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Event Notification Report for January 22, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/21/2016 - 01/22/2016

** EVENT NUMBERS **


51651 51652 51653 51656 51660 51664

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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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Agreement State Event Number: 51653
Rep Org: PA DEP BUREAU OF RAD PROTECTION
Licensee: CIVIL & ENVIRONMENTAL CONSULTANTS
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-1147
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/14/2016
Notification Time: 10:31 [ET]
Event Date: 01/13/2016
Event Time: [EST]
Last Update Date: 01/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received from the State of Pennsylvania via facsimile:

"On January 13, 2016, the Department [PA DEP Bureau of Radiation Protection] was notified that a Troxler gauge was damaged while on the job site in Pennsylvania. This event is reportable within 24-hours per 10 CFR 30.50(b)(2).

"A Troxler gauge was hit with a truck while on a job site. The source rod became detached from the gauge and rendered the gauge unusable. The area was secured and a local service provider was notified to recover the gauge. The gauge was not found to be leaking and was secured for shipment back to Troxler for repair. There was no exposure to workers or the public.

"Gauge Model: 3440
"Test Date: 7/6/2015
"Gauge S/N: 18936

"A local service provider assisted with retrieval of the gauge. A reactive inspection was performed by the Department. More information will be provided upon receipt."

PA Event Report ID No: PA160001

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Agreement State Event Number: 51656
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: SOUTHWEST RESEARCH INSTITUTE
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 04958
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/14/2016
Notification Time: 19:57 [ET]
Event Date: 01/14/2016
Event Time: [CST]
Last Update Date: 01/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - RADIATION LEVELS ON PACKAGE GREATER THAN 1 REM/HR LIMIT

The following report was received from the Texas Department of State Health Services via email:

"On January 14, 2016, the licensee notified the Agency [Texas Department of State Health Services] that it had received an exclusive use shipment of sources in Type A containers that originated in Maryland. The dose rate on one of the containers, which held an 8.4 curie Cobalt-60 source (current activity/decay corrected), exceeded the 1,000 mR/hr limit. The highest dose rate reading on the exterior of the container was 1,900 mR/hr. The licensee surveyed the cab of the truck and measured a dose rate of less than 0.05 mR/hr for the driver. The exterior of the trailer was surveyed and the left side highest measurement was 120 mR/hr and the right side was 50 mR/hr. These dose rates for cab and trailer are below regulatory limits. The licensee reported that none of its workers received any overexposure. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I 9371

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 51660
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: NANCY PARR
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/17/2016
Notification Time: 07:22 [ET]
Event Date: 01/17/2016
Event Time: 05:29 [EST]
Last Update Date: 01/21/2016
Emergency Class: ALERT
10 CFR Section:
70.32(i) - EMERGENCY DECLARED
Person (Organization):
DEBORAH SEYMOUR (R2DO)
LAURA DUDES (R2)
CRAIG ERLANGER (NMSS)
SCOTT MOORE (NMSS)
BERNARD STAPLETON (IRD)

Event Text

ALERT DECLARED FOR FIRE NOT EXTINGUISHED WITHIN 15 MINUTES

A plant employee discovered a fire in the mechanical factory strap plating room and activated the fire alarm. At 0529 EST, the licensee notified the Richland County Fire Department. The fire was extinguished and the Alert declaration was terminated at 0709 EST. No radioactive materials were involved and no injuries were reported.

The licensee notified the State and R2 (Michel).

Notified DHS, FEMA, USDA, HHS, DOE, DHS NICC, EPA EOC, FEMA NWC (via email), FDA EOC (via email) and Nuclear SSA (via email).


* * * RETRACTION FROM NANCY PARR TO HOWIE CROUCH AT 1726 EST ON 1/21/16 * * *

Upon further review and investigation by the licensee, it was determined that the fire was extinguished within 15 minutes. As such, no Alert declaration was required. Based on these facts, the licensee has retracted this event notification.

The licensee has notified their R2 Senior PM (Carmen Riviera-Crespo).

Notified R2DO (McCoy). Notified NMSS (Erlanger, Moore) and IRD (Stapleton, Gott) via email.

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Power Reactor Event Number: 51664
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: ROBERT MONTGOMERY
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/19/2016
Notification Time: 18:41 [ET]
Event Date: 01/20/2016
Event Time: 04:00 [CST]
Last Update Date: 01/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED PREVENTATIVE MAINTENANCE

"At 0400 CST on Wednesday, January 20, 2016, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system will be removed from service for planned maintenance activities. During the maintenance, the TSC Ventilation will be shut down. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed in approximately 43 hours.

"Contingency plans are in place so that if an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning (EP) procedures and checklists. If radiological or environmental conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will relocate the TSC staff in accordance with station procedures.

"The NRC Resident Inspector has been notified."


* * * UPDATE AT 0049 EST ON 1/22/16 FROM STEVEN MELL TO JEFF HERRERA * * *

"At 2223 CDT on 1/21/16, Dresden TSC Ventilation was restored. The Dresden TSC Ventilation is functional at this time.

"The NRC Resident Inspector has been notified."

Notified R3DO (Cameron).

Page Last Reviewed/Updated Friday, January 22, 2016
Friday, January 22, 2016