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Event Notification Report for October 13, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/09/2015 - 10/13/2015

** EVENT NUMBERS **


51303 51435 51437 51438 51441 51442 51462 51464

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Part 21 Event Number: 51303
Rep Org: ATC-NUCLEAR
Licensee: MOORE INDUSTRIES
Region: 1
City: OAK RIDGE State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RAY CHALIFOUX
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/10/2015
Notification Time: 13:50 [ET]
Event Date: 06/11/2015
Event Time: [EDT]
Last Update Date: 10/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 INTERIM REPORT - POTENTIAL DEFECT ON P/N 535-601 MOORE INDUSTRIES MILLIAMP MODULES

The following information is a summary that was excerpted from a facsimile received from ATC-Nuclear:

"The basic component which is the subject of this notification is identified as Moore Industries Milliamp Module with part number (P/N) 535-601 (alternate P/N: 535-601-SSTRV) which has been provided individually and/or contained within a STS 535 Single Loop Process Controller.

"On December 22, 2014, ATC Nuclear received a 535 controller from Detroit Edison (DTE) with a failed Milliamp Module (P/N 535-601). The customer requested ATC Nuclear to perform a failure analysis to determine the cause of no output (0 Ma) on output 2 of the 535 controller. ATC Nuclear initiated a failure analysis in January 2015 that was broken down into several stages to determine the cause of the Milliamp Module failure. ATC Nuclear is continuing to evaluate the cause of the Milliamp Module failure and has preliminarily identified workmanship issues with a surface-mount fuse that is installed in the Milliamp Modules. ATC Nuclear has provided the results of the analysis to Moore Industries and Littelfuse to support or refute the workmanship concerns.

"Preliminary information provided by Littelfuse on June 11, 2015, was sufficient evidence to identify the existence of a deviation potentially associated with a substantial safety hazard (i.e., discovery as defined in 10 CFR Part 21). This information was documented as part of CAR 15T-24. Evaluation of reportability in accordance with 10 CFR Part 21 was not able to be completed within the 60 day evaluation period.

"The discovery date of the deviation requiring evaluation under 10 CFR Part 21 is June 11, 2015.

"ATC Nuclear has preliminarily identified a total of 285 Milliamp Modules with P/N 535-601 that have been supplied to customers by ATC Nuclear since 2010. However, there is not sufficient evidence to establish that all Milliamp Modules supplied to customers have defective Littelfuse surface-mount fuses (P/N 0448.100MR) installed. ATC Nuclear will continue to work with Moore Industries and Littelfuse to define the population of Milliamp
Modules that potentially have a defective surface-mount fuse installed. This information will become available once our 10 CFR Part 21 evaluation is completed.

"ATC Nuclear is reviewing customer purchase orders for Milliamp Modules to identify the population of Milliamp Modules that potentially have a defective surface-mount fuse installed. Additionally, ATC Nuclear is working with Moore Industries to purge its stock of potentially defective fuses. Additional time is needed to evaluate the condition of new surface-mount fuses and it is expected that this evaluation will be completed no later than October 9, 2015.

"Littelfuse identified a very low failure rate (< 0.001 %) in a preliminary report issued June 2015 spanning approximately an eighteen month period commencing January 2014. There were 356,250 fuses manufactured during this period. Littelfuse is conducting a more thorough review of this failure mechanism. There is no additional advice at this time."

For additional information, contact the following;

Ray Chalifoux
Vice President QA, ATC-Nuclear
777 Emory Valley Road, Oak Ridge, TN 37830
(865) 384-0124


* * * UPDATE FROM RAY CHALIFOUX TO DONALD NORWOOD AT 1602 EDT ON 10/9/2015 * * *

The following information is a synopsis of information received via facsimile:

ATC Nuclear has concluded that the identified deviation could be considered a defect on the surface-mount fuses supplied by Littelfuse. However, ATC Nuclear determined that it does not have the capability to complete a 10 CFR Part 21 evaluation to determine if a substantial safety hazard exists.

A total of 285 Milliamp Modules with P/N 535-601 have been supplied to customers by ATC Nuclear since 2010. However, there is not sufficient evidence to establish that all Milliamp Modules supplied to customers have defective Littelfuse surface-mount fuses installed. ATC Nuclear identified Milliamp Modules supplied in the January 2013 - June 18, 2015 timeframe as potentially having defective Littelfuse surface-mount fuses. Nuclear plants that received Milliamp Modules which potentially have a defective surface-mount fuse were as follows: LaSalle, Fermi 2, Limerick, and Clinton.

ATC Nuclear has developed a Technical Bulletin to direct the purchasers and/or affected licensees for inspections to determined if the manufacturing defect could be present in their applications.

Notified R1DO (Bickett), R3DO (Stone), and via E-mail Part 21 Group.

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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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Agreement State Event Number: 51441
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXON MOBIL CHEMICAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2316-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/02/2015
Notification Time: 16:54 [ET]
Event Date: 10/01/2015
Event Time: [CDT]
Last Update Date: 10/02/2015
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 SHUTTER STUCK OPEN

The following report was received via fax:

"An OHMART gauge was discovered with the shutters malfunctioning on a level gauge installed on processes. The shutters were stuck in the open position due to the buildup of grime and corrosive material from the operational environment. This device does not pose a radiation exposure hazard or a threat the work force or the general public. The device will remain in operation on the processes until the repair or replacement.

"The detected malfunction was discovered during the annual inventory/operational checks. These checks are required by condition # 7 of the radioactive material license, LA-2316-L01. The repairs will be made and documentation will be reviewed during the next inspection.

"The gauge detected was an OHMART Corp. gauge, Model Number SHF-2. The gauge/device S/N unknown is loaded with approximately 671 mCi of Cs-137 with source S/N 5895GK. BBP Sales was contacted to fix the problem by repairing the gauge or replacing the device."

Louisiana Event: LA-150016

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Agreement State Event Number: 51442
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: WAKE FOREST BAPTIST HEALTH
Region: 1
City: WINSTON-SALEM State: NC
County:
License #: 034-0158-8
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/02/2015
Notification Time: 17:59 [ET]
Event Date: 10/02/2015
Event Time: [EDT]
Last Update Date: 10/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO INCORRECT LOCATION

The following report was received via e-mail:

"A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015.

"The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency [North Carolina Division of Health and Human Services] scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee.

"Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time."

North Carolina NMED #NC150026

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: 51462
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JOHN CAVES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/09/2015
Notification Time: 14:04 [ET]
Event Date: 10/09/2015
Event Time: 10:02 [EDT]
Last Update Date: 10/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SHAKUR WALKER (R2DO)

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

FITNESS-FOR-DUTY REPORT INVOLVING A NON-SUPERVISORY LICENSED EMPLOYEE

A non-supervisory, licensed employee had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51464
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: SCOTT MEIKLEJOHN
HQ OPS Officer: VINCE KLCO
Notification Date: 10/09/2015
Notification Time: 21:59 [ET]
Event Date: 10/09/2015
Event Time: 18:00 [CDT]
Last Update Date: 10/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NICK TAYLOR (R4DO)

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

Event Text

INADVERTENT SIREN ACTIVATION DURING TESTING

"At 1800 [CDT] on October 9, 2015 a polling test was initiated in Saint Johns Parish to test the circuitry of the installed sirens. During the polling test no sirens are expected to sound as it is only a circuitry test. Siren number SJ39 inadvertently sounded for 15 to 20 minutes, and no others. Saint Johns Parish notified the parish residents that the sounding of the siren was inadvertent via a Parish wide cable television channel and a press release. A contract vendor has disabled the siren and will troubleshoot and repair starting on October 12, 2015. All remaining sirens within Saint Johns Parish remain operational and capable of being activated when required. 0% of the population is affected by the loss of this siren due to siren overlap.

"Time to repair and restore siren SJ39 to service is still being investigated.

"This event is reportable pursuant to 10CFR 50.72 (b)(2)(xi), News Release or Notification of Other Government Agency.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, October 13, 2015
Tuesday, October 13, 2015