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Event Notification Report for February 24, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/23/2015 - 02/24/2015

** EVENT NUMBERS **


50758 50818 50819 50820 50821 50823 50846 50847

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Agreement State Event Number: 50758
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: N/A
Region: 1
City: JERSEY CITY State: NJ
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: JENNY GOODMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2015
Notification Time: 16:02 [ET]
Event Date: 01/23/2015
Event Time: [EST]
Last Update Date: 02/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - LOAD OF GARBAGE REJECTED AT LANDFILL DUE TO ELEVATED RADIATION READINGS

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

"A Pennsylvania landfill rejected a load of garbage based on elevated radiation readings (188 uR/h) and sent it back to NJ. PA identified the nuclides as Mn-54 and Co-57. [A New Jersey Department of Environmental Protection (NJDEP)] inspector went to the NJ garbage facility to verify the readings and nuclides.

"[NJDEP informed] the waste facility that [they] would be coming to observe the separation/isolation process, but [before the] inspector got there, they had already done everything. According to the facility personnel, there was a bag of metal parts (they opened it up), but had double bagged it by the time [the inspector] got there. [The] inspector got 23 mR/h on contact, 849 uR/h at 1 foot and 62 uR/h at 1 meter. Discussions revealed that no one picked it up with their hands and they were not near the source for very long. [NJDEP] identifier/Ortec readings confirm Co-57 and Mn-54 also Co-60 and Co-56. It appears to be activated metal. [A certified contractor] has been hired to package [the material]. He will be there sometime later next week. [The inspector did] not see any identifying markings. [The inspector] also took wipes of the bag and the floor area where it was dumped. These were clear. The garbage that was taken out along with the source was scanned and found to be background. That material will remain in NJ. [The] inspector surveyed the original truck with the remainder of the garbage, and [it] was found to be clear. They are running [the truck] through their portal monitor and if ok, will send [it] back to PA. The truck did not leave from this facility originally so it did not go through a monitor before going to PA. The activated metal has been isolated and secured."

* * * UPDATE FROM JENNY GOODMAN TO JOHN SHOEMAKER AT 1331 EST ON 1/26/15 * * *

The following update was received via email from the State of New Jersey via email:

"Upon NJDEP arrival at the waste facility on 1/23/15, the [landfill] facility staff had already isolated the material causing the radiation levels. The bag of waste they isolated measured as follows with a 1.5 by 1.5 NaI probe:
Near contact: 23 mR/hr
At ~1 foot: 840 microR/hr
At ~3 feet: 62 microR/hr
At ~6 feet: 10 microR/hr
Background: 3-4 microR/hr

"The tipping floor, where material had been laid out, and the three individuals involved in sorting the load were surveyed with a pancake probe. No radiation levels above background were detected. A wipe of the bag revealed no removable contamination.

"[NJDEP] surveyed the truck carrying the remainder of the MSW [Municipal Solid Waste] load and detected no elevated [radiation] levels. The truck was released to return to the PA landfill. [NJDEP] has not received an update from the facility to confirm acceptance of that material.

"[NJDEP] obtained a spectrum with the Ortec Detective-EX which identified Co-56, Co-57, Co-60, & Mn-54. A manual review of the spectrum additionally indicated Co-58. These isotopes are typical for metal activated from operation of an accelerator. Today, [NJDEP] contacted the DNDO [Domestic Nuclear Detection Office] JAC [Joint Analysis Center] for secondary reachback analysis of the spectrum. [NJDEP] received verbal confirmation of the isotopes detected. A written report is expected by tomorrow. Subsequently, [NJDEP] received a telephone call from an FBI bomb tech who had been informed of [NJDEP's] request for analysis. [The FBI] was seeking confirmation that there was no suspicious packaging or other threat associated with the package. [NJDEP] explained that we routinely find items in the waste stream and there was no specific threat or suspicious packaging.

"[NJDEP] is still awaiting follow-up from the waste facility to confirm acceptance of the remainder of the load released Friday and details for their plans for disposal. [NJDEP] will plan to return when their consultant packages the material to see if any other information can be gathered to identify a possibly point of origin for the material."

Notified R1DO (Cahill), ILTAB (Wray), and NMSS Events Notification via email.

* * * UPDATE FROM JAMES MCCULLOUGH TO HOWIE CROUCH AT 0913 EST ON 2/23/15 * * *

"On 2/18/2015 the facility's consultant removed the material for proper disposal. The radioactive item was determined to be a small metal foil. No specific point of origin could be determined."

New Jersey Department of Environmental Protection considers their investigation closed.

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

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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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Part 21 Event Number: 50846
Rep Org: CURTISS WRIGHT
Licensee: QUALTECH NP, HUNTSVILLE
Region: 1
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BAMBI RHOADES
HQ OPS Officer: VINCE KLCO
Notification Date: 02/23/2015
Notification Time: 17:05 [ET]
Event Date: 02/20/2015
Event Time: [CST]
Last Update Date: 02/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
STEVE ROSE (R2DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21- POTENTIAL DEFECT IN A SOCKET USED SEPARATELY OR IN A CONNECTOR KIT

The following information was received by facsimile:

"[The Curtiss-Wright] letter is issued to provide notification of a potential defect in Socket (PIN: GB-1 A-5) sold separately or supplied as part of a GRAYBOOT 'A'' (GB-1A) Connector Kit. There is one affected lot of Sockets (Lot#: 092413). The potential defect is that the socket was not zone annealed which will possibly affect the ability to crimp the socket onto the wire conductor. Zone annealing is specified for the crimp barrel to return the crimp barrel to a soft condition to counteract the effects of previous heat treating required to develop spring tension in the socket tines that mate with the pin contact.

"The nine affected Customers and their associated Purchase Orders are listed below. All Customers will be notified by February 24, 2015 and supplied with the information we have at this time.

1. Vattenfall- Forsmark Kraftgrupp AB, P.O. 4500301916
2. Vattenfall- Forsmark Kraftgrupp AB, P.O. 4500301916
3. Decon International (HK) Ltd., P.O. DIL00590
4. Ringhals AB, P.O. 641511-090
5. Dremel Inc., P.O. 13-040
6. Bruce Power L.P., P.O. 00185336
7. Kanata Electronic Services Limited, P.O. 34513
8. Meggitt Safety Systems Inc., P.O. 104057
9. Meggitt Safety Systems Inc., P.O. 104345

"Based on our recent in-house testing of socket Lot #: 092413, the defective sockets appear to be more difficult to crimp than sockets that have been zone annealed. Some of the Lot #: 092413 sockets showed cracking or bending under magnification. We did not have any sockets actually break apart during the crimping process. All the test specimens crimp barrels remained intact. If a severe fracture had occurred at the time of crimping we believe it would have been very noticeable to the technician installing the contact. Once crimped, the socket appears to function well by conducting electricity and exhibiting acceptable electrical resistance. Many of these sockets from Lot #: 092413 may already be installed. Customers will need to determine if replacing the sockets is required.

"All customers listed may choose to replace already installed sockets. It is requested that any uninstalled sockets be returned for replacement. All customers requesting replacement sockets should contact Bambi Rhoades at brhoades@curtisswright.com or by phone at 256-924-7424 for arrangements or Jim Tumlinson, contact information listed below.

"Send all defective sockets to QualTech NP; 120 West Park Loop; Huntsville, AL 35806. Customer can contact Cindy Tidwell at ctidwell@curtisswright.com or by phone at (256) 924-7436 for help with international or freight collect shipping instructions. Ship all defective sockets collect to UPS Account No. 35254E.

"Additional details, corrective actions and root causes will be provided once our report of the recent testing complete. If you require additional information or would like to discuss this further please do not hesitate in contacting [Jim Tomlinson; Office Phone: (256) 924-7429; email:jtomlinson@curtisswright.com]."

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Power Reactor Event Number: 50847
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/24/2015
Notification Time: 01:02 [ET]
Event Date: 02/23/2015
Event Time: 21:40 [EST]
Last Update Date: 02/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JOHN ROGGE (R1DO)

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

Event Text

AUTOMATIC REACTOR SCRAM ON REACTOR HIGH PRESSURE SIGNAL

"At 2140 EST on 02/23/2015, Unit 1 reactor automatically scrammed on a valid reactor high pressure signal (1096#). The reactor high pressure signal was caused by the closure of the 1C inboard main steam isolation valve (MSIV), causing reactor pressure to rise, exceeding the reactor protection system (RPS) setpoint of 1096# pressure.

"The shutdown was normal and the plant is stable in Hot Shutdown with normal pressure control via the main steam bypass valves to the main condenser and normal level control using the feedwater system.

"The closure of the 1C inboard MSIV appears to have been caused by a loss of primary containment instrument gas (PCIG) pneumatic supply to the valve. Instrument air was aligned to the remaining MSIV's.

"Limerick Unit 1 will remain in Hot Shutdown until repairs can be made."

All rods inserted into the core during the scram. No relief or safety valves actuated during the transient. The electric grid is stable and supplying all plant loads. There was no affect on Unit 2.

The licensee notified the NRC Resident Inspector, Pennsylvania Emergency Management Agency, and Berks, Chester and Montgomery counties.

Page Last Reviewed/Updated Tuesday, February 24, 2015
Tuesday, February 24, 2015