| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
03/27/2015 - 03/30/2015 ** EVENT NUMBERS ** |
 | 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 |
| 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. |
| 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). |
| 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 |
| 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. |
| Agreement State | Event Number: 50910 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ATI MIDLAND
Region: 1
City: MIDLAND State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 03/20/2015
Notification Time: 12:29 [ET]
Event Date: 03/17/2015
Event Time: [EDT]
Last Update Date: 03/20/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text AGREEMENT STATE REPORT - ORPHAN SOURCE FOUND IN SCRAP METAL
The following report was received via fax:
"The Department [Pennsylvania Department of Environmental Protection] received notification on March 18, 2015 regarding a source that set off an alarm at a steel mill facility.
"A truck load of scrap set off a radiation monitor alarm at the ATI Midland steel mill. ATI rejected the load and sent it back to the scrap yard which contacted an approved service provider. Applied Health Physics isolated and identified the source as Americium-241 (Am-241). Contact reading of the source was 30 mR/hr and 1 mR/hr at 1 meter.
"Source: Am-241
Manufacturer: Unknown
Manufacturer Date: 4-13-88
SN: # 7435LV"
Pennsylvania Report: PA150007 |
| Non-Agreement State | Event Number: 50913 | Rep Org: DEPARTMENT OF THE ARMY
Licensee: DEPARTMENT OF THE ARMY/TACOM LIFE CYCLE MANAGEMENT COMMAND
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: THOMAS DOUGHERTY
HQ OPS Officer: DONALD NORWOOD | Notification Date: 03/20/2015
Notification Time: 19:35 [ET]
Event Date: 03/20/2015
Event Time: 13:30 [EDT]
Last Update Date: 03/20/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
| Person (Organization):
GREGORY ROACH (R3DO)
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
|
| This material event contains a "Less than Cat 3 " level of radioactive material. | Event Text LOST GENERAL LICENSED RADIOACTIVE MATERIAL
The following occurred at Joint Base Lewis-McChord which is located in the State of Washington. At 1330 PDT on 3/20/2015, it was confirmed that items containing general licensed radioactive material had been converted into scrap material and then sent offsite to an as yet undetermined smelter. It is believed that the disposition of this material occurred on 4/30/2014.
The lost general licensed radioactive material was contained in the following equipment with activities as listed:
Smiths Detection, Sabre 4000, Serial #: 43105, 15 mCi Ni-63
Smiths Detection, Sabre 4000, Serial #: 43135, 15 mCi Ni-63
GE, VaporTracer2, Serial #: K190014411, 10 mCi Ni-63
GE, VaporTracer2, Serial #: K190014412, 10 mCi Ni-63
Safran, Itemiser 3, Serial #: 050449010283, 10 mCi Ni-63
The Department of the Army is continuing to try to ascertain where this material ended up. There are no known exposures, injuries or contaminations due to this event.
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 |
| Power Reactor | Event Number: 50932 | Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: JASON HARNER
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 03/27/2015
Notification Time: 16:57 [ET]
Event Date: 03/27/2015
Event Time: 13:00 [EDT]
Last Update Date: 03/27/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
TODD JACKSON (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text SEISMIC MONITOR NOT AVAILABLE FOR EMERGENCY PLAN ASSESSMENT
"Three Mile Island Station has completed a review of seismic monitor performance. The seismic monitor is currently operable however, this review identified 1 time 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 date:
1) August 7, 2012
''This unplanned inoperable condition of the seismic monitor was entered into the Three Mile Island Corrective Action Program when it 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." |
| Power Reactor | Event Number: 50933 | Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LINSAY GREEN
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 03/27/2015
Notification Time: 17:12 [ET]
Event Date: 03/27/2015
Event Time: 09:41 [CDT]
Last Update Date: 03/27/2015 | 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 | 93 | Power Operation | 93 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text SEISMIC MONITOR NOT AVAILABLE FOR EMERGENCY PLAN ASSESSMENT
"Braidwood Generating Station has completed a review of seismic monitor performance. The emergency preparedness plan requires seismic monitoring instruments to diagnose an earthquake for emergency action levels (EAL) HA4 (natural and destructive phenomena affecting vital areas) or HU4 (natural and destructive phenomena affecting the protected area). Contrary to that requirement, this review identified 5 times in the past 3 years that the seismic monitor was non-functional such that emergency classification at the ALERT or UNUSUAL EVENT level could not be obtained with site instrumentation.
"The seismic monitor is currently functional; however, the seismic monitor was determined to be non-functional on the following dates:
1. April 24, 2012
2. December 5, 2012
3. December 20, 2012
4. June 17, 2013
5. October 8, 2014
"These non-functional conditions of the seismic monitor have been corrected and were entered into the Braidwood Corrective Action Program.
"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 Braidwood 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.
"Corrective actions are in progress.
"The licensee has notified the NRC Resident Inspector." |
| Part 21 | Event Number: 50935 | Rep Org: UNITED CONTROLS INTERNATIONAL
Licensee: UNITED CONTROLS INTERNATIONAL
Region: 1
City: NORCROSS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LUIS SANCHEZ
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 03/27/2015
Notification Time: 17:33 [ET]
Event Date: 01/30/2015
Event Time: [EDT]
Last Update Date: 03/27/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
| Person (Organization):
TODD JACKSON (R1DO)
PART 21/50.55 REACT (EMAI)
| Event Text PART-21 NOTIFICATION - SENSE AND TRANSFER MODULE RESISTIVE SHORT
The following excerpted report was received via e-mail:
"Sense & Transfer Module (part number 41-09-339904) was provided to PSEG under purchase order 4500726553. The customer identified an abnormal curve trace (resistive short) on the integrated circuit installed at location IC825 pin 6 on this printed circuit board. The customer performed an evaluation which included dissection of the subject IC [integrated circuit] however, this dissection provided inconclusive results as to the cause of the IC anomaly.
"At this time, UCI requires additional time to evaluate the results provided by PSEG and to work with the manufacturer in identifying the root cause. UCI currently considers this issue to be an isolated event as no previous instances of this failure have been observed by UCI to date. PSEG has returned the item to UCI for evaluation and rework [received by UCI on 3/25/2015].
"If you have any questions or wish to discuss this matter or this report, please contact:
Wesley Hickle
Procurement Engineer
whickle@unitedcontrols.com
770-496-1406 x 165"
Potentially affected plants are Salem and Hope Creek. |
| Fuel Cycle Facility | Event Number: 50938 | Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: ROBERT POSEY
HQ OPS Officer: STEVE SANDIN | Notification Date: 03/28/2015
Notification Time: 12:53 [ET]
Event Date: 03/27/2015
Event Time: 16:30 [MDT]
Last Update Date: 03/28/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
| Person (Organization):
DAVID AYRES (R2DO)
MARISSA BAILEY (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text ACCUMULATION OF SAMPLE CYLINDERS IN THE CHEMISTRY LAB EXCEEDS AMOUNT ALLOWED
"Event Summary: An amount of Uranium greater than that analyzed in the associated HAZOP [Hazardous Operation] for the Chemistry Laboratory is present in the laboratory. The HAZOP states that approximately 5 kg at any given time, and a maximum of 9 kg per year, will exist in the laboratory. This HAZOP was never updated for changes in customer orders and the resultant accumulation of 1S cylinders which has exceeded the original 9 kg limit.
"Nuclear Criticality Safety (NCS) staff have identified the condition as stable and safe. At no time were the enrichment levels or quantities of U235 in an unsafe condition.
"This is a condition different than that analyzed in the Integrated Safety Analysis (ISA).
"An NCS posting has been applied to prevent the removal or introduction of any material until a detailed evaluation of the condition and measures necessary for resolution are determined."
Samples in 1S cylinders are provided to the Chemistry Lab which is located in the CRDB [Chemistry Receipt Dispatch Building] prior to shipment of product to the customer. Due to a slowdown in business these samples have accumulated to an amount exceeding the approved ISA which had not been updated to reflect current business practices. This condition was discovered by the MC & A [Material Control & Accounting] Group during a review of the process and will be addressed at an Emergency ISA Meeting on Monday, 3/30/15. | |