United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2015 > December 11

Event Notification Report for December 11, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/10/2015 - 12/11/2015

** EVENT NUMBERS **


51578 51581 51582 51583 51599

To top of page
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

To top of page
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

To top of page
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.

To top of page
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.

To top of page
Power Reactor Event Number: 51599
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JACK MCCOY
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/11/2015
Notification Time: 02:30 [ET]
Event Date: 08/03/2015
Event Time: 15:30 [CST]
Last Update Date: 12/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BOB HAGAR (R4DO)

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

OFFSITE NOTIFICATION FOR CONDENSATE SPILL IN TURBINE BUILDING

"On August 1, 2015, during tagging activities to support planned maintenance on a condensate demineralizer, operators incorrectly positioned certain air-operated components which, combined with apparent leakage past a solenoid valve, resulted in a drain opening on a demineralizer that was in service. Flow through the drain line caused a turbine building sump to overflow to the floor of the 67 foot elevation of the Turbine Building. Immediate actions were taken to stop the leak.

"The spill volume was approximately 60,000 gallons of condensate. The tritium activity of the water is estimated at 1.32E-2 microCi/ml. Gamma activity was from noble gases only in a concentration of approximately 2.30E-6 microCi/ml. The spill was confined to the Turbine Building. The affected area contains degraded floor seals which might allow the spill to reach groundwater.

"The reason for this notification is that industry and governmental officials were notified of this event on August 3, 2015. The NRC Senior Resident Inspector was notified and informal notification was made to the NRC Region IV office, the Louisiana Department of Environmental Quality, and West Feliciana Parish government authorities. The Nuclear Energy Institute was informed as specified in their ground water protection initiative.

"Plant cleanup activities arising from the spill are complete."

Page Last Reviewed/Updated Friday, December 11, 2015
Friday, December 11, 2015