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Event Notification Report for July 24, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/21/2017 - 07/24/2017

** EVENT NUMBERS **


52851 52853 52854 52855 52856 52858 52860 52867

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Agreement State Event Number: 52851
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: VINCE KLCO
Notification Date: 07/13/2017
Notification Time: 10:33 [ET]
Event Date: 07/12/2017
Event Time: 11:00 [MDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF TREATMENT

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

"This is an initial report regarding a misadministration event in Colorado.

"University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached.

"Follow-up information will be provided after they are available."

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: 52853
Rep Org: NV DIV OF RAD HEALTH
Licensee: MET-CHEM TESTING LABS, INC.
Region: 4
City: CARLIN State: NV
County:
License #: UT1800146
Agreement: Y
Docket:
NRC Notified By: MICHAEL W, SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 08/07/2013
Event Time: [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY DEVICE

The following was received from the State of Nevada via email:

"A radiography device was involved in a structural collapse at Barrick Goldstrike Mines, north of Carlin. A wind gust collapsed a steel tank and the scaffolding around it where a radiographer (met chem reciprocity) was working. The device fell approx. 60 ft., damaging the shutter end. The radiographer was not seriously injured and determined that the radiation source was secure and there was no leakage. He packaged the camera and returned to Utah."

Item Number: NV130013

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Agreement State Event Number: 52854
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VEGAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0720-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 01/27/2016
Event Time: 16:35 [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING AND RECOVERED TROXLER GAUGE

The following was received from the State of Nevada via email:

"Incident involving a lost Troxler Portable gauge, Model 3430, S/N 23626 was reported to the State of Nevada Radiation Control Program on 01/27/2016 at 1635 [PST].

"The RSO of Las Vegas Valley Water District reported the gauge missing. An operator was distracted before the transportation of the gauge and failed to block and brace the gauge or close the tailgate of the transport vehicle. The operator had forgotten the pound plate on-site and walked to where he left it, retrieved the plate but then was distracted and did not secure the gauge. He then started back to the office but realized part way back he had lost the gauge from the back of his vehicle. He retraced his steps, called the RSO and asked another operator to help find the gauge. The gauge was not found at that time. The RSO call the Las Vegas Metropolitan Police [LVMPD]. The Duty Officer for the State of NV, RCP [Radiation Control Program] was notified.

"Update 01/28/2016: The RCP Duty Officer received a call from LVMPD ARMOR that the General Contractor on site found the gauge on 01/27/2016 and took it his storage and secured it over night.

"Update 01/29/16: The person who found it was non English speaking and locked it up at his work. He brought it back in the morning to the general contractor who called Armor the next morning. John and I gave 3 violations for security, blocking & bracing and type A container breach (pop rivets with their license information).

"We [Radiation Control Program] leak tested the gauge and it was negative, and they are having either Troxler or the local InstroTek repair it next week. It is tagged out of service right now.

"Update 05/10/2016: The LVWD has retrained all staff on properly securing device prior to driving vehicles. Investigation is considered closed."

The Troxler Model 3430 usually contains 8mCi of Cs-137 and 40 mCi of Am241/Be.

Item Number: NV160002

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: 52855
Rep Org: NV DIV OF RAD HEALTH
Licensee: CONSTRUCTION MATERIALS ENGINEERS
Region: 4
City: RENO State: NV
County:
License #: 00-11-0009-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 06/27/2016
Event Time: 18:45 [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING AND RECOVERED TROXLER GAUGE

The following was received from the State of Nevada via email:

"On 06/27/2016 at 1845 [PDT], it was reported to the State of Nevada, Radiation Control Program that a moisture/density gauge, Troxler model 3440, containing 40mCi of Am-241/Be and 8mCi of Cs-137 was missing/lost. The gauge fell out of the back of a transport vehicle and was lost in Reno, Nevada. The gauge user set the gauge on the tailgate of his truck and took a phone call. He was distracted by the phone call and did not place the gauge in it's transport case or secure the gauge and drove back to the office where he realized the gauge had fallen out of the transport vehicle. The gauge user immediately called the RSO and retraced his route to find the gauge. The gauge was not found and it was reported to the Nevada Highway patrol, Washoe County Sheriff and Reno Police Department. The State is following the incident and working with local authorities to develop a press release. Follow-up information will be provided to NRC on the recovery of the lost gauge and entered into NMED.

"Update 6/29/2016: 2 hours following the press release, the gauge was recovered and returned to the owner."

Item Number: NV160010

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: 52856
Rep Org: NV DIV OF RAD HEALTH
Licensee: ROBINSON NEVADA MINING COMPANY
Region: 4
City: RUTH State: NV
County:
License #: 17-11-0372-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 11/02/2015
Event Time: [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER MALFUNCTION

The following was received from the State of Nevada via email:

"Report of an equipment failure incident to the State of Nevada Radiation Control Program, fixed gauge malfunctioning shutter, Ohmart model SR-A, S/N: 1015GK at the Robinson Mine, Ruth, Nevada phoned in on 01/26/2016 at 1400 [PST].

"The RSO of Robinson Mine reported the shutter malfunction. He called the vendor to come on site and force the shutter closed. They were successful. The gauge was locked out/tagged out, but not removed from the service area in the mill central processing plant. The vendor stated the shutter malfunctioned because the shielding shifted due to process vibrations. The RSO has been instructed to submit a plan for the gauge."

Gauge contained 1.85 MBq of Cs-137.

Item Number: NV160003

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Agreement State Event Number: 52858
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: GEOTEK INSITE, INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-495
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: VINCE KLCO
Notification Date: 07/14/2017
Notification Time: 11:13 [ET]
Event Date: 07/13/2017
Event Time: [MST]
Last Update Date: 07/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED SHUTTER

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

"This First Notice constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received WITHOUT verification or evaluation, and is basically all that is known by the Agency [Arizona Radiation Regulatory Agency] Staff at this time.

"During an inspection of the licensee on July 13, 2017, an inspector found one portable gauge where the radiation source exposure shutter would not close when moved to the closed position. The inspector's dose measurement at contact with the device was approximately 100 mR/hr. The gauge is a Troxler model 3430, Serial Number 30302, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241. The licensee has contacted a repair company to fix the gauge as soon as possible.

"The Agency is investigating the event.

"The Governor's office and U.S. NRC are being notified of this event. "

Arizona First Notice: 17-009

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Agreement State Event Number: 52860
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VEGAS PAVING CORP
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0255-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/14/2017
Notification Time: 16:36 [ET]
Event Date: 07/14/2017
Event Time: [PDT]
Last Update Date: 07/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED PORTABLE GAUGE

The following was received from the State of Nevada via email:

"It was reported to the Nevada Radiation Control Program duty officer that a portable gauge had been recovered at a temporary job site in Las Vegas, Nevada. The individual who reported the event is a Nevada radioactive material licensee and said on 7/14/2017, at approximately 0735 [PDT], 'a nuclear density gauge was found in North Las Vegas at Cheyenne Ave and Berg St on the road. The gauge was recovered by an employee and quickly brought it to a secure storage location. The gauge was found in good condition and not damaged or source exposed.' At 0930 [PDT] on 7/14/2017, it was reported to the Nevada Radiation Control Program, by the ARSO from the company who lost the gauge, the gauge fell off the tailgate of a transport vehicle at a temporary jobsite, and the operator realized the loss and returned to the site within 5 minutes, but the gauge had already been recovered by [the reporting licensee]. The operator from [the licensee who lost the gauge] was informed that the gauge was recovered by [the reporting licensee] and relayed that information to the ARSO at [the licensee who lost the gauge]. The gauge was intact, no damage, transported back to the owner's storage location, and taken out of service. An investigation of the event will commence [on] 07/17/2017."

Item Number: NV170006

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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Part 21 Event Number: 52867
Rep Org: SUSQUEHANNA NUCLEAR LLC
Licensee: EATON/CUTLER HAMMER
Region: 1
City: BERWICK State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JASON JENNINGS
HQ OPS Officer: VINCE KLCO
Notification Date: 07/21/2017
Notification Time: 10:40 [ET]
Event Date: 07/14/2017
Event Time: 16:46 [EDT]
Last Update Date: 07/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - EATON/CUTLER HAMMER A200 SERIES STARTER

The following information was received by the licensee via email:

"Pursuant to 10 CFR 21, this is a non-emergency notification by Susquehanna Nuclear, LLC concerning a defect in an Eaton/Cutler Hammer A200 series starter that failed while in service at Susquehanna Steam Electric Station. The failed starter was manufactured by Eaton Corporation in 2014 and purchased by Susquehanna from AZZ/NLI as part of an MCC bucket assembly. The starter failed with its contacts stuck in the energized state when it was de-energized. A failure analysis identified the contactor sticking to be due to the pole faces of the coil laminations and those of the armature laminations adhering to one another at normal operating temperatures. There was residue/material on the pole faces which closely matched Polydimethylsiloxane (PDMS) and silicone grease. One of the characteristics of PDMS is that at cooler temperatures it is more of a solid consistency, and at higher temperatures it becomes more viscous and tacky.

"A previous Part 21 report submitted by Curtiss-Wright QualTech NP (Event Notification Number 51611) in December 2015 provided notification of Eaton/Cutler Hammer A200 series starters failures due to silicon based mold release that remained on the molded parts and would come between the moving (magnet) and fixed armatures. The Part 21 stated that when heated for extended period of time, the material would become sticky causing anywhere from a minor delay in opening to a frozen closed condition. Eaton/Cutler Hammer determined that the silicone mold release was first introduced into the manufacturing facility in May 2008 and used periodically until October 2012. According to Eaton/Cutler Hammer, any starters manufactured after January 1, 2013 should be silicon mold release free.

"Following the failure of the 2014 starter at Susquehanna, Eaton Corporation performed an investigation and reconfirmed that silicon mold release was banned from molding production in October 2012 and has not been used since that time. Eaton concluded that the contamination does not appear to be systemic, but rather random and intermittent and that the contamination was most likely introduced either by operators and assemblers on the manufacturing lines, or by others who disassemble and inspect the product after shipment from their plant. Susquehanna does not take the components apart during receipt for testing or visual inspection. Eaton concluded that there is no evidence that the issue is systemic and considers it a random event. Susquehanna has evaluated the condition and has concluded that the condition could create a substantial safety hazard."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, July 24, 2017
Monday, July 24, 2017