuclear Plant Unit 1 reactor was manually tripped due to rapidly dropping main condenser vacuum. Concurrent with the reactor trip the Auxiliary Feedwater system actuated as designed.

"All Control and Shutdown rods fully inserted. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and S/G PORVs. Main Steam Isolation Valves are closed. The Station is in a normal shutdown electrical alignment.

"The cause is currently under investigation.

"This is being reported under 10CFR 50.72(b)(3)(iv)(A) and 10CFR 50.72 (b)(2)(iv)(B).

"The NRC Senior Resident has been notified."

This event had no affect on Unit 2 (Under Construction)

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Power Reactor Event Number: 50841
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MIKE CICCONE
HQ OPS Officer: VINCE KLCO
Notification Date: 02/21/2015
Notification Time: 21:35 [ET]
Event Date: 02/21/2015
Event Time: 19:50 [EST]
Last Update Date: 02/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1DO)

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

SITE STACK RADIATION MONITOR FAILURE

The Millstone site stack radiation monitor, RM-8169, failed and was declared inoperable at 1950 EST on February 21, 2015. Repairs are in progress.

This event is reportable pursuant to 10 CFR 50.72(b)(3)(xiii) as any event that results in a major loss of emergency assessment capability, off-site response capability, or off-site communications capability.

The Instrument and Controls Department is conducting troubleshooting and repair. The cause of the radiation monitor failure was sample pump failure.

The licensee has notified the NRC Resident Inspector and applicable State and Local authorities.

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Power Reactor Event Number: 50842
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: CHARLIE ACUNA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/22/2015
Notification Time: 02:36 [ET]
Event Date: 02/21/2015
Event Time: 21:22 [EST]
Last Update Date: 02/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1DO)

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

Event Text

REACTOR VESSEL LEVEL MONITORING SYSTEM INOPERABLE

The licensee declared the reactor vessel level monitoring system (RVLMS) inoperable when an intermittent failure occurred in the 'B' train reactor vessel level monitoring system (RVLMS) concurrent with the loss of the 19% level sensor in the 'A' train. This caused entry into a 7-day LCO action statement under Technical Specification 3.3.6, Action E.

The 'B' train instrumentation was reset and indication returned to normal and the LCO action was exited after 36 minutes. A Condition Report was submitted to determine cause and repair, if needed.

The licensee has notified the NRC Resident Inspector as well as state and local authorities.

Page Last Reviewed/Updated Monday, February 23, 2015
Monday, February 23, 2015