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Event Notification Report for December 18, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/17/2015 - 12/18/2015

** EVENT NUMBERS **


51594 51596 51597 51598 51609

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Non-Agreement State Event Number: 51594
Rep Org: NASA GODDARD
Licensee: NASA GODDARD
Region: 1
City: GREENBELT State: MD
County:
License #: 19-05748-03
Agreement: Y
Docket:
NRC Notified By: DAN SIMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/09/2015
Notification Time: 09:05 [ET]
Event Date: 12/08/2015
Event Time: 12:00 [EST]
Last Update Date: 12/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

IRRADIATOR EQUIPMENT FAILURE

"At approximately noon on December 8, 2015, the source located inside the right side of the J. L. Shepherd Model 81-24Q Beam Irradiator didn't move upward from its normal down shielded position to the normal operational position when the operator pressed the button on the operation console. A second attempt was made to have the source be raised to its normal operational position, but the source remained at its normal down shielded position. An emergency shutter built into the system was deployed just as a precaution. Facility Manager notified the Radiation Safety Officer in the Radiation Protection Office (RPO).

"Upon entering the room, it was noted that the source position indicator found on the operating tower mounted on the top of the irradiator showed that the source was located at its normal down shielded position in the irradiator. RPO staff conducted a radiation survey surrounding the irradiator and found that all readings were similar to levels noted in previous surveys conducted when the sources in the irradiator were in their shielding position and the highest reading was noted as 1 mR/hr on contact with the irradiator.

"Contact was made to J. L. Shepherd and arrangements are being made to have a representative come onsite to conduct an evaluation of the system. Arrangements are being made to have that evaluation be conducted during the week of December 14th and the Radiation Safety Officer has given direction for the irritator to not be used until this evaluation by the manufacture can be conducted."

No personnel exposures were reported.

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Non-Agreement State Event Number: 51596
Rep Org: DEPARTMENT OF THE ARMY
Licensee: BROOKE ARMY MEDICAL CENTER
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 42-01368-01
Agreement: Y
Docket:
NRC Notified By: MAJ. DAVID BYRD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 11:48 [ET]
Event Date: 11/17/2015
Event Time: [CST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GLENN DENTEL (R1DO)

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

Event Text

LOST IODINE-125 SEED

"One 180 microCi I-125 seed for breast radioactive seed localization (I-125 RSL) was lost at Brooke Army Medical Center (BAMC) on 17 November 2015.

"Loss of the I-125 seed occurred in BAMC Pathology on 17 November 2015 due to lack of training and supervision of new Residents during the removal of the seed while grossing the specimen. Health Physics Service (HPS) was notified and responded to Anatomic Pathology/Histology at approximately 1130 on 20 November.

"According to events leading up to the loss, the I-125 seed was not removed from the specimen prior to being submitted for sectioning. Typically, RSL seeds are tracked on a BAMC I-125 Seed Tracking Form, which indicates when the seed is removed from the specimen. In this case, the tracking form was completed only to the point of Pathology receiving the specimen with the seed still within. A radiograph illustrating the seed within the specimen was taken on 16 November 2015 in Mammography and delivered with the specimen to Pathology. Due to a lack of supervision and training, [the Pathology Resident] did not verify on the tracking form that the seed had been removed. The I-125 Seed Tracking Form was found incomplete on 20 November 2015 by the RSO [Radiation Safety Officer], who then contacted [the Pathology Resident] and informed the Health Physics personnel. Health Physics personnel immediately responded and performed a survey of the entire Histology suite focusing on all work stations and processing equipment used in the preparation of this specimen; the seed was not located within the Histology suite. According to [the Pathology Resident], the step to verify seed removal was overlooked, and confirmation of the seed's absence with a radiation probe was skipped. Furthermore, the tissue was grossed and submitted entirely for sectioning. Most likely, the seed stuck to the grid and was disposed of as biohazard waste. The biohazard disposal route from Pathology on the 4th floor to the hospital exit passes through radiation monitors located on the fourth floor and in basement utility rooms and the biohazard waste room, but due to the low activity of one I-125 seed in biohazard bag with unknown amount of material the monitors would not alarm.

"Initial activity of the I-125 RSL seed was 300 microCi on 7 October 2015, and had decayed to 180 microCi on 20 November 2015. Assuming no shielding, an exposure rate of 0.03 mR/hr at 1 meter is to be expected. Personnel are not likely to handle the waste for an extended period of time and the waste was likely incinerated at Stericycle.

"Steps have been taken since the incident to prevent recurrence.
A. Procedure: The grossing staff pathologist will ensure seed disposal via inspection of appropriate paperwork and scanning with appropriate probe rather than verbal assurance.
B. Additional training sessions on the use of the NeoProbe and I-125 RSL seed procedure.

"Based on accounts above, the I-125 seed was left with the specimen during grossing and was then submitted to sectioning and the seed was lost. In addition to ensuring the proper training and SOPs [Standard Operating Procedures] are in place and followed, we will continue to have radiation monitors in place on each floor and the back loading docks of the facility to make certain there is full accountability of the I-125 seeds."

The licensee notified NRC Region 4 (Torres).

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: 51597
Rep Org: TERRACON CONSULTANTS, INC
Licensee: TERRACON CONSULTANTS, INC.
Region: 4
City: GREAT FALLS State: MT
County:
License #: 030-32176
Agreement: N
Docket:
NRC Notified By: KATIE GILCHRIST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 17:40 [ET]
Event Date: 12/10/2015
Event Time: 12:40 [MST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

While in use at a remote job site, a Troxler moisture density gauge (Model 3440, Serial Number 37384) was damaged when it was struck by a bulldozer. The source rod was out at the time of the incident but the source was able to be retracted into the shielded position.

The licensee surveyed the meter and found no abnormal radiation readings. The gauge was transported back to the licensee facility for storage awaiting results of the swipe test. Once the swipe test results are returned, the licensee intends to ship the gauge to the vendor for repair or replacement.

The licensee will provide the model and source information for the gauge once is it obtained. No personnel overexposures occurred during this incident.

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Agreement State Event Number: 51598
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: AMERICAN TESTING SERVICES, INC.
Region: 4
City: COTTONWOOD HEIGHTS State: UT
County:
License #: UT1800062
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 19:43 [ET]
Event Date: 12/10/2015
Event Time: 08:30 [MST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"The licensee stopped and parked their truck in Cottonwood Heights, Utah. Licensee personnel stepped away from the truck but left it unlocked and running. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Troxler Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case with the source rod locked (gauge and source information listed below). The licensee notified the police and has begun actions to recover the gauge (Cottonwood Police Department, Case Number 15x7206).

"Troxler Moisture Density Gauge:
Gauge Serial Number: 12386
Source Information: CS-137 (8.7 mCi) S/N: 50-0529
Source Information: Am241: BE (40.0 mCi) S/N: 47-7684

"This incident is still being investigated [by the State of Utah]."

Utah Event Report ID No.: UT150009

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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Power Reactor Event Number: 51609
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WAYNE SEXSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/17/2015
Notification Time: 14:33 [ET]
Event Date: 12/17/2015
Event Time: 13:18 [CST]
Last Update Date: 12/17/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
NICK VALOS (R3DO)
ALLEN HOWE (NRR)
JEFFERY GRANT (IRD)
BILL DEAN (NRR)
DARRELL ROBERTS (R3 D)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO FIRE ALARM IN CONTAINMENT NOT VERIFIED WITHIN 15 MINUTES

"Unusual Event HU2.1 declared at 1318 [CST]. A fire alarm was received in unit 2 containment at 1307 [CST]. Due to the location of the alarm, personnel were unable to verify the status within 15 minutes. At 1343 [CST], the fire alarm in containment cleared. This alarm came in shortly after a unit 2 reactor trip. The reactor trip was due to a turbine trip. Decay heat removal is via forced circulation with aux feed and steam dumps providing secondary cooling. Offsite power remains available."

The reactor trip was uncomplicated and all control rods inserted. 25B feedwater heater relief valve lifted and has reseated. No offsite assistance was requested.

The licensee has notified the NRC Resident Inspector. State and local authorities were notified.

* * * UPDATE ON 12/17/2015 AT 1734 EST FROM TOM HOLT TO DONG PARK * * *

"The licensee terminated the NOUE [Notification of Unusual Event] at 1450 CST. The basis for the termination was determination that there was no smoke or fire in the Unit 2 containment observed during containment entry.

"NRC Resident Inspectors were notified. State and local governments were notified. The health and safety of the public was not at risk."

Notified the R3DO (Valos), NRR EO (Morris), IRD (Grant), DHS SWO, FEMA Ops enter, and NICC Watch Officer. E-mailed FEMA NWC and Nuclear SSA.

Page Last Reviewed/Updated Friday, December 18, 2015
Friday, December 18, 2015