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Event Notification Report for November 17, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/16/2015 - 11/17/2015

** EVENT NUMBERS **


51519 51520 51524 51525

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Agreement State Event Number: 51519
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BASF CORPORATION
Region: 4
City: GEISMAR State: LA
County:
License #: LA-2304-L01,
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2015
Notification Time: 17:14 [ET]
Event Date: 11/04/2015
Event Time: 14:30 [CST]
Last Update Date: 11/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - HAIRLINE CRACK FOUND IN HOUSING OF A BERTHOLD LEVEL DENSITY GAUGE

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

"On 11/04/2015, the ARSO [Assistant Radiation Safety Officer] for [the licensee] called the LA DEQ [Louisiana Department of Environment Quality] about a hairline crack on the housing of a Berthold level density gauge. The crack was noticed when the annual operational inspections were being performed. The level gauges are required to be inspected by Condition Number 6 of the licensee's radioactive material license.

"The [gauge is located] in Geismar, LA within the secure boundary the licensee's chemical plant.

"The fixed gauge is installed on a hopper/drum, but the gauge has not been used as a qc/qa [quality control/quality assurance] device since March 21, 2003, when the device was locked-out. The crack or hairline crack was not detected or documented before the November 2015 annual inspections. The notification to LA DEQ is required by Condition Number 6 of the license. The gauge remained installed on the hopper since 2003, but was not functioning as a gauge during that time.

"LA DEQ was notified on November 4, 2015, at approximately 1430 CST, that during [the licensee's] annual operational inspections, they detected a hairline crack in the housing of an installed locked-out density measuring device (gauge). The device was a Berthold gauge Model LB 7440D loaded with approximately 60 mCi of Cs-137.

"On 11/04/2015, the licensee's ARSO called LA DEQ to make a preliminary report about a hairline crack found in a gauge housing/source holder. The crack was at the union of the gauge shielding and the mounting plate of the device.

"[A contract company] has been contacted to provide services at [the licensee' facility], for packaging the source to be shipped and for the source disposal. This will be the 'corrective action' and it was speculated the crack possibly happened due to the vibration of the hopper. The source or device is not leaking. The source is not exposed or removed from the shielded position. This appears to be reportable under 10 CFR 31.5(c)(5). The source was not being used/operational when the crack was detected.

"There is no possible exposure to the plant workers because the gauge is still installed on an elevated process. Surveys were taken of the source/gauge housing and they were in the same range as before noticing the crack. The exposure level is approximately 150 mR/hr. The gauge has been locked-out since March 20, 2003. The shutter remains closed and the gauge does not cause a safety hazard to the plant personnel. The gauge operated in the open direction without a problem. [The ARSO] called and reported the incident to comply with Condition Number 6 of [licensee's] Radioactive Material License. The gauge is a Berthold, model #LB-7440D [originally] loaded with approximately 100 mCi of Cs-137 and received and installed in 1992. The SN for the source is 3029-9-90. The corrective action will be disposal by [the contractor]. The Department [LA DEQ] considers this item OPEN until the disposal. The records will be reviewed during a site visit and the next inspection."

Louisiana Event Report ID No.: LA 15-0020, T167164

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Agreement State Event Number: 51520
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2015
Notification Time: 20:24 [ET]
Event Date: 11/05/2015
Event Time: [MST]
Last Update Date: 11/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

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

"On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma.

"It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.)

"The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation."

Utah Event Report No.: UT150005

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: 51524
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: NEWPAGE WISCONSIN SYSTEMS, INC.
Region: 3
City: STEVENS POINT State: WI
County:
License #: 141-1258-01
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/09/2015
Notification Time: 14:33 [ET]
Event Date: 11/08/2015
Event Time: [CST]
Last Update Date: 11/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

FIXED GAUGE STUCK SHUTTER

The following was received from the State of Wisconsin via email:

"On Sunday November 8, 2015, the Wisconsin Radiation Protection Section received a phone call from the mill Radiation Safety Officer (RSO) for the Wisconsin Rapids facility that the licensee had a fixed gauge with a shutter stuck open. An alarm light on the panel indicated that the shutter was not closed. The operator notified the mill RSO who then contacted the corporate RSO. The RSO had Voith Paper, who is authorized for non-routine maintenance to come in to fix the shutter. He pulled the scanner offline around 2230 [CST] with the shutter stuck open. The manufacturer's representative was able to fix the shutter. The scanner went back online around 0030, Monday, November 09, 2015."

Wisconsin Event Report ID No.: WI150020

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Agreement State Event Number: 51525
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOCKHEED MARTIN SPACE SYSTEMS COMPANY, INC
Region: 4
City: SUNNYVALE State: CA
County:
License #: 0169-43
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/09/2015
Notification Time: 17:14 [ET]
Event Date: 10/20/2015
Event Time: [PST]
Last Update Date: 11/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSNS (MEXICO) (FAX)

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

Event Text

LOST STATIC ELIMINATOR SOURCE

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

"On 10/30/15, the RSO at Lockheed Martin reported the following to RHB [California] via an email:

"On 10/20/15, the RSO had declared a missing Po-210 static eliminator source from their inventory. The device model is Nuclecel P-2035 static eliminator, S/N A2KB502. The sealed source contained 10 mCi as of 10/15/14. As of 10/29/15, the source would have remaining activity of 1.5 mCi. The lab using the static eliminator had recently relocated operations between buildings within the Sunnyvale campus and the licensee suspects that it was lost during this process.

"RHB [California] will be following up with this incident."

California 5010 Number: 103015

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, November 17, 2015
Tuesday, November 17, 2015