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Event Notification Report for September 21, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/18/2015 - 09/21/2015

** EVENT NUMBERS **


51384 51387 51388 51389 51390 51409 51410 51412

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Agreement State Event Number: 51384
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNKNOWN
Region: 1
City: ASHLAND State: KY
County:
License #: UNKNOWN
Agreement: Y
Docket:
NRC Notified By: ERIC PERRY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/10/2015
Notification Time: 10:40 [ET]
Event Date: 09/08/2015
Event Time: [CDT]
Last Update Date: 09/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - ORPHAN Ra-226 SOURCE

The following report was received via e-mail:

"KY RHB [Kentucky Radiation Health Branch] was notified on 9/8/2015 via the request and issuance of DOT Special Permit No. 10656 KY-KY-15-018 of a rail car emitting ionizing radiation above normal background levels. Personnel at the facility performed exposure rate surveys on the exterior of the rail car. Highest reading was reported as 20 mR/hr with a background reading of 0.005mR/hr. The rail car was returned to the point of origin on 9/8/2015. On 9/9/2015 RHB dispatched a team of inspectors to the origin facility in order to better determine the source of the ionizing radiation. The team discovered 1 Ra-226 static eliminator bar most likely registered under SS&D certificate number NR-654-D-829-U. The team further discovered additional pieces of what appear to be at least one more static eliminator bar in the vicinity of the facility's metal shredding equipment. At this time no removable contamination has been found and there are no indications of personnel overexposures. A decommissioning, decontamination contractor has been contacted by the facility. RHB continues to monitor the situation with onsite inspectors. RHB will update the Commission as more information becomes available. RHB is tracking this event as KY-15-0006."

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Agreement State Event Number: 51387
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HI TECH TESTING
Region: 4
City: LONGVIEW State: TX
County:
License #: L05021
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2015
Notification Time: 15:41 [ET]
Event Date: 09/11/2015
Event Time: [CDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

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

"The licensee reported [to Texas Department of State Health Services] that a disconnect had occurred and that an investigation is in progress. The radiography crew was working at a temporary job site [in Gainesville, TX] and the person reporting the event did not have complete information. Source activity and details of the disconnect are not available at this time."

The State of Texas does not believe that any over exposures have occurred.

Texas Report #I 9337

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Agreement State Event Number: 51388
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HOAG MEMORIAL HOSPITAL PRESBYTERIAN
Region: 4
City: NEWPORT BEACH State: CA
County:
License #: 0272-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2015
Notification Time: 15:42 [ET]
Event Date: 08/26/2015
Event Time: [PDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSNS (MEXICO) (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL

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

"On August 26, 2015, [Nordion] shipped three packages containing approximately 200 mCi of Yttrium-90 to Hoag Hospital by [a commercial shipping company]. One of the three packages did not arrive at Hoag Hospital. The Radiation Safety Officer (RSO) reported that [Nordion] was contacted on 8/27/15, to report that one of the three packages had not arrived. [Nordion] told the RSO that they reported this event to the Canadian authority and that [the commercial shipping company] was the responsible party since [Nordion] had turned the packages over to [the commercial shipping company] for shipping. The [commercial shipping company] health physics consultant contacted [California Department of Public Health/Radiologic Health Branch] CDPH/RHB on 9/11/15, (this was the first CDPH/RHB learned of this event) to report that a [commercial shipping company] investigation had identified that the missing package had fallen off of a conveyor belt in the [the commercial shipping company's] Costa Mesa, CA sorting facility and landed in a waste container. This information was identified by [the commercial shipping company] personnel review of video within their facilities. The package was not noticed to have fallen into the waste container, and the waste container was subsequently emptied into a larger trash receptacle by a cleaning crew. The larger trash receptacle was picked up for disposal at a local landfill. The half life of the Y-90 is 64 hours."

California report #091015

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: 51389
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: BRIGHTON State: CO
County:
License #: CO 902-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2015
Notification Time: 16:07 [ET]
Event Date: 09/10/2015
Event Time: 17:45 [MDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - INDUSTRIAL RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following report was received from the State of Colorado via email:

"Event description: The Department [Colorado Department of Public Health and Environment] received a phone report from [licensee] on 09/11/15, at 0906 [MST]. It was reported that a source disconnect occurred on 09/10/15, at about 1745. At that time, the licensee RSO [Radiation Safety Officer], went out and retrieved the source according to procedures for source retrieval. The source was successfully retrieved, and no over exposure was reported.

"The Department [Colorado Department of Public Health and Environment] is preparing for a visit to investigate the event and is expecting a full report from the licensee within 30 days. No reported over exposure from this event."

No additional information on the Radiography Camera or source strength is available at this time.

Event Report ID No.: CO15-I15-26

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Agreement State Event Number: 51390
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NEW YORK STATE
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/11/2015
Notification Time: 16:41 [ET]
Event Date: 09/10/2015
Event Time: [EDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL TREATMENT DOSE LOWER THAN PRESCRIBED

The following was received from the State of New York via fax:

"A New York State licensee informed the Department [New York State Department of Rad Health] of a patient receiving HDR therapy being delivered a fractionated dose that differed from the prescribed fractionated dose by more than 50 percent. The written directive called for a vaginal treatment consisting of three fractions of 1050 cGy per fraction. The second of the three fractions was scheduled on September 10, 2015. Treatment began as planned with both the AU and the AMP at the console. After successful extension and retraction of the dummy source, it was noticed that treatment countdown time was increasing instead of decreasing. The source extension was in contradiction to the console, which indicated 'treatment terminated' although the source extension warning light was also activated near the console. Two AMPs engaged the Emergency-Stop, terminating the treatment and retracting the source to the shielded position. Surveys of the patient and the HDR unit verified that the source was returned to the shielded position. The HDR console indicated that 41.8 seconds had elapsed with source extended. The Patient received an estimated dose of 105 cGy. The patient was informed of the event and no further patients were treated that day.

"Electa was contacted and a service engineer arrived that same afternoon. He was unable to reproduce the fault condition. Electa is currently investigating the internal performance log of the unit. The physicist performed a complete QC and no aberrations were noted. The HDR unit seems to be performing properly. The last source exchange was on August 14, 2015. Source activity on 9/10/15 was approximately 8 curies."

New York event # NY-15-08

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: 51409
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARTIN NEWSHAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/18/2015
Notification Time: 18:01 [ET]
Event Date: 09/18/2015
Event Time: 14:08 [EDT]
Last Update Date: 09/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
SILAS KENNEDY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation

Event Text

EQUIPMENT FAILURE RESULTS IN INOPERABLE SECONDARY CONTAINMENT

"At 1408 EDT on 9/18/2015, Secondary Containment Refuel Floor exhaust flow degraded due to an equipment malfunction in the running Refuel Floor exhaust train. The degraded exhaust flow caused Secondary Containment differential pressure to go positive for approximately three minutes, resulting in Secondary Containment being declared inoperable. Corrective action to start the Stand-by Gas Treatment System and the alternate Refuel Floor exhaust train restored Secondary Containment operable by re-establishing its required negative differential pressure.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(C) and per the guidance of NUREG-1022, Rev. 3, 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'

"The Duty Team has been activated to develop a repair plan.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51410
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SHANE HARVEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/19/2015
Notification Time: 00:11 [ET]
Event Date: 09/18/2015
Event Time: 20:00 [CDT]
Last Update Date: 09/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
KENNETH RIEMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

REACTOR VESSEL HEAD PENETRATION REPAIR DID NOT MEET ACCEPTANCE CRITERIA

"On 9/18/2015 at 20:00 [CDT], during the Byron Station Unit 1 refueling outage, it was determined that the results of a planned Liquid Penetrant (PT) examination performed on a previous overlay repair of the reactor vessel head did not meet applicable acceptance criteria. The penetration requires repairs prior to returning the vessel head to service. These indications are not in the reactor coolant pressure boundary; however they are very near the previously repaired J-groove weld. The examination was being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1, to ensure the structural integrity of the reactor vessel head pressure boundary. No ultrasonic indications have been identified at this time. Repairs are currently being planned in accordance with the ASME Code of Record. The repairs will be completed prior to returning the vessel head to service.

"This event is being reported under 10 CFR 50.72(b)(3)(ii)(A) for 'Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.'

"The licensee has notified the NRC Resident Inspector.

"Per regulatory commitment, Exelon Generation Company, LLC (EGC) is notifying NRC staff of the Division of Component Integrity or its successor, of changes in indication(s) or findings of new indication(s) in the penetration nozzle or J-groove weld beneath a seal weld repair, or new linear indications in the seal weld repair, prior to commencing repair activities.

"The original indications that led to the overlay repairs were discovered during ultrasonic testing and were reported to the NRC and assigned EN46686 and EN48311."

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Power Reactor Event Number: 51412
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHARLES BERGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/20/2015
Notification Time: 02:53 [ET]
Event Date: 09/17/2015
Event Time: 00:30 [CDT]
Last Update Date: 09/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KENNETH RIEMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

CONTROL ROOM AREA RADIATION MONITORS NOT ABLE TO PROVIDE RADIATION LEVEL INFORMATION

"On 9/17/2015 at 0030 [CDT], during the Byron Station Unit 1 refueling outage, Main Control Room area radiation monitors were removed from service to support an electrical bus outage. During this time, the Main Control Room area radiation monitors were not able to generate Main Control Room annunciation or provide area radiation level information necessary for Emergency Action Level (EAL) threshold determination until the area radiation monitor is restored which is scheduled for 9/20/15.

"This event is being reported under 10 CFR 50.72(b)(3)(xiii) for 'Any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability.'

"The licensee has notified the NRC Resident Inspector."

The licensee discovered this issue at 2145 CDT on 9/19/15. The licensee established compensatory measures upon discovery of the issue.

Page Last Reviewed/Updated Monday, September 21, 2015
Monday, September 21, 2015