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Event Notification Report for March 27, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/26/2015 - 03/27/2015

** EVENT NUMBERS **


50770 50902 50904 50905 50906 50908 50926 50927 50928

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 50770
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CANCER CENTER OF GAITHERSBURG MARYLAND
Region: 1
City: GAITHERSBURG State: MD
County:
License #: 31-385-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2015
Notification Time: 14:49 [ET]
Event Date: 01/26/2015
Event Time: 14:30 [EST]
Last Update Date: 03/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"On 1/27/15 at 0830 EST, [Maryland Department of the Environment (MDEP) personnel] discussed preliminary findings [with the licensee] regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO [Radiation Safety Officer]. The initial notification came to [the Maryland] RHP [Radiological Health Program] on 1/26/15 at 1600 EST.

"The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878.

"The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR [High Dose Rate].

"The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose.

"[The Licensee] stated no history of previous medical incidents.

"The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray.

"Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur.

"The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed.

"Present at the therapy - Oncologist, Medical Physicist, and Therapist.

"[The Medical Physicist] stated that the licensee will re-examine all quality assurance oversight for HDR therapies.

"Preliminary consideration for corrective actions: All new treatment plans will be given new identities [and] the licensee will explore ways to delete previous treatment plans.

"The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day.

"[The Medical Physicist] was informed that RHP will investigate the incident."

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.

* * * UPDATE FROM ALAN JACOBSON TO JEFF HERRERA ON 01/28/2015 AT 0828 EST * * *

The following information was provided by the State of Maryland via email:

The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci.

Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email).

* * * EVENT RETRACTED AT 1205 EDT ON 3/26/2015 BY RAY MANLEY TO MARK ABRAMOVITZ * * *

This event is retracted because the dose delivered matched the written directive. Due to a software error, the dose was reported as double the actual dose. The patient, doctor and NMED have been notified.

Notified the R1DO (Jackson) and NMSS Events Resource (via e-mail)

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Non-Agreement State Event Number: 50902
Rep Org: MALLINCKRODT PHARMACEUTICALS
Licensee: MALLINCKRODT PHARMACEUTICALS
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: MANUAL DIAZ
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/19/2015
Notification Time: 10:39 [ET]
Event Date: 02/26/2015
Event Time: [CDT]
Last Update Date: 03/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GREGORY ROACH (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GLENN DENTEL (R1DO)

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

Event Text

MOLYBDENUM-TECHNETIUM GENERATOR LOST DURING SHIPMENT

A Mo-Tc Generator was sent to Baptist Hospital in Miami, Florida. The generator was used for approximately 2 weeks before being shipped back on 1/18/14. It was picked up by the common carrier on 1/19/14. The Mo-Tc generator did not make it back to the Mallinckrodt facility.

A search was initiated at the Mallinckrodt facility and Baptist Hospital. When the Mo-Tc generator could not be located, it was declared missing on 2/26/15.

The generator is approximately 65 lbs. total and contains 8.1 mCi of depleted uranium-238. The shield was stamped with the number 2116.


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: 50904
Rep Org: ALABAMA RADIATION CONTROL
Licensee: VITAL INSPECTION PROFESSIONALS
Region: 1
City: Alabaster State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2015
Notification Time: 13:17 [ET]
Event Date: 03/17/2015
Event Time: 21:30 [CDT]
Last Update Date: 03/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANGELA MCINTOSH (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER POTENTIAL OVEREXPOSURE

The following information was received via fax:

"On March 18, 2015, the Radiation Safety Officer for Vital Inspection Professionals, Alabaster, Alabama notified the Office of Radiation Control [for the State of Alabama] in regards to a potential overexposure which may have occurred while conducting radiography at the Alabama Power, Miller Steam Plant.

"On March 17, 2015 at approximately 2130 CDT, a crew was conducting radiography. The crew consisted of one radiographer and three assistants. They were completing two exposures lasting 35 seconds, and with a set-up time of approximately 15 to 18 minutes. After completing the two exposures, the radiographer noticed that his pocket dosimeter (200 mR) was off-scale. The first assistant's pocket dosimeter was reading 50 mR, the second assistant's pocket dosimeter was off scale and the third assistant was not wearing any dosimetry. The radiographer and first assistant acknowledged that their alarming rate meters were functioning correctly, the second assistant and third assistant were not wearing an alarming rate meter.

"The crew notified their Radiation Safety Officer at 2130 CDT, but did not contact him until around midnight. The crew immediately stopped work and was told to meet the Radiation Safety Officer the next morning to discuss the events. All available dosimetry was sent off for emergency processing and [dose information] should be received by noon, March 19, 2015. From the discussion it was determined that the survey meter had an apparent electrical short and was not measuring properly. The camera was checked and determined to be functioning properly. Based on the licensee's preliminary dose estimates it was determined that one crew member may have received up to 45 Rem whole body.

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Agreement State Event Number: 50905
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: PORT LAVACA State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/19/2015
Notification Time: 14:45 [ET]
Event Date: 03/04/2015
Event Time: [CDT]
Last Update Date: 03/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

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).

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Agreement State Event Number: 50906
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: PORT LAVACA State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/19/2015
Notification Time: 14:45 [ET]
Event Date: 03/17/2015
Event Time: [CDT]
Last Update Date: 03/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - OHMART SH-F2 GAUGE SHUTTER HANDLE PIN SHEARED

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

"On March 19, 2015, the licensee notified the Agency [Texas Department of State Health Services] that on March 17, 2015, while preparing for a shutdown for maintenance, it closed the shutter on an Ohmart SH-F2 gauge, which contained a 200 milliCurie cesium-137 source, and the pin on the shutter handle sheared off. 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 contacted a service company and the gauge was repaired and returned to service on March 19, 2015. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I 9286

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Agreement State Event Number: 50908
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - FRANKLIN, INC.
Region: 3
City: FRANKLIN State: WI
County:
License #: 079-1375-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/19/2015
Notification Time: 17:18 [ET]
Event Date: 03/18/2015
Event Time: [CDT]
Last Update Date: 03/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREGORY ROACH (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDER DOSAGE OF PATIENT UNDERGOING TREATMENT

The following report was received from the State of Wisconsin Department of Health Services via email:

"On March 18, 2015, the Wisconsin Radiation Protection Section received a notice from the Radiation Safety Officer (RSO) at Wheaton Franciscan Healthcare-Franklin of a medical event that occurred from a halted administration of Yttrium 90 SIR-Spheres. During the administration, air bubbles were noticed to be collecting in the tubing delivering the dose. The procedure was stopped in order to avoid injecting air bubbles into the patient. The prescribed dose was 33.26 mCi. 26.35 mCi had been delivered to the patient, based on pre-and post-procedure assays of the material. This is 79.2% of the prescribed dose. The licensee believes placement of the needles drawing the solution was to blame for the collection of air bubbles. The Radiation Protection Section will perform an investigation and update through NMED."

Wisconsin Event Report ID No.: WI150005

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: 50926
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/26/2015
Notification Time: 15:19 [ET]
Event Date: 03/26/2015
Event Time: 13:30 [CDT]
Last Update Date: 03/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)

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

Event Text

SEISMIC MONITOR NOT AVAILABLE FOR EMERGENCY PLAN ASSESSMENT

"LaSalle Station has completed a review of seismic monitor performance. The seismic monitor is currently operable; however, this review identified 6 times in the past 3 years that the seismic monitor was inoperable such that emergency classification at the ALERT level could not be obtained with site instrumentation. The seismic monitor was determined to be inoperable on the following dates:

1) January 28, 2015
2) May 28, 2014
3) January 1, 2014
4) August 5, 2013
5) April 17, 2013
6) April 10, 2012

"These unplanned inoperable conditions of the seismic monitor were entered into the LaSalle Corrective Action Program when they occurred.

"While Exelon procedural direction allowed the use of offsite sources to obtain seismic data when the seismic monitor is incapable of assessing emergency plan Emergency Action Levels (EALs), this was not explicitly referenced in the approved EALs. The loss of assessment capability is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii). This report is required per 10 CFR 50.72(a)(1)(ii) as an event that occurred within 3 years of the date of discovery."

The licensee has notified the NRC Resident Inspector.

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Research Reactor Event Number: 50927
Facility: OREGON STATE UNIVERSITY
RX Type: 1100 KW TRIGA MARK II
Comments:
Region: 4
City: CORVALLIS State: OR
County: BENTON
License #: R-106
Agreement: Y
Docket: 05000243
NRC Notified By: TODD KELLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/26/2015
Notification Time: 15:23 [ET]
Event Date: 03/25/2015
Event Time: 16:00 [PDT]
Last Update Date: 03/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
KEVIN HSUE (E-MAIL) (NPR)
ALEXANDER ADAMS (NPR)
SPIROS TRAIFOROS (NPR)
MICHAEL BALAZIK (NPR)

Event Text

RESEARCH AND TEST REACTOR TECHNICAL SPECIFICATION VIOLATION

"We would like to report a potential violation of our Technical Specifications, section 6.7.2.a.8 which states an observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy causes or could have caused the existence or development of an unsafe condition with regard to reactor operations. The details of the event are as follows:

- January 14, [2015,] the Reactor Supervisor submitted paperwork for license renewal of an SRO [Senior Reactor Operator] to the director for signature. The director signs the paperwork. It was then assumed that the paperwork would be routed to the NRC for license renewal. The paperwork was signed but not sent to the NRC.
- March 10, [2015,] the license for the SRO expires.
- March 19, [2015,] the SRO completes the control room portion of the startup checklist. This includes manipulation of console controls and placing the reactor in 'OPERATING' condition. The SRO does not perform the reactor startup.
- March 25, [2015,] staff determines that the reactor was placed in an OPERATING condition without a licensed operator at the console on March 19. No other staff was present in the control room during the performance of the startup checklist.
- March 26, [2015,] reactor operation was suspended.

"It has been determined that the SRO did not perform any other license duties after his license had expired. The SRO will not perform license duties until his license is officially renewed."

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Power Reactor Event Number: 50928
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: AL MEURS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/26/2015
Notification Time: 16:36 [ET]
Event Date: 03/26/2015
Event Time: 13:30 [CDT]
Last Update Date: 03/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)

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

Event Text

SEISMOGRAPH NOT AVAILABLE FOR EMERGENCY PLAN ASSESSMENT

"Quad Cities Station has completed a review of the station strong motion seismograph's performance. The seismograph is currently functional; however, this review identified 3 times in the past 3 years that the seismograph was non-functional such that emergency classification at the ALERT level could not be obtained with site instrumentation:

1) 02/03/2014
2) 10/07/2014
3) 10/19/2014

"These unplanned non-functional conditions of the seismograph were entered into the Quad Cities Corrective Action Program when they occurred.

"While Exelon procedural direction allowed the use of offsite sources to obtain seismic data when the seismograph was nonfunctional, this was not explicitly referenced in the approved Emergency Action Levels. The loss of assessment capability is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii). This report is required per 10 CFR 50.72(a)(1)(ii) as an event that occurred within 3 years of the date of discovery."

Corrective actions are in progress.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 27, 2015
Friday, March 27, 2015