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Event Notification Report for March 27, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/24/2017 - 03/27/2017

** EVENT NUMBERS **


52613 52614 52616 52617 52620 52622 52638 52639 52640

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Agreement State Event Number: 52613
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: JOHNS HOPKINS UNIVERSITY
Region: 1
City: BALTIMORE State: MD
County:
License #: MD-07-005-05
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/16/2017
Notification Time: 09:44 [ET]
Event Date: 03/15/2017
Event Time: [EDT]
Last Update Date: 03/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR ROD STUCK IN UP POSITION

The following report was received from the Maryland Radioactive Materials Division via email:

"This afternoon [3/15/17], our [Johns Hopkins University (JHU)] JL Shepherd Mark I irradiator malfunctioned. This is a manual model. The source is lifted up into position by a knob that lifts a rod attached to the source. When lifting the knob up, the rod became jammed. The rod is stuck in an up position, slightly past halfway. It will not move up or down.

"JL Shepherd was called for help. One suggestion was to move the knob slightly from side to side while lifting or lowering. This had no effect. Because this is a manual model not much can be done besides a repair by manufacturer. The technician [at JL Shepherd] said the most likely cause was due to some part (bearing, spring, etc.) falling down into transfer tube causing it to jam.

"The irradiator's power supply is controlled by computer and is off now. The door latch on the irradiator is locked. The alarming area radiation monitor on the irradiator door is on and functioning. The key to both the irradiator controller and the door latch have been removed from the irradiator room. The irradiator room is locked and monitored by corporate security and a Remote Monitoring System. The irradiator room is only accessible to approved individuals. Because this unit is a self-shielded irradiator, radiation levels outside the unit are minimal, <0.2 mR/hr) even with the source being partially exposed inside. There is no sample inside the chamber. There is no way to physically open the irradiator door due to an electric interlock. The interlock will not function without power and will not function without the rod in the fully down position. A sign has been put on the irradiator, 'Do Not Use'.

"JL Shepherd was scheduled to visit [the JHU] site to calibrate another irradiator in March. On Thursday we [JHU] will find out when we [JHU] can have a technician here to fix the problem.

"Source Make: J.L. Shepherd and Associates
Source Model: 6810-G
Source Serial #: 81Cs-S14
NSTS Source ID Number: 6729
Isotope: Cs-137
Activity: 5329 Ci
Activity Date: 02/25/2017"

MD Event Report ID No.: 52613

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Non-Agreement State Event Number: 52614
Rep Org: SIOUXLAND UROLOGY CENTER
Licensee: SIOUXLAND UROLOGY CENTER
Region: 4
City: DAKOTA DUNES State: SD
County:
License #: 40-34223-01
Agreement: N
Docket:
NRC Notified By: RUSS RUPOLO
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/16/2017
Notification Time: 14:28 [ET]
Event Date: 03/16/2017
Event Time: 08:00 [CDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - PATIENT DOSAGE HIGHER THAN PRESCRIBED

At approximately 0800 CDT today, a patient was treated with 110 Palladium-103 seeds (1.68 milliCuries each) to the prostrate. The quantity was determined by calculation for a prescribed dose of 125 Gy, however the calculation was incorrect. The mistake was discovered after the patient's treatment. Only 80 seeds should have been implanted. The activity injected is 38 percent higher than prescribed.

The referring physician has been notified. The physician is notifying the patient. It is believed that this event will not result in any harm to the patient. The licensee is in the process of determining corrective action to prevent reoccurrence.

* * * UPDATE FROM GREG HAAR TO BETHANY CECERE VIA EMAIL 1241 EDT ON 3/17/17 * * *

"This email is to confirm our notification to the NRC of a possible medical event that occurred during an LDR [Low Dose Rate] brachytherapy prostate seed implant at our clinic on (3/16/2017) at approximately 0800 [CDT]. The associated license number is #40-34223-01.

"The procedure was a Palladium-103 implant, with a prescribed dose of 125 Gy. The implant was using Pd-103 seeds with an average activity of 1.68 milliCuries per seed. During this implant, 110 seeds were implanted into the patient instead of 80 seeds. This resulted in a total implanted activity of 184.8 milliCuries, which we estimate to exceed the prescribed dose to the patient by 20 percent.

"The patient and the referring physician have been notified."

Notified R4DO (O'Keefe) and NMSS Events Notification (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: 52616
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THE AMERICAN ONCOLOGY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0293
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/17/2017
Notification Time: 12:52 [ET]
Event Date: 03/16/2017
Event Time: [EDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT DOSAGE LOWER THAN PRESCRIBED

The following report was received via email:

"On March 16, 2017, a patient was prescribed a 12.16 milliCurie treatment dosage of Y-90 Sirspheres. As the AU [Authorized User] was pushing on the syringe he noticed a strong resistance, as did the interventional radiologist. Therefore, the administration was stopped to prevent any further safety issues. The micro catheter was pulled from the patient and the vial with the micro catheter and other radioactive waste was put in the jar for measuring. As the micro catheter was pulled, a very small defect was observed. The activity administered was 53% less than the prescribed dosage (5.64 milliCuries). The outer wrapping of the catheter was kept. The patient will be notified once recovered from the anesthesia. The licensee is investigating.

"The cause of the event may be a potential manufacturing defect.

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

PA Event Report ID No: PA 170005

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: 52617
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: PA-0415
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/17/2017
Notification Time: 13:14 [ET]
Event Date: 03/17/2017
Event Time: 07:00 [EDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
HAROLD GRAY (R1DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
BERNARD STAPLETON (IRD)

Event Text

AGREEMENT STATE REPORT - TRANSPORTATION ACCIDENT DAMAGING LICENSED MATERIAL

The following report was received via email:

"At about 0700 [EDT] on March 17, 2017, the Department [Pennsylvania Bureau of Radiation Protection] received notification through the Pennsylvania Emergency Management Agency of a vehicle fire near mile marker 286 on I-76 (PA Turnpike) [near Reading, PA]. The vehicle was carrying approximately 0.6 Ci (22 GBq) Tc-99m and 1 Ci (37 GBq) of F-18 for Cardinal Health (PA licensee PA-0415). Department emergency response and radiological health physics staff responded to the scene. The vehicle was entirely engulfed in flames and allowed to burn itself out. There are no reports of injuries. A representative from the licensee was on scene and collected contaminated debris and ash which was returned to their facility for decay.

"The vehicle will be removed from the scene and isolated to allow any remaining material to decay. Departmental health physics inspector will oversee operations."

PA Event Report ID No: PA 170006

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Agreement State Event Number: 52620
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GFK & ASSOCIATES
Region: 4
City: DUBLIN State: CA
County:
License #: 6810-01
Agreement: Y
Docket:
NRC Notified By: EPHRIME MEKURIA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/17/2017
Notification Time: 16:45 [ET]
Event Date: 03/16/2017
Event Time: 16:04 [PDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"RHB-North [Radiologic Health Branch - North] received an email from CDPH [California Department of Public Health], Emergency Preparedness Office, Disaster Information Coordinator that they received a message from CAL OES [California Office of Emergency Services] stating that a nuclear density gauge was run over and damaged by earth moving equipment.

"Incident location: 308 Love Lane, Danville, CA 94526 - Contra Costa County, time 16:04 [PDT].

"RHB North contacted the Manager, Pacific Nuclear Technology (PNT), to survey the area and collect the damaged gauge. [He] went to the incident location, evaluated the moisture density gauge, and confirmed that the sealed sources Cs-137 and Am-241:Be were intact and were in the shielded position. In addition [he] surveyed the gauge and the surrounding area with a Ludlum Model 3, PR 44-9 and found no contamination, [he] further verified that exposure at 1 meter was 0.4 mRem/hr.

"Because the source was not damaged and the TI [Transportation Index] was within the limit, the licensee owner/operator insisted in taking the damaged gauge to the storage location . . . . [The owner/operator] said that the following day he will take the damaged gauge to CPN InstroTek Inc. for exchange or disposal.

"On March 17, 2017 RHB-North verified that CPN InstroTek Inc. has received the damaged gauge and the leak test result was negative.

"PNT equipment: Ludlum Model 3, PR 44-9, Calibration date 04/28/2016."

5010 Number: 031617

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Agreement State Event Number: 52622
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: RANGER EXCAVATING LP
Region: 4
City: AUSTIN State: TX
County:
License #: 06314
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/18/2017
Notification Time: 13:54 [ET]
Event Date: 03/18/2017
Event Time: 06:15 [CDT]
Last Update Date: 03/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
DESIREE DAVIS (ILTA)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On March 18, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that a Troxler model 3440 moisture density gauge, serial #64732, containing a 1.48 GBq (40 mCi) Am-Be source and a 0.3 GBq (8 mCi) Cs-137 source was stolen. The licensee stated a technician improperly took the gauge home and left it in the back of his pickup truck. The sources were locked and inside their case. The case was secured by two locking mechanisms, both were cut sometime during the night before 0615 [CDT]. Local law enforcement was notified. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9472

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: 52638
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DON HARTINGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/24/2017
Notification Time: 17:15 [ET]
Event Date: 03/20/2017
Event Time: 16:39 [CDT]
Last Update Date: 03/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ROBERT ORLIKOWSKI (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

HISTORICAL EVENT RELATED TO PAST OPERABILITY

"On February 3, 2017, Prairie Island staff performed maintenance on the transom above Battery Room Door 225. This activity resulted in the transom being unlatched for approximately five minutes. On February 6, 2017, a question from the NRC Resident Inspector resulted in an evaluation of this condition for past operability. On March 20, 2017, the past operability evaluation of Door 225 concluded that, in the event of a postulated HELB [High Energy Line Break], the transom being unlatched during the five minute maintenance period resulted in the inoperability of multiple systems in the Unit 1 and Unit 2 battery, auxiliary feedwater, and Unit 1 safeguards bus rooms that would be required to mitigate the postulated HELB.

"The loss of safety functions required to mitigate the postulated HELB make the condition reportable under 50.72(b)(3)(ii) for an unanalyzed condition that significantly degrades plant safety.

"Unlatching the transom above the Battery Room Door creates an opening not accounted for in design bases documents. This occurred due to an improperly prepared work permit. Corrective actions are in place to preclude recurrence."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 52639
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: SCOTT BRAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/24/2017
Notification Time: 20:25 [ET]
Event Date: 03/24/2017
Event Time: 20:00 [EDT]
Last Update Date: 03/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MIKE ERNSTES (R2DO)

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

VIRGINIA DEQ NOTIFIED OF SMALL GLYCOL RELEASE TO JAMES RIVER

"On 03/24/2017 at approximately 1500 hours [EDT], a hydraulic line on vendor supplied cleaning equipment failed and leaked approximately 8 gallons of 65% glycol solution into the Surry Power Station Unit 2 D intake bay. Since the intake bay communicates with the James River, the State of Virginia Department of Environmental Quality (DEQ) was notified of the discharge at 2000 hours.

"The glycol solution is water soluble and dispersed quickly. All work stopped while the issue is being investigated and corrective actions implemented. No sheen was observed and no impact to state waters is expected to result from this issue.

"This non-emergency notification is being made in accordance with 10 CFR 50.72(b)(2)(xi), any event or situation related to the protection of the environment for which notification to other government agencies has been made."

The NRC Senior Resident Inspector has been notified.

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Power Reactor Event Number: 52640
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: ANDREW MCNEIL
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/25/2017
Notification Time: 09:28 [ET]
Event Date: 03/25/2017
Event Time: 01:42 [EDT]
Last Update Date: 03/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRICE BICKETT (R1DO)

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

REFUELING WATER TANK LEVEL INADVERTENTLY LOWERED BELOW TS

"While performing a purification subsystem alignment on the Unit-2 Refueling Water Tank, an inadvertent transfer of Refueling Water Tank level to the common Spent Fuel Pool occurred. This transfer resulted in lowering Unit-2 Refueling Water Tank level below the Technical Specification [TS] required limit for the current mode of operation at 0142 [EDT] on 3/25/17. Upon recognition of the inadvertent transfer, Operations secured the lineup and restored Unit-2 Refueling Water Tank level to its normal operating band at 0225 on 3/25/17.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) '...any event or condition that at the time of discovery could have prevented the fulfillment of the safety function structures or systems that are needed to mitigate the consequences of an accident.' With less than the required Technical Specification volume in the Refueling Water Tank, insufficient volume existed in the Refueling Water Tank to maintain 30 minutes of full flow Safety Injection, and subsequent continued pump operation after transition to recirculation mode of operation."

This level is required by Technical Specification 3.5.4.B and has a one hour action statement to restore level.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Monday, March 27, 2017
Monday, March 27, 2017