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Event Notification Report for November 29, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/28/2016 - 11/29/2016

** EVENT NUMBERS **


52375 52376 52379 52385 52386 52387 52398

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Agreement State Event Number: 52375
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: B. BRAUN MEDICAL GROUP, INC.
Region: 1
City: ALLENTOWN State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/18/2016
Notification Time: 10:20 [ET]
Event Date: 09/01/2016
Event Time: [EST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - POLONIUM-210 STATIC ELIMINATOR GAUGE MISSING

The following information was obtained from the Commonwealth of Pennsylvania via email:

"Event Description: During an inventory record check on September 1, 2016, the general licensee discovered that the static eliminator gauge was missing. Its last known use was during the first six months of the year 2011. The general licensee was unaware of its reporting responsibility.

"Gauge info:
Radionuclide: Polonium-210
Manufacturer: NRD, Inc.
Model: P-2021-5000
Device SN#: A2HM769
Activity: 10.2 milliCuries

"Cause of the Event: Unknown at this time, the general licensee believes that the equipment was lost when the company reconfigured its machinery at some point during 2012.

"Actions: A reactive inspection is planned by the Department [PA Department of Environmental Protection]. More information will be provided upon receipt. Note: Given that over 13 half-lives have transpired since the gauge was lost, there is no current public health and safety hazard."

PA Event Report ID: PA160035

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: 52376
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MOUNT AUBURN HOSPITAL
Region: 1
City: CAMBRIDGE State: MA
County:
License #: 44-0017
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/18/2016
Notification Time: 12:22 [ET]
Event Date: 11/16/2016
Event Time: 09:00 [EST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL RADIATION TREATMENT OVERDOSE

The following information was received via E-mail:

"The licensee reported on November 17, 2016 that the licensee administered on November 16, 2016 to a patient a first fraction dose of 1100 centigray to the vagina instead of the prescribed first fraction dose of 600 centigray to the vagina.

"This dose was the first of three fractionated doses, the second and third fractionated doses have not yet been administered. Each fractionated dose was prescribed to be 600 centigray for a total dose of 18 gray (1,800 centigray).

"The licensee used a Varian Medical Systems, Inc. GammaMed plus iX High Dose Rate (HDR) remote afterloader unit containing 7 curies of iridium-192 to deliver the dose.

"This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(a)3.

"The licensee reported that the patient and the referring physician have been notified and that no harmful effect to the patient has been reported.

"The licensee reported that the event occurred because the physician's plan was not performed as prescribed in the written directive and that no other cause was known at time of report.

"The Agency (Massachusetts Radiation Control Program) Director requested the licensee to cease HDR use until a corrective action to prevent recurrence has been implemented.

"The Agency plans to perform a special inspection and considers this event to be open."


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: 52379
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TUV RHEINLAND-NORTH AMERICA (TUVR)
Region: 1
City: WOODSTOCK State: AL
County:
License #: TX-L06724
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/18/2016
Notification Time: 19:57 [ET]
Event Date: 11/18/2016
Event Time: 12:00 [CST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - AUTOMATIC LOCKING DEVICE FAILURE

The following is a synopsis of information received via E-mail from the Louisiana Department of Environmental Quality (LDEQ):

TUV Rheinland (TUVR) was working at the Sasol Mega Project in Westlake, Louisiana under reciprocity (RC-662). TUVR was utilizing four industrial radiography exposure devices but only had a problem with one device.

TUVR made an exposure and then retracted the source into the shielded position. The source returned to the shielded position, but the automatic locking device did not lock/engage. The exposure device was manually locked with the plunger-lock and then key locked. It appears that the spring in the locking mechanism was either broken or blocked from working. The device is a Sentinel model 880D with S/N D13509. The device contains an INC model 7 source with 36.9 Curies of Ir-192 with S/N T0274. Safety surveys were made and there appears to be no radiation exposure hazard. The device was taken out of service, 'locked and tagged' out of service, and is being transported back to Woodstock, Alabama for a complete evaluation.

LDEQ was notified of the event by a phone call and a follow-up written report. From the report, it appears there is not a Radiation Safety Officer named on the Texas license at this time. A copy of the complete evaluation report will be provided when available.

Louisiana Event Report ID No.: LA-160014

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Agreement State Event Number: 52385
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: NONDESTRUCTIVE & VISUAL INSPECTION LLC
Region: 4
City: CARTHAGE State: TX
County:
License #: 06162
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/21/2016
Notification Time: 16:30 [ET]
Event Date: 11/19/2016
Event Time: [CST]
Last Update Date: 11/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT

The following information was received via E-mail:

"On November 21, 2016, the licensee notified the Agency [Texas Department of State Health Services] that on November 19, 2016, one of its radiography crews had been unable to retract an iridium-192 source back into a Spec 150 radiography exposure device (camera).

"Following their third exposure on a pipeline inspection at a temporary job site [near Mentone, Texas], one of the radiographers retracted the source and went to the camera to disconnect the guide tube. The 6-foot guide tube was laying over the top of the pipe they had been inspecting and the collimator was on the opposite side from the radiographer. When he disconnected the guide tube, the collimator was pulled to the top of the pipe. The radiographer's alarming rate meter sounded and his survey meter went off-scale. He left the area, monitored the 2 mR/hr boundary and called the site radiation safety officer (SRSO).

"The SRSO, on the license to perform retrievals, responded and retrieved the source. The control cable was found to be broken approximately one inch from the connector and the licensee suspects the automatic securing mechanism malfunctioned. The device and control assembly have been sent to the manufacturer for evaluation/repair.

"The radiographer's pocket dosimeter had a reading of 80 mR. The other radiographer had a reading of 10 mR on his pocket dosimeter. The SRSO had the following readings on pocket dosimeters located on his chest and taped to the backs of his hands: chest 131 mR; right hand 163 mR; and, left hand 167 mR. Their dosimetry badges have been sent for emergency processing. More information will be provided as it is obtained in accordance with SA-300.

"Device: SPEC 150 SN: 1845

"Source: Iridium-192, 66 curies, SPEC G-60, SN: XI-0909"

Texas Incident #: I-9443

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Agreement State Event Number: 52386
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHICAGO TESTING LABORATORY INC
Region: 3
City: CHICAGO State: IL
County:
License #: IL-02065-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2016
Notification Time: 13:18 [ET]
Event Date: 11/19/2016
Event Time: 18:00 [CST]
Last Update Date: 11/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GUAGE

The following information was received via E-mail:

"On Saturday at 2300 CST, the licensee's radiation safety officer called the Agency [Illinois Emergency Management Agency] to report that a vehicle carrying a moisture density gauge had been stolen. The theft had occurred around 1800 [CST] that evening while the truck was in Chicago, IL. It was reported that, at the time of the theft, the gauge was secured in the truck in accordance with the 'two lock' rule within a toolbox. The operator indicated that after he started the truck, he realized he had left his cell phone in the house and gone in to retrieve it without turning off the truck. When he returned, the truck was already being driven off down the street. The Chicago Police Department has been contacted about the theft and are aware that the gauge was present in the vehicle as well as several other company issued tools. Given the manner of the theft, it is not believed the device with radioactive sources was targeted for the theft, but that it was a theft of opportunity."

Troxler model: 3440
Serial number: 15107
Chicago Police report: HZ522208

Illinois event: IL16013

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: 52387
Rep Org: US ARMY
Licensee: US ARMY
Region: 1
City: ALBANY State: GA
County:
License #: 21-32838-01
Agreement: Y
Docket:
NRC Notified By: KAREN McGUIRE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2016
Notification Time: 13:38 [ET]
Event Date: 10/12/2016
Event Time: 14:24 [EST]
Last Update Date: 11/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JAMES DWYER (R1DO)
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST SHIPMENT OF MATERIAL CONTAINING TRITIUM

"USMC shipped the package [containing 45.06 Ci of tritium] via [common carrier] out of Hawthorne Army Depot, Hawthorne, NV on October 6, 2016 to MARCORLOGBASE, Director Fleet Support Dir Code 587, Radford Blvd, Suite 20320, Albany, GA. The package was signed for with initials and a signature showing delivery on October 12, 2016 at 1424 [EDT]. There were several attempts of delivery before the package was delivered. The initials of who signed for the shipment cannot be traced to anyone and the signature is unreadable. [The common carrier] indicates delivery to the address of a receptionist. The package had UN2911 markings on opposite sides of the package.

"USMC RADCON conducted a physical search of USMC Albany locations to include the Post Office with no results. Defense Logistics Agency (DLA) Albany was contacted and DLA performed a physical search with no results. Also, another shipment from Hawthorne was sent out to a different location, which was received. This location was checked for receipt of the concerned package. On November 2, 2016, an Albany All Hands/Base wide official message was sent out regarding the package.

"The conclusion at this time is that the package is considered missing and likely somewhere at MCLB, Albany. The US Navy indicates that physical searches and base wide notifications continue in the effort to locate the package."

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: 52398
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF YEAGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/29/2016
Notification Time: 01:41 [ET]
Event Date: 11/28/2016
Event Time: 21:05 [EST]
Last Update Date: 11/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
KARLA STOEDTER (R3DO)

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

Event Text

SECONDARY CONTAINMENT TECHNICAL SPECIFICATION NOT MET

"On November 28, 2016, starting at 2105 hrs. EST, high wind conditions encountered on site resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met numerous times. The duration of time that the secondary containment Technical Specification was not met was approximately 1 second for each instance.

"All plant equipment responded as required to the changing environmental conditions and Reactor Building HVAC returned secondary containment pressure within TS limits. At 0055 EST on November 29, 2016, high wind conditions had subsided and secondary containment vacuum was greater than the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) and steady, and the LCO was exited. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable is reportable under 10CFR50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Tuesday, November 29, 2016
Tuesday, November 29, 2016