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Event Notification Report for June 16, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/15/2015 - 06/16/2015

** EVENT NUMBERS **


51127 51130 51138 51139 51140 51148 51154 51156

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Non-Agreement State Event Number: 51127
Rep Org: INDIANA UNIVERSITY HEALTH
Licensee: INDIANA UNIVERSITY HEALTH
Region: 3
City: MUNCIE State: IN
County:
License #: 13-00951-03
Agreement: N
Docket:
NRC Notified By: ALVIS FOSTER
HQ OPS Officer: VINCE KLCO
Notification Date: 06/05/2015
Notification Time: 09:27 [ET]
Event Date: 06/05/2015
Event Time: 02:00 [EDT]
Last Update Date: 06/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

RADIOACTIVE SURFACE CONTAMINATION EXCEEDS LIMITS

The licensee nuclear medicine technologist ordered a package containing radioisotopesTc-99m and Xenon for a patient. The package was delivered by an offsite nuclear pharmacy to the Indiana University Health- Ball Memorial Hospital. When the technician surveyed the package, the surface contamination exceeded specified limits and nominally measured about 14,000 dpm. The package was quarantined and the vendor/shipper was notified concerning the surface contamination. The package was placed in a gamma camera and the indicated camera spectrum indicates Xenon package contamination. The Radiation Safety Officer has ordered the package to remain quarantined. No personnel contamination resulted from this event.

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Agreement State Event Number: 51130
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County: PULASKI
License #: ARK-0001-0211
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/05/2015
Notification Time: 15:22 [ET]
Event Date: 06/04/2015
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL TREATMENT INCORRECT DOSE

The following was received via email:

"On June 5, 2015, the Arkansas Department of Health (ADH) received notification from the licensee's Radiation Safety Officer (RSO) of a possible medical event that occurred during an Yttrium-90 Theraspheres procedure on June 4, 2015. The licensee has not completed the investigation and has provided limited information to determine if the procedure constituted a medical event.

"The patient was treated with Y-90 TheraSpheres. The written directive prescribed a dose of 114 Gy, but received a dose of 18.3 Gy. Preliminary findings seem to indicate that an incorrect dose may have been administered to the patient.

"The patient and referring physician have been notified.

"The licensee and ADH are continuing to investigate this event. ADH considers this event to be opened and will provide more information as it becomes available.

"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."

ARKANSAS EVENT #2015-005

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Agreement State Event Number: 51138
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: KING COUNTY MATERIALS LAB
Region: 4
City: RENTON State: WA
County:
License #: WN-LO22-1
Agreement: Y
Docket:
NRC Notified By: STEPHEN MATTHEWS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2015
Notification Time: 13:03 [ET]
Event Date: 06/05/2015
Event Time: [PDT]
Last Update Date: 06/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

The following report was received via e-mail:

"A Troxler 3450 moisture density gauge was run over by a soft tire roller. The gauge housing was cracked open with no apparent damage to the source or shielding. The gauge was placed in its case and transported to the CTL lab in Tacoma."

The sources are: 10 mCi Cs-137 and 50 mCi Am-241

Washington Incident: WA-15-017

* * * UPDATE AT 1704 EDT ON 6/10/2015 FROM STEVE MATTHEWS TO MARK ABRAMOVITZ * * *

"A Troxler 3450 moisture density gauge was damaged by a soft tire roller at 2140 [PDT] Friday night, June 5th. The location was 15433 West Snoqualmie Valley Road, between Woodinville and Duvall near Carnation. The gauge housing was cracked open but there was no apparent damage to sources or shielding. The gauge was placed in its Type A package and transported to the licensee's facility in Puyallup. From there, the gauge was picked up by a gauge manufacture representative for repair and leak test. The incident occurred because the portable gauge operator turned away momentarily to speak with another construction worker and didn't see the roller getting close and making contact with the gauge. The licensee will be conducting additional training on constant control. There will be a citation for lack of constant surveillance and not notifying our office [Washington Office of Radiation Protection]. The actual notification we received was from the licensees customer, King County Materials Lab."

Notified the R4DO (Werner) and NMSS Events Notification (via e-mail).

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Non-Agreement State Event Number: 51139
Rep Org: ECS MID-ATLANTIC, LLC
Licensee: ECS MID-ATLANTIC, LLC
Region: 1
City: HANOVER State: MD
County:
License #: 19-31261-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL DEAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/08/2015
Notification Time: 15:51 [ET]
Event Date: 06/08/2015
Event Time: 14:30 [EDT]
Last Update Date: 06/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(a) - PROTECTIVE ACTION PREVENTED
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MOISTURE/DENSITY GAUGE DAMAGED BY COMPACTOR ROLLER

At a work site on the U.S. Naval Academy grounds, a compactor roller backed over and damaged a Troxler Model 3430 moisture/density gauge. The gauge contains an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source. Upon inspection of the gauge and surrounding area, the gauge case was found to be separated, but no damage was noted to the sources. The sources were in the shielded position at the time of the incident. The licensee will place the gauge back in its case, transport it to its normal storage location, and contact the manufacturer for repair/disposal.

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Agreement State Event Number: 51140
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP, INC
Region: 4
City: GEISMAR State: LA
County:
License #: LA-10968-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2015
Notification Time: 16:35 [ET]
Event Date: 06/08/2015
Event Time: 07:00 [CDT]
Last Update Date: 06/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - UNATTENDED RADIOGRAPHY CAMERA

The following report was received via fax:

"The incident happened on June 8, 2015, and was corrected and under the licensee's control by 0840 CDT. It was not reported to the Department [Louisiana Department of Environmental Quality] until 1150 CDT on June 8, 2015.

"A radiography exposure device was left in a company radiography rig parked at the Baton Rouge Metro Airport. A radiographer was flying out of the Baton Rouge Airport after working a job in the field. The radiographer went through security and boarded the plane departing at 0700 CDT. However, the person who was to retrieve the rig with the camera did not arrive at the airport until 0840 CDT. This means the camera alarm system was left unattended for 1 hour and 40 minutes.

"The IC alarm system for the radiography rig sounds/alarms to a 'key fob' while in the field. One potential responder was in the air with one alarming device and the other alarming device had not made it to the airport. The radiography rig was parked in a parking lot unattended. The rig and camera were retrieved at 0840 CDT the same morning.

"The camera was an AEA Delta 880, SN D8086 exposure device loaded with 34 Ci of Ir-192. The camera and the vehicle were locked and secured, but the alarming device was unmanned for approximately 2 hrs.

"The Radiation Safety Officer called in his report at approximately 1150 CDT on 06/08/2015. The situation did not result in a radiation incident. However, the potential for a radiation incident or security breach was the problem.

"At this time, LDEQ [Louisiana Department of Environmental Quality] considers this incident still open. The incident is still under investigation and review by the staff. Enforcement and corrective actions will be determined by the out-come of the investigation. The incident was considered under control by MISTRAS and reported after the exposure device was back at the MISTRAS'S Geismar, LA location."

Louisiana Report: id No.: LA150009

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Power Reactor Event Number: 51148
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROBERT NORRIS
HQ OPS Officer: STEVEN VITTO
Notification Date: 06/11/2015
Notification Time: 13:15 [ET]
Event Date: 06/10/2015
Event Time: 15:20 [CDT]
Last Update Date: 06/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
EUGENE GUTHRIE (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 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY

A licensed employee supervisor had a confirmed positive test for a controlled substance during a random fitness-for-duty test. The employee's plant access has been placed on administrative hold.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 51154
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BLAKE BAXTER
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/15/2015
Notification Time: 17:42 [ET]
Event Date: 06/16/2015
Event Time: 07:00 [CDT]
Last Update Date: 06/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATTY PELKE (R3DO)

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 100 Power Operation 100 Power Operation

Event Text

TSC VENTILATION TO BE REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"On 6/16/2015, planned preventive maintenance activities [will be] performed on the Braidwood Generating Station Technical Support Center (TSC), Ventilation System. The work will be completed within approximately 48 hours. This activity includes preventative maintenance that requires the TSC ventilation system to be out of service which will render the TSC ventilation system 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 event is reportable per 10 CFR 50.72(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 or ventilation system 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: 51156
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: LUKE HEDGES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/15/2015
Notification Time: 20:15 [ET]
Event Date: 06/15/2015
Event Time: 19:20 [EDT]
Last Update Date: 06/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DUE TO TURBINE TRIP

"On June 15, 2015 at 1920 EDT, Indian Point Unit 3 received a Turbine trip which directly led to a Reactor trip. Operators entered [plant procedure] E-0, Reactor Trip or Safety Injection. All control rods fully inserted. All safety systems responded as expected. The Auxiliary Feedwater (AFW) system actuated as expected. Offsite power and electrical lineups are normal. No primary or secondary code safety valves lifted. All MSIVs are open and the Main Condensers are being used as the heat sink. The Reactor is in Mode 3 and stable. Unit 2 was unaffected and remains at 100% power. Preliminary investigation determined that Breaker Number 1 in the Ring Bus was intentionally opened [by plant personnel on switching orders from the district operator] due to a problem on W93 [output feeder from Ring Bus]. Subsequently Breaker #3 went open and caused a Turbine/Reactor trip of the Unit."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, June 16, 2015
Tuesday, June 16, 2015