United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > June 17

Event Notification Report for June 17, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/16/2016 - 06/17/2016

** EVENT NUMBERS **


51989 51990 51991 51992 51993 51997 52010 52011

To top of page
Agreement State Event Number: 51989
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EXXONMOBILE CORPORATION
Region: 4
City: BEAUMONT State: TX
County:
License #: 02316
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/08/2016
Notification Time: 10:03 [ET]
Event Date: 06/06/2016
Event Time: [CDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - CABLE ON BERTHOLD LB 300 MODEL FAILED

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

"On June 7, 2016, the Agency [Texas Department of State Health Services] was notified by the Licensee's consultant that on June 6, 2016, the licensee found the cable on a Berthold LB 300 model gauge that connects the operating rod to a 500 milliCurie cobalt 60 source had failed. The source is currently inserted in the in source well in the normal operating position and cannot be removed. The failure does not create any additional exposure risk to the licensee's workers or members of the general public. The licensee stated there is no access to the vessel the source is located in during operation. The licensee intends to work with the manufacturer to repair the gauge during its next outage. Additional information on this event will be provided in accordance with SA-300."

Texas Incident Report No.: I-9410

To top of page
Non-Agreement State Event Number: 51990
Rep Org: PARAGON MEDICAL
Licensee: PARAGON MEDICAL
Region: 3
City: PIERCETON State: IN
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: DAMIEN SHRIVER
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/08/2016
Notification Time: 14:14 [ET]
Event Date: 06/01/2016
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

LOST GENERAL LICENSED MATERIAL

The licensee lost two general licensed devices containing Po-210 sources. These were lost between 2011 and 2014.

Manufacture: NRD Inc.
Model Number: P-2021-8101, P-2101-8101
Device Serial Number: A2HW030, A2JJ603
Original activity per device: 10.00 mCi, 10.00 mCi
Current activity: 0.0 mCI, 0.0 mCi
Original ship date: 10/4/2011, 1/7/2013

The licensee notified R3 (Sulaiman).

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

To top of page
Agreement State Event Number: 51991
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2909-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 08/13/2015
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"Mount Sinai Medical Center (MSMC) reported that a patient only received 62 percent of their prescribed Y-90 microsphere (BTG International / Nordion model TheraSpheres) dose during treatment performed on 8/13/2015. The patient was prescribed to receive 1.81 GBq (48.92 mCi) of Y-90 microspheres for an exposure of 15,000 cGy (rad) to the liver. Access to the liver was gained through the femoral artery, with catheterization performed using a reverse curve catheter and coaxial micro-catheter. Following completion of the treatment procedure, radiation surveys using a Rados detector revealed 0 mR/hour. The microsphere delivery kit was then taken to the hot laboratory for further radiation surveys. At that time MSMC discovered a residual activity of approximately 33.7 percent of the microspheres in the vial. The cause was determined to be a procedure problem. Corrective actions included procedure modifications."

NMED: 150485

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.

To top of page
Agreement State Event Number: 51992
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN KETTERING CANCER CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2968-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 01/16/2015
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"Memorial Sloan-Kettering Cancer Center reported that a pediatric male patient only received 64.38 MBq (1.74 mCi) of I-124 labeled monoclonal 8H9 on 1/16/2015, instead of the prescribed 120.25 MBq (3.25 mCi). The patient had been diagnosed with pontine glioma. The incident occurred because the infusion process along the gauze at the site of the catheter connector leaked. The leak was not obvious on visual inspection. The cause was determined to be a procedure problem. Corrective actions included generating a new procedure and improvements to radioactive material labeling and handling."

NMED: 150094

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.

To top of page
Agreement State Event Number: 51993
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ANHEUSER-BUSCH, LLC
Region: 1
City: WILLIAMSBURG State: VA
County:
License #: GL 1385
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 16:11 [ET]
Event Date: 05/25/2016
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER WILL NOT FULLY OPEN

The following report was received via e-mail:

"On May 27, 2016 the Virginia Radioactive Material Program (VRMP) received a reciprocity notification from Heuft USA, Inc., to perform maintenance on a fixed gauge which was not properly functioning. The gauge is a Heuft Model 45US, serial number 1254AR containing 45 mCi of Am-241.

"On May 31, 2016 the Heuft service engineer arrived at the Anheuser-Busch facility to investigate the gauge not functioning. The shutter was able to be fully closed but would not fully open. The engineer determined this to be due to a thin piece of material present in the shutter assembly which is not normal, and which interfered with the shutter opening fully. The engineer reported that the root cause of the problem appears that a cylindrical portion of the liner has broken off, perhaps as a result of cyclical thermal stress.

"The shutter assembly was replaced and is working properly. There was no public health exposure or environmental release from this event."

Virginia report: VA-16-006

To top of page
Agreement State Event Number: 51997
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: QUAD CITY TESTING LAB, INC
Region: 3
City: DAVENPORT State: IA
County:
License #: 0186182IR1
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/09/2016
Notification Time: 15:56 [ET]
Event Date: 05/31/2016
Event Time: [CDT]
Last Update Date: 06/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following was received from Iowa via email:

"The licensee [Quad City Testing Lab] reported a source disconnect on a QSA Global 880 Delta radiography camera containing 66.3 curies of lr-192. The RSO was able to retrieve the source and return it to the shielded position. The time from disconnect to retrieval was less than two hours. During the RSO investigation, it was determined that the radiographer trainee did not properly connect the source pigtail to the drive cable and this action was not noticed by the radiographer trainer. Total doses during the event as indicated by pocket dosimeters were: RSO 130 mRem, radiographer trainer 55 mRem, and radiographer trainee 30 mRem. No member of the public received any dose from this event."

Incident Number IA160001

To top of page
Power Reactor Event Number: 52010
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: TOM COBBLEDICK
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/16/2016
Notification Time: 14:59 [ET]
Event Date: 06/16/2016
Event Time: 11:37 [EDT]
Last Update Date: 06/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
LAURA KOZAK (R3DO)

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

Event Text

UNANALYZED CONDITION OF EMERGENCY DIESEL GENERATOR DURING TORNADO LOW PRESSURE

"Upon review of recent industry operating experience, an issue was identified for the potential impact of the low barometric pressure associated with a tornado on the Emergency Diesel Generators (EDGs). The Davis-Besse Nuclear Power Station EDGs are equipped with a crankcase positive pressure trip with a set point of approximately 1 inch of water. This crankcase pressure trip is bypassed during an emergency start signal of the EDG from the Safety Features Actuation System or from an essential bus under voltage condition. Engineering has determined that a design basis tornado could create sufficient low pressure to potentially actuate the crankcase positive pressure trip due to different vent paths between the EDG Room and the EDG crankcase. If the crankcase pressure trip occurs before the EDG starts on an emergency signal due to the tornado, the crankcase pressure trip would cause an EDG lockout condition. The EDG lockout condition would then prevent either normal or emergency start of the EDG until operators could manually reset the lockout condition locally at the EDG. This condition could potentially affect both EDGs simultaneously.

"No severe weather warnings or watches are forecast in the local areas that could challenge the crankcase pressure trip. Compensatory measures are being established that upon notification of a Tornado Watch or Tornado Warning that would be implemented to defeat the crankcase pressure trip function and allow the EDGs to perform their required safety function during a potential tornado."

The NRC Resident Inspector has been notified.

To top of page
Power Reactor Event Number: 52011
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW PLEASANT
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/16/2016
Notification Time: 16:19 [ET]
Event Date: 06/16/2016
Event Time: 07:45 [PDT]
Last Update Date: 06/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVID PROULX (R4DO)
FFD GROUP (EMAI)

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

Event Text

FITNESS FOR DUTY - UNOPENED HERBAL TEA IDENTIFIED IN THE PROTECTED AREA

An employee self-reported possession of an unopened herbal tea containing naturally occurring alcohol in the protected area. The drink was removed from the protected area.

The licensee will notify the NRC Resident Inspector.


* * * UPDATE FROM MATTHEW PLEASANT TO DONALD NORWOOD AT 1955 EDT ON 6/16/2016 * * *

"While investigating the incident for EN #52011, it was determined that 'cooking wine' used in the cafeteria should be removed from the protected area."

The licensee will notify the NRC Resident Inspector. Notified R4DO (Proulx) and FFD Group via email.

Page Last Reviewed/Updated Friday, June 17, 2016
Friday, June 17, 2016