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Event Notification Report for January 21, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/20/2016 - 01/21/2016

** EVENT NUMBERS **


51645 51647 51648 51651 51652 51669

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Agreement State Event Number: 51645
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CENTRAL TESTING CO., INC.
Region: 4
City: SULPHUR State: LA
County:
License #: LA-2393-L01A
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/12/2016
Notification Time: 10:56 [ET]
Event Date: 01/11/2016
Event Time: 03:16 [CST]
Last Update Date: 01/12/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
LANCE ENGLISH (ILTA)
PAMELA HENDERSON (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - QUANTITY OF CONCERN ATTEMPTED THEFT

Unauthorized entry and attempted theft of Category 2 material. Licensee informed local law enforcement.

Louisiana Event Report ID # LA160001

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Agreement State Event Number: 51647
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: QUALSPEC SERVICES INC
Region: 4
City: CORPUS CHRISTI State: TX
County:
License #: 06351
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/12/2016
Notification Time: 11:31 [ET]
Event Date: 01/11/2016
Event Time: 22:45 [CST]
Last Update Date: 01/12/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE COULD NOT BE RETRACTED TO SHIELDED POSITION

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

"On January 12, 2016, the Agency [Texas Department of State Health Services] received notice that on January 11, 2016, a radiography source could not be retracted to the shielded position. The camera was an 880D with a 99.8 curie Iridium-192 source. An extension to the guide tube had not been connected, and the drive cable slipped the gears of the crank assembly. The drive cable and crank assembly were reassembled and the source was returned to the shielded position. No overexposures resulted from this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9370

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Non-Agreement State Event Number: 51648
Rep Org: CRITTENTON HOSPITAL MEDICAL CENTER
Licensee: CRITTENTON HOSPITAL MEDICAL CENTER
Region: 3
City: ROCHESTER State: MI
County:
License #: 21-13562-01
Agreement: N
Docket:
NRC Notified By: WILLIAM BELL Jr.
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/12/2016
Notification Time: 15:39 [ET]
Event Date: 01/11/2016
Event Time: [EST]
Last Update Date: 01/12/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED

In preparation for lymphoscintigraphy, a patient was injected with 2.4 mCi of unfiltered technetium sulfur colloid (Tc-99) instead of the prescribed dose of 0.5 to 1.0 mCi.

The Radiation Safety Officer and Hospital Medical Physicist were notified. The patient's primary physician was also notified. No adverse effects to the patient are expected.

This event was caused by the administering technologist's failure to double check the dose given to the patient. The technologist has been counseled.

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: 51651
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: RADAMERICA
Region: 1
City: BALTIMORE State: MD
County:
License #: MD0505103
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/13/2016
Notification Time: 16:24 [ET]
Event Date: 12/15/2015
Event Time: [EST]
Last Update Date: 01/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - BRACHYTHERAPY SOURCE NOT PLACED IN INTENDED TREATMENT LOCATION

This is a preliminary notification by the State of Maryland, Radiological Health Program of a medical event. During both the first and second of four High Dose Rate brachytherapy treatments to one of the patient's lungs occurring on December 15, 2015 and December 21, 2015, the radioactive source was incorrectly placed between 2 and 3 centimeters away from the intended placement location. The radioactive source being used was Iridium 192. The activity level of the radioactive source is unknown at this time.

The placement error was discovered during the third treatment on January 13, 2016. The reason for the placement error involved the use of an incorrect connection between the marker and the catheter.

The State of Maryland, Radiological Health Program will conduct an investigation on January 18, 2016.

* * * UPDATE FROM ALAN JACOBSON TO JOHN SHOEMAKER AT 1249 EST ON 1/15/16 * * *

This updated licensee report was received from the State of Maryland via email:

"On January 12, 2016, while treating the third treatment fraction for an HDR patient with exuberant granulation tissue of the right lung lower lobe bronchus, we [the licensee] found out a discrepancy in our simulation imaging procedure which contributed to a geographic miss of approximately 4 cm. The geographic miss occurred for the patient's 1st and 2nd fractions on 12/15/2015 and 12/21/2015, respectively. The activity of the source was 6.9 Curies on 12/15/2015.

"In this procedure a dummy marker is normally sent into the catheter and radiographed to mark the dwell source position for treatment. It was found that in previous two treatments the dummy marker was not sent all the way through the catheter because it was used with an adapter piece on. The adapter piece was used with dummy markers in the previous microSelectron afterloader but it is not supposed to be used with the Flexitron afterloader system that we have been upgraded to since August 2014.

"The patient was treated correctly on 1/12/2016, however, the Radiation Oncologist is stating that no harm was done to the patient from the geographical miss in last two treatments. Since we reported this case to the State [Maryland Department of the Environment] on Wednesday 1/13/2016, we have found two more patients treated with intrabronchial HDR since the upgrade to Flexitron at this center that may have had a geographic miss. Investigation is still under way for these cases."

Notified the R1DO (Gray) and NMSS Events Notification via email.

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: 51652
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: INTERNATIONA PAPER COMPANY
Region: 1
City: RIEGELWOOD State: NC
County:
License #: 024-0013-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/13/2016
Notification Time: 17:40 [ET]
Event Date: 01/05/2016
Event Time: [EST]
Last Update Date: 01/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE - FIXED NUCLEAR GAUGE REPORTED MISSING

The following report was received from the North Carolina Department of Health and Human Services via email:

"The RSO [Radiation Safety Officer for International Paper Company], first noticed the missing FNG [fixed nuclear gauge] after the renovation of an older chute and replacement by the new metal chute. The older scrap parts had been taken to Southern Metals in Wilmington, NC scrapyard. The six month inventory was due at the time and the specific date of the inventory check was January 5, 2016. Several rechecks have been made within the storage areas where other gauges are stored and secured and contacts with the metal chute manufacturer, ICBS Group, and the scrapyard have been made, without a trace of the gauge.

"Source/Radioactive Material: Cs137, 9 mCi; Thermo Measure Tech, source model 57157C

"Device: Thermo Measure Tech, gauge model 5192 SN# B3195

"State inspectors [North Carolina Department of Health and Human Services] will be conducting a reactive on site investigation tomorrow (1/14/2016) to determine causes and if any corrective actions have been implemented. Our Agency [North Carolina Department of Health and Human Services] will also be visiting the scrapyard where old licensee parts were shipped in the event the gauge was sent there by accident. Portal monitors and scrap material will be checked for functionality and presence of heightened radiation, respectively."

NC Report ID No.: NC160003

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: 51669
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVID TICKLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2016
Notification Time: 18:31 [ET]
Event Date: 01/20/2016
Event Time: 13:11 [CST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMNES CAMERON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text

PRIMARY-SECONDARY CONTAINMENT PRESSURE DIFFERENTIAL EXCEEDED DUE TO CCP EXHAUST FAN TRIP

"At 1308 CST on January 20, 2016, the main control room received an alarm that the containment building (VR) ventilation system continuous containment purge (CCP) exhaust fan (1VR07CB) tripped. At 1311 CST, primary-to-secondary containment differential pressure was reported to be +0.411 psid. Technical Specification (TS) Limiting Condition for Operation (LCO) 3.6.1.4, Primary Containment Pressure, Action A.1, was entered due to the differential pressure outside the 0.25 psid requirement. At 1327 CST, the CCP B subsystem was restarted and at 1339 CST, primary-to-secondary differential pressure was restored to within the limits of TS 3.6.1.4. The cause of the trip of the 1VR07CB is under investigation.

"This event is reportable under 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that could have prevented the fulfillment of the primary containment function due to the differential pressure being outside the primary containment initial conditions to ensure that containment pressures remain within design values during a loss of coolant accident. This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of the primary containment function for the same reason.

"The NRC Resident has been notified."

Page Last Reviewed/Updated Thursday, January 21, 2016
Thursday, January 21, 2016