Event Notification Report for July 09, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/08/2015 - 07/09/2015
Non-Agreement State
Event Number: 51218
Rep Org: TTL ASSOCIATES, INC.
Licensee: TTL ASSOCIATES, INC.
Region: 3
City: PLYMOUTH State: MI
County:
License #: 21-26666-01
Agreement: N
Docket:
NRC Notified By: JEFF ELLIOTT
HQ OPS Officer: DANIEL MILLS
Licensee: TTL ASSOCIATES, INC.
Region: 3
City: PLYMOUTH State: MI
County:
License #: 21-26666-01
Agreement: N
Docket:
NRC Notified By: JEFF ELLIOTT
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/09/2015
Notification Time: 15:10 [ET]
Event Date: 07/09/2015
Event Time: 14:00 [EDT]
Last Update Date: 07/09/2015
Notification Time: 15:10 [ET]
Event Date: 07/09/2015
Event Time: 14:00 [EDT]
Last Update Date: 07/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
TROXLER MOISTURE DENSITY GAUGE DAMAGED BY BULLDOZER
At a temporary construction site in Yale, MI, a Troxler Model 3440, s/n 26515, was run over by a bulldozer. The gauge user was injured and taken to a local hospital. TTL Associates, a materials testing lab located in Plymouth, MI, is responding to the scene to recover the damaged gauge and perform radiation surveys. Local HAZMAT was also contacted. The gauge was in a wheel barrow and not in use at the time it was struck. The licensee is contacting Troxler for instructions to return the gauge.
The Troxler Model 3440 contains two sources; Cs-137 and Am:Be-241 of 8 mCi and 40 mCi, respectively [typical values].
* * * UPDATE AT 1731 EDT ON 07/09/15 FROM JEFF ELLIOTT TO DANIEL MILLS * * *
The gauge was recovered from the construction site with the source still in the locked and stored position and is enroute to TTL Associates for evaluation prior to return to Troxler Labs. A survey of the affected area found no contamination.
At a temporary construction site in Yale, MI, a Troxler Model 3440, s/n 26515, was run over by a bulldozer. The gauge user was injured and taken to a local hospital. TTL Associates, a materials testing lab located in Plymouth, MI, is responding to the scene to recover the damaged gauge and perform radiation surveys. Local HAZMAT was also contacted. The gauge was in a wheel barrow and not in use at the time it was struck. The licensee is contacting Troxler for instructions to return the gauge.
The Troxler Model 3440 contains two sources; Cs-137 and Am:Be-241 of 8 mCi and 40 mCi, respectively [typical values].
* * * UPDATE AT 1731 EDT ON 07/09/15 FROM JEFF ELLIOTT TO DANIEL MILLS * * *
The gauge was recovered from the construction site with the source still in the locked and stored position and is enroute to TTL Associates for evaluation prior to return to Troxler Labs. A survey of the affected area found no contamination.
Power Reactor
Event Number: 51219
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT FRECK
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT FRECK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/09/2015
Notification Time: 18:05 [ET]
Event Date: 07/09/2015
Event Time: 17:32 [EDT]
Last Update Date: 07/09/2015
Notification Time: 18:05 [ET]
Event Date: 07/09/2015
Event Time: 17:32 [EDT]
Last Update Date: 07/09/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GERALD MCCOY (R2DO)
SCOTT MORRIS (NRR)
BERNARD STAPLETON (IRD)
VICTOR McCREE (R2RA)
BILL DEAN (NRR)
GERALD MCCOY (R2DO)
SCOTT MORRIS (NRR)
BERNARD STAPLETON (IRD)
VICTOR McCREE (R2RA)
BILL DEAN (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF UNUSUAL EVENT - FIRE IN CONTAINMENT
The Vogtle Unit-1 control room received a fire alarm from inside the containment building. Per plant requirements, verification of the fire was not obtained within 15 minutes and an Unusual Event was declared. Plant personnel were able to enter containment and verify that there was no fire present. The reactor remained at 100% power throughout the event.
Unusual Event entered: 1732 EDT
Unusual Event exited: 1848 EDT
The licensee notified the NRC Resident Inspector, State, and local governments.
Notified DHS, FEMA, and NICC. NuclearSSA (email) and FEMA NWC (email).
The Vogtle Unit-1 control room received a fire alarm from inside the containment building. Per plant requirements, verification of the fire was not obtained within 15 minutes and an Unusual Event was declared. Plant personnel were able to enter containment and verify that there was no fire present. The reactor remained at 100% power throughout the event.
Unusual Event entered: 1732 EDT
Unusual Event exited: 1848 EDT
The licensee notified the NRC Resident Inspector, State, and local governments.
Notified DHS, FEMA, and NICC. NuclearSSA (email) and FEMA NWC (email).
Agreement State
Event Number: 51229
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINAS MEDICAL CENTER NORTHEAST
Region: 1
City: CONCORD State: NC
County:
License #: 013-0028-3
Agreement: Y
Docket:
NRC Notified By: DAVID P. CROWLEY
HQ OPS Officer: JEFF HERRERA
Licensee: CAROLINAS MEDICAL CENTER NORTHEAST
Region: 1
City: CONCORD State: NC
County:
License #: 013-0028-3
Agreement: Y
Docket:
NRC Notified By: DAVID P. CROWLEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/14/2015
Notification Time: 14:20 [ET]
Event Date: 07/09/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/14/2015
Notification Time: 14:20 [ET]
Event Date: 07/09/2015
Event Time: 00:00 [EDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - IMPLANT BRACHYTHERAPY OVERDOSE
The following report was received from the North Carolina Department of Health and Human Services via email:
"Narrative event description: I-125 Prostate seed implant medical event occurred when physicist ordered the incorrect activity and number of seeds. The patient plan had the correct planned activity, but when the order was placed with air kerma, the wrong activity was ordered and subsequently implanted to the patient.
"Event date and notification date: Implanted 7/9/15. Identified and reported the medical event 7/13/15.
"Phone Call received from Physicist to NC RAM [North Carolina Radioactive Materials] Branch at 1246 [EDT] on 7/13/15.
"Cause and corrective actions: Incorrect calculations and human error in conversion from air kerma to activity; [The licensee] ordered and implanted [the] wrong activity.
"Notifications: NC RAM Branch notified 7/13/2015
"Indicate if there are any generic implications: Lack of attention to units and procurement procedures for seeds.
"Source/Radioactive Material: Iodine 125 brachytherapy seeds from Theragenics Corporation
"Procedure administered; dose intended and actual dose administered; isotope and activity administered; target organ: Prostate Seed Implant, Intended Dose 144 Gray or 23.48 mCi (71 seeds), Implanted Dose of 31.299 mCi (75 Seeds), ~33% overdose based on activity alone (physicist reported 28%), I-125 seeds and 31.299 mCi administered, prostate was target organ.
"[The] patient and Referring Physician were notified 7/13/15.
"Report identification number: NC150017"
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.
The following report was received from the North Carolina Department of Health and Human Services via email:
"Narrative event description: I-125 Prostate seed implant medical event occurred when physicist ordered the incorrect activity and number of seeds. The patient plan had the correct planned activity, but when the order was placed with air kerma, the wrong activity was ordered and subsequently implanted to the patient.
"Event date and notification date: Implanted 7/9/15. Identified and reported the medical event 7/13/15.
"Phone Call received from Physicist to NC RAM [North Carolina Radioactive Materials] Branch at 1246 [EDT] on 7/13/15.
"Cause and corrective actions: Incorrect calculations and human error in conversion from air kerma to activity; [The licensee] ordered and implanted [the] wrong activity.
"Notifications: NC RAM Branch notified 7/13/2015
"Indicate if there are any generic implications: Lack of attention to units and procurement procedures for seeds.
"Source/Radioactive Material: Iodine 125 brachytherapy seeds from Theragenics Corporation
"Procedure administered; dose intended and actual dose administered; isotope and activity administered; target organ: Prostate Seed Implant, Intended Dose 144 Gray or 23.48 mCi (71 seeds), Implanted Dose of 31.299 mCi (75 Seeds), ~33% overdose based on activity alone (physicist reported 28%), I-125 seeds and 31.299 mCi administered, prostate was target organ.
"[The] patient and Referring Physician were notified 7/13/15.
"Report identification number: NC150017"
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.