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Event Notification Report for October 9, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/08/2015 - 10/09/2015

** EVENT NUMBERS **


51434 51435 51437 51438 51460

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Non-Agreement State Event Number: 51434
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-02
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2015
Notification Time: 15:59 [ET]
Event Date: 09/30/2015
Event Time: [EDT]
Last Update Date: 10/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
FRED BOWER (R1DO)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

MISSING TROXLER MOISTURE DENSITY GAUGE

The U.S. Army contracted with [common carrier] to pick up two Troxler moisture density gauges from their Life Cycle Management center in Warren, Michigan and deliver them to an Army National Guard (ANG) center in Methuen, Massachusetts. On 9/28/15, [common carrier] tracking indicated that only one of the gauges was delivered. The ANG center didn't receive the gauge until 9/29/15. The RSO at U.S. Army TACOM contacted [common carrier] about the status of the second gauge.

On 9/30/15, [common carrier] informed the RSO that the gauge was "misplaced" and an investigation and search was underway.

The missing gauge is a Troxler Model 3440+, serial number 68419, containing 8 mCi of Cs-137 and 40 mCi of Am-241.

The U.S. Army will update this report as appropriate.

* * * UPDATE FROM KAREN MCGUIRE TO JOHN SHOEMAKER AT 1140 ON 10/01/15 * * *

The common carrier located and delivered the remaining gauge to the proper location.

Notified R1DO (Bower), R3DO (Orth), and NMSS Events Notifications via email.

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: 51435
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KU HOSPITAL AUTHORITY
Region: 4
City: KANSAS CITY State: KS
County:
License #: 18-C801
Agreement: Y
Docket:
NRC Notified By: JASON BARNEY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/01/2015
Notification Time: 10:23 [ET]
Event Date: 09/29/2015
Event Time: [CDT]
Last Update Date: 10/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN UNDERDOSE TO THE PATIENT

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

"Yesterday afternoon [the State of Kansas] was contacted by [the licensee's], RSO [Radiation Safety Officer] for KU Hospital Authority lic# 18-C801, to report a medical event. On the morning of 9/29/15, a Thera-spheres Y-90 therapy procedure was found to have underdosed the patient by 36%. The details are as follows:

"A RADose RAD 60R personal electronic dosimeter is attached to the plexiglass 'box' which holds the vial containing the Y-90 Thera-spheres during the procedure. This dosimeter is the only method of detection to ensure that all of the Y-90 material is placed within the patient. In comparison, the Sir-sphere, similar material and procedure, utilizes a contrast to better ensure material is where it's supposed to be.

"Prior to the procedure, the dosimeter was checked for current calibration and source checked and found to be satisfactory including low battery indicator not active. During this pre-procedure check, the dosimeter exhibited fluctuating readings. A backup dosimeter of the same make and model was searched for but could not be located. The dosimeter was then re-checked and the fluctuations could not be duplicated, thus it was decided to utilize the dosimeter for the procedure. The Y-90 procedure was then completed, with the dosimeter reading at levels that indicated the required Y-90 had been placed within the patient. At this point, the 'waste' from the procedure i.e. vials, tubing, pads is taken back to the hot lab and surveyed to calculate the remaining Y-90. It was discovered that 36% still remained and that the patient did not receive the entire prescribed dose. It was determined that enough of the Y-90 had been administered to the patient to receive a satisfactory therapeutic dose thus another procedure would not be necessary.

"Exposure to staff was also determined to be negligible due to the nature of the material/shielding/remaining concentration. The RSO stated that the dosimeter was again rechecked and the low battery indicator was active during the check. The RSO made the preliminary assessment that the dosimeter was possibly functioning just above the 'cutoff' point of low battery.

"The licensee stated that a detailed report is in process and will be submitted within the required time parameters."

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: 51437
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CITGO REFINING AND CHEMICAL COMPANY
Region: 4
City: CORPUS CHRISTI State: TX
County:
License #: 00243
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/01/2015
Notification Time: 15:26 [ET]
Event Date: 10/01/2015
Event Time: 09:30 [CDT]
Last Update Date: 10/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SOURCE DISCONNECTED

The following report was received via e-mail:

"On October 1, 2015 the Agency was notified by the licensee's radiation safety officer that a source was disconnected and dropped into a vessel. [This was caused by] a shutter malfunction which occurred on October 1, 2015 at 0930 [CDT] on a nuclear gauge. The source is an Ohmart Model MDTS, Serial Number 8480GK, Cesium 137, 9.5 mCi source. The shutter malfunction occurred during a routine check of the shutter operation. This particular device utilizes a tape which is connected to the source. The tape allows the source to be lowered and raised inside a well within the vessel. During the routine shutter checks, the tape disconnected from the source. At this time, the source is located inside the well near its normal operational position. A radiation survey was conducted at areas which would contain general employee access. All radiation readings were at background level. This event did not cause any additional radiation exposure than normal day to day operations. The gauge manufacturer has been notified and will be on-site October 7, 2015 to repair the device. Updates will be provided in accordance with SA-300 guidelines."

Texas Incident: I-9342

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Non-Agreement State Event Number: 51438
Rep Org: LANTHEUS MEDICAL IMAGING
Licensee: LANTHEUS MEDICAL IMAGING
Region: 1
City: San Juan State: PR
County:
License #: 52-25361-02
Agreement: N
Docket: 030-3811
NRC Notified By: EDUARDO DIAZ MONTES
HQ OPS Officer: DANIEL MILLS
Notification Date: 10/01/2015
Notification Time: 17:18 [ET]
Event Date: 10/01/2015
Event Time: [EDT]
Last Update Date: 10/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANGELA MCINTOSH (NMSS)
PATRICIA MILLIGAN (NMSS)

Event Text

RADIATION WORKER OVER EXPOSURE

Lantheus Medical Imaging received notification that the dosimeter of an employed radiation worker indicated a whole body over exposure for the month of August 2015. The indicated dose is 7929 mRem for August and the 2015 total is 8500 mRem. The employee is a technician in charge of operating the cyclotron and has been removed from radiation work. The licensee has notified the employee and is conducting an investigation.

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Power Reactor Event Number: 51460
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: MICHAEL WHALEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/08/2015
Notification Time: 18:23 [ET]
Event Date: 10/07/2015
Event Time: 21:47 [EDT]
Last Update Date: 10/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SHAKUR WALKER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH ENERGY LINE BREAK DOOR FOUND UNLATCHED

"At approximately 2147 EDT on October 7, 2015, a high energy line break (HELB) door between the Turbine Building (TB) and the safety related Emergency Switchgear Room (ESGR) was determined to be unlatched. The door was immediately closed (latched). Investigation determined the door was unlatched for approximately 47 minutes. At 1617 EDT on October 8, 2015, it was determined the Unit 2 ESGR was outside of the design analysis for a Unit 1 HELB. A high energy line break in the TB with the door open could result in equipment in the Unit 2 ESGR experiencing high temperature, pressure, or humidity beyond conditions analyzed for equipment qualification which has the potential to render redundant safety-related equipment inoperable.

"This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition and in accordance with 10 CFR 50.72(b)(3)(v)(A) & (B) & (D) as a condition that could have prevented the fulfillment of safety functions to shutdown the reactor and maintain it in a safe shutdown condition, remove residual heat, and mitigate the consequences of an accident.

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, October 09, 2015
Friday, October 09, 2015