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Event Notification Report for March 15, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/14/2017 - 03/15/2017

** EVENT NUMBERS **


52593 52595 52596 52598 52603 52604 52606 52608 52609 52610 52611

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Agreement State Event Number: 52593
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/06/2017
Notification Time: 11:40 [ET]
Event Date: 03/04/2017
Event Time: [EST]
Last Update Date: 03/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING IODINE 125 CALIBRATION SOURCES

The following information was provided by the State of New York via Facsimile:

"A New York Licensee's RSO [Radiation Safety Officer] left voice mail on March 5, Sunday afternoon, stating that he was informed on the evening of the previous day (March 4, 2017) that 2 vials containing 15 seeds of I-125 that were to be used for calibration purposes were missing from their inventory. The total activity of the 15 seeds was reported to be less than 7 mCi. The surface exposure rates at the exterior of the lead shielded vials was stated to be at background radiation levels. The AU [Authorizing User] physician and the RSO conducted a thorough search on March 5, 2017, but and were unable to locate the seeds.

"DOH will staff became aware of the event earlier this morning [March 6, 2017] on arrival at work. Will update after following up with the licensee."

NY State Event Report ID NO. NYDOH-NY-17-05

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: 52595
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TICONA POLYMERS INC
Region: 4
City: BISHOP State: TX
County:
License #: L-02411
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/07/2017
Notification Time: 11:32 [ET]
Event Date: 03/06/2017
Event Time: 18:30 [CST]
Last Update Date: 03/07/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER DEVICE

The following was received by email from the Texas Department of State Health Services:

"On March 7, 2017, the Agency [Texas Department of State Health Services] was contacted by a representative of the licensee to report that on the previous day a gauge was found to have a stuck shutter. The gauge is a Berthold LB 7442D with a 30 mCi Cs-137 source. The shutter is stuck in the normal operating position. The licensee is in contact with the manufacturer for a repair plan and with licensing for an exemption to operate the gauge temporarily with a stuck shutter. No exposures to the public are expected. Additional information will be shared as it becomes available in accordance with SA-300.

"Texas Incident #: I-9470"

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Non-Agreement State Event Number: 52596
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: PATTON PETTIJOHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/07/2017
Notification Time: 13:44 [ET]
Event Date: 03/06/2017
Event Time: 20:00 [YST]
Last Update Date: 03/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JESSE ROLLINS (R4DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

RADIOGRAPHY CAMERA SOURCE DID NOT LOCK IN THE SHIELDED POSITION WHEN RETRACTED

While performing radiography in arctic conditions at the Alpine oil field between ice roads CD1 and CD5, the radiographer retracted the source after an exposure and failed to recognize that the source was not in the locked position. Prior to moving the radiography camera to the next area for an exposure, the survey indicated the source was in the shielded position. The radiographer picked up the camera to take it to the next weld location for an exposure. When the radiographer placed the radiography camera down, his dosimeter rate alarm sounded, his survey meter (on the 10 scale setting) was off scale and his pocket dosimeter was off scale. It is believed that during the moving of the camera to the next shot location the source came out of the fully shielded position. The exact time and distance of the exposure is not known. Calculations show that the radiographer may have received between 3.5R - 39R of exposure. The radiographer's dosimeter has been sent for processing and results are expected in approximately 2 days. The assistant radiographer was not in the direct vicinity and received no exposure due to this event. The radiography camera involved was a QSA Global Model 880D with a 84.6 Ci Ir-192 source.

* * * UPDATE FROM PATTON PETTIJOHN TO HOWIE CROUCH AT 1148 EDT ON 3/13/17 * * *

The badge reading of the radiographer indicated that he received 452 mR exposure for the month therefore no overexposures occurred due to this event.

Notified R4DO (O'Keefe), NMSS (McIntosh) and NMSS Events Notification email.

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Agreement State Event Number: 52598
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: REGENTS OF THE UNIVERSITY OF CA-UCSF
Region: 4
City: SAN FRANCISCO State: CA
County:
License #: 1725-38
Agreement: Y
Docket:
NRC Notified By: ARUNIKA HEWADIKARAM
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/07/2017
Notification Time: 20:00 [ET]
Event Date: 02/23/2017
Event Time: [PST]
Last Update Date: 03/07/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSNS (MEXICO) (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was provided by the State of California via email:

"On 02/23/17, the RSO [Radiation Safety Officer] contacted RHB [California Radiologic Health Branch] to report a lost I-125 seed with an activity of 0.388 mCi. Licensee stated that three lead pigs each with an I-125 seed (0.303 mCi and 0.388 mCi from February 22nd and a 0.388 mCi I-125 seed from February 8th) believed to be accidentally thrown in Mission Bay Hospital general waste. When this was discovered, licensee contacted Recology, requested an urgent pickup of their waste compactor container at Recology site on 02/23/17. Digging through the waste, licensee was able to locate two of the three lead pigs (both from February 22nd). The pig containing 0.388 mCi I-125 from February 8th was not recovered and believed to be buried in the landfill. UCSF [University of California, San Francisco] was getting seeds from Oncura, [which] was recently bought out by Theragenics. UCSF medical physicists were accustomed to receiving just the patient seeds. Theragenics, the new vendor, had included an additional calibration seed in a separate led pig in the same package and physicist were not looking for this additional seed.

"RHB will be following up on the corrective actions."

CA 5010 Number: 022317

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: 52603
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: TEAM INDUSTRIAL SERVICES INC.
Region: 3
City: ROSEVILLE State: MN
County:
License #: 1192
Agreement: Y
Docket:
NRC Notified By: TYLER S. KRUSE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/10/2017
Notification Time: 13:08 [ET]
Event Date: 03/09/2017
Event Time: [CST]
Last Update Date: 03/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK JEFFERS (R3DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIRE DURING RADIOGRAPHY OPERATIONS

The following information was provided by the State of Minnesota via email:

"A Team Industrial Services radiography crew was working at Flint Hills Refinery on March 9, 2017. Approximately 7 minutes after starting a 13 minute exposure, one of the radiographers (Radiographer 1) noticed a fire had started near the exposure device. Radiographer 1 instructed the other radiographer (Radiographer 2) to call the plant's fire department and notify the Team's lead radiographer at their Rosemount location. Radiographer 1 then attempted to retract the source and was unsuccessful. Radiographer 1 then successfully extinguished the fire however the fire started again shortly after. At this point Radiographer 1 exited the unit. [The Team's lead radiographer] instructed the crew to extend their boundaries and wait for assistance. [The Team's lead radiographer] contacted the Team's Radiation Safety Officer.

"The fire department arrived and was able to extinguish the fire from a ladder truck located outside the radiographer's boundaries. The Team's lead radiographer and [another individual] arrived on-site and assessed the situation. Other available radiographers were dispatched to the site to assist in monitoring the site boundaries. [The Team's lead radiographer] sent pictures of the site to [the Team's Radiation Safety Officer] who contacted QSA for assistance in planning the source retrieval. The retrieval team was able to identify that the drive cables conduit was melted, exposing the drive cable and separating the connection from the camera causing the crank to malfunction. They manually attempted to retract the drive cable and were able to confirm with survey meters that the source was still connected to the drive cable. The drive cable was manually retracted and the source was pulled into the shielded position. Surveys were taken to confirm the source was shielded, and the source was locked in position.

"The source has been leak tested and the sample was overnighted to QSA for analysis. The plant is assessing the situation and will issue a report regarding the cause of the fire. The pocket dosimeter readings for the crew were as follows:

Radiographer 1: 54 mR
Radiographer 2: 15 mR
Another individual: 13 mR
Team's lead radiographer: 5 mR

"The licensee is in the process of assessing the dose received by the fire fighters, however it is assumed that their doses were minimal based on the doses received by the radiography crew and their distance from the source. The licensee is preparing and will issue a written report within the required 30 day time frame.

"Exposure device: QSA 880 D. Source: A-424-9, Ir-192, 64 curies"

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Agreement State Event Number: 52604
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NUTTING ENGINEERS
Region: 1
City: BOYNTON BEACH State: FL
County:
License #: 0934-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/10/2017
Notification Time: 13:52 [ET]
Event Date: 03/10/2017
Event Time: [EST]
Last Update Date: 03/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The following report was received from the State of Florida Bureau of Radiation Control via email:

"[The licensee] left the gauge on the tailgate of his truck and drove away from the jobsite. Realizing that he had forgotten to secure the gauge properly he retraced his travel back to the last known location, but could not find the missing gauge.

"Device Type: Moisture Density
Manufacture: Troxler
Model Number: 3430
Serial Number: 70824
Isotope and Activity: Cs-137, 8 mCi and AmBe 40 mCi.

"Florida Incident Number: FL17-074"

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: 52606
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOURCE PRODUCTION & EQUIPMENT COMPANY, INC.
Region: 4
City: ST. ROSE State: LA
County:
License #: LA-2966-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/13/2017
Notification Time: 11:48 [ET]
Event Date: 03/13/2017
Event Time: 09:50 [CDT]
Last Update Date: 03/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
PAM HENDERSON (NMSS)
JEFF GRANT (IRD)
ADAM TUCKER (ILTA)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IR-192 SOURCE SHIPPED TO THE WRONG LOCATION

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

"On Friday, March 10, 2017, TEAM Industrial Services, Inc., in Borger, TX expected to receive two Ir-192 radiography camera sources from Source Production & Equipment Co., Inc., in St. Rose, LA. Only one source arrived at TEAM Industrial. The transportation company began a search for the missing source and discovered that the source had been shipped to Portland, OR. The source, 105 Ci of Ir-192 (as of 3/13/17), is enroute to TEAM Industrial in Texas and expected to be there by Thursday 3/16/17. The source was a G-60 source, serial number YC0801, in a SPEC-150, serial number 137."

Louisiana Event Report ID No.: LA170003

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 52608
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: GERDAU AMERISTEEL US, INC.
Region: 3
City: ST. PAUL State: MN
County:
License #: 1109
Agreement: Y
Docket:
NRC Notified By: LYNN FORTIER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/13/2017
Notification Time: 17:11 [ET]
Event Date: 03/09/2017
Event Time: [CDT]
Last Update Date: 03/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK IN OPEN POSITION

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

"Minnesota Dept. of Health [MDH] was notified by phone message March 10, 2017. The message was retrieved March 13, 2017 by the RAM [Radioactive Material] unit Supervisor. MDH visited the site March 13, 2017 and gathered the following information regarding the source holder.

"Category: External EMS Housings
Source Model: P-2608-100 (Co-60)
Gauge Model: LB 300 ML
Manufacture Date: 10/2013
Manufacturer: Berthold Systems, Inc.
Source Number: 1816-10-13 (mold housing 12)
Original Activity: 1.5 mCi
Current Activity: 1.4050 mCi

"The licensee is a steel processor and the incident involved molten steel encasing the source holder, locking the shutter in an open position. This is not a typical occurrence. The licensee is working with a consultant (Applied Health Physics) to develop a plan for removing the source holder from the mold and determining whether the source holder is repairable or if it needs to be disposed of."

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Power Reactor Event Number: 52609
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: JUSTIN WIEMER
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/13/2017
Notification Time: 17:45 [ET]
Event Date: 03/13/2017
Event Time: 15:45 [CDT]
Last Update Date: 03/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
NEIL OKEEFE (R4DO)

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

SAFEGUARDS REPORT - DEGRADED VITAL AREA BARRIER

Safeguards system degradation related to vital area barrier. Compensatory actions taken.

The licensee will notify the NRC Resident Inspector.


* * * UPDATE ON 3/14/17 AT 1728 EDT FROM JUSTIN WIEMER TO DONG PARK * * *

Safeguards system degradation related to vital area barrier potentially occurred earlier than originally reported. Compensatory actions remain in place.

The licensee has notified the NRC Resident Inspector.

Notified R4DO (O'Keefe).

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Agreement State Event Number: 52610
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AESCO TECHNOLOGIES, INC.
Region: 4
City: HUNTINGTON BEACH State: CA
County:
License #: 7197-30
Agreement: Y
Docket:
NRC Notified By: KATHLEEN HARKNESS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/13/2017
Notification Time: 18:09 [ET]
Event Date: 03/12/2017
Event Time: [PDT]
Last Update Date: 03/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSNS (MEXICO) (FAX)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

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

"A Troxler model 3440, serial number 69286 moisture density gauge was stolen from a gauge user's locked vehicle during the night of March 11, 2017. The vehicle was parked at his residence overnight (in Northridge, CA and with permission from the RSO) due to an early morning job on March 12, 2017. This Troxler model contains an 8 mCi Cs-137 sealed source and a 40 mCi Am-241:Be sealed source.

"The Troxler's Cs-137 source rod was locked into SAFE mode with a padlock and the transport case had two locked padlocks. One chain with two locks secured the transport case to the crew cab seat, within the locked truck. Los Angeles Police Dept. [LAPD] responded and found the truck's window had been broken. The police took fingerprints from the vehicle and filed a report. In addition, LAPD advised AESCO to place a Craigs List ad under Lost and Found offering a reward for the return of the stolen gauge."

California report number: 5010-031217


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: 52611
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2017
Notification Time: 17:35 [ET]
Event Date: 02/16/2017
Event Time: [CDT]
Last Update Date: 03/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was received from the Commonwealth of Kentucky via email:

"Hardin Memorial Hospital (HMH) reported that a patient only received 106 mCi of I-131, instead of the prescribed 150 mCi post-thyroidectomy on 2/16/17. Two capsules of I-131 were received from the radiopharmacy in a single vial. When the technologist gave the patient the vial, the patient shook the contents of the vial into her mouth only swallowing one capsule. The tech did not see one capsule remained in the vial. Surveys on the package (containing the vial) that was to be sent back to the radiopharmacy were higher than background so [it] was held for decay. Another survey on 2/28/17 was taken and was still higher than background so the tech opened the package and discovered the remaining pill."

Kentucky Event Report ID No.: KY170002

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.

Page Last Reviewed/Updated Wednesday, March 15, 2017
Wednesday, March 15, 2017