Event Notification Report for May 18, 2016

AGREEMENT STATE REPORT - PATIENT OVERDOSE OF IODINE-125 DURING MEDICAL TREATMENT

The following report was received from the Kentucky Department of Public Health and Safety, Radiation Health Branch via email:

"The KY Radiation Health Branch [RHB] was notified on 6/28/16 by the RSO at the University of Louisville that a patient received 297.7 cGy (rad), instead of the prescribed 31 cGy (rad). The patient was implanted with a 7.4 MBq (200 uCi) I-125 localization seed for treatment of non-palpable breast cancer on 3/18/16. The seed was to be removed within five days after implant. However, shortly after induction of anesthesia on the day of removal the patient became unstable, surgery was cancelled, the patient was placed in ICU, and the seed wasn't removed until 5/18/16. The dose was calculated by the radiation oncologist with a reference point of 1 cm around the seed. KY RHB has been in contact with the licensee and expects additional information to be provided by the licensee."

KY Event Report ID No.: KY160006

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.

PART 21 - INTERIM EVALUATION OF A DEVIATION - CONTACTOR FAILURE

The following was received via FAX:

On May 18, 2016, Nuclear Logistics INC. (NLI) determined that a contactor failure that occurred at the Shearon Harris plant had failed due to an auxiliary contact chatter present on the seal-in circuit for the coil voltage. The auxiliary contact chatter was caused by the loss of the shading
coils. NLI will be submitting a full report on the issue to the NRC within 60 days.

The contactor that failed was a Size 4 Eaton Freedom Series with a special coil for degraded voltage condition.

Reference Number: P21-05192016

NLI reported that the following plants have these types of contactor's:

Region 2: Oconee, Turkey Point, Shearon Harris and North Anna

Region 4: Columbia and Waterford

* * * UPDATE AT 1832 EDT ON 06/20/16 FROM TRACY BOLT TO DANIEL MILLS * * *

The following is excerpted from the licensee submission:

"The specific part which fails to comply or contains a defect: The Contactor that failed in service is a Size 4 Eaton Freedom Series with an AZZ/NLI special coil for meeting specific degraded voltage conditions.

"Extent of condition: Size 3, 4 and size 5 Eaton Freedom Series contactors or starters with an NLI special degraded voltage coil that have been supplied by AZZ/NLI since December 2010.

"NLI procured the commercial grade contactors and installed the special coil that was required to achieve the specific degraded voltage condition. The units were qualified, dedicated and supplied for safety related applications. The contactors were commercially procured from Eaton, the Original Equipment Manufacturer (OEM).

"For contactors/starters utilized in continuous duty applications. the OEM shading coils on the contactor core ... have the potential to become loose and fall off. If the shading coils are not in the intended location on the core, there is the potential for excessive chatter to occur on the normally open auxiliary contacts that are closed when the contactor is energized.

"The safety function of the contactor is to reliably supply uninterrupted power (no contact chatter) to a load on demand. For special degraded voltage applications, the NLI supplied contactor is equipped with an NLI special coil that replaces the OEM coil.

"When the contactor/starters that have the special coil installed are utilized in a continuous duty operation (continuously energized greater than 60 minutes) the special coil reaches a higher temperature than the original manufacturer's coil. The increased heat is potentially causing degradation of the acrylic resin that is utilized by the manufacturer to hold the OEM shading coils onto the OEM core. After the acrylic resin is no longer providing a secure hold on the shading coils, the shading coils can then become loose from the iron core.

"Name and address of the individual or individuals informing the Commission.
"Tracy Bolt, Director of Quality Assurance
"Nuclear Logistics, Inc.
"7410 Pebble Drive
"Ft. Worth, TX 76118"

AZZ/NLI Part 21 Report No: P21-05192016, Rev. 0

Plants potentially impacted include Oconee, Shearon Harris, Columbia, Turkey Point, North Anna, and Waterford.

Notified R4DO (Rollins), R2DO (Musser) and Part 21/50.55 Reactors group (via email).

AGREEMENT STATE NOTIFICATION - TRANSPORTED PACKAGE EXCEEDS LIMITS

The following was received via FAX:

"The licensee notified the Department [Pennsylvania Bureau of Radiation Protection] by telephone on May 18, 2016, of an event that required reporting based on 10 CFR 20.1906(d)(2).

"Event Description: On May 18, 2016, a PETNET courier mistakenly picked up a white [shielded container] from a PA licensee which he assumed was empty because it was near other PET cases he was returning to the PETNET North Wales Pharmacy. As he was loading the cases into his trunk, the lid of the white [shielded container] opened and two rods fell out on the ground. He did not realize they were radioactive material. He placed them in his trunk using his hands, leaving the rods unshielded, and proceeded to return to the pharmacy. He placed the [shielded container] and 2 rods on top of the empty cases in PETNET's loading area. The PETNET Radiation Safety Officer (RSO) found the rods and surveyed them, noting the dose rate > [greater than] 200 mRem/hour on the surface. She immediately placed the sources in a shielded [container], and began her investigation. Survey/wipes were taken of the rods, the courier vehicle, the area in which the rods were discovered, and the courier's hands. No removable contamination was found. Dose modeling by the RSO determined there was enough interposed shielding with the large number of other [shielded containers] in his vehicle to reduce his exposure to below regulatory limits. Rods are going to be properly packaged and shipped back to the PA licensee.

"Cause of the Event: Human Error.

"Actions: A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt.

"Media Attention: None at this time.

"Event Report ID No: PA160015"

* * * UPDATE FROM JOSEPH MELNIC TO VINCE KLCO ON 5/24/16 AT 1217 EDT * * *

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

"EVENT DESCRIPTION: On May 18, 2016, a PETNET courier mistakenly picked up a white pig from a PA licensee which he assumed was empty because it was near other PET cases he was returning to the PETNET North Wales Pharmacy. As he was loading the cases into his trunk, the lid of the white pig opened and two rods fell out on the ground. He did not realize they were radioactive material. The rods were two Ge/Ga-68 calibration sources containing 2.16 mCi each. He placed them in his trunk using his hands, leaving the rods unshielded, and proceeded to return to the pharmacy. He placed the pig and 2 rods on top of the empty cases in PETNET's loading area. The PETNET Radiation Safety Officer found the rods and surveyed them, noting the dose rate >200 mr/hr on the surface, 1.4 mR/hr at one meter. She immediately placed the sources in a shielded pig, and began her investigation. Surveys/wipes were taken of the rods, the courier vehicle, the area in which rods were discovered and the courier's hands. results of the wipes were 0 dpm, all surveys were background. No removable contamination was found. A survey by the RSO has shown no overexposure to the courier's hands as a result of picking up the rods and the RSO determined there was enough interposed shielding with the large number of other pigs in his vehicle to reduce his exposure to belowú regulatory limits. The rods are going to be properly packaged and shipped back to the PA licensee. The courier's whole body badge was sent for analysis. No finger extremity badge was worn.

"ACTIONS: A reactive inspection has been performed by the Department [State of Pennsylvania]. Dose modeling of the courier's hands will be requested to determine dose to the hands More information will be provided upon receipt."

Notified R1DO (Lilliendahl) and NMSS Events via email.

LOST AM-241 SOURCE

"A B-52 bomber crashed shortly after take-off at Andersen AF base in Guam at 0830 local time (2230 GMT, Wednesday, 18 May 2016). The B-52 had a Sniper Pod which contained 12 microcuries of Am-241. So far the safety team could not locate the Sniper Pod at the incident spot.

"The value for Am-241 listed in Appendix C to [10 CFR] Part 20 is 0.001 microcuries. Each Sniper Pod carries 12 microcuries of Am-241. Hence, we [USAF] reported the incident to the NRC Operations Center in accordance with 10 CFR 20.2201. We will provide you [NRC with a written] incident report within 30 days."

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

AGREEMENT STATE REPORT - FAILED SHUTTER DEVICE

The following report was excerpted from an email from the Commonwealth of Kentucky, Department for Public Health, Radiation Health Branch:

On May 18, 2016, a fixed gauge was discovered to have a failed shutter device at the licensee's site at West Centertown, Kentucky. There was a failure of on/off mechanisms on one fixed gauge to function as designed. Failure discovered during routine testing of on/off mechanism by licensee. The licensee has contacted a service provider to schedule removal/repair.

The licensee notified the Kentucky Department for Public Health on May 24, 2016.

The fixed gauge is in a remote area of the plant and no overexposures of personnel have occurred.

Kentucky Event Report ID: KY160005.