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Event Notification Report for September 22, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/21/2015 - 09/22/2015

** EVENT NUMBERS **


51363 51387 51388 51389 51390 51393

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Part 21 Event Number: 51363
Rep Org: SOR MEASUREMENT AND CONTROL
Licensee: SOR MEASUREMENT AND CONTROL
Region: 4
City: LENEXA State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MELANIE DIRKS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/02/2015
Notification Time: 15:31 [ET]
Event Date: 09/02/2015
Event Time: [CDT]
Last Update Date: 09/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
GREG WARNICK (R4DO)
PART 21 MATERIALS (EMAI)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

PART-21 REPORT - NUTHERM IRRADIATION CERTIFICATION WITH INSUFFICIENT MARGIN

The following report was received via fax:

"SOR Inc. was notified by Nutherm International, Inc. that irradiation certification performed by Steris Isomedix did not meet the additional 10 percent margin to meet the requirements of IEEE 323 due to measuring and test equipment uncertainties.

"This issue was originally identified by STERIS lsomedix Services, Whippany, New Jersey as part of NRC Inspection Report No. 99901445/2014-201. Nutherm International, Inc. has completed their evaluation of work performed for SOR, Inc. and has identified a potential impact to the conclusions of equipment qualification testing under SOR Inc. purchase order number 166984. Nutherm International, Inc. has reported this potential issue and forwarded an update to the NRC per Event Notification Report Number 50359.

"SOR Inc. is conducting an evaluation of projects to determine whether a defect or failure to comply exists as defined by 10 CFR Part 21. At the conclusion of the evaluation, any customer impacted by this issue will be notified and the U.S Nuclear Regulatory Commission will be notified in accordance with 10 CFR Part 21.21.

"If you have any questions regarding this issue, please contact Mike Bequette, Vice President of-Engineering at (913) 8882630 or email mbequette@sorinc.com."

* * * UPDATE FROM MELANIE DIRKS TO JOHN SHOEMAKER AT 1729 EST ON 9/21/15 * * *

The following updated information was excerpted from a SOR, Inc. report received via email:

"As a result, corrections were made to test report SOR-12043R revision 1, approved 9/8/2015. The uncertainty calculations by the radiation lab used for the qualification program reduced the qualification level from 35 Mrad to 33.8 Mrad.

"SOR found that there were three switches potentially affected as shown [on table I provided with this report]. While these switches were shipped before completion of the of test report SOR-12043R, revision 0, it has been established that there was a contractual agreement between SOR and Xcel Energy-Monticello Nuclear Generating Plant that these switches would be equivalent to those to be qualified in the new test report. Also listed are recipients of the original test report SOR-12043R revision 0 [on table II provided with this report].

"In either Case, SOR does not have the capability to perform further evaluations to determine if a safety hazard exists as the specific customer application and end use is not known by SOR. Since the release of revision 0 of the test report, SOR has not provided certificate of conformance to any 141 series product shipped citing the 12043R test report other than qualification units for Excel Energy - Monticello Nuclear Generating Plant.

Recipients, Customer, Utility Names:
- Xcel Energy - Monticello Nuclear
- Progress Energy - Brunswick
- Entergy Corporation - Pilgrim

"In accordance with the requirements of 10 CFR Part 21.21, the customers listed have been notified regarding this issue to allow them to evaluate this deviation or failure to comply and its potential safety hazard."

lf you have any questions regarding this matter, please contact;

For technical issues;
Joe Modig
SOR Inc.
14685 W. 105th Street
Lenexa, KS 66215-2003
Ph: (913) 956-3046
jmodig@sorjnc.com

And for any other questions;
Melanie Dirks
Director of Quality Assurance
SOR Inc.
14685 W. 105th Street
Lenexa, KS 66215-2003
Ph: (913) 956-3160
Email: mdirks@sorinc.com

Notified R1DO ( Welling), R2DO (Sykes), R3DO (Dickson), R4DO (Pick), and Part 21 Reactors and Part 21 Materials via email.

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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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Non-Agreement State Event Number: 51393
Rep Org: NOAA MARINE LABORATORY
Licensee: NOAA MARINE LABORATORY
Region: 1
City: MIAMI State: FL
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: BENJAMINE VANDINE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/14/2015
Notification Time: 14:07 [ET]
Event Date: 04/01/2014
Event Time: [EDT]
Last Update Date: 09/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RODRIGUEZ-LUCCIONI (NMSS)

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

Event Text

LOST HEWLETT-PACKARD GAS CHROMATOGRAPH

"The NOAA Atlantic Oceanographic and Meteorological Laboratory (AOML) reported a lost Ni-63 source. The licensed device is an [generally licensed, Hewlett Packard/Agilent Technologies Gas Chromatograph, [Model 5890A, Serial Number M1827, containing a 15 mCi Ni-63 source]. [It was discovered that the chromatograph was missing after an April 2014 inventory.] According to several end users of the device, the item was disposed of prior to the annual 2014 inventory. To the best of NOAA's knowledge, the device was disposed of through UNICOR and the Federal Bureau of Prisons (FBP) by a previous property custodian, who has since retired from the agency. Documentation does not exist for this transfer. Another previous property custodian, requested that this item be removed from AOML inventory on 8/4/2014, based on the verbal report from the previous property custodian. Between July 28 and August 19th, 2014, the current property custodian unsuccessfully attempted to contact UNICOR, to confirm that this device did get transferred to UNICOR."

It cannot be confirmed the device was been disposed of via UNICOR and is therefore considered lost.

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

Page Last Reviewed/Updated Tuesday, September 22, 2015
Tuesday, September 22, 2015