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Event Notification Report for August 12, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/11/2015 - 08/12/2015

** EVENT NUMBERS **


51284 51286 51287 51307 51308 51309

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Agreement State Event Number: 51284
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: RABA-KISTNER CONSULTANTS
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 01571
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/03/2015
Notification Time: 17:35 [ET]
Event Date: 08/03/2015
Event Time: [CDT]
Last Update Date: 08/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - DAMAGED HUMBOLDT MOISTURE DENSITY GAUGE

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

"On August 3, 2015, the licensee reported to the Agency [Texas Department of State Health Services] that one of its technicians had run over and damaged a Humboldt 5001 EZ moisture/density gauge at a temporary job site in Belton, Texas. The gauge contained a 10 millicurie cesium-137 source and a 40 millicurie americium-241/beryllium source. The technician had started the test and the cesium source was extended four inches into the ground. The technician decided to move his pickup and while doing so he backed over the gauge and then pulled forward over it again. The source rod handle broke completely off of the gauge. A boundary around the gauge was marked and the licensee's radiation safety officer called a licensed service company. The service company responded and reported that the source was inside the gauge and not down in the hole, that it had apparently been pulled back into the gauge when it was run over. The service technician performed surveys and found no contamination. No member of the public received any exposure as a result of this event. No elevated exposures are anticipated for the technicians. An investigation into this event is ongoing. More information will be provided as it is obtain in accordance with SA-300."

Texas Incident #: I-9329

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Agreement State Event Number: 51286
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SUTTER SURGICAL - FAIRFIELD
Region: 4
City: FAIRFIELD State: CA
County:
License #: 7602
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/04/2015
Notification Time: 14:06 [ET]
Event Date: 07/20/2013
Event Time: [PDT]
Last Update Date: 08/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - HISTORICAL MEDICAL EVENTS DISCOVERED DURING STATE INVESTIGATION

The following information was provided by the State of California via email:

"RHB [ California Radiation Heath Branch] personnel noted irregularities in the way brachytherapy was being performed by an authorized user and investigated all facilities where he is authorized to perform brachytherapy.

"On August 3, 2015, after reviewing files and consulting with the RSO of the facility, it was determined that there had been two medical events that had gone unreported. Both events were prostate Pd-103 implants performed in 2013 and 2014. One treatment resulted in a dose of only 37.6 percent of the target dose to the prostate (139.5 mCi Pd-103) and the second resulted in a dose of 66.9 percent of the target dose to the prostate (189.1 mCi Pd-103). The licensee will submit a follow up report within 15 days."

CA 5010 (Date Notified): 072015

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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Non-Agreement State Event Number: 51287
Rep Org: SANFORD HEALTH
Licensee: SANFORD HEALTH
Region: 4
City: SIOUX FALLS State: SD
County:
License #: 40-12378-01
Agreement: N
Docket:
NRC Notified By: STEVEN MOECKLY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/04/2015
Notification Time: 18:09 [ET]
Event Date: 07/30/2015
Event Time: 12:00 [CDT]
Last Update Date: 08/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT RESULTING FROM ACTUAL TREATMENT DOSE 30 PERCENT GREATER THAN PRESCRIBED

On 7/31/2015, a patient was undergoing a single treatment for liver cancer using Y-90 microspheres (SIR-Spheres) with a prescribed dose from the physicians written directive of 29.43 milliCi. On 8/4/2015, it was discovered that the patient actually received 38.2 milliCi dose due a calculation error based on the physician's initial written directive when the physician had decided on a final dose reduction prior to treatment. The physician has been notified and believes that there will be no adverse effects to the patient. The patient will be notified on 8/5/2015.

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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Power Reactor Event Number: 51307
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MICHAEL SLABY
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/11/2015
Notification Time: 02:01 [ET]
Event Date: 08/10/2015
Event Time: 23:32 [EDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAY POWELL (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

INADVERTENT SIREN ACTIVATION

"At approximately 2332 EDT on August 10, 2015, the Ginna Control Room was notified of an inadvertent siren activation by the Monroe County Emergency Center. It is unclear at this time why the siren inadvertently activated. Company personnel are addressing the issue with the siren.

"The licensee notified the NRC Resident Inspector."

The siren activated for approximately 1 minute. The licensee will remove the siren from service until the cause of the inadvertent actuation can be corrected. The licensee has a sufficient number of sirens to allow this siren to be removed from service.

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Power Reactor Event Number: 51308
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK COVEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/11/2015
Notification Time: 05:19 [ET]
Event Date: 08/11/2015
Event Time: 01:39 [CDT]
Last Update Date: 08/11/2015
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):
BOB HAGAR (R4DO)

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

Event Text

AUTOMATIC REACTOR TRIP AFTER AN OFFSITE ELECTRICAL FAULT

"Reactor trip caused by turbine trip. Turbine tripped immediately following the trip of one of four 345KV offsite lines. The reason for protective relaying not preventing the grid disturbance from tripping the turbine generator is not known at this time. All normal offsite and onsite power sources are available.

"Auxiliary Feedwater actuated as expected on low steam generator level following the trip from 100% power. All systems functioned as expected in response to the trip.

"The NRC Senior Resident Inspector has been notified."

An electrical fault on a 345 kV line 2 miles from the site caused the bus to strip and reclose, which cleared the fault. All control rods fully inserted and the plant is in its normal shutdown electrical lineup.

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Part 21 Event Number: 51309
Rep Org: ROTORK CONTROLS
Licensee: ROTORK CONTROLS
Region: 1
City: ROCHESTER State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PATRICK SHAW
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/11/2015
Notification Time: 09:55 [ET]
Event Date: 07/28/2015
Event Time: [EDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
RAY POWELL (R1DO)
ANTHONY MASTERS (R2DO)
ROBERT ORLIKOWSKI (R3DO)
BOB HAGAR (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART-21 NOTIFICATION - MICRO SWITCH INTERMITTENT VARIATION IN RESISTANCE

The following report was received via fax:

"On June 4, 2015, Rotork Controls Inc. opened a formal Part 21 [10 CFR 21.21] investigation into a self-identified anomaly relating to a basic micro switch - Pt No N69-921, description 'V12'. The anomaly is intermittent variation in electrical contact resistance and was first observed during the factory acceptance test of a Rotork safety related NA Range Electric Actuator; also referred to as an electric Valve Operator.

"Rotork and the switch manufacturer are currently characterizing switch population contact resistance to establish whether an unsafe condition could exist as defined under 10 CFR 21."

Page Last Reviewed/Updated Wednesday, August 12, 2015
Wednesday, August 12, 2015