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Event Notification Report for June 28, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/27/2016 - 06/28/2016

** EVENT NUMBERS **


52013 52014 52015 52016 52017 52018 52024 52045 52046 52047

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 52013
Rep Org: KING COMPANY, INC
Licensee: KING COMPANY, INC
Region: 3
City: HOLLAND State: MI
County:
License #: GL-62625-20
Agreement: N
Docket:
NRC Notified By: RANDY KING
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/17/2016
Notification Time: 08:01 [ET]
Event Date: 06/17/2016
Event Time: [EDT]
Last Update Date: 06/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LAURA KOZAK (R3DO)
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSC (CANADA) (EMAI)

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

Event Text

LOST NUCLEAR DENSITY GAUGE

During the process of license renewal of a nuclear density gauge, the owner of King Company, Inc. could not find the density gauge in the storage location in the company warehouse. The time frame the density gauge was lost could not be determined and is currently being investigated.

The gauge model, activity and quantity of sources could not be provided by the licensee when the report was made.

"We [the licensee] have searched file archives, and were unable to find the original purchase documents for Device Key 497158, however, we did find the purchase documents for the Device Key 497157. We believe these devices with purchase dates of 5/15/1993 and 8/27/1995, contained identical components." The "identical" equipment was a digital density gauge with a 2 Ci Cs-137 source.

Whereabouts of the Device Key 497158, Serial No. B880, are unknown.

* * * RETRACTION ON 6/21/16 AT 0723 EDT FROM RANDY KING TO BETHANY CECERE * * *

The following is a synopsis of information received via a telephone conversation.

When this condition was initially reported, the database for the original supplier of the gauge, TN Technologies, was unavailable. Following a review of the database, when it became available, it was discovered that this gauge (Device Key 497158) was never sold to the licensee and was never in their possession. According to the TN Technologies database, Device Key 497158 had been sold to another company outside the United States.

Notified R1DO (Dentel) and R3DO (Orlikowski). Notified NMSS Event Notification Group and CNSC (Canada) by email.

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: 52014
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2016
Notification Time: 12:06 [ET]
Event Date: 06/16/2016
Event Time: [PDT]
Last Update Date: 06/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG PATIENT

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

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion Therasphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event."

5010 Number: 061616

* * * UPDATE AT 1740 EDT ON 06/21/16 FROM ANDREW TAYLOR TO S. SANDIN VIA EMAIL * * *

"This is a revision/update of EN #52014.

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event.

"Two patients were scheduled to be treated with Nordion TheraSpheres containing yttrium 90, one on June 16 and the other on June 17. The first treatment occurred on June 16; however, the treatment dosage of 4.02 GBq (108.6 mCi) was approximately 1.9 times the prescribed dosage, apparently because the dosage for the second patient was given to the first patient. As a result, the first patient received a liver dose of 226.3 gray (22,630 rad) instead of the prescribed dose of 120 gray (12,000 rad).

"The patient has been notified, and the licensee is investigating to determine the cause of the event."

Notified R4DO (Rollins) 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: 52015
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: FLINT HILLS RESOURCES CORPUS CHRISTI LLC
Region: 4
City: LONGVIEW State: TX
County:
License #: 06708
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2016
Notification Time: 14:24 [ET]
Event Date: 06/16/2016
Event Time: [CDT]
Last Update Date: 06/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON NUCLEAR GAUGE

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

"On June 17, 2016, the Agency was notified by the licensee that it had discovered the shutter on a Ohmart model SH-F1 nuclear gauge containing a 50 millicurie (original activity) Cs-137 source would not close. Open is the normal position for the gauge. The licensee stated the gauge does not create an exposure risk to it's employees or members of the general public. The licensee stated a service company will be on site the week of June 27, 2016 to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9413

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Agreement State Event Number: 52016
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXONMOBIL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2349-L01
Agreement: Y
Docket:
NRC Notified By: RUSSELL CLARK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/17/2016
Notification Time: 17:15 [ET]
Event Date: 06/16/2016
Event Time: [CDT]
Last Update Date: 06/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TWO SOURCES STUCK IN DIP TUBES DURING ANNUAL SHUTTER TEST

The following information was received from the State of Louisiana via fax:

"On June 16, 2016, at approximately 1500 CDT, [the] Radiation Safety Officer of ExxonMobil notified LDEQ [Louisiana Department of Environmental Quality] of a potential equipment malfunction. A custom built Berthold level/density gauge installed on G-Line Reactor Vessel, V5300 and possessing seven 10 mCi Co-60 sealed sources, was undergoing a routine annual shutter test in which the sealed sources were pulled upwards in their dip tubes via connecting cables to the top of the source holder. The sources in dip tubes #2 and #6 became stuck in the dip tubes and could not be pulled upward further. The other sources were pulled up to the top of the source holder successfully. All sources were successfully returned to their normal operating positions. [The RSO] called Berthold contract service engineer [at] Radcon, LLC and discussed the potential malfunction. [The service engineer] stated that differential thermal expansion between the source capsules and dip tubes under heating within the reactor vessel likely caused the sources to begin sticking as they were being pulled upward in their dip tubes. The licensee placed another service call to [the service engineer] on June 17, 2016, but was unable to contact him, but left a message. Radcon, LLC will conduct a maintenance inspection and repair of the gauge which is tentatively planned for July 11, 2016. This is not an emergency situation. ExxonMobil Radiation Safety Office staff are monitoring the vessel condition and have the situation under control. There is no potential for off-site exposure."

Event Report ID No.: LA160007

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Agreement State Event Number: 52017
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: AECOM (URS CORPORATION)
Region: 4
City: SEATTLE State: WA
County:
License #: WNI-0172-1
Agreement: Y
Docket:
NRC Notified By: STEVE MATTEWS
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2016
Notification Time: 18:36 [ET]
Event Date: 06/17/2016
Event Time: 00:30 [PDT]
Last Update Date: 06/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE DAMAGED BY VEHICLE AT WORKSITE IN ALASKA

The following information was received from the State of Washington via email:

"At about 1230 Pacific time an AECOM employee and authorized user of the nuclear density gauge backed a pickup truck into the gauge. The gauge was not in operation at the time and the rod was in the up and shielded position. The rod was not bent however the outside case of the gauge was damaged. Observation of the gauge indicated that the damage appeared to be confined to the outer casing and the electronic controls. The sealed sources did not have any visible signs of damage.

"The incident occurred at the Red Dog Mine in Alaska where [AECOM] was using the gauge under a reciprocity agreement with the NRC.

"A radiation detection instrument was used to confirm that the sources were not leaking and to check the area of the incident for any radiation. This survey indicated that the gauge was not leaking and that the area of the incident did not show any indication that the sources had leaked."

Nuclear Density Gauge involved: CPN, MC Series containing two (2) sources; 0.01 Ci or 0.37 GBq Cs-137 and 0.05 Ci or 1.85 GBq Am-241.

Incident Number: WA-16-028.

* * * UPDATE FROM FRED MERRILL (AECOM) TO DANIEL MILLS AT 1810 EDT ON 06/20/2016 * * *

The licensee, AECOM, contacted NRC to report that the damaged device was being securely stored onsite at the mine until it can be shipped back to the manufacturer. The licensee also corrected the license number.

Notified R4DO (Rollins) and NMSS (via email).

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Agreement State Event Number: 52018
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CEDARS-SINAI MEDICAL CENTER
Region: 4
City: LOS ANGELES State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: JEFF DAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2016
Notification Time: 20:46 [ET]
Event Date: 06/09/2016
Event Time: [PDT]
Last Update Date: 06/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED THREAPEUTIC DOSE AT LOCATION NOT AUTHORIZED BY FACILITY LICENSE

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

"Cedar Sinai called LA County Radiation Management on Friday 6/17/16 at 4:25pm [PDT] to report that Cardinal Health delivered Xofigo (Ra-223) to a Los Angeles clinic which is not authorized to have the material. The therapy dose was then given to the patient. Cedar Sinai has a broad scope license and is authorized to have the material, the location that received the material is not an authorized use location, and the doctor who administered the material is not an authorized user for the material. The current assumption which is being verified is the clinic (previously Targenix RML#7145) had its own license prior to a merge and was allowed to have the material and the doctor was previously authorized to administer the material. The patient records have been reviewed by an authorized doctor and [the patient] would have received the treatment at an authorized location by an authorized user if referred. The balance of the treatments will be at an authorized location with an authorized user. Cedar Sinai will continue to investigate and report their findings."

5010 Number: 061716

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: 52024
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: DENNIS HALLS BODY SHOP
Region: 1
City: MEMPHIS State: TN
County:
License #: GL 860
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/20/2016
Notification Time: 10:29 [ET]
Event Date: 06/07/2016
Event Time: [EDT]
Last Update Date: 06/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN STATIC ELIMINATOR GUN

The following report was received by the Tennessee Division of Radiological Health via email:

"During an inspection [by Tennessee Division of Radiological Health] on 06/07/16 the device could not be located, inspector called [Dennis Hall's Body Shop owner] back on 06/13/16 to find out if they had found the device. At that time she stated that she had been told that a painting contractor had taken the device by a former employee. They had several painting contractors and could not remember which one had taken the device."

The Tennessee Division of Radiological Health stated that the device owner did not know when the device had been taken.

Device:
Static Eliminator Gun
NRD Model P-20510AB
Serial Number: 156990
Activity: 10mCi Po-210

TN Event Report ID No.: TN-16-091

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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Power Reactor Event Number: 52045
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUSTIN SCURLOCK
HQ OPS Officer: VINCE KLCO
Notification Date: 06/26/2016
Notification Time: 23:08 [ET]
Event Date: 06/26/2016
Event Time: 21:15 [EDT]
Last Update Date: 06/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GLENN DENTEL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

OFFSITE NOTIFICATION DUE TO AN OIL SPILL

"The United States Coast Guard reported an oil sheen in the vicinity of the station's circulating water system effluent. Investigation by station personnel has not determined the source. The circulating water pumps were secured to mitigate the potential source. The United States Coast Guard response Center, and New York State Department of Environmental Conservation have been notified."

The licensee notified the NRC Resident Inspector.

Notified DOE, EPA, USDA, HHS, FEMA.

* * * UPDATE ON 06/27/2016 AT 02:52 FROM DUSTIN SCURLOCK TO DAN LIVERMORE * * *

"The source of the oil sheen has been identified. The source, main turbine lubricating oil, has been stopped and cleanup efforts are underway."

Notified R1DO (Gray), DOE, EPA, USDA, HHS, and FEMA.

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Power Reactor Event Number: 52046
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: PHILLIP PRATER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 06/27/2016
Notification Time: 12:21 [ET]
Event Date: 06/27/2016
Event Time: 10:50 [CDT]
Last Update Date: 06/27/2016
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
CYNTHIA PEDERSON (RA)
MICHELE EVANS (NRR)
JEFFERY GRANT (IRD)
ELIOT BRENNER (PAO)

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

Event Text

DRESDEN UNIT 3 DECLARES ALERT

"At 1050 CDT, [on 6/27/16], an Alert was declared at Dresden Unit 3. The Alert is due to Unit 3 experiencing a fire in the HPCI (High Pressure Coolant Injection) system, auxiliary oil pump motor. The fire is out.

"This notification is being made per 10 CFR 50.72(a)(1)(i)."

Dresden Unit 3 is stable and continues to operate at 100% power and HPCI has been declared inoperable. There is no impact on Dresden Unit 2.

The licensee has notified the NRC Resident Inspector

Notified DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, and FEMA National Watch Center, FDA EOC, NuclearSSA via email only.

* * * UPDATE FROM MICHAEL HAYES TO JOHN SHOEMAKER AT 1433 EDT ON 6/27/16 * * *

"Termination of MA-5 [Alert]. Fire in HPCI room verified extinguished. HPCI system is inoperable. [Technical Specification] TS 3.5.1 condition G in effect, per 10 CFR 50.72(c)(i) - notification of termination of Alert."

Dresden Unit 3 terminated the Alert at 1319 CDT, on 6/27/16. Dresden Unit 3 continues to operate at 100% power.

The licensee will notify the NRC Resident Inspector.

Notified R3DO (Kunowski), NRR (Miller), IRD (Grant), DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, and FEMA National Watch Center, FDA EOC, NuclearSSA via email only.

* * * UPDATE FROM MICHAEL CSERNAK TO JOHN SHOEMAKER AT 1755 EDT ON 6/27/16 * * *

"At 1042 [CDT] on 6/27/16, the U3 High Pressure Coolant Injection (HPCI) system was declared inoperable after the Auxiliary Oil Pump failed.

"This event is reportable per 10CFR50.72(b)(3)(v)(D); any event or condition that at the time of discovery could have prevented fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. This is an eight hour reporting requirement.

"The Dresden NRC Resident [Inspector] has been notified."

Notified R3DO (Kunowski).

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Power Reactor Event Number: 52047
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [1] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: PHYLLIS DOMINGUEZ
HQ OPS Officer: VINCE KLCO
Notification Date: 06/27/2016
Notification Time: 22:14 [ET]
Event Date: 06/27/2016
Event Time: 07:29 [PDT]
Last Update Date: 06/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned
2 N N 0 Defueled 0 Defueled
3 N N 0 Defueled 0 Defueled

Event Text

FITNESS FOR DUTY

A non-licensed contract employee had a confirmed positive for alcohol following a for-cause fitness-for-duty test. The employee access to the plant has been terminated.

This information will be sent to the NRC Region 4 Office as San Onofre no longer has a resident.

Page Last Reviewed/Updated Tuesday, June 28, 2016
Tuesday, June 28, 2016