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Event Notification Report for May 19, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/18/2015 - 05/19/2015

** EVENT NUMBERS **


51039 51056 51058 51059 51062 51074 51078 51079

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Agreement State Event Number: 51039
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER, INC.
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 17:52 [ET]
Event Date: 05/01/2015
Event Time: [CDT]
Last Update Date: 05/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED Y-90 DOSE

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

"On May 4, 2015, the Wisconsin Radiation Protection Section received a notice from an Authorized Medical Physicist [AMP] at Gundersen Lutheran Medical Center, Inc., of a medical event that occurred during a Yttrium-90 Therasphere procedure on May 1, 2015. The licensee did not have enough information to determine if the procedure constituted a medical event on May 1, 2015. Upon further evaluation, the AMP determined it was a medical event as of 3 pm CST May 4, 2015. The patient was scheduled to receive two separate Y-90 Therasphere doses to two separate segments of the liver. During the first injection, the overpressure valve opened and filled the overflow vial with the Authorized User applying very little pressure to the saline filled syringe. The patient was to get 147 Gy to Segment 6 of the liver. From residue measurements, the patient received 35.5 percent or 52.2 Gy to Segment 6. The Radiation Protection Section will perform an investigation and update through NMED [Nuclear Material Events Database].

"Event Report ID No.: WI150006"

* * * UPDATE AT 0938 EDT ON 5/18/2015 FROM CAL WALTON TO MARK ABRAMOVITZ * * *

The correct Wisconsin event ID is WI150007.

Notified the R3DO (Peterson) and NMSS (via e-mail).

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: 51056
Rep Org: CARDINAL HEALTH NUCLEAR PHARMACY
Licensee: CARDINAL HEALTH NUCLEAR PHARMACY
Region: 3
City: DUBLIN State: OH
County:
License #: 34-29200-01MD
Agreement: Y
Docket:
NRC Notified By: DAN HILL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/08/2015
Notification Time: 08:05 [ET]
Event Date: 05/08/2015
Event Time: 05:40 [CDT]
Last Update Date: 05/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BARRY WRAY (ILTA)

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

Event Text

STOLEN RADIOPHARMACEUTICALS

The following event occurred in Kansas City, MO.

The corporate office of Cardinal Health Nuclear Pharmacy was notified that a vehicle being used to deliver material to the VA [Veterans Affairs] Hospital in Kansas City, MO had been stolen at approximately 0540 CDT on 5/8/2015. Inside the vehicle were two packages, each containing Tc-99m. The maximum combined activity of the Tc-99m in the two packages was less than 250 millicuries.

Both VA security and the Kansas City, MO police were notified. VA security is reviewing security videos for possible leads. The Kansas City, MO police case number is 15-31091.


* * * UPDATE FROM DAN HILL TO DONALD NORWOOD AT 1052 EDT ON 5/8/2015 * * *

The following information was received via E-mail:

"The vehicle was located in Overland Park, KS by the police in Overland Park. Cardinal Health Kansas City sent drivers to retrieve the vehicle. It is now back at the Cardinal Health Kansas City nuclear pharmacy as of 0935 CDT on May 8, 2015. Packages containing radioactive materials in the vehicle with tamper resistant seals are intact and unopened."

Apparently the vehicle was stolen by a patient of the VA Hospital. The identity of this individual was able to be confirmed.

Notified R3DO (Skokowski), ILTAB (Wray), and NMSS Events Notification..

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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Non-Agreement State Event Number: 51058
Rep Org: BROOKE ARMY MEDICAL CENTER
Licensee: BROOKE ARMY MEDICAL CENTER
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 42-01368-01
Agreement: Y
Docket:
NRC Notified By: DAVID BYRD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/08/2015
Notification Time: 11:53 [ET]
Event Date: 05/07/2015
Event Time: 11:11 [CDT]
Last Update Date: 05/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GREG PICK (R4DO)
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST IODINE-125 SEED

"On May 7, 2015, [Command Radiation Safety Officer (CRSO)] was notified by Brooke Army Medical Center [BAMC] Pathology that they could not find a I-125 seed. The seed was from a radioactive seed localization procedure for a breast biopsy. [The licensee's] Health Physics Service sent two personnel to investigate the loss and attempt to find the seed. After tracking the chain of custody and attempting to find the seed [the licensee] concluded that the seed was thrown away into the bio-hazard waste in pathology with the specimen tray.

"On May 6, 2015, the pathologist transferred a biopsy specimen from a receiving tray to an examination tray. [The pathologist] then discarded the receiving tray in the bio-waste and used an RSL [radioactive seed localization] node seeker to confirm seed presence in the specimen. [The pathologist] misread the meter, marking on the seed tracking chain of custody form that the seed was present. [The licensee] examined the radiograph of the specimen, taken just before arriving at pathology, and found that the seed was on the edge of the biopsy specimen. [The licensee] believes the seed fell into the receiving tray upon transfer of the specimen and the seed was discarded along with that tray.

"The bio-hazard waste was disposed after this point, [approximately] 0600 [CDT] on May 7, 2015. On May 7, 2015, during clinical examination of the specimen and during the procedure to extract the seed, the pathologist could not find the seed. The RSO was called at this point and the investigation began. [The licensee] notified our environmental services branch and the waste disposal company to notify them that they may encounter a radioactive seed.

"The seed is I-125. The initial activity was 0.300 mCi on March 27, 2015, and was 0.185 mCi as of May 7, 2015.

"Today, BAMC Health Physics Service conducted an inventory and has accounted for all other I-125 RSL seeds besides the one mentioned in this email. [The licensee] will retrain the pathology section on proper procedures and conduct an in-service on how to read the RSL node seeker for confirming the presence of the seeds. [The licensee] will also discuss with pathology additional physical measures that can be implemented to ensure this does not happen again.

"[The CRSO] will send a full report along with memorandums and status on measures taken to prevent future occurrences."

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: 51059
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RIO TINTO MINERALS / U.S. BORAX
Region: 4
City: BORON State: CA
County:
License #: GLD57
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/08/2015
Notification Time: 12:33 [ET]
Event Date: 10/01/2014
Event Time: [PDT]
Last Update Date: 05/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN ON A FIXED GAUGE

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

"At 1510 [PDT] on May 7, 2015, the licensee notified us [California Radiation Control Program] that the shutter on their belt weight scale on the Coarse Gangue Belt in Plant 1 is stuck in the open position. This is a generally licensed device (Berthold Technologies, Model: LB300L, s/n: 17729-1061-10003 containing 18 mCi Cs-137). The shutter malfunction was initially found during their six month shutter check in October 2014, however, the licensee only became aware of the reporting requirement last week when they contacted the manufacturer to repair the device. The device is in a restricted area 100 feet above the ground on a conveyance structure. The source is below the belt and the beam path is upward with no real exposure potential to any personnel in the area. The only way to access the belt and the source is via a catwalk which is not in the beam path. The dose rate on the catwalk is approximately 0.4 mRem/hr."

CA 5010 Number: (Date Notified): 050715

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Non-Agreement State Event Number: 51062
Rep Org: U.S. AIR FORCE
Licensee: U.S. AIR FORCE
Region: 1
City: FALLS CHURCH State: VA
County:
License #: 42-23539-XXAF
Agreement: Y
Docket:
NRC Notified By: ANTONY CAGLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/11/2015
Notification Time: 09:48 [ET]
Event Date: 04/13/2015
Event Time: 10:30 [EDT]
Last Update Date: 05/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST/MISSING CALIBRATION SOURCE

The following was received by email:

"Notification from Master Material License [MML] No. 42-23539-XXAF, issued to the Department of the Air Force. The following report of a possible lost or missing source likely involves a source not specifically licensed under the MML:

"On 13 April 2015 at 1030 hours, an officer newly assigned to Cannon AFB [Air Force Base] discovered a source on the radioactive material inventory he could not physically locate. The source was listed as an Am-241 check source for a Smiths model 1500 instrument, with no information provided except for a previous storage location. The officer could not locate any records of disposition for this source, but continues to investigate disposition records for the base. The officer interviewed a predecessor who asserted the Am-241 line item on the inventory could be a clerical error.

"The licensee contacted Smiths Detection which to date could not verify the existence of a Smiths Model 1500 or an Am-241 check source.

"They are unaware of any exposures at this time.

"The base will ensure complete/accurate data entry for radioactive material inventories and subsequent verification of inventory through physical 'eyes-on' inventories."

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: 51074
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: ADAM FAIRCLOTH
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/15/2015
Notification Time: 23:48 [ET]
Event Date: 05/15/2015
Event Time: 21:48 [CDT]
Last Update Date: 05/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JACK WHITTEN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO 2 AC INVERTERS INOPERABLE

"Class 1E A/C Unit SGK05A cools safety related electrical train 'A' and was found tripped at 2148 [CDT]. As a result, the following supported safety related electrical equipment were declared inoperable: 4.16 KV Bus NB01, 480 Volt Buses NG01 and NG03, 120 volt Instrument AC Inverters and Buses NN11, NN13, NN01 and NN03, 125 VDC Chargers and Buses NK11, NK13, NK01 and NK03. T/S 3.0.3 was entered from T/S 3.8.7 due to two out of four 120 volt AC Inverters (NN11 and NN13) being inoperable. All electrical systems listed above remain available but are declared inoperable due to inadequate room cooling capability. Plant shutdown to mode 5 commenced at 2244 [CDT]. No major equipment is out-of-service. All systems have functioned normally. Plant is currently at 99% with power ramping down. Plant must be in mode 3 by 0448 CDT. No compensatory measures have been established.

"The NRC Resident Inspector has been notified."

See EN #51071 for an earlier T/S required shutdown required at 0436 CDT on 5/15/15, due to the same conditions.

* * * UPDATE FROM BRET DAVIS TO VINCE KLCO ON 5/18/15 AT 1600 EDT * * *

"For both EN 51071 and 51074, the low lube oil pressure switch tripped the SGK05A unit. Oil pressures were verified to be normal and the SGK05A unit was successfully started. The plant shutdown each time was terminated. A fault in the Electronic Oil Pressure control which monitors the low lube oil pressure switch was identified. A jumper has been installed that bypasses the oil switch while maintenance is being conducted. The unit was declared functional but degraded. Indication of low oil pressure is still provided. "

The licensee notified the NRC Resident Inspector.

Notified the R4DO (Okeefe).

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Part 21 Event Number: 51078
Rep Org: AECOM ENERGY & INDUSTRIAL CONST.
Licensee: AECOM ENERGY & INDUSTRIAL CONST.
Region: 1
City: PRINCETON State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART LEMBO
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/18/2015
Notification Time: 15:18 [ET]
Event Date: 05/18/2015
Event Time: [EDT]
Last Update Date: 05/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
JAMES DWYER (R1DO)
BRIAN BONSER (R2DO)
MICHAEL KUNOWSKI (R3DO)
NEIL OKEEFE (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

INTERIM 10 CFR PART 21 REPORT REGARDING DEVIATIONS WHILE UTILIZING BENTLEY SOFTWARE STAAD.PRO ON SAFETY RELATED CALCULATIONS

"This letter provides an Interim report in accordance with 10 CFR 21.21(a)(2) pertaining to the identification of deviations associated with calculations that were supplied to various licensees. The deviations stemmed from recently identified errors in vendor supplied software that is used in various structural analysis and design applications.

"The software that was used, STAAD.Pro, is provided by Bentley Systems Incorporated. The present QA validated version of STAAD.Pro, V8i SELECT Series 4 Version 20.07.09.31, and prior versions have been used on various safety related calculations for nuclear power plants as well as a general analysis and design tool for non-safety related calculations for nuclear and non-nuclear power plants and facilities.

"In accordance with our [AECOM] Nuclear QA Program, URS Energy & Construction (an AECOM Company) became aware of the deviations as a result of our periodic review of vendor issued error reports; specifically, STAAD.Pro Critical Error Report SPRO5336 and STAAD.Pro Critical Error Report SPRO5682. The noted errors can create instances that generate incorrect internal forces and moments in a structural member at various locations along the member's length. The result can be non-conservative evaluations of structural members (i.e., can under estimate the stress level in the analyzed members) and can potentially result in the inadequate design of structural components.

"The software vendor is actively working to correct the noted deviations. Bentley anticipates that a modified version to STAAD.Pro will be issued in the third quarter of 2015. Alternate approaches are being pursued to accelerate completion of the evaluation of the noted deviation. We [AECOM] are notifying our clients of this issue and will provide follow-up written notification to the NRC within 30 days.

"If you have any questions concerning this information, please contact Steve Mannon, Director of Licensing, at 803-412-5145.

"At this time the potentially affected customers that have been notified concerning this issue are Exelon and DTE Energy. We [AECOM] are continuing our evaluation of potentially affected customers."

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Power Reactor Event Number: 51079
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN McILNAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/18/2015
Notification Time: 15:45 [ET]
Event Date: 03/17/2015
Event Time: 13:06 [EDT]
Last Update Date: 05/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BRIAN BONSER (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

INVALID ACTUATION OF AUXILIARY FEEDWATER SYSTEM DURING ELECTRICAL TESTING

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid actuation of the Auxiliary Feedwater (AFW) system at Watts Bar Nuclear Plant Unit 1.

"On March 17, 2015, at 1306 EDT, Watts Bar Unit 1 was in Mode 1 at 100% power, when during the performance of 6.9 Kv phase verifications for the FLEX Diesel Generator, maintenance technicians were installing a multimeter (Simpson 260 Series) which resulted in starting the Unit 1 train B: motor-driven auxiliary feedwater pump, centrifugal charging pump, component cooling pump and thermal barrier booster pump, and isolated steam generator 1 and 3 blowdown. A secondary 6 ampere fuse opened due to an overcurrent and actuated (dropped-out) the associated blackout relays which started the identified pumps. At the time of the event, the train B standby diesel generator was removed from service for maintenance. The 6.9 Kv shutdown board did not lose power during the event and safety injection system and standby diesel generator features were not actuated.

"The maintenance technicians performing the phase verifications immediately recognized that several supply breakers had closed after the last test lead was connected and promptly reported the event to the control room. Work was halted and TVA conducted a prompt investigation. While not conclusive, it is likely that the maintenance technicians created a shunt or ground condition while installing test equipment, causing a circuit overcurrent which opened the fuse, activating the black-out relays and actuating the identified pumps and valves. Plant operators responded appropriately to the event and the applicable Technical Specification Required Actions were exited at 1612 EDT, when equipment restoration had been completed. TVA is continuing to evaluate this event in accordance with the corrective action program (reference: PER nos.1003213 and 1027101).

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, May 19, 2015
Tuesday, May 19, 2015