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Event Notification Report for July 22, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/21/2015 - 07/22/2015

** EVENT NUMBERS **


51226 51227 51229 51230 51244 51246

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Agreement State Event Number: 51226
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ERWIN RESIN SOLUTIONS
Region: 1
City: ERWIN State: TN
County:
License #: TRML R-86011-
Agreement: Y
Docket:
NRC Notified By: MICHAEL SINGLETON
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/13/2015
Notification Time: 17:24 [ET]
Event Date: 07/12/2015
Event Time: 21:05 [EDT]
Last Update Date: 07/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
PATRICIAL MILLIGAN (EMAI)

Event Text

AGREEMENT STATE REPORT- POTENTIAL RAD WORKER OVEREXPOSURE

The following report was provided by the Tennessee Division of Radiological Health via email:

"At approximately 2105 [EDT] on the night of July 12th, using our local access control program (i.e., Canberra HIS20) and a DMC 3000 series electronic dosimeter, an Erwin Resin Solutions employee was exiting the Radiological Controlled Area when he received a message stating that he had exceeded his TEDE [Total Effective Dose Equivalent] limit. According to the access control program, a dose of 10002.2 mrem was received. The employee was immediately removed from the area and follow up surveys were conducted. Surveys indicated that general area dose rates were 2-15 mr/hr and that the highest individual package dose rate was 45 mr/hr. The individual had been in the area for approximately 0.47 hours and he recalls at one point looking down at his dosimeter to see a display of 2.4 mrem. The employee's TLD has been pulled and sent off to Mirion for an emergency read, results are expected within 24-48 hrs. The individual will remain out of the RCA until the investigation has concluded.

"Access records have been pulled from the HIS20 program and the doses given were not reflective of a normal entry. A START READ of 0 mrem was given and an END READ of 0 mrem was also given. A GAMMA COMPONENT READ of 10002.2 mrem was given but should have been the same as the END READ which was 0 mrem. All indicators lead to a faulty electronic dosimeter, the dosimeter in question is being sent to our instrument department for further evaluation.

"Tennessee Event Report ID No.: TN-15-101"

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Agreement State Event Number: 51227
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MC SQUARED, INC.
Region: 1
City: TAMPA State: FL
County:
License #: 3424-1
Agreement: Y
Docket:
NRC Notified By: CLARK CONNELLY
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/13/2015
Notification Time: 19:17 [ET]
Event Date: 07/13/2015
Event Time: 16:00 [EDT]
Last Update Date: 07/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ROBERT BUNCH (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST/STOLEN TROXLER DENSITY GAUGE

At approximately 1745 EDT the State of Florida was contacted by the Radiation Safety Officer for MC Squared, Inc. The RSO reported a probable stolen Troxler gauge. Model number 3411B Serial Number: 13563. The company vehicle was parked at a contractor's site at the intersection of Anderson and West Waters Avenue in Tampa, FL. The gauge and packaging were chained and locked to the bed of the truck and was also strapped down. When the technician came out around 1600 EDT he noticed it was missing. They were only parked in that area between 30 minutes to an hour and the lock is also missing. The Hillsboro County Sherriff's office was notified. A report was filed by the Hillsboro County Deputy, Report Number: 15-441038. When the report is completed it will be available to the State of Florida.

The Troxler gauge sources are 40 mCi of Am/Be, and 8 mCi of Cs-137.

State of Florida Incident Number: FL15-068.

The State of Florida is continuing to investigate this event.

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: 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
Notification Date: 07/14/2015
Notification Time: 14:20 [ET]
Event Date: 07/09/2015
Event Time: [EDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

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.

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Agreement State Event Number: 51230
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STANFORD
Region: 4
City: STANFORD State: CA
County:
License #: 0676
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/14/2015
Notification Time: 15:20 [ET]
Event Date: 06/09/2015
Event Time: [PDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST CD-109 SOURCE

The following report was received from the California Radiation Health Branch via email:

"Stanford University RSO [Radiation Safety Officer] informed RHB [California Radiation Health Branch] that a 0.285 mCi Cd-109 source had been lost."

The licensee has implemented corrective actions to bolster inventory accountability.

California 5010 Number: 062515

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: 51244
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BRET RICKERT
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/21/2015
Notification Time: 07:40 [ET]
Event Date: 07/21/2015
Event Time: 05:04 [EDT]
Last Update Date: 07/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MICHAEL F. KING (R2DO)
SCOTT MORRIS (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 5 Power Operation 0 Hot Standby

Event Text

SURRY UNIT 2 TRIP DURING REACTOR STARTUP

"Unit 2 Reactor automatically tripped during Unit start up following a maintenance outage. The first indication of the reactor trip was the annunciator Reactor Trip by Turbine Trip. There were no complications following the trip and Unit 2 is stable at Hot Shut Down. Decay Heat Removal is being maintained by dumping steam to the Main Condenser. Steam Generator water level is being maintained by the Main Feedwater system.

"At the time of the Reactor Trip, Overspeed Protection Circuitry (OPC) Test was being performed on the Unit 2 Main Turbine. The SOV Turbine Trip annunciator was received. The cause of the reactor trip is under investigation.

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) for 4-hour notification of Reactor Protection System activation. The Plant responded as expected for the trip. The NRC resident has been notified of the event.

"There was no radiation release due to this event, nor were there any personnel injuries or contamination events."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 51246
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CRAIG HARVEY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/21/2015
Notification Time: 21:22 [ET]
Event Date: 07/21/2015
Event Time: 14:53 [PDT]
Last Update Date: 07/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
HEATHER GEPFORD (R4DO)

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

SINGLE EMERGENCY SIREN INADVERTENT ACTUATION

"On 7/21/2015, at approximately 1453 Pacific Daylight Time (PDT), while performing quiet testing of the early warning system, a Pacific Gas and Electric (PG&E) Telecommunications Technician identified that a single emergency response siren was making a full sound output when it should not have been. PG&E Technicians took action and deactivated the single siren. The siren sounded for approximately 1 minute. As a result, this issue is being reported under 10 CFR 50.72(b)(2)(xi) for notifications to other offsite government agencies as the licensee notified the County of San Luis Obispo of the siren deactivation. The San Luis Obispo County Sheriff Watch Commander has been notified of the need to implement alternate means of alert and notification for the areas affected by the deactivation of the single siren. This was accounted for in pre-planning efforts and neither the utility nor 911 received any calls [from the public] related to this matter. The source of the activation signal has not been determined and is being investigated.

"There was no impact to the health and safety of the public as a result of this event as the offsite response capabilities remain functional with a single siren failure. The site is operating normally with no emergency conditions present. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, July 22, 2015
Wednesday, July 22, 2015