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Event Notification Report for June 13, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/10/2016 - 06/13/2016

** EVENT NUMBERS **


51916 51973 51977 51978 51979 51980 51981 52000

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 51916
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ALCOA WORLD ALUMINA ATLANTIC
Region: 4
City: POINT COMFORT State: TX
County:
License #: 05186
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/10/2016
Notification Time: 17:03 [ET]
Event Date: 05/09/2016
Event Time: [CDT]
Last Update Date: 06/10/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE STUCK SHUTTER

The following information was received via E-mail:

"On May 10, 2016, the Agency [Texas Depart of State Health Services] received notification from the licensee's radiation safety officer (RSO) that the shutter on a Thermo Fisher Scientific Model 5176-SN B2578 density gauge, containing a 500 millicurie cesium-137 source SN MA3200, was found open during inventory/operational checks. It appears the weld had failed on the gauge. Open is the normal operating position of the gauge shutter. The gauge does not create an exposure hazard to the licensee's employees or a member of the general public. The licensee has contacted the service company who will inspect the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9399

* * * RETRACTION FROM CHRIS MOORE TO RICHARD SMITH ON JUNE 10, 2016 AT 1541 EDT * * *

The following was received from the State of Texas via email:

"I-9399, EN51916 is retracted. The manufacturer inspected the gauge and shutter. All components were fully operational. The transmitter in the density detector failed, giving an erroneous reading on the meter. The licensee incorrectly assumed it was due to a broken shutter."

Notified R4DO(Kramer) and NMSS Events Notification via email.

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Agreement State Event Number: 51973
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: JOHN G. FASSELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/02/2016
Notification Time: 20:22 [ET]
Event Date: 05/27/2016
Event Time: [PDT]
Last Update Date: 06/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE

The following was received from the State of California via email:

"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016.

"A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure.

"The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube.

"The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications."

5010 Number: 060216

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: 51977
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GLATFELTER PAPER
Region: 3
City: CHILLICOTHE State: OH
County:
License #: 31201720002
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 05/27/2016
Event Time: [EDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was received by the State of Ohio via email:

"Shutter stuck in open (normal operating) position on Berthold Model LB300L Fixed Gauge, containing approximately 20 microCi Co-60. Service provider has been contacted to repair. Gauge is not accessible to personnel and continues to operate in process line."

Berthold Gauge Serial Number: 623/3-04-04

Ohio Item Number: OH160004

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 51978
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: FLOWER HOSPITAL
Region: 3
City: SYLVANIA State: OH
County:
License #: 02120490004
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 05/31/2016
Event Time: [EDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was received by the State of Ohio via email:

"Leak test of sealed source indicated greater than 185 Bq (0.005 microCi) of removable contamination.

"Cs-137 vial source, 177 microCi, 44,000 cpm removable.

"Several wipes were performed as well as a measurement with a multi-channel analyzer to confirm the radioisotope. The source was placed in a lead pig, taped closed, labeled as a leaking sealed source, and placed in the main hot lab hot-waste storage container. Area wipes were performed to verify that no contamination was present in the vicinity. The source has been removed from service."

Serial Number: 1074-22-5

Ohio Item Number: OH160005

* * * RETRACTION ON 6/3/16 AT 1624 EDT FROM STEPHEN JAMES TO DONG PARK * * *

After further review, report OH160005 previously submitted to the Ops Center was not subject to 24-hour notification.

Notified R3DO (Hills) and NMSS Events Notification via email.

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Agreement State Event Number: 51979
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120780000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 04/21/2016
Event Time: [EDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSC (CANADA) (FAX)

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

Event Text

AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received by the State of Ohio via email:

"On 4/21/2016 in OR [Operating Room] 11, during seed loading, the dosimetrist noticed that one seed was missing from the transferring stylet as he was transferring the seeds to the loading needle. He immediately notified the physicist in the room. The physicist then checked the sterile area around the cartridge with a survey meter and picked up radiation reading by the luer - lock hub of the cartridge. The physicist assumed that the source had fallen in the sterile towel under the cartridge and determined loading should continue, and they will retrieve the dislodged seed after all needles have been loaded. After all needles were loaded and while implantation was still in progress the physicist and the dosimetrist went to retrieve the dislodged seed but they were not able to locate it. They resurveyed the spot where it was and there was no radiation detected. The physicist emptied the cartridge to verify the number of seeds remaining in the cartridge and the count was as stated in the loading summary. The dislodged seed was missing.

"To prevent a recurrence, surgical drapes will be used to cover the area under and around the cartridge/loading area instead of sterile hand towels. This would make it easier to identify any seed that may have fallen out during loading. Loose/broken seed(s) will be placed in the lead pig immediately. If there is a dislodged/loose seed that could not be recovered immediately, the physicist will ensure that everyone leaving the room is surveyed.

"Licensee has previously observed that I-125 seeds are prone to static buildup and have the tendency to cling to plastic, glass walls, and other surfaces. Most likely, the lost seed was swept up and discarded with normal trash.

"Based on the relatively low activity and low energy of the I-125 seed and measured background readings in the operating room, there was no radiation exposure to personnel or members of the public due to this loss."

Source/Radioactive Material: Sealed source brachytherapy
Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125, 0.000382 Ci

Ohio Item Number: OH160006

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: 51980
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120780000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 04/26/2016
Event Time: [EDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSC (CANADA) (FAX)

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

Event Text

AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received by the State of Ohio via email:

"On 4/26/2016, Physics reported that during prepping a return shipment the dosimetrist discovered one I-125 prostate seed was missing from the lead pig. The lead pig contained loose/broken seeds from the implant performed on 4/6/2016. There were three seeds in the vial where there should've been four. The RSO interviewed the dosimetrist and the physicist who worked this case. Inventory log and loading summary were audited. Inventory log recorded 28 seeds returned to storage. Of the 28 seeds returned, 24 were in the cartridge and 4 were loose/broken seeds stored in the lead pig. It was not until 4/26/2016 when Physics discovered only 3 seeds were in the lead pig. Radiation surveys records were audited. Surveys were performed accordingly and readings were background level.

"At this time, the seed has not been located. Based on the information provided by the medical physicist and the dosimetrist, it is still unclear as to precisely determine when and how the seed became missing. Licensee believes there was no radiation exposure to the individual(s) involved. To prevent a recurrence, two individuals shall visually count the seeds in the lead pig before leaving the operating room. Furthermore, two individuals shall review loading summary to confirm all seeds are accounted for.

"Licensee has previously observed that 1-125 seeds are prone to static buildup and have the tendency to cling to plastic, glass walls, and other surfaces. Most likely, the lost seed was swept up and discarded with normal trash. Based on the relatively low activity and low energy of the 1-125 seed and measured background readings in the operating room, there was no radiation exposure to workers or members of the public due to this loss."

Source/Radioactive Material: Sealed source brachytherapy
Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125, 0.000396 Ci

Ohio Item Number: OH160007

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: 51981
Rep Org: PERRY COUNTY MEMORIAL HOSPITAL
Licensee: PERRY COUNTY MEMORIAL HOSPITAL
Region: 3
City: PERRYVILLE State: MO
County:
License #: 24-17037-02
Agreement: N
Docket:
NRC Notified By: KENNETH ANDREWS
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 16:17 [ET]
Event Date: 06/03/2016
Event Time: 07:30 [CDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

PATIENT ADMINISTERED THE WRONG BYPRODUCT MATERIAL

The following was received via email:

"This is a report and notification of a medical event for Perry County Memorial Hospital, located in Perryville, Missouri, which occurred today June 3, 2016 at approximately 7:30 a.m. CST. This medical event is being reported as required under 10 CFR Part 35.3045 (a)(2)(i), administration of a wrong radioactive drug containing byproduct material resulting in an effective dose equivalent of greater than 0.05 Sv or 5 rem.

"At approximately 8:15 a.m. today, [The Diagnostic Radiological Physicist] received a call from Perry County Memorial Hospital, that one of his nuclear medicine technologists had inadvertently administered a 63 y/o female patient a bulk unit dose of approximately 128 mCi of Tc-99m Sodium Pertechnetate intravenously. This female patient was scheduled to receive a 25 mCi dose of Tc-99m Medronate intravenously for bone scintigraphy. Using a Tc-99m Sodium Pertechnetate package insert provided by the unit dose supplier, [the Diagnostic Radiological Physicist] estimated that the resultant effective dose equivalent to the patient will be approximately 0.06 Sv or 6 rem. The resultant highest dose to any organ or tissue is estimated to be approximately 27 rads, which would be to the patient's upper lower intestinal wall.

"The patient has been notified with regards to this medical event. In addition, the RSO [Radiation Safety Officer] / Authorized User for Perry County Memorial Hospital has also been notified."

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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Power Reactor Event Number: 52000
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WALTER ORF
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/12/2013
Notification Time: 23:51 [ET]
Event Date: 06/12/2013
Event Time: 20:13 [EDT]
Last Update Date: 06/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
FRANK ARNER (R1DO)
CHRIS MILLER (NRR)
BERNARD STAPLETON (IRD)

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

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN AND REACTOR TRIP

At 2013 EDT on 6/12/16, Millstone Unit 3 commenced a Technical Specification (TS) required shutdown due to excessive Reactor Coolant System leakage from the "A" Reactor Coolant Pump (RCP) third stage seal. The leakage from the third stage seal was approximately two gpm which is greater than the Technical Specification (TS) limit of less than one gpm.

During the shutdown, oscillations developed in the Main Feedwater which required the operator to initiate a manual reactor trip. Unit 3 is currently stable in Mode 3. Decay heat is being released via the Steam Dumps to the Main Condenser. Normal offsite power is available and the unit is in a normal shutdown electrical line-up. The cause of the Main Feedwater oscillations is being investigated.

The licensee notified the NRC Resident Inspector. The licensee notified State and local government agencies.


* * * UPDATE FROM WALTER ORF TO DONALD NORWOOD AT 0129 EDT ON 6/13/2016 * * *

The following clarifies Feedwater isolation vs. Feedwater oscillation:

"At 2337 EDT on 6/12/16, a manual reactor trip was initiated on Unit 3 following feedwater isolation. As expected, Aux Feedwater system (AFW) initiated on the reactor trip. The trip was uncomplicated and the plant is currently in Mode 3 with a normal electric line-up and decay heat is being removed via steam dumps to the condenser. This is reportable under 10 CFR 50.72(b)(2)(iv)(B) - RPS Actuation - Critical and 10 CFR 50.72(b)(3)(iv)(A) - Valid Specific System Actuation."

"The Feedwater isolation occurred due to high Steam Generator water level."

The licensee notified the NRC Resident Inspector.

Notified R1DO (Arner).

Page Last Reviewed/Updated Monday, June 13, 2016
Monday, June 13, 2016