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Event Notification Report for April 7, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/06/2015 - 04/07/2015

** EVENT NUMBERS **


50929 50930 50931 50934 50937 50940 50957 50960

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Agreement State Event Number: 50929
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SYSTEM ONE HOLDINGS LLC
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-1148
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/27/2015
Notification Time: 13:49 [ET]
Event Date: 02/24/2015
Event Time: [EDT]
Last Update Date: 03/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHIC SOURCE FAILS TO RETRACT

The following report was received via e-mail:

"A radiographic source tube was damaged which temporarily restricted retraction of the source.

"The guide tube became crushed by a falling object thereby preventing the source from retracting. The assistant RSO performed a source recovery with help from an assistant radiographer. The damaged guide tube was removed from service. Licensee personnel were trained on proper stabilization techniques. No individual received a dose in excess of limits.

"Manufacturer: QSA
Model: 880D
Serial No.: 9212
Source: lr-192
Activity: 29 Ci"

PA Event #: PA150008.

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Agreement State Event Number: 50930
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: AFFILIATED ONCOLOGISTS, LLC d/b/a SOUTHLAND ONCOLOTY
Region: 3
City: MOKENA State: IL
County:
License #: IL-02344-01
Agreement: Y
Docket:
NRC Notified By: DAREN TERRERO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/27/2015
Notification Time: 14:17 [ET]
Event Date: 03/10/2014
Event Time: [CDT]
Last Update Date: 03/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN EXCESSIVE DOSE DELIVERED TO THE WRONG SITE

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

"On March 25, 2015, Agency [Illinois Emergency Management Agency] representatives were advised via voicemail message by a medical physicist associated with the licensee's facility that a medical event had occurred at a point in the past. The medical physicist had been conducting a retrospective review of cases performed at the site which were similar to another case that had resulted in a medical event at another facility.

"The review included all 5 cases performed at the licensee's facility since August of 2013 when treatments were first started. The treatment protocols involved using a Strut Adjusted Volume Implant (SAVI) catheter, a Nucletron high dose rate afterloader and the Oncentra treatment planning system which was also used in the similar situation. They determined that at least one of the treatments conducted March 10-14, 2014, involved an error of greater than 20 percent which would meet the criteria of a medical event and dose to an unintended organ exceeding 50 rem.

"On March 26, 2015, a radiation oncologist from the licensee contacted the Agency with information to confirm the medical event. The patient had been treated twice a day for five days for a total intended V95 dose of 34 Gy in ten equal fractions. The target only received 43 percent of the intended dose with the majority instead being delivered to the catheter insertion site (approximately 30 Gy). It was determined that although the patient had later returned on June 24, 2014, with pain and redness at the incision site of the left breast, the cause of damage to the 21 cc tissue area was not attributed to radiation damage. The patient was referred to their surgeon who excised the affected area during an outpatient procedure.

"The licensee has suspended treatments using the protocol pending a full investigation and evaluation of appropriate corrective measures to prevent a recurrence by a physicist not associated with the treatments. The Agency is conducting its own investigation as well. This matter remains open at this time."

This event strongly parallels that of an event which the State of Illinois reported on February 13, 2015, see EN #50818.

Illinois State Item Number: IL15009

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: 50931
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MQC LABS
Region: 1
City: ABERDEEN State: MD
County:
License #: MD-19-28683-0
Agreement: Y
Docket:
NRC Notified By: ANTHONY SANDS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/27/2015
Notification Time: 16:06 [ET]
Event Date: 03/25/2015
Event Time: [EDT]
Last Update Date: 03/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK IN GUIDE TUBE

The following report was received via e-mail:

"Radiograph work was being performed on March 25, 2015, at Dominion Power in Dumfries, VA. After the second exposure was finished, the magnetic stand holding the source fell on the guide tube. The source became stuck inside the guide tube. [The radiographers] tried multiple times to retract the source, but did not succeed. At that time, the licensee secured the area and called the RSO [Radiation Safety Officer]. This occurred around 1830 EDT. The RSO and President [of MQC Labs] arrived at approximately 2200 EDT. The RSO called QSA Global, Inc. to retrieve the source. Subsequently, the RSO contacted the Virginia EOC to notify the VRMP [Virginia Radiation Materials Program] of the incident. QSA Global, Inc. arrived at 1330 EDT on March 26,2015, to retrieve the source at Dominion Power in Dumfries, VA. VRMP staff was present to observe the source retrieval. MQC LABS will submit its written report within 30 days. VRMP will review the report and discuss any corrective action with MQC Labs and Maryland RMP [Radiation Materials Program]".

MQC was performing work in Virginia under a reciprocity program with Maryland.

Virginia Report # VA-15-05

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Agreement State Event Number: 50934
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VALEZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/27/2015
Notification Time: 17:28 [ET]
Event Date: 03/25/2015
Event Time: 12:00 [CDT]
Last Update Date: 03/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DURING PROSTATE BRACHYTHERAPY

The following report was received via e-mail:

"RHB [Kentucky Radiation Health Branch] was notified by telephone on 3/26/15, by the licensee's RSO [Radiation Safety Officer] of a medical event involving an I-125 permanent prostate brachytherapy implant. A CT [computerized tomography] scan performed approximately 5 weeks post-implant revealed that 30% of the implanted activity was administered outside the treatment site (PTV). The delineation of PTV corresponds to a 3 mm margin around the contoured prostate gland, except in the direction of the rectum, prostate base and apex. The error was caused by the inherent difficulty in ultrasound imaging of the prostate, changes in the prostate volume before, during, and after an implant, subjectivity in the contouring of the prostate gland, and a common tendency to drop the seeds slightly inferior to the gland as the needle is retracted. The authorized user reviewed the post plan metrics with the patient and referring physician within 24 hours of the discovery of the medical event. The KY RHB [Kentucky Radiation Health Branch] has requested additional information."

Kentucky Report #: KY150002

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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Non-Agreement State Event Number: 50937
Rep Org: CARMEUSE LIME & STONE
Licensee: CARMEUSE LIME & STONE
Region: 3
City: RIVER ROUGE State: MI
County: WAYNE
License #: 21-32513-01
Agreement: N
Docket:
NRC Notified By: JAMES MOSIER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/28/2015
Notification Time: 12:19 [ET]
Event Date: 02/19/2015
Event Time: [EDT]
Last Update Date: 03/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

BROKEN SHUTTER SHIELDING BLOCK ON A FIXED PROCESS GAUGE

During a routine shutter check on 2/19/15, the licensee discovered the shutter shielding block had fallen off a fixed process gauge for the #2 lime conveyor.

The licensee had a representative from Vega America inspect the gauge on 3/25/15. Vega America determined that the shutter shield block cannot be repaired. The licensee is considering having Vega America replace the gauge with a new model and disposing of the old gauge. The shutter is normally open and the gauge remains in service. The gauge does not present a hazard to plant personnel due to it's normally inaccessible location.

The gauge is 1960s vintage, Ohmart SH-100, Model # A-2102, Serial #73799, with a 100 mCi Cs-137 source.

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Agreement State Event Number: 50940
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: McGEORGE CONTRACTING COMPANY, INC.
Region: 4
City: NORTH LITTLE ROCK State: AR
County:
License #: ARK-0785-0312
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/30/2015
Notification Time: 15:48 [ET]
Event Date: 03/30/2015
Event Time: 06:25 [CDT]
Last Update Date: 03/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT -TROXLER MOISTURE DENSITY GAUGE STOLEN FROM TEMPORARY JOB SITE

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

"On March 30, 2015, at 0703 [CDT], McGeorge Contracting Company, Inc., Arkansas Radioactive Material License Number ARK-0785-03121, reported a stolen moisture density gauge. The gauge has been stolen from a temporary jobsite on Interstate 40, near North Little Rock, sometime between 1600 [CDT] on Friday, March 27, 2015 and 0625 [CDT] on Monday, March 30, 2015.

"The gauge is identified as a Troxler Electronic Laboratories, Model 3440, Serial Number 25959, with original source activities of 40 millicuries of Am-241:Be and 8 millicuries of Cesium-137.

"The gauge was stolen along with other engineering equipment utilized by the licensee.

"The Arkansas State Police has investigated and the Arkansas Department of Health has issued a press release.

"The Radioactive Materials Program is monitoring this event under Arkansas Event Number AR-2015-002."

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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Power Reactor Event Number: 50957
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GREG HARNOIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/06/2015
Notification Time: 09:09 [ET]
Event Date: 04/06/2015
Event Time: 08:09 [CDT]
Last Update Date: 04/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED MAINTENANCE

"On 04/06/2015, planned preventive maintenance activities are being performed on the Braidwood Generating Station Technical Support Center (TSC) Ventilation System. The work will be completed within approximately 42 hours. This activity includes preventive maintenance on the TSC condensing unit which affects the TSC ventilation. During the planned maintenance, the TSC condensing unit will be rendered non-functional.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff as necessary. This planned maintenance will not impact the emergency filtration capability of the TSC.

"This event is reportable per 10CFR50.72(b)(3)(xiii) for 'any event that results in a major loss of emergency assessment capability.' The planned maintenance will not be able to restore the TSC condensing unit to service within the facility activation time specified in the emergency plan (1 hour) in the event of an accident. The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 50960
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: DONALD NORWOOD
Notification Date: 04/06/2015
Notification Time: 19:11 [ET]
Event Date: 04/06/2015
Event Time: 17:00 [EDT]
Last Update Date: 04/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
SHAKUR WALKER (R2DO)

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

UNANALYZED CONDITION DUE TO VOLUME CONTROL TANK ISOLATION TIME ANALYSIS ERROR

"On April 6, 2015, Watts Bar determined that the current Unit 1 Fire Protection Report (FPR) analysis for 10 CFR 50, Appendix R contained a non-conservative time for isolation of Volume Control Tank (VCT) following a postulated fire in room 737.0-A1A. Due to multiple fire-induced failures, Component Cooling System (CCS) cooling of letdown flow to the VCT will be lost in conjunction with increased Reactor Coolant System (RCS) injection flow through Reactor Coolant Pump (RCP) seals and Boron Injection Tank (BIT) flowpaths. As a result, VCT temperature and pressure would increase, which could cause RCP seal damage and loss of RCS inventory, and net positive suction head (NPSH) to the Centrifugal Charging Pumps (CCPs) could be lost. In this postulated fire scenario, Thermal Barrier Cooling is also not available due to fire-induced failures. The current FPR analysis assumes a time of 70 minutes for closure of VCT outlet isolation valves. Preliminary analysis performed by TVA showed that VCT outlet isolation is required in approximately 4 minutes.

"As a result, Watts Bar Unit 1 is in an unanalyzed condition. This condition significantly degrades plant safety because operator action to isolate the VCT in the event of a postulated fire in room 737.0-A1A would not have been performed in time to prevent RCP seal damage and loss of RCS inventory and eventual loss of NPSH to the CCPs.

"Watts Bar is utilizing previously established fire watches in the affected fire areas as a compensatory measure.

"This issue is being reported under 10 CFR 50.72(b)(3)(ii)(B), 'unanalyzed condition that significantly degrades plant safety.'

"The Watts Bar NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, April 07, 2015
Tuesday, April 07, 2015