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Event Notification Report for December 10, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/09/2015 - 12/10/2015

** EVENT NUMBERS **


51573 51575 51578 51581 51582 51583 51595

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Agreement State Event Number: 51573
Rep Org: COLORADO DEPT OF HEALTH
Licensee: BY DESIGN HOMES
Region: 4
City: FORT COLLINS State: CO
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/01/2015
Notification Time: 10:17 [ET]
Event Date: 11/17/2015
Event Time: [MST]
Last Update Date: 12/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA ()
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

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

"Event Date and Time: 11/17/15. Time is unknown as the current owner took possession of the property after a business had remodeled the interior of the structure. This report is for an exit sign that was disposed of between 2007 to 2012.

"Event Type: Lost Exit Sign

"Event Description: An exit sign was purchased during the renovation of a church to an office. By Design Homes purchased the property in 2007 and used the property for their offices until the renovation was completed and resold as private residence in 2012. The disposition of the exit [sign] is unknown. By Design Homes was unaware of the exit sign containing Tritium.

"Detail: During an audit of the records, a contact was made with one of the investors who worked with By Design Homes. During the discussion, we [Colorado Department of Public Health and Environment (CDPHE)] discovered the transition [of] the property from a church to By Design Homes. They renovated the property [into] a private residence. It is unknown what happened with the exit sign. Speculation is the sign was taken down and disposed of in a dumpster during the renovation from the business to a residence.

"The current owner does not have any record of an exit sign being in the home when purchased in 2012.

"Our [CDPHE] office made contact with By Design Homes, leaving emails with the investor to relay the incident and to obtain a corrective action report. No further communication has been received at this date."

Colorado Event Report ID No.: CO15-I15-34


* * * UPDATE FROM LINDA BARTISH TO DONALD NORWOOD AT 1211 EST ON 12/1/2015 * * *

The following information was received via E-mail:

"Additional information regarding the exit sign: Model Number is 1091, Serial Number is U1796, Activity is 7.5 Ci of H-3, Manufacturer is Safety Light, Shipped on 7/25/2007."

Notified R4DO (Gepford). E-mailed ILTAB (Johnson) and NMSS Events Notification group.


* * * UPDATE FROM LINDA BARTISH TO DONALD NORWOOD AT 1438 EST ON 12/1/2015 * * *

The following information was received via E-mail:

"Correction, the Model Number is 101."

Notified R4DO (Gepford). E-mailed ILTAB (Johnson) and NMSS Events Notification group.

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: 51575
Rep Org: COLORADO DEPT OF HEALTH
Licensee: FEDEX FREIGHT
Region: 4
City: HENDERSON State: CO
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/01/2015
Notification Time: 15:35 [ET]
Event Date: 12/01/2015
Event Time: 12:15 [MST]
Last Update Date: 12/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA ()
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was provided by the State of Colorado via email:

"Event date and time: 12-1-2015, 12:15 MST. The exit sign is considered to be lost material and it is unknown what date the sign was removed or abandoned.

"Event location: 9351 Willow Court, Henderson, CO

"Event type: Lost Exit Sign Model # SLX 60, Serial Number 11-13624, 6.2 Ci, H-3, Shipped from Isolite Corporation on 4/26/2011.

"Event description: The onsite manager completed an inspection of the property. No Tritium exit sign was discovered. The exit sign is considered to be lost. The company representative will provide a written policy and procedure to resolve this from happening in the future."

Event Report ID No.: CO15-I15-35

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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Non-Agreement State Event Number: 51578
Rep Org: EUROFINS EATON ANALYTICAL, INC
Licensee: EUROFINS EATON ANALYTICAL
Region: 3
City: SOUTH BEND State: IN
County:
License #: GL-638703
Agreement: N
Docket:
NRC Notified By: DALE PIECHOCKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/02/2015
Notification Time: 10:04 [ET]
Event Date: 12/02/2015
Event Time: [EST]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTINE LIPA (R3DO)
NMSS_EVENTS_NOTIFICA ()
DARYL JOHNSON (ILTA)

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

Event Text

LOST ELECTRON CAPTURE DEVICE (ECD)

"Eurofins Eaton Analytical, Inc., (EEA) located at 110 South Hill Street, South Bend , IN 46617 is reporting a lost ECD serial #B798 that was listed under the General License GL-638703 held by MAS Technologies.

"A notice to the NRC was sent on November 25, 2015 stating that the devices under General License GL-638703 was transferred to EEA located at 110 South Hill Street, South Bend, Indiana 46617. At this time it was brought to our attention by Hector Rodriguez-Luccioni, of the Material Safety Licensing Branch, that ECD, Serial #B798 should be in our possession. After a thorough search of the facility and records we could not locate ECD B798.

"Written report in accordance to 10 CFR 20.2201.
(i) Lost device ECD, Serial #B798, Model #02-0001972-00, isotope 63Ni, activity 15 mCi, was manufactured by Varian Associates, Inc.
(ii) Was not located in a recent inventory check.
(iii) The ECD was more than likely returned to Varian for disposal before 2008.
(iv) No known exposures have been reported from this ECD at this time.
(v) We performed a thorough search of the facility and in-house records. In addition we attempted to contact Varian. In 2010 Varian was sold off to Agilent and Buker Corp. Buker Corp then sold off their portion of Varian Gas Chromatography equipment to Scion in 2014. All three companies were contacted in order to determine who currently holds the Varian ECD records. None of the companies contacted claimed to hold the records.
(vi) We now maintain a list of ECDs showing each ECD location. The list is maintained by the laboratory and monitored by the RSO."

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: 51581
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BASF COMPANY
Region: 4
City: GEISMER State: LA
County:
License #: LA-2304-01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2015
Notification Time: 15:59 [ET]
Event Date: 12/02/2015
Event Time: 09:50 [CST]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE STUCK OPEN SHUTTER

The following information was received via E-mail:

"On December 2, 2015, BASF Corporation notified LDEQ [Louisiana Department of Environmental Quality] of an equipment malfunction. An Ohmart gauge, source serial number 6241GK, with 34 mCi Cs-137, was found to have a stuck open shutter during an annual inspection. The stuck open position of the shutter does not affect the use of the gauge in its normal day to day operation.

"BASF has contacted BBP Inc. and ordered a repair kit. The kit will arrive within a few weeks. BBP Inc. will repair the gauge which is planned to happen in January 2016."

Louisiana Event Report ID No.: LA150021

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Non-Agreement State Event Number: 51582
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: PAT PETTIJOHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/02/2015
Notification Time: 16:07 [ET]
Event Date: 12/01/2015
Event Time: 01:00 [YST]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

RADIOGRAPHY CAMERA FAILS TO LOCK SOURCE AUTOMATICALLY WHEN RETRACTED

On 12/01/2015 at 0100 AST, a radiography crew was working in blizzard conditions at a job site located on the Kuparuk Oil Field, North Slope, Alaska. After finishing a camera exposure, the source was being retracted, but the automatic lock for the exposure device did not lock the source in the camera. One of the radiographers manually engaged the slide to lock the source in the camera. No abnormal exposures were noted.

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Agreement State Event Number: 51583
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: SAINT FRANCIS HEALTH SYSTEM
Region: 4
City: TULSA State: OK
County:
License #: OK-07163-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/02/2015
Notification Time: 16:13 [ET]
Event Date: 11/09/2015
Event Time: [CST]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL DOSE ADMINISTERED TO WRONG PATIENT

The following information was provided by the State of Oklahoma via E-mail:

"On November 10, 2015, Saint Francis Health System [SFHS] notified the DEQ [Oklahoma Department of Environmental Quality] that, on November 9, 2015, a patient undergoing Sentinel Node Scintigraphy was accidently administered a radiopharmaceutical dose intended for another patient. The patient, who was supposed to receive a 0.5 mCi interstitial injection of Technetium-99m, instead received a 30 mCi dose of Tc-99m intended for another patient undergoing a bone scan. On November 20, 2015, we performed a reactive inspection of SFHS and spoke with the two technologists involved, both of whom were CNMTs [Certified Nuclear Medicine Technologist]. According to the technologist who performed the Sentinel Node Scintigraphy (Tech A) these procedures were nearly always done in Surgery however, in this instance, the surgeon requested that the patient be injected and imaged in Nuclear Medicine first. Therefore, when [Tech A] arrived at work, [Tech A] retrieved the scintigraphy dose from the hot lab and placed it in the imaging room she intended to use. [Tech A] then went to get the patient, who had already been prepped for surgery and was in the pre-op ward. On the way she encountered the other technologist (Tech B), and told her that she was going to get the scintigraphy patient and that the first out-patient of the day, a bone scan, was waiting. Tech B misunderstood this to mean that Tech A was going to surgery to do the scintigraphy procedure there as usual. Tech B then retrieved the bone scan dose from the hot lab and, not noticing that the scintigraphy dose was already present, placed it in the same imaging room that Tech A intended to use. She then went to get the bone scan patient and began preparing them for the procedure.

"While Tech B was occupied with the bone scan patient, Tech A returned with the scintigraphy patient and placed her in the imaging room, but did not notice that two doses were now present. She then proceeded to inject the patient with the 30 mCi bone scan dose instead of the correct 0.5 mCi scintigraphy dose. It should be noted that SFHS procedures call for the technologist to verify the patient identity on the dose pig immediately before administering it, but Tech A failed to carry out this check. Immediately after she had administered the dose, Tech A discovered her error and notified the RSO. The patient was evaluated by the staff Authorized Medical Physicists who concluded that she was unlikely to experience any medical effects from the incident. It is unclear whether this incident meets the criteria in 10 CFR 35.3045(a)(2) because there are no internal dose models which are applicable to interstitial administrations such as this. However, since the possibility cannot be ruled out, we are proceeding on the assumption that this is a Medical Event. SFHS submitted a written report on the incident, as required by 10 CFR 35.3045(d), on November 22, 2015."


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: 51595
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID A. RICHARDSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/09/2015
Notification Time: 22:28 [ET]
Event Date: 12/09/2015
Event Time: 14:43 [EST]
Last Update Date: 12/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
GLENN DENTEL (R1DO)

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

REACTOR RECIRCULATION LOOP FLOW TRANSMITTERS OUT OF TOLERANCE

"During surveillance testing, 2 reactor recirculation loop flow transmitters, which input to the Average Power Range Neutron Monitors (APRM's) associated with the 'A' Reactor Protection Trip System (RPS), were found out of tolerance in the non-conservative direction.

"Non-conservative reactor recirculation flow setpoints for all 'A' side APRM's results in a loss of safety function for the APRM Neutron Flux High (Flow Biased) trip function of RPS.

"All instruments were adjusted back to within tolerance as allowed by the procedure, restoring the RPS safety function. Extent of condition and instrument drift issues are under evaluation via the corrective action process.

"This is an 8 hour reportable event under 10CFR50.72(b)(3)(v)(A) - 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: (A) Shutdown the reactor and maintain it in a safe shutdown condition.

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, December 10, 2015
Thursday, December 10, 2015