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Event Notification Report for July 7, 2015

U.S. Nuclear Regulatory Commission
Operations Center

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

** EVENT NUMBERS **


51130 51155 51183 51188 51189 51201

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 07/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFICA ()

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

* * * RETRACTION FROM JARED THOMPSON TO VINCE KLCO ON 7/6/2015 AT 1614 EDT * * *

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

"The Arkansas Department of Health (ADH) is requesting the retraction of NRC Event Number [51130].

"ADH received a report from the licensee dated June 18, 2015. The report and investigation conducted by the licensee determined that this event did not qualify as a reportable medical event. A review of the written directive indicated that the radiation dose that was prescribed by the authorized user was delivered to the patient. The authorized user had intended to prescribe 114 Gray.

"This was confirmed by ADH after further review of the documentation obtained during the on-site investigation.

"The patient completed this treatment on June 29, 2015.

"The licensee has implemented revisions in the treatment procedures for further safety improvements.

"The ADH considers this event to be closed."

Notified the R4DO (Haire) and NMSS Events Notification Group via email.

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Agreement State Event Number: 51155
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: SPEEDIE & ASSOCIATES
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-209
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/15/2015
Notification Time: 16:20 [ET]
Event Date: 06/12/2015
Event Time: [MST]
Last Update Date: 07/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ROBERT BUNCH (ILTA)
CNSNS (MEXICO) (EMAI)

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 12, 2015, a portable gauge was being stored in a locked box in the back of a truck which was locked in one of the user's garages. An ex-girlfriend, who had a copy of the truck keys, broke into the user's house and stole the truck with the gauge still in the back. The truck was reported stolen to the RSO on the morning of June 13, 2015. The RSO then made a police report and contacted the Agency's [Arizona Radiation Regulatory Agency] duty officer. The RSO stated that someone spotted the truck in Mesa, Arizona on the night of June 13, 2015. The gauge is a Troxler Model 3400 series, Serial Number 5310, containing 7.4 millicuries of Cesium-137 and 40 millicuries of Americium-241.

"The truck is a white, 2007 GMC Sierra crew cab with Arizona license plate number: 415ZGV.

"The investigation into this event is ongoing.

"The US NRC, Maricopa County sheriff's office, Arizona DPS [Department of Public Safety], California, New Mexico, Utah, Nevada, and Arizona governor's office are being notified of this event."

Arizona First Notice Number: 15-009

* * * UPDATE ON 07/06/15 AT 1448 EDT FROM BRIAN GORETZKI TO JEFF HERRERA * * *

The following update was provided by the Arizona Radiation Regulatory Agency via email:

"On July 5, 2015, City of Mesa police identified the stolen truck in the parking lot of Mountain View Medical Center. The portable gauge was still with the vehicle and it was relocated to the licensee's office. The licensee will perform a leak test prior to the gauge being used."

Notified the R4DO (Haire), ILTAB (Johnson), NMSS Events (via email) and CNSNS (MEXICO 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: 51183
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: GREGG YOUNG CHEVROLET
Region: 4
City: OMAHA State: NE
County:
License #: NE GL-0488
Agreement: Y
Docket:
NRC Notified By: JULIA SCHMITT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/26/2015
Notification Time: 10:28 [ET]
Event Date: 12/31/2008
Event Time: [CDT]
Last Update Date: 06/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BARRY WRAY (ILTA)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

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

"On June 26, 2015, Gregg Young Chevrolet (GL0488) reported a loss of 10 exit signs containing tritium (Evenlite 201) via letter. Each sign originally contained 10.5 curies and current approximate activity is 3.852 curies. Our records show that the registrant possessed these signs in 2013 (latest inventory) however, the registrant assumes these signs were removed from their facility by a tenant sometime in 2008."

NE Item Number: NE150002

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: 51188
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LAKELAND PLASTICS
Region: 3
City: MUNDELEIN State: IL
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2015
Notification Time: 12:56 [ET]
Event Date: 05/15/2015
Event Time: [CDT]
Last Update Date: 06/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING STATIC ELIMINATOR

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

"By letter received on June 23, 2015 the registrant [Lakeland Plastics] advised [the Illinois Emergency Management Agency] that a static eliminator provided to them under general license is missing although believed to be still at their facility. The device was received on May 22, 2014 for use with special projects to control dust. When the lease for the device came up for renewal a year after its initial receipt, it was discovered to be missing. It was last used in March of this year. Efforts have been underway since June 11, 2015, to locate the device. The registrant indicates that a new and more rigorous check out procedure has been developed to prevent future recurrence of this event for its other static eliminator. The current activity of the missing item is 1.4 milliCi. Given the age, form and design of the static eliminator, no exposures to employees or the public is suspected. This item will remain open for the required time until the source is declared as lost or is recovered.

"Radionuclide: Po-210
"Activity: 0.0014 Ci [1.4 milliCi] or 0.0518 GBq
"Manufacturer: NRD, Inc.
"Model Number: P-001
"Serial Number: A2JX845

"IL Report ID: IL15014"

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: 51189
Rep Org: MALLINCKRODT PHARMACEUTICALS
Licensee: MALLINCKRODT PHARMACEUTICALS
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: MANUEL DIAZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2015
Notification Time: 14:45 [ET]
Event Date: 06/19/2015
Event Time: [CDT]
Last Update Date: 06/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LAURA KOZAK (R3DO)
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

LOST SHIPMENT OF I-123

On 06/8/15, a shipment of I-123, 1.4 mCi, used for diagnostic imaging, was shipped from the Mallinckrodt Maryland Heights, MO facility for overnight delivery via highway carrier to a company located in Baltimore, MD. The material was not received in Maryland as scheduled. The shipper, carrier and customer performed searches. The shipper concluded that the material was missing as of 6/19/15.

The half-life of I-123 is 13.3 hours.

The licensee will submit a written report within the 30 day requirement.

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: 51201
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: DAVID PORTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/06/2015
Notification Time: 20:41 [ET]
Event Date: 07/06/2015
Event Time: 14:20 [PDT]
Last Update Date: 07/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MARK HAIRE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 64 Power Operation 64 Power Operation

Event Text

POSTULATED MULTIPLE SPURIOUS OPERATIONS SCENARIO THAT COULD ADVERSELY IMPACT POST-FIRE SAFE SHUTDOWN

"A recent review of Fire Protection and Post Fire Safe Shutdown (PFSS) Programs at Columbia Generating Station (CGS) identified a potential unanalyzed condition with Multiple Spurious Operation (MSO) Scenario 2x.

"Review of the circuit design for High Pressure Core Spray (HPCS) HPCS-V-10, HPCS-V-11 and HPCS-V-15 identified that fire-induced circuit failure (hot shorts) on the OPEN function control circuits for each valve would create the flow path to potentially drain inventory from the suppression pool (SP). The normal operation of HPCS-P-3 (keep-fill pump) would allow additional inventory from the SP to be transferred to the CSTs [Condensate Storage Tank]. If a fourth hot short is postulated, HPCS-P-1 would transfer inventory from the SP to the CST at a much faster rate.

"HPCS-V-11 was deactivated on 6/12/2015 due to a maintenance repair issue and will be left in the fully closed position. This plant alignment resolves current concern for MSO scenario 2x as fire-induced circuit damage cannot cause spurious opening of HPCS-V-11. However, with an incomplete analysis for MSO scenario 2x, compliance with PFSS MSO requirements would have been challenged from the completion of the MSO project (October 2012) up to June 2015.

"CGS is reporting this event as an unanalyzed condition in conformance with 10 CFR 50.72(b)(3)(ii)(B). Further analyses are being implemented to confirm the condition and to develop appropriate remedial actions."

The licensee will notify the NRC Resident Inspector.

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