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Event Notification Report for April 28, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2015 - 04/28/2015

** EVENT NUMBERS **


50684 50991 50992 50993 50995 50996 50998 51017 51018

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 50684
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: IBA MOLECULAR
Region: 1
City: TOTOWA State: NJ
County:
License #: 452369
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/16/2014
Notification Time: 16:16 [ET]
Event Date: 12/16/2014
Event Time: 13:40 [EST]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (EMAI)
PATRICIA MILLIGAN (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MARISSA BAILEY (NMSS)
PAMELA HENDERSON (NMSS)
DUNCAN WHITE (NMSS)

Event Text

AGREEMENT STATE REPORT - INDIVIDUAL EXCEEDS OCCUPATIONAL DOSE LIMIT OF 50 REM TO THE SKIN

The following report was received from the State of New Jersey via fax:

"Event Description: [The licensee,] IBA is a PET [Positron Emission Tomography] manufacturer and radiopharmacy. When the dosimetry reports for November 2014, were reviewed, it was noted that one individual exceeded the 20.1201(a)(2)(ii) occupational dose limit of 50 rem to the skin of an extremity. This was caused by a November dose of greater than 46 rem to the left extremity, bringing the year to-date dose to greater than 62 rem. The licensee is investigating this unusual November dose and will be preparing a written report. The individual has been removed from work with radioactive materials and the dosimeter for December has been sent in early for processing."

* * * RETRACTION AT 1512 ON 4/27/2015 FROM CATHY BIEL TO MARK ABRAMOVITZ * * *

After discussions with the licensee, the dose to the left hand was reduced from 46 Rem to 20.592 Rem which gives an annual dose to the extremity of 37 Rem. This dose is below the reporting requirements and the event is retracted.

Notified the R1DO (Gray) and NMSS Events Notification Group (via e-mail).

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Agreement State Event Number: 50991
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH AND SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2015
Notification Time: 12:43 [ET]
Event Date: 04/15/2015
Event Time: [PDT]
Last Update Date: 04/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE MOVED DURING MEDICAL TREATMENT

"On 4-15-15 the patient was to receive a fractionated dose of 4 Grays to the 'vaginal cuff' region using a 10.175 Curie Ir-192 source. The dose was to be administered using a Varian Model VariSource 200t remote HDR [High Dose Rate] afterloader, serial number 600349.

"The plan was to administer 6 radiation treatments using a cylinder applicator and holder, the treatment length intended to be 5 cm. Imaging was done after placement of the cylinder prior to treatment to verify location, however, post-treatment imaging showed that the cylinder applicator had come loose from the holder and shifted 3 cm. This was the first of the six fractions.

"Hospital staff physicists are currently working to determine the delivered dose to the target and why the shift occurred. Physician notification has not been verified at this time. The patient has been notified."

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: 50992
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: PCS NITROGEN FERTILIZER LP
Region: 4
City: GEISMAR State: LA
County:
License #: LA-4903-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2015
Notification Time: 17:10 [ET]
Event Date: 04/15/2015
Event Time: 15:50 [CDT]
Last Update Date: 04/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILED OPEN

The following report was received via e-mail:

"Installed fixed level gauge on a process. The shutters on a fixed level gauge would not close properly due to a breakage of a shutter pin. The situation is the result of extended usage. The gauge was purchased and put into service in 1985. The problem with the shutter function is considered equipment failure of this device. Corrective action will be to de-install this device and [dispose of it]. The gauge will be replaced with a new lower activity source device. The failure is that the shutter blades would not open and close due to a shutter pin breaking. There was no removable radiation released into the environment. The gauge/source holder was 'fixed', and the RSO tagged and posted the broken device. Additionally, all personnel working in the vicinity of the devise were informed of the problem. The RSO advised the employees the radiation exposure levels were in the normal operational range.

"The gauge was an Accuray Mfg. device, SH302, s/r HS302-S6, approximately 200 mCi of Cs-137 when installed and manufactured in 1985. The source serial number is CS11166."

Louisiana Report: LA150007, T163028

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Agreement State Event Number: 50993
Rep Org: COLORADO DEPT OF HEALTH
Licensee: VISTA RIDGE ACADEMY
Region: 4
City: ERIE State: CO
County:
License #: None
Agreement: Y
Docket:
NRC Notified By: CHERI HALL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2015
Notification Time: 19:34 [ET]
Event Date: 04/13/2015
Event Time: [MDT]
Last Update Date: 04/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - RADIUM SOURCE FOUND

The following report was received via e-mail:

"Reported by Weld County DPHE [Department of Public Health and Environment] on behalf of Vista Ridge Academy, Erie, Colorado on Monday April 13, 2015.

"The material was discovered in a glass vial marked 'radium dust' which was verified as Radium 226 using a portable MCA (IdentiFINDER 2, S/N 910383-80, background 0.01 mrem/hr). The readings on contact and at one foot from the vial were 2.8 mrem/hr and 0.1 mrem/hr respectively. Due to the elevated nature of the readings, it was determined shielding should be put in place to protect individuals from exposure. The material was placed in plastic bags to contain the material in the event the lid falls off or the glass is broken. Additionally, ceramic bricks were used to build a temporary storage area for the vial to reduce the exposure in the area. The exposure on the outside of the brick shielding was 0.3 mrem/hr on contact. The material is stored in a secured closet. The mass of the contents in the vial were determined to be 204.5 grams with an approximate volume of 84.78 cubic centimeters. (The mass was determined using a school scale and a similar empty vial. The volume was determined by approximation of the diameter and height of the material in the vial.)

"Surveys were performed around the work bench area, storage shelf and a removable contamination wipe was done on the vial. It was determined during the site visit no contamination was present in the lab or storage area indicating no exposures to students or staff.

"Using the information gathered and making a few assumptions about efficiency, there is an estimated 50 to 100 uCi in the vial.

"Report ID number: CO15 - I15 -12

"A provisional license will be issued until the material can be properly disposed."

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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Non-Agreement State Event Number: 50995
Rep Org: OAKWOOD HOSPITAL AND MEDICAL CENTER
Licensee: OAKWOOD HOSPITAL AND MEDICAL CENTER
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: TALJIT SANDHU
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/20/2015
Notification Time: 16:24 [ET]
Event Date: 04/08/2015
Event Time: [EDT]
Last Update Date: 04/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
NICK VALOS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

LOST BRACHYTHERAPY SEED

The medical center performed a procedure where an I-125 seed (0.3 mCi) was implanted in a breast lumpectomy site. The Brachytherapy Radiation Safety Officer believes that when the lump was removed, the implanted seed was also discarded as bio-waste. The seed dimensions are 4.5 mm long by 0.1 mm in diameter. The biological waste is no longer on site.


* * * UPDATE FROM TALJIT SANDHU TO DAN LIVERMORE ON 04/21/2015 AT 1441 EDT * * *

Corrected the event date from 04/20/2015 to 04/08/2015 and corrected the CFR section from 20.2201(a)(1(i) to 20.2201(a)(1)(ii).

Notified R3DO (Valos) and NMSS Events Notification via email.

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: 50996
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CENTRAL TESTING COMPANY INC
Region: 4
City: SULPHUR State: LA
County:
License #: LA-2393-LO1A,
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/20/2015
Notification Time: 16:43 [ET]
Event Date: 03/13/2015
Event Time: [CDT]
Last Update Date: 04/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA FAILED SOURCE DISCONNECT/MISCONNECT TEST

The following was received from the State of Louisiana via email:

"A radiography inspection was being performed on a Central Testing crew at the Tri-7 facility in Sulphur, LA. At a point during the inspection, the inspector requested that the crew demonstrate a misconnect/disconnect test on the camera and drive cables in use. The crew stated that the equipment had passed the test before the equipment was put into service for the day. However, during the demonstration, the 'control assembly' on the crankout set functioned in a test failure mode. The control assembly easily slipped into position without the drive cable being attached to the source assembly, 'pigtail.' With this failure, the RSO was contacted and an additional set of crankouts were brought to the jobsite.

"The crankout was evaluated and it was determined that the control assembly is what failed during the test. The control assembly was replaced on the crankout and it corrected the misconnect/disconnect test failure. This test is to be performed on the equipment daily with use. This is a requirement of LA Radioactive Material License LA-2393-L01A, Condition # 16.

"The exposure device was a SPEC Model 150 camera, S/N 1057, loaded with a 63 Ci Ir-192 source, SPEC Model G-60. The associated equipment was manufactured by SPEC, crankout and control assembly, with unknown model and s/ns. When the equipment was replaced, the radiography crew was allowed to resume their work."

LA Event Report ID: LA 15-0004

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Power Reactor Event Number: 50998
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE BRUNSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/20/2015
Notification Time: 21:26 [ET]
Event Date: 08/07/2014
Event Time: 17:07 [EDT]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ALAN BLAMEY (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
2 N Y 90 Power Operation 90 Power Operation

Event Text

THIS IS A CONTINUATION OF EN #50351

* * * UPDATE FROM STEVE BRUNSON TO CHARLES TEAL ON 4/20/15 AT 2126 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was found at penetration 1Z43H594D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- Near penetration 1Z43J837D, and approximately 12" south and above 1Z43H837D, gaps were observed in the mortar joint between CMU on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A triangular gap 1" wide, 1" tall and 6" deep was found at penetration 1Z43H592D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A gap 4" tall and 3" wide was found behind Turn Box TB1-1272 which covers penetrations 1Z43H590D, 1Z43H589D, 1Z43H588, and 1Z43H587D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- At the architectural joint between the vertical wall to the horizontal floor/ceiling assembly above door 1C-22, above and to the south of 1Z43H1105D, a gap was observed approximately " tall, 3" wide, and 6" deep on the west wall of the U1 East Cableway Foyer (separating Fire Area 1105 and Fire Area 0014K)

- Gap between the grout and the conduit of penetration 1Z43H778D approximately " tall x 1.5" wide x 6" deep on the east wall of the Unit 1 130' Elevation Control Building Working Floor Hallway (separating Fire Area 0014K and Fire Area 1105)

"The nonconforming conditions observed for the affected fire penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensure the safe shutdown paths are preserved until the degraded conditions are repaired.

"CR 10058276; CR 10058278

"The following deficiencies were also observed causing the affected penetrations to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H532D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 0014M)

- A gap 1/8" wide, 1" tall and 6" deep was located at penetration 1Z43H780D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M)

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H781D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M). A " x " defect was also identified at penetration 1Z43H781D on the east wall of the Men's Restroom in the Control Building (separating Fire Area 0014M and Fire Area 1104)

"The nonconforming conditions observed for the affected penetrations were identified as affecting both safe shutdown paths for Unit 1 and Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until degraded conditions are repaired.

"CR 10058277

"The expanded scope inspection activity is continuing and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."

The licensee has notified the NRC Resident Inspector. Notified R2DO (Blamey).

* * * UPDATE FROM SCOTT BRITT TO DONG PARK ON 4/23/15 AT 1654 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A gap 1/4" wide, 1" tall and 7" deep was found at penetration 1Z43H1138D on the east wall of the U1 RPS MG Set Room (separating Fire Area 1013 and Fire Area 0040). No seal material was seen between the sleeve and the cinderblock on the north side of penetration.

- A void 1" tall, 1" wide, and 7" deep was found in the south upper corner under a concrete beam at column line T12 above penetration 1Z43H941D on the east wall of the U1 RPS MG Set Room (separating Fire Area 1013 and Fire Area 0040).

- At penetration 1Z43H1139D, it appears that combustible neoprene insulation is used around the pipe within the plane of the west wall of the Vertical Cable Chase Room (separating Fire Area 0040 and Fire Area 1013). Combustible materials would not be part of a rated pen seal.

- A gap 1" wide, 1" tall and 7" deep was observed at penetration 1Z43H1138D on the west wall of the Vertical Cable Chase Room (separating Fire Area 0040 and Fire Area 1013).

"The nonconforming conditions observed for the affected fire penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10060228"

The licensee will notify the NRC Resident Inspector. Notified R2DO (Blamey).

* * * UPDATE FROM STANLEY STONE TO DONG PARK ON 4/27/15 AT 2047 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

-An opening in the grout 1/4" wide, 1/2" tall and over 7" deep was found between the wall and the outside sleeve for penetration 2Z43H028D on the west wall of the U2 Transformer Room (separating Fire Area 2019 and Fire Area 2016).

-A 1/4" diameter hole in the grout approximately 2.5" deep was found above conduit 2MI2128 on the west wall of the U2 Transformer Room (separating Fire Area 2019 and Fire Area 2016).

"The nonconforming conditions observed for the affected penetration and fire barrier were identified as affecting both safe shutdown paths for Unit 1 and Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10061830"

The licensee notified the NRC Resident Inspector. Notified R2DO (Blamey).

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Power Reactor Event Number: 51017
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LONNIE CRAWFORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/27/2015
Notification Time: 15:46 [ET]
Event Date: 04/27/2015
Event Time: 08:50 [EDT]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MEL GRAY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N N 0 Refueling 0 Refueling

Event Text

SECONDARY CONTAINMENT BOUNDARY DOOR FOUND AJAR

"On 4/27/2015 at 0850 [EDT], Secondary Containment (Unit 1 Reactor Building) Boundary Door-721 was found ajar. The door was closed by operators. A status walkdown was performed and no other doors were found in this condition.

"Although, Secondary Containment differential pressure was maintained throughout the time period that the door was not fully closed and latched. The door serves as a Secondary Containment boundary and is required to be closed for Secondary Containment Operability.

"This event is being reported under 10 CFR 50.72(b)(3)(v) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

This door is in the railroad bay and was posted as a containment boundary door. Investigation into why this door was not closed and latched is continuing.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51018
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CHET W. JOZWIAK
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/27/2015
Notification Time: 18:56 [ET]
Event Date: 04/27/2015
Event Time: 15:27 [PDT]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GEOFFREY MILLER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Defueled 0 Defueled
3 N N 0 Defueled 0 Defueled

Event Text

OFFSITE NOTIFICATION TO LOCAL AGENCY

Notification was made to the San Diego Regional Water Quality Control Board, and a message was left for exceeding the daily maximum parts per million (ppm) of oil and grease in the North Industrial Area Yard Drain Sump. Sump pumps are currently in "OFF" and the site is investigating. The oil in the drain sump did not reach "reportable quantities" and did not require notifying other Federal Agencies.

Page Last Reviewed/Updated Tuesday, April 28, 2015
Tuesday, April 28, 2015