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Event Notification Report for May 11, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/10/2017 - 05/11/2017

** EVENT NUMBERS **


52721 52723 52726 52728 52730 52742 52744

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Agreement State Event Number: 52721
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: BAXTER HEALTHCARE CORPORATION
Region: 4
City: MOUNTAIN HOME State: AR
County:
License #: GL-0026
Agreement: Y
Docket:
NRC Notified By: ANGIE D. HALL
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2017
Notification Time: 14:16 [ET]
Event Date: 04/29/2017
Event Time: 18:30 [CDT]
Last Update Date: 05/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE WITH STUCK SHUTTER

The following report was received from the State of Arkansas via e-mail:

"The Arkansas Department of Health was notified via telephone and e-mail on Monday, May 1, 2017, at approximately 1337 [CDT] of the licensee's general licensed device stuck shutter and the failure of the shutter mechanism. The equipment failure appears to have occurred from strong thunderstorms. The lockout procedure was verbally verified with the licensee.

"The licensee's fixed gauge is a ThermoFisher Scientific, Model Number E-SFL10-XX, Serial Number SP9810, which contains approximately 1,178.42 mCi Kr-85 (approximately 43.60 GBq Kr-85).

"The original activity: 1,250 mCi Kr-85 (approximately 46.25 GBq Kr-85) as of June 1, 2016. The source's Model Number is TFC-185 and the Serial Number is QC00256.

"Licensee operations with the gauge are twenty-four hours a day. The gauge has a fail-safe closing shutter mechanism and the gauge immediately went into the safe mode electronically during the thunderstorm. The closed shutter position was verified by the visual colored indicators in place.

"There have been no known radiation exposures to personnel and/or members of the public. There have been no known radiological health and safety concerns.

"The shutter will be repaired by the manufacturer today, May 2, 2017, whom will perform a root cause analysis. The State of Arkansas is awaiting information from today's evaluation, repairs, and surveys.

"The State is awaiting a 30 day written report from the licensee."

State Event Number: ARK-2017-002

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Agreement State Event Number: 52723
Rep Org: NC DEPT OF HEALTH & HUMAN SERVICES
Licensee: TROXLER ELECTRONIC LABORATORIES
Region: 1
City: RESEARCH TRIANGLE PARK State: NC
County:
License #: 032-0182-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/02/2017
Notification Time: 16:29 [ET]
Event Date: 05/01/2017
Event Time: [EDT]
Last Update Date: 05/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL SHIPMENT EXCEEDING RADIATION LIMITS

The following was received by the state of North Carolina by email:

"On 5/1/2017, licensee received a 5 gallon shielded drum containing 8 Cf-252 sources with a total activity of 148 MBq (4.0 mCi). Shipment of the sources originated from E&Z Isotope Products, License Number: 1509-19. Shipment was made through [a common carrier]. The drum was labeled Yellow-III and had a TI [Transport Index] of 9.4. The licensee followed procedures for receiving and securing radioactive materials shipments. Once the drum was secured, the licensee noted surveys of the drum were higher than expected:

Side survey of the drum was 18 mrem/hr (gamma) on contact and 90 mrem/hr (neutron) for a total of 108 mrem/hr.

Top survey of the drum was 40 mrem/hr (gamma) on contact and 400 mrem/hr (neutron) for a total of 440 mrem/hr.

Bottom survey of the drum was 3 mrem/hr (gamma) on contact and 20 mrem/hr (neutron) for a total of 23 mrem/hr.

"The drum was then shielded with polyethylene and cadmium. Upon resurveying the drum to confirm readings the following differences were noted: With the drum upright and the neutron detector on top of the drum, the reading was 400 mrem/hr. With the drum on its side and the neutron detector in contact with the drum, the reading was 440 mrem. Wipes of the drum were then taken and the results were [less than] MDL (Minimum Detectable Levels).

"The drum was then opened for further inspection by the licensee. It was noticed that a polyethylene bag containing sources was sitting on top of the shield plug and was only about 2 inches from the top of the drum and not covered by any shielding indicating that the sources were not shielded correctly prior to shipment.

"The sources were in-processed by the licensee and are still in the licensee's possession (quantity and activity as approved per their NC License).

"North Carolina Radiation Protection, [the common carrier] and E&Z Isotope Products were notified of the event on 5/1/2017.

"NC Radiation Protection is actively investigating this event at this time.

"Report ID Number (NC): NC170020

"At this time the cause and corrective action is to be determined. NC Radiation Protection will be reaching out to E&Z Isotope Products and [the common carrier] for more information. The licensee was authorized to receive the materials in the quantity and activity they received."

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Agreement State Event Number: 52726
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: EVOQUA WATER TECHNOLOGIES
Region: 1
City: UNION State: NJ
County:
License #: 506782
Agreement: Y
Docket:
NRC Notified By: JOSEPH POWER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 12:28 [ET]
Event Date: 06/04/2015
Event Time: [EDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (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 - LOST SOURCE

The following was received from the State of New Jersey via email:

"An inspection of Evoqua Water Technologies was conducted on 4/30/15. During the inspection, a device listed on Generally Licensed Device Registration Form #664 could not be found. The device was a model 4000 [SN 732], manufactured by Metorex Inc, and contained 10 mCi of Am-241. The device was listed as being at the facility since 1989. However, no current employee remembered the device being in use for several years. On 5/15/15, the original unit was discovered, but without the attached probe which contained the source. On 6/4/15, after repeated search attempts, the probe was declared lost."

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: 52728
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: VA NEW JERSEY HEALTH CARE SYSTEM
Region: 1
City: EAST ORANGE State: NJ
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: LYNN L. GRAVES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 12:58 [ET]
Event Date: 12/03/2015
Event Time: [EDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

ADMINISTERED DOSAGE DIFFERENT FROM PRESCRIBED DOSAGE

The following was received from the Veterans Affairs National Health Physics Program via email:

"As requested via a telephone conversation with the NRC Operation Center, this is a written notification, pursuant to 10 CFR 35.3045(a)(1), regarding a series of medical events that occurred at the VA New Jersey Health Care System in East Orange, New Jersey. A brief description of the events, cause of the events, and other required information are contained in the enclosure. The East Orange VA facility holds VHA Permit Number 29-04481-01 under our master material license, NRC License No. 03-23853-01VA.

"There are six apparent medical events with four resulting from the use of a pre-printed form with the incorrect unit selected; the first occurring on December 3, 2015 involving a dosage of 155 microCuries of radium-223 dichloride; the second on March 7, 2016 involving a dosage of 128 microCuries of radium-223 dichloride; the third on June 3, 2016 involving a dosage of 131 microCuries and the fourth on August 14, 2016 involving a dosage of 155 microCuries of radium-223 dichloride that was administered to patients for treatment of osseous metastases from prostate cancer. The written directives incorrectly stated the intended dosages as 155 milliCuries; 128 milliCuries; 131 milliCuries and 155 milliCuries, respectively. The fifth medical event occurred on February 20, 2016 involving a dosage of radium-223 dichloride 121 microCuries when the written directive stated 211 microCuries. The prescribed dose was 211 microCuries. The dose administered was 121 microCuries, which is a 43% variance. The whole body dose calculation is 85.50 rad/mCi x 0.09 mCi = 7.7 rem, which exceeds the 5 rem dose limit. However, the physician intended to administer 121 microCuries and had transposed the numbers on the written directive. The sixth occurred on March 28, 2017 with 25 milliCuries of sodium iodide iodine-131 where the written directive stated 25 milliCuries of radium-223 dichloride with the intended dose of 25 milliCuries of sodium iodide iodine-131 ordered and administered. No harm to the patients is expected since these treatments were successfully performed by administration of a dosage that was in accordance with the intentions of the authorized user physician. The details of corrective actions are being ascertained at the facility due to the absence of the Radiation Safety Officer at the time of discovery. NHPP [National Health Physics Program] staff was on site and discovered the events on May 2, 2017, during a routine inspection. We notified the NRC Operations Center by telephone on May 3, 2017.

"As part of our routine, we evaluated circumstances of the medical events, reviewed actions to prevent a recurrence, and assessed regulatory compliance."

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: 52730
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXON MOBILE CHEMICAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2316-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 15:57 [ET]
Event Date: 05/02/2017
Event Time: 14:00 [CDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - LEVEL DENSITY GAUGE SHUTTER STUCK OPEN

The following information was obtained from the state of Louisiana via email:

"On 05/03/2017, the Assistant Radiation Safety Officer (RSO) for ExxonMobil Chemical received notice that a level density gauge was having difficulty with the operation of the shutters on a gauge installed on a process. During follow-up checks, the one level gauge was found with shutters that were stuck in the open position and the manual operation handle had broken. The report was received by the RSO at approximately 1400 [CDT] on May 02, 2017.

"The gauge was an Ohmart Corporation Gauge, devices involved, Model Number SHF-2-45. The gauge/device S/N unknown is loaded with approximately 200 mCi of Cs-137 and the S/N 5828GK. The source and source holder usually have one S/N for the whole device. BBP Sales/Service Company was contacted to fix the problem by repairing the gauge or replacing the device. The gauge is installed on processes and does not pose a health and safety threat to the general public or the employees. The source survey revealed the readings were less than 2 mR/hr and proper safety precautions will be taken when personnel enters the area. This is considered an equipment failure with the manual shutter handle device breakage."

LA Event Report ID No.: LA-170007

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Power Reactor Event Number: 52742
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ASHLEY MALEK
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/10/2017
Notification Time: 11:46 [ET]
Event Date: 05/10/2017
Event Time: 07:55 [CDT]
Last Update Date: 05/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVID HILLS (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

OFFSITE NOTIFICATION DUE TO INADVERTENT SIREN ACTUATION

"At approximately 0755 CDT, on May 10, 2017, Pierce County inadvertently actuated their sirens while performing a scheduled weekly cancel test. All fifty two (52) Pierce County sirens actuated county wide for approximately 11 seconds before Pierce County Dispatch canceled the activation. This 4-hour non-emergency report is being made per 10 CFR 50.72(b)(2)(xi), Offsite Notification. Capability to notify the public was never degraded during this time. All Emergency Notification sirens remain in service. No press release is planned at this time. The license has notified the NRC Senior Resident Inspector."

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Power Reactor Event Number: 52744
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOHN WHALEY
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/10/2017
Notification Time: 21:40 [ET]
Event Date: 05/10/2017
Event Time: 14:11 [EDT]
Last Update Date: 05/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DON JACKSON (R1DO)

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

Event Text

APPENDIX J LOCAL LEAKAGE EXCEEDED ACCEPTANCE CRITERIA

"On Wednesday May 10, 2017, at 1411 EDT, with the reactor at 0 percent core thermal power (CTP), Pilgrim Nuclear Power Station (PNPS) was in a Refueling Outage, performing a review of Local Leak Rate Testing results, when it was concluded that PNPS had exceeded its Title 10 Code of Federal Regulations Part 50, Appendix J, Option B, Type B and C Local Leak Rate Test (LLRT) leakage criteria.

"Previously, on April 22, 2017, when PNPS was performing LLRT of the High Pressure Coolant Injection (HPCI) steam exhaust line check valves, both valves failed to meet their LLRT acceptance criteria specified in plant procedures. Neither of the check valves seated acceptably. Based on the ongoing evaluation of these test exceedances, it was concluded that these test results cause the plant to exceed the overall as-found minimum path Appendix J acceptance criteria of 0.6 La (126.3 SLM [Standard Liters per Minute]).

"Further investigation is ongoing.

"This event has no impact on the health and safety of the public.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A), any event or condition that resulted in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded.

"The licensee will notify the Commonwealth of Massachusetts Emergency Management Agency."

Page Last Reviewed/Updated Thursday, May 11, 2017
Thursday, May 11, 2017