United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2015 > June 12

Event Notification Report for June 12, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/11/2015 - 06/12/2015

** EVENT NUMBERS **


51114 51118 51121 51122 51125 51147 51149 51150

To top of page
Non-Agreement State Event Number: 51114
Rep Org: FABRI-FORM COMPANY
Licensee: FABRI-FORM COMPANY
Region: 3
City: BLUFFTON State: IN
County:
License #: GL720487
Agreement: N
Docket:
NRC Notified By: SUSAN LONG
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2015
Notification Time: 11:53 [ET]
Event Date: 06/02/2015
Event Time: [EDT]
Last Update Date: 06/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

MISSING IONIZERS

The following was excerpted from information received via facsimile:

"This letter follows up on an [initial] telephone report provided to the NRC Operations Center [at 1153 EDT] today pursuant to 10 CFR 20.2201(a)(i) regarding potentially missing NRC-regulated devices. During that call, Fabri-Form was asked to also submit [additional information] via facsimile to the NRC, providing information about the material contained in the devices, their serial numbers, and explaining how we became aware of the loss. Fabri-form is also submitting this letter pursuant to that request. We are also conducting an internal investigation into the matter and will submit a written report, as required under 10 CFR 20.2201(b), within 30 days.

"It appears that the potentially missing devices are six P-2021-8000 Ionizers, which are manufactured by NRD LLC. As we understand, these ionizers originally contained 10 mCi of polonium 210 and the serial numbers for the devices are A2FG071- 076.

"Fabri-Form became aware that it might possess NRC generally licensed devices on March 31, 2015, when it received a standard letter from the NRC's Office of Nuclear Material Safety and Safeguards, stating that the company possesses generally licensed devices subject to NRC oversight. The letter did not specify what those devices were and after internal inquiry, Fabri-Form was unable to determine what those devices were. Fabri-Form contacted Hector Rodriguez-Luccioni, the NRC contact listed in the letter [on 6/2/2015] and based on information provided by the manufacturer to the NRC, he was able to provide us with additional information, including what these devices were, the manufacturer, device serial numbers, and that their delivery date to Fabri-Form was August 2006. Fabri-Form also contacted the manufacturer yesterday, who confirmed the NRC's information. Fabri-Form has only one employee that has been with the company since 2006, and that individual was unable to recall specific details about these devices when we initially contacted them. Thus, after conversations with the NRC and NRD LLC yesterday, Fabri-Form first determined what these devices were and that they are potentially missing yesterday, and we promptly notified the NRC within 24 hours, as required under 10 CFR 20.2201(a)(i).

"Fabri-Form will continue to investigate this matter and detail the findings of our investigation in the required written report."

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

To top of page
Agreement State Event Number: 51118
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RIVERSIDE MEDICAL CENTER
Region: 3
City: KANKAKEE State: IL
County:
License #: IL-01242-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 12:28 [ET]
Event Date: 06/02/2015
Event Time: [CDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MIS-ADMINISTRATION OF Y-90 SIR-SPHERES

The following information was received via E-mail:

"The Director of Radiology at Riverside Medical Center, Kankakee, IL called the Agency [Illinois Emergency Management Agency] to advise that a medical event had occurred during the administration of a Y-90 SIR-Sphere treatment on the morning of June 2, 2015. 35.2 mCi of Y-90 was intended to be delivered to the patient's liver to treat metastatic cancer lesions via the hepatic artery. However, when the patient was imaged immediately following the treatment, the kidney was observed as the organ which had received the dose with no material evident in the liver. It was determined that the infusion catheter was improperly placed. Instead of placement in the patient's hepatic artery, the renal artery was the infusion site. This was the facility's first patient to undergo this treatment modality. As a result, the manufacturer's proctor was present in addition to the treatment team members which included the radiologist, the radiation safety officer, the nuclear medicine technologist as well as others.

"The radiologist immediately informed the patient of the error while he was in post-op. As the facility had a second dose of Y-90 on hand of the same amount, and the patient consented, a second attempt was made that same afternoon where the infusion went as expected and the intended dose was delivered as originally planned to the liver with no complications.

"Although normally, an outpatient procedure, the patient was held overnight. Universal precautions were implemented throughout the time period and although the patient's sweat and saliva were not sources of contamination, the hospital managed the patient as they would an I-131 therapy patient and routine collection and measurement of the patient's urine was performed before discharge to the sewer system.. Radioactivity was confirmed as present in the urine when measured with a Geiger counter near the surface of the container. No other contamination was noted in the room. The patient was discharged the next day and follow up appointments are pending with the radiologist as well as a urologist.

"Dose estimates to the patient's kidney as a result of the event are being performed by the manufacturer as well as the medical center's consultant. The Agency is investigating this event and the licensee has been advised that a written report must be submitted per regulation."

Illinois Item Number: IL15013

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.

To top of page
Agreement State Event Number: 51121
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LEIGHTON & ASSOCIATES
Region: 4
City: IRVINE State: CA
County:
License #: 3109-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 14:32 [ET]
Event Date: 06/03/2015
Event Time: [PDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAVEY TOTTERER (ILTA)
CNSNS (MEXICO) (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE/DENSITY GAUGE

The following information was received via E-mail.

"On June 3, 2015, Leighton & Associates notified RHB [California Department of Public Health, Radiologic Health Branch] that a moisture/density gauge was stolen from a pick-up truck's bed at a temporary job site in Riverside that morning. The gauge is a 2014 InstroTek model MC-3 Elite, s/n 30481, containing a 10 mCi Cs-137 source, s/n CZ4587 and a 50 mCi Am-241/Be source, s/n 038/14.

"The authorized gauge technician reported the security cables were cut and the density gauge was missing while he was parked at the job site but away from his vehicle. He immediately notified his RSO and the Riverside Police, who took report number P15-082748. RHB's inspector spoke with the RSO and recommended that a lost and found ad be placed in the local newspaper offering a cash reward for the return of the stolen gauge and requested additional information from the responsible technician. The Inspection/Compliance/Enforcement section will review the security measures that were in place to determine if a violation of their license condition took place."

California 5010 Report Number: 060315

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

To top of page
Non-Agreement State Event Number: 51122
Rep Org: ARCELORMITTAL BURNS HARBOR
Licensee: ARCELORMITTAL BURNS HARBOR
Region: 3
City: BURNS HARBOR State: IN
County:
License #: 13-32670-01
Agreement: N
Docket:
NRC Notified By: CHRIS SARVANIDIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/04/2015
Notification Time: 15:12 [ET]
Event Date: 06/04/2015
Event Time: 08:30 [EDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

STUCK GAUGE SHUTTER

The following was received via email:

"On June 4, 2015 at approximately 0830 [EDT], [the Radiation Safety Officer] was contacted by radiation trained employees at the licensee's Hot Rolling Facility. The employees indicated that the shutter on one of the slab detection radiation gauges would not close. The employee also indicated he noticed a shiny metallic material adjacent to the gauge housing on one side. As a result, they contacted the Radiation Safety Officer (RSO) and [he] proceeded to the site to investigate.

"[The RSO] informed them to barricade the area until [he] arrived. Upon arrival, [the RSO] conducted a survey of the area and compared the levels to prior surveys (including the installation survey). [The RSO] found no significant difference in radiation levels. [He] also performed a wipe test on the gauge and checked it with a survey meter and pancake probe, finding no detectable radiation. The melted metallic material appeared to possibly be lead from the device shielding. As a result, [he] believes some shielding may have overheated and blocked the shutter open.

"Because radiation levels were normal and the device was functioning normally, the device was left in its operating position on the furnace. This was the safest possible scenario until resources can be obtained to safely remove and store the device with the shutter open. The RSO will obtain a container that will house the device safely and will transport the device to a secure location in the plant (controlled by the RSO) until it can be retrieved and repaired by Ronan Engineering (manufacturer). The furnace will be in operation until the device is removed so there is no physical possibility of anyone being inside the furnace and being exposed."

To top of page
Agreement State Event Number: 51125
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BASF CORPORATION
Region: 4
City: FREEPORT State: TX
County:
License #: 01021
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 18:10 [ET]
Event Date: 06/03/2015
Event Time: [CDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SHUTTERS ON FOUR FIXED NUCLEAR GAUGES TO CLOSE

The following information was received via E-mail:

"On June 4, 2015, the licensee notified the Agency [Texas Department of State Health Services] that on June 3, 2015, it was performing routine shutter checks on fixed nuclear gauges at its facility and found the shutters on four of the gauges would not close. All four gauges were Ronan Model SA-1 containing cesium-137 sources (20, 40, 50, and 200 millicuries). The licensee lubricated the shutter mechanisms on all four gauges and let them sit overnight. Two of the gauges closed the next morning (June 4th) with no problem. The other two shutters still would not close. The licensee contacted an outside service group and it recommended using a different lubricant. The licensee followed the suggestion and both became operable that afternoon. These gauges normally operate with the shutter in the open position. There were no radiation exposures or increased risk of exposure as a result of this event. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9318

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51147
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JAY VAN HULZEN
HQ OPS Officer: STEVEN VITTO
Notification Date: 06/11/2015
Notification Time: 12:10 [ET]
Event Date: 06/11/2015
Event Time: 08:22 [EDT]
Last Update Date: 06/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT EMERGENCY PLAN SIREN ACTUATION

"This is a non-emergency notification to the NRC in accordance with 10 CFR 50.72(b)(2)(xi).

"On 6/11/15, at 0822 [EDT], Miami-Dade Fire Department notified the site of an alarming single Emergency Plan siren. Investigation is ongoing for alarming siren. At no time was there an emergency requiring the siren activation. FPL [Florida Power and Light] has not issued a news release.

"This notification is made in accordance with 10 CFR 50.72 (b)(2)(xi).

"The Senior NRC Resident [Inspector] has been notified."

* * * RETRACTION FROM ALEX CHOMAT TO DANIEL MILLS AT 1552 EDT ON 6/11/15 * * *

"The investigation of the reported alarming EP siren did not confirm that it had been activated or had malfunctioned. The notification received from the Miami-Dade Fire Department apparently resulted from an erroneous call from a member of the public.

"This event notification is retracted based on the fact that no EP siren activation occurred necessitating notifications.

"The Senior NRC Resident [Inspector] has been updated."

Notified R2DO (Guthrie)

To top of page
Power Reactor Event Number: 51149
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: ANGELO LEONE
HQ OPS Officer: STEVEN VITTO
Notification Date: 06/11/2015
Notification Time: 22:28 [ET]
Event Date: 06/11/2015
Event Time: 16:54 [EDT]
Last Update Date: 06/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMES DWYER (R1DO)

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

Event Text

DEGRADED CONTAINMENT SPRAY FLOW CHECK VALVE

During containment spray pump inservice testing the minimum flow recirculation line recorded negative flow indicating reverse flow in the line. After the troubleshooting, it was determined that a degraded minimum flow check valve was allowing a path to the refueling water storage tank (RWST) for certain post loss of coolant accident (LOCA) conditions. The minimum flow isolation has been closed to eliminate the path. No actuation occurred during this time.

The NRC Resident Inspector, Connecticut Department of Energy and Environmental Protection (DEEP) Hartford, and Watertown Dispatch have been notified.

To top of page
Power Reactor Event Number: 51150
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: CHRISTOPHER SMOLINSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/11/2015
Notification Time: 23:37 [ET]
Event Date: 06/11/2015
Event Time: 20:56 [EDT]
Last Update Date: 06/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DWYER (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

LOSS OF TONE ALERT RADIO SYSTEM

"At 2205 [EDT] on June 11, 2015, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County 911 Center notified JAF that the tone alert weather radios had been out of service since 2056 [EDT].

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) population for the JAF Nuclear Power Plant. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The [Oswego] County alert sirens which also function as part of the public prompt notification system remain operable.

"The loss of the tone alert radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the prompt notification system be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement personnel are also available for 'Route Alerting' of the affected areas of the EPZ.

"JAF was notified by Oswego County 911 Center that the tone alert radio system was restored to service at 2257 [EDT].

"The event has been entered into the corrective action program and the [NRC] Resident Inspector has been briefed."

Page Last Reviewed/Updated Friday, June 12, 2015
Friday, June 12, 2015