Event Notification Report for March 04, 2015

AGREEMENT STATE REPORT - MEDICAL EVENT DURING BRACHYTHERAPY TREATMENT

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

"Maine General Medical Center reported that a patient received less dose than prescribed to the treatment site and dose to an unintended site during HDR (Varian model GammaMed Plus) brachytherapy using an Ir-192 source. The patient was prescribed to receive a 1,350 cGy (rad) boost dose to the vaginal cuff in three weekly fractions of 450 cGy (rad) each. The first fraction was delivered on 2/25/2015 using a 3.5-cm applicator. Post insertion CT images were reviewed by the physician and the first fraction was delivered correctly. During the second fraction on 3/4/2015, a second physician was unable to insert the 3.5-cm applicator due to edema and tenderness. A new treatment plan was developed to deliver the prescribed 450 cGy (rad) dose using a 2.6-cm applicator. Upon review of the previous week's images, the second physician noted that the applicator was approximately 7 cm short of the intended position such that the tip of the applicator did not contact the vaginal cuff. On 3/11/2015, a fraction was correctly delivered using the 2.6-cm applicator. The second physician reviewed the treatment deviation with the patient and recommended that an additional fraction of 450 cGy (rad) be administered, which was scheduled for 3/18/2015. The cause was determined to be human error."

This event was reported to the State of Maine on 03/11/2015. An NMED report was submitted on 03/12/2015 [NMED Item Number: 150165].

Maine Report Nr.: ME150002 and ME150002A

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.

INTERIM PART 21 REPORT - INABILITY TO COMPLETE EVALUATION REGARDING CRACKING IN KCR-13 STANDBY BATTERY JARS

The following was received via email:

"The purpose of this letter is to provide the NRC a report in general conformity to the requirements of 10 CFR Part 21.21(a)(2). On March 4, 2015, C&D Technologies, Inc. (C&D) was informed by Entergy Nuclear Northeast that a KCR-13 battery installed at the Indian Point Nuclear Energy Center had developed a crack in the polycarbonate jar material. This is the second KCR-13 at this site that has experienced a crack in the jar material [see EN 49667]. The jar is a safety related component with the primary function of containing electrolyte. The battery has not been returned to C&D for analysis, and analysis of the previous issue was inconclusive.

"C&D is submitting this interim report to the NRC and notifying C&D's customers that use C&D KCR-13 batteries, of this Interim report, and is initiating an action plan to evaluate the reported potential defect and determine whether it could pose a substantial safety hazard for any US licensee using such batteries.

"KCR-13 Batteries manufactured in 2005, battery manufacturing date is on the label. Note: C&D has not completed its evaluation of the reported potential defect and whether it could pose a substantial safety hazard at any US licensee using such batteries.

"The cracked jar has not been fully evaluated and may or may not indicate a potential defect which could create a substantial safety hazard.

"KCR -13 batteries used at Nuclear Plants in 1E applications made in 2005:

"Utility/Plant Name/Battery Model/Quantity of Batteries

"Entergy/Indian Point /KCR-13 NUC/72

"Xcel Energy/Monticello/KCR-13 NUC/62

"Concurrent Actions underway to complete the evaluation:

"a) On receipt of the battery from Indian Point, C&D will perform a failure analysis with the intent of determining the root cause of the cracking issue. Maximum time 30 days from receipt of the battery.

"b) In conjunction with the licensees identified in Section VI, C&D will recommend maintenance assessment of all KCR-13 batteries at these locations to determine their status and specifically, the presence of any evidence of potential defects via visual examination. For any cells exhibiting the presence of potential defect, C&D shall further recommend that they be returned for analysis. Estimated completion date of analysis is thirty (30) days from the receipt of the returned batteries.

"U.S. Licensees using batteries possibility containing the alleged defect have been notified of the filing of this interim report with recommendations that they examine their batteries for any signs of problems. NOTE: A similar notification and advice was provided in December 2013 with the previous battery. C&D did not receive any reports of similar problems from other product users.

"If you have any questions or wish to discuss this matter or this report, please contact:"

Robert Malley
VP Operational Excellence
bmalley@cdtechno.com
(215) 619-7830

The similar notification and advice provided in December 2013 is EN 49667.

* * * RETRACTION AT 1409 EDT ON 10/30/17 FROM ROBERT MALLEY TO S. SANDIN VIA EMAIL * * *

The following information was received from C&D Technologies via email:

"Subject: Retraction of Interim Report - Inability to Complete 10CFR Part 21 Evaluation Regarding Cracking in KCR-13 Standby Battery Jars

"On May 29, 2015 C&D Technologies submitted an interim Part 21 report (ML15155A575, Part 21 log 2015-34-00) regarding jar cracks discovered in a KCR-13 battery at Indian Point Nuclear Energy Center. This report was issued as the analysis of this battery jar had not yet been completed. The analysis was subsequently completed, and it was determined that the jar cracking was not related to the design or production of this battery, and thus is not a defect reportable under Part 21. Indian Point Nuclear Energy Center was notified of the findings of the report; however, no final Part 21 report was issued by C&D to the NRC, leaving the interim Part 21 report open.

"Based on the results of the analysis the Interim Report (NRC Log No. 2015-34-06) dated May 29, 2015 is retracted."

Notified R1DO (McKinley), R3DO (Stone) and Part 21/50.55 Reactors via email.

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENTS DUE TO A MISALIGNED GAMMA KNIFE

On March 4, 2015, the licensee notified the State of Oregon that they discovered that their Elekta Leksell Gamma Knife was off target by approximately 1.87mm. This was allegedly due to maintenance performed in early January 2015, that resulted in a misaligned couch. Since the misalignment, eight patients have undergone gamma knife surgery. The licensee Medical Physicist is currently evaluating each case to determine whether an underdose/overdose occurred to any of the patients.

The Elekta Leksell Gamma Knife is licensed for up to 6.6 kCi of Co-60.

The State of Oregon will update this report as more information becomes available.

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.

SUPPLEMENTAL WORKER FOUND WITH SYNTHETIC URINE

A non-licensed, non-supervisory supplemental worker was found with synthetic urine on their person during a search at the security entrance station. The individual's access was terminated on site and in PADS.

The NRC Resident Inspector and NRC Regional Inspector was notified.

OFFSITE NOTIFICATION DUE TO ELEVATED TRITIUM DETECTED ONSITE

"On March 3, 2015, PSEG [Public Service Enterprise Group] confirmed the presence of tritium at a concentration of approximately [0.01] microCurie/ml in ice samples taken in a small area immediately adjacent to the north side of the Hope Creek Turbine Building. The New Jersey Department of Environmental Protection Bureau of Nuclear Engineering was notified at 1408 [EST] on March 4, 2015, in accordance with NEI 07-07, Industry Ground Water Protection Initiative.

"Samples were taken and analyzed in response to ice which was observed to be forming along the exterior of the north Turbine Building wall. Sample results show detectable tritium is confined within the site boundary and there is no impact to the health and safety of the employees or the public.

"A catch containment was installed in the affected area. PSEG is continuing to evaluate this issue and develop corrective actions.

"The licensee has notified the NRC Resident Inspector."

The local Township will be notified.

AGREEMENT STATE REPORT - SHUTTER NOT OPERATING PROPERLY ON NUCLEAR PROCESS GAUGE

The following information was received from the Los Angeles Radiation Management Department via facsimile:

"On March 4, 2015, the Radiation Safety Officer (RSO), Exxon Mobil Oil Corporation (License #0113-19) reported to LA County Radiation Management that the shutter on one of their Thermo Nuclear gauges was not operating such that it could be completely closed per the manufacturer's design/specifications. This issue was discovered while Exxon Mobil was testing the integrity of all sources and source holders located in the area affected by the explosion that took place on February 18, 2015 (5010 #021815).

"At approximately 0900 [PST], [the RSO], along with a licensed Thermo Nuclear technician discovered that the Thermo Nuclear source holder, would not close completely, despite multiple attempts by the Thermo Nuclear technician. A radiation survey was performed around the source holder and the surrounding area was taped off with caution tape. The radiation level surrounding the source holder was found to be approximately 4 mR/hr. Exxon Mobil identified the source holder as Thermo Nuclear Model 5197, S/N CN-2435, with a 100 mCi Cs-137 source (S/N B8849).

"Upon discovery, [the RSO] immediately contacted LA County Radiation Management to report the findings. In addition to taping off the area, [the RSO] stated that the source is still in its normal position, approximately 10 feet from the ground and away from any routine traffic. Exxon Mobil has 24 gauges in the area that [were] impacted by the explosion on February 18, 2014. [The RSO] stated that only 11 gauges have been inspected thus far for leakage and damage. The remaining gauges will be inspected by the end of the week. Should Exxon Mobil discover another damaged source or source holder, they have been instructed to report the findings to LA County Radiation Management immediately."

California 5010 Number: 030415

MISSING TRITIUM EXIT SIGN

A tritium exit sign was discovered missing during a December 2014 inventory. The missing tritium exit sign is an Isolite Model 2000 containing two (2) 10 Ci sources, S/N 11-38620 and 11-38621. It was originally scheduled for installation in December 2012 at the University of Missouri Power Station but not installed due to other extensive renovations. The licensee conducted an investigation contacting both the contractor who was to perform the install and the manufacturer before concluding that the sign was missing.

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

AGREEMENT STATE REPORT - OHMART SHLM-CR3 CABLE DETACHED FROM SOURCE

The following report from the Texas Department of State Health Services was provided via email:

"On March 19, 2015, the licensee notified the Agency [Texas Department of State Health Services] that on March 4, 2015, while preparing for a shutdown for maintenance, it retracted a cesium-137 source back into its Ohmart SHLM-CR3 source holder when the cable came off of the source. The gauge contains a 2,400 milliCurie (original activity 04/1991) cesium-137 source. The licensee performed a survey to confirm the source was in the fully shielded position and placed a lock on the shutter. No individual received any exposure as a result of this event. The licensee is coordinating with the manufacturer to have the gauge repaired. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I 9285

* * * UPDATE AT 1804 EDT ON 3/24/2015 FROM KAREN BLANCHARD TO MARK ABRAMOVITZ * * *

The following was received by e-mail:

"The licensee initially reported the wrong event date. The licensee has advised the Agency [Texas Department of State Health Services] that the event actually occurred on March 2, 2015 (and not March 4, 2015 as previously reported)."

Notified the R4DO (Gaddy) and NMSS Events Notification (via e-mail).

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER OPEN IMPROPERLY DURING MAINTENANCE WORK

The following is a synopsis of information received from the State of Utah:

Two workers entered a confined space to perform work near a fixed gauge. One of the workers remained in the area for 9 minutes and the other remained in the area for 90 minutes. It was later determined that the fixed gauge shutter had not been closed. Surveys conducted by the licensee to measure dose rates in the area where the workers had been present indicated dose rates ranging from 0.5 mR/hr to 4 mR/hr. Utah inspectors performed confirmatory measurements that indicated dose rates between 0.97 mR/hr and 2.2 mR/hr.

Utah Event ID Number: UT150001