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Event Notification Report for March 17, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/16/2016 - 03/17/2016

** EVENT NUMBERS **


51291 51778 51779 51781 51782 51783

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Part 21 Event Number: 51291
Rep Org: ALPHA-OMEGA SERVICES, INC
Licensee: ALPHA-OMEGA SERVICES, INC
Region: 4
City: BELLFLOWER State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TROY HEDGER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/05/2015
Notification Time: 19:02 [ET]
Event Date: 08/04/2015
Event Time: [PDT]
Last Update Date: 03/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RAY AZUA (R4DO)
PART 21 MATERIALS (EMAI)

Event Text

PART 21 - POTENTIAL RADIOACTIVE MATERIAL TRANSPORT PACKAGING SHIELDING FAILING TO COMPLY WITH 10CFR71.47 AND/OR 10CFR71.51

The following information is a summary that was excerpted from a facsimile received from Alpha-Omega Services, Inc.:

"Pursuant to 10CFR 21.21 (d)(3)(ii) Alpha-Omega Services, Inc. [AOS] is providing the USNRC with written notification of the identification of a potential failure to comply. The following information is required per 10CFR 21.21 (d)(4):

"Name and Address of the individual or individuals informing the Commission. Troy Hedger, President, Alpha-Omega Services, Inc., 9156 Rose Street, Bellflower, CA 90706

"Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect. AOS Document Number FM9054, Rev. H, Radioactive Material Transport Packaging System Safety Analysis Report for Model AOS-025, AOS-050, and AOS-100 Transport Packages (Revision H, December 30, 2012; Docket No. 71-9136) Model AOS-100A Package, USA/9316/B(U)-96 (Certificate of Compliance #9316)

"Nature of the defect of failure to comply and the safety hazard which is created or could be created by such defect of failure to comply. There is a potential issue that shielding fails to comply with 10CFR 71.47 and/or 10CFR 71.51 (a)(2). This is not a 'defect' of the package, but rather an un-analyzed condition that could lead, if credible, to a safety hazard. DAHER-TLI Engineering Services notified AOS via telephone conversation on July 28, 2015 that there is a possible discrepancy in the original SAR shielding calculations originally performed. The potential discrepancy was discovered in conjunction with the independent preparation of a DAHER-TLI symposium paper that they are working on for presentation for future use of the AOS Cask family products. Specifically, DAHER-TLI observed that the AOS SAR does not analyze the radiation levels on the exterior of the package when a point source is located in a corner of the cask cavity.

"In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part. Currently, four (4) AOS-100A packages have been fabricated and three (3) were certified for use prior to August 4, 2015; one (1) is currently not in service. There are two (2) AOS-050 packages which are on hold for completion of fabrication activities. The following are the locations of the active units: AOS - Bellflower, CA, Serial no. AOS-100A-0001 (not currently in service); Elekta - Nordion Ottawa, Canada, Serial no: AOS-100A-0002; AOS - GE Vallecitos Sunol, CA, Serial no: AOS-100A-0003; Elekta - Nordion Ottawa, Canada, Serial no: AOS-100A-0004"

* * * UPDATE FROM TROY HEDGER TO JOHN SHOEMAKER AT 0954 EDT ON 8/7/15 * * *

The following update information is a summary that was excerpted from a facsimile received from Alpha-Omega Services, Inc.:

"As of August 6, 2015, responsible personnel for the owner/users of the AOS Packages have been notified in writing, as follows:
Elekta AB
GE-Hitachi
International Isotopes, Inc.
Nordion
Source Production and Equipment Co., Inc.

"Based on our initial evaluation, AOS has initiated CAPA No. FM9016.1-082015-001 for providing corrective action relating to the above-identified subject. A 10 CFR Part 21 Applicability Form (re. FM9015.2-082015-001) has also been prepared and is currently under evaluation. The CAPA identifies the issue and begins the internal investigation process to determine the cause and to identify corrective action(s); this investigation is currently in progress.
1. AOS has initiated a Part 21 evaluation to determine applicability.
2. In parallel, AOS has contacted the NRC to inform the project manager of the concern; and to seek guidance/advice as to the direction that this evaluation needs to proceed.
3. Assuming that all of the activity is condensed in a point source in the corner of the cavity is a very conservative assumption.
4. In reality there may not be a problem due to self-shielding and distributed activity; i.e., it is very unlikely to have all of our activity in a single source and if we did, we would constrain it to the center of the cavity.

"In parallel to this notification, AOS is notifying the owners and users of the AOS-100 package of this potential failure to comply."

For additional information, contact the following;
Troy Hedger, President
Alpha-Omega Services, Inc.
9156 Rose Street
Bellflower, CA 90706

Notified R4DO (Azua) and Part 21 Materials Group via email.

* * * UPDATE FROM TROY HEDGER (VIA FAX) TO HOWIE CROUCH AT 1315 EDT ON 3/16/16 * * *

The analysis and corrective actions stated in previous updates have been completed therefore the vendor considers this Part 21 notification completed.

Notified R4DO (Warnick) and Part 21 Materials group via email.

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Agreement State Event Number: 51778
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TICONA POLYMERS, INC
Region: 4
City: BISHOP State: TX
County:
License #: 02441
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/08/2016
Notification Time: 09:42 [ET]
Event Date: 03/07/2016
Event Time: [CST]
Last Update Date: 03/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE STUCK SHUTTER

The following was received from Texas via email:

"On March 7, 2016, the Agency [Texas Dept. Of State Health Services] was notified by the licensee that while performing routine checks, the shutter on an Ohmart SH-F2 nuclear gauge was stuck in the open position. Open is the normal operation position for the shutter. The gauge contains a 100 millicurie cesium-137 source. The gauge does not create an exposure hazard to the licensee's employees or any member of the general public. The licensee has contacted their service company who will inspect the gauge on March 9, 2016. Additional information will be provided as it is received in accordance with SA-300."

Texas incident # I-9384

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Agreement State Event Number: 51779
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: WORLD TESTING, INC.
Region: 1
City: MOUNT JULIET State: TN
County:
License #: MS-1035-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/08/2016
Notification Time: 15:34 [ET]
Event Date: 03/06/2016
Event Time: 22:33 [CST]
Last Update Date: 03/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

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

"The Licensee notified DRH [Mississippi Department of Radiation Health] on 3/7/2016, that an incident had occurred at 2233 [CST on 3/6/16], at the client's site [in Holly Springs, MS]. The Licensee's two (2) man radiography crew was performing radiography inside a twelve (12) foot, open end vessel, thirty six (36) feet long, and nine (9) foot off the ground. The radiography camera in use was a Sentinel model 880D, serial No. D1120. During one exposure the guide tube became crimped preventing the source from retracting back into the camera. This was due to the camera falling off the scaffolding to the vessel floor while the radiographer was retracting the source. The resulting action caused the guide tube connected to the camera and magnetic stand to become crimped at the camera connection point. The licensee's radiography supervisor was notified and the restricted area boundary was increased by the two (2) radiographers.

"Source retrieval was performed by the radiography supervisor with assistance from the radiography crew. A survey was performed using a NDS, ND-2000, SN: 20113, Calibration date: 1/15/2016, at the opposite end of the vessel thirty two (32) feet away from the source revealing a reading of two hundred twenty (220) mR/hr. A decision was made to pull the camera to one opening of the vessel by the camera cranks. The restricted area was then readjusted for two (2) mR/hr.

"While the camera was being lowered to the ground with a guide rope out of the vessel opening, the guide tube became straight enough to allow for source retraction. The guide tube and magnetic stand hung at the opening of the vessel causing the guide tube to straighten out from the weight of the camera below the vessel opening. The radiographers made another attempt to retract the source with success when the guide tube was straight. Once the camera was on the ground, the Licensee's survey of 46 mR/hr confirmed the source was retracted back into the camera.

"Doses to the radiography crew and supervisor were all below 60 millirems (mR). Instadose radiation badges were used with the highest dose reported of thirty nine (39) mR to both radiographers. Pocket dosimeters were also used with the highest dose reported by the radiography supervisor of fifty five (55) mR.

"Licensee's written report was received on 3/7/2016. The camera has been removed from service pending a sealed source and DU wipe test. Implemented corrective actions included adequate lighting at night and tying the camera off when it is used over twelve (12) inches off the ground."

The radiography camera contains a 79.9 Ci Ir-192 Source, model A424-9, serial number 28799G.

The State of Mississippi instructed the licensee to submit a 30 day written report and considers this case to be closed.

Mississippi State Report number: MS-16002.

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Agreement State Event Number: 51781
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: NRG ENERGY SERVICES
Region: 1
City: NEW FLORENCE State: PA
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/09/2016
Notification Time: 14:11 [ET]
Event Date: 03/07/2016
Event Time: [EST]
Last Update Date: 03/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

The following report was received from the Commonwealth of Pennsylvania via email and facsimile:

"Event Type: Loss of licensed material in a quantity greater than or equal to 1000 times the Appendix C quantities in part 20.

"Notifications: NRG Energy discovered the event on March 7, 2016, [at their Seward, PA location,] and submitted a report to the Department [Pennsylvania Department of Environmental Protection] on March 9, 2016. This event is reportable as per 10 CFR 20.2201(a)(1)(i).

"Event Description: On Monday March 7, 2016, while conducting the six month inventory check of the radioactive sources at the Seward Power Plant, one tritium exit sign was found missing. The exit sign was installed above a door located in Seward's Fuel Barn. The last inventory check was conducted September 11, 2015, and the exit sign was present at that time. The exit sign was manufactured by EMERG-LITE and was an Everlite series sign. The sign contained between 9.5 - 11.5 Ci of tritium gas at the time of manufacture and was to be replaced before February 2023. The sign was last known to be in good condition and not damaged. No cause for the missing sign has been identified and no exposures have been recorded at this time.

"Cause of the Event: Unknown at this time. The plant is currently searching the site and conducting interviews with personnel.

"Actions: The Department will be following up with the facility for any additional information. The plant is also conducting refresher radiation training to plant personnel. More information will be provided upon receipt."

Pennsylvania Event Report ID No: PA160009.

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: 51782
Rep Org: PATRIOT ENGINEERING & ENVIRONMENTAL
Licensee: PATRIOT ENGINEERING & ENVIRONMENTAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-32725-01
Agreement: N
Docket:
NRC Notified By: BRYON KING
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/09/2016
Notification Time: 15:10 [ET]
Event Date: 03/08/2016
Event Time: [EST]
Last Update Date: 03/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

DAMAGED SIEMENS DENSITY GAUGE

The licensee reported that a Siemens C-200 Gauge, model L 640 containing a Ra-226 0.005 Ci source, was run over by a pick up truck and damaged. Damage to the gauge was limited to the electronics package and battery. The source remains properly contained and un-damaged. A survey of the area indicates no leakage and no exposures to personnel. The gauge has been placed in a secure location and will be sent back to the manufacturer for repairs.

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Non-Agreement State Event Number: 51783
Rep Org: USAF
Licensee: USAF
Region: 1
City: FALLS CHURCH State: VA
County:
License #: 42-23539-01AF
Agreement: Y
Docket: 030-2864
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/09/2016
Notification Time: 16:36 [ET]
Event Date: 02/17/2016
Event Time: 09:00 [EST]
Last Update Date: 03/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
DAVID PROULX (R4DO)
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSC (CANADA) (FAX)

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

Event Text

LOST AM-241 CHECK SOURCE

"Organization Possessing Source(s): 711HPW, USAFSAM/OE.

"Specific Location(s): Wright-Patterson AFB, OH Bldg. 20840, Room W329D, OEA Radioactive Material Storage.

"What Happened: One (1) each Isotope Product Laboratory, 12.8 nCi Am-241 check source, RP# 0895 was to be shipped, along with three other sources, to Nellis AFB in support of USAFSAM/OEC personnel. The PRSO [Permit Radiation Safety Officer] could not immediately locate RP# 0895.

"The PRSO checked the RAM [Radioactive Material] sign-out log to determine if the source had been signed out to other OE personnel. The log did not show evidence of the source having been signed out. The PRSO questioned Radioanalytical Lab, Dosimetry Lab, Calibration Lab, AFRAT, Consulting and Education personnel to determine if anyone was using the source. All of them had a negative reply. All laboratories were thoroughly searched as were the OEC equipment cases used in the Nellis operations. AFRAT equipment cases in WRM were also searched. The source was not located.

"The PRSO determined the source had last been accounted for during the RAM inventory dated 17 August 2015. Additional investigation revealed that the prior PRSO had been requested to send the source, along with two other sources, to Nellis AFB in support of OEC personnel in September 2015. These sources were never signed out of the inventory when sent to Nellis AFB. Additionally, no OEC personnel recall using the source during that period. The other two sources requested were received back at USAFSAM on 5 October 2015. DOE personnel working with OEC personnel at Nellis AFB, as well as the Nellis IRSO [Installation Radiation Safety Officer], were contacted to see if they had the source in their possession. All had a negative reply. It cannot be determined if the source was lost at USAFSAM or Nellis AFB.

The PRSO contacted the IRSO, at 1531, 17 February 2016 to inform him of the potential lost source.

USAF Master Materials License: 42-23539-01AF Docket: 030-28641.
Applicable USAF RAM Permit: OH-00563-00/14AFP Docket: 030-00563.
Commodity (i.e., compasses, etc.): Isotope Product Laboratory check source.
Radioisotope(s) Involved: Am-241
Activity: 12.8 nCi
Sealed Source Model/Serial No: K-845/0895

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

Page Last Reviewed/Updated Thursday, March 17, 2016
Thursday, March 17, 2016