| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
03/15/2016 - 03/16/2016 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 51774 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALLEGHENY GENERAL HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOESPH MELNIC
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 03/07/2016
Notification Time: 14:56 [ET]
Event Date: 03/02/2016
Event Time: [EST]
Last Update Date: 03/07/2016 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANGELA MCINTOSH (NMSS)
| Event Text AGREEMENT STATE REPORT - CONTAMINATION EVENT WITH POSSIBLE SHALLOW DOSE EXCEEDING FEDERAL LIMITS
The following report was received from the Commonwealth of Pennsylvania via facsimile:
"Notifications: The event occurred on March 2, 2016, the licensee discovered the event on March 3, 2016, and notified the Department [Pennsylvania Department of Environmental Protection] on March 4, 2016, via a phone call. The event is reportable per 10 CFR 30.50(b)(1)(i) and 10 CFR 20.2202(b)(1)(iii).
"Event Description: On March 2, 2016, a technologist was injecting a samarium-153 'Quadramet' dose (approximately 81 milliCuries) when there was a problem with the syringe/tubing connection. A 'blowback' occurred and a small amount, believed to be approximately 1-2 mCi, of the dose spilled. The patient was released [and sent] home. The technologist stated that he had gloves on, washed his hands, surveyed the area and called the lead technologist to notify her of the incident. Radiation Safety [at the hospital] was not notified until March 3rd. The technologist was surveyed and found to have contamination on his hands and forearms. An initial calculation indicated a skin dose above 50 rem. Radiation Safety then took smears throughout the department and contamination was found on various surfaces including the floor, other technologist's hands, gloves, shoes, survey meters, chairs, and clothing. Removable contamination was also found in a technologist's vehicle. Radiation Safety has decontaminated most areas. Surfaces and rooms that were not able to be decontaminated were closed off (for decay) or covered with paper to prevent any further spread of contamination. It is believed that after the spill, the technologist attempted to clean up the area. Apparently it was not sufficient, for when housekeeping did their routine cleaning, they may have unknowingly further spread the contamination with floor mopping and other cleaning. No biological effects are expected with any individual. The RSO [Radiation Safety Officer] feels that a 'medical event' did not occur with the patient. The patient returned for a scheduled scan on March 3rd, and that scan appeared normal. The patient did not show any signs of detectable contamination on her skin.
"Cause of the Event: Human error. The technologist may not have followed proper procedures, and contributed to the contamination spreading beyond initial spill area.
"Actions: A reactive inspection is planned by the Department [Pennsylvania Department of Environmental Protection]. More information will be provided upon receipt."
Event Report ID No: PA160008 |
| Fuel Cycle Facility | Event Number: 51776 | Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: CHARLES SLAMA
HQ OPS Officer: HOWIE CROUCH | Notification Date: 03/07/2016
Notification Time: 19:17 [ET]
Event Date: 03/07/2016
Event Time: 16:15 [MST]
Last Update Date: 03/07/2016 | Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
| Person (Organization):
MARVIN SYKES (R2DO)
SHANA HELTON (NMSS)
WILLIAM GOTT (IRD)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text ADMINISTRATIVE ITEMS RELIED ON FOR SAFETY (IROFS) NOT PERFORMED
"During the afternoon of March 7, 2016, UUSA [Urenco USA] operators moved drums containing uranic material into an IROFS [Items Relied On For Safety] controlled array. This IROFS requires initial and independent operator verification to ensure a subcritical geometry exists prior to adding any new material to the array. The operators moving the drums did not perform the administrative IROFS; that is, neither an initial nor an independent
verification were completed prior to adding five additional drums to the array.
"UUSA management and nuclear criticality staff have ensured the drums are in a safe and subcritical configuration.
"The drums contain clean up materials contaminated with UF6 at unknown levels of enrichment. A nuclear criticality did not occur. The array is in a subcritical geometry. No external events are affecting this event. No emergencies have been, nor will any be declared.
"No state or other federal agencies will be notified. No press releases are planned.
"Number and types of controls necessary under normal operating conditions: One enhanced sole IROFS. The enhancement is an initial verification and an independent verification of geometry prior to movement of material into the area.
"Number and types of controls which functioned properly under upset conditions: Neither the IROFS initial verification, nor the independent verification of geometry were performed before movement occurred.
"Number and types of controls necessary to restore a safe situation: A member of operations management passed through during a routine plant tour, questioned the operators, and determined that the drums had been placed in a safe geometry in the array without performing the required IROFS surveillance.
"Safety significance of events: Loss of geometry controls preventing criticality.
"Safety equipment status: The array is in a subcritical geometry.
"Status of corrective actions: Corrective actions to be developed." |
| Agreement State | Event Number: 51778 | Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TICONA POLYMERS, INC
Region: 4
City: BISHOP State: TX
County:
License #: 02441
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DANIEL MILLS | Notification Date: 03/08/2016
Notification Time: 09:42 [ET]
Event Date: 03/07/2016
Event Time: [CST]
Last Update Date: 03/08/2016 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text AGREEMENT STATE REPORT - DENSITY GAUGE STUCK SHUTTER
The following was received from Texas via email:
"On March 7, 2016, the Agency [Texas Dept. Of State Health Services] was notified by the licensee that while performing routine checks, the shutter on an Ohmart SH-F2 nuclear gauge was stuck in the open position. Open is the normal operation position for the shutter. The gauge contains a 100 millicurie cesium-137 source. The gauge does not create an exposure hazard to the licensee's employees or any member of the general public. The licensee has contacted their service company who will inspect the gauge on March 9, 2016. Additional information will be provided as it is received in accordance with SA-300."
Texas incident # I-9384 |
| Agreement State | Event Number: 51779 | Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: WORLD TESTING, INC.
Region: 1
City: MOUNT JULIET State: TN
County:
License #: MS-1035-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 03/08/2016
Notification Time: 15:34 [ET]
Event Date: 03/06/2016
Event Time: 22:33 [CST]
Last Update Date: 03/08/2016 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE
The following report was received from the State of Mississippi via facsimile:
"The Licensee notified DRH [Mississippi Department of Radiation Health] on 3/7/2016, that an incident had occurred at 2233 [CST on 3/6/16], at the client's site [in Holly Springs, MS]. The Licensee's two (2) man radiography crew was performing radiography inside a twelve (12) foot, open end vessel, thirty six (36) feet long, and nine (9) foot off the ground. The radiography camera in use was a Sentinel model 880D, serial No. D1120. During one exposure the guide tube became crimped preventing the source from retracting back into the camera. This was due to the camera falling off the scaffolding to the vessel floor while the radiographer was retracting the source. The resulting action caused the guide tube connected to the camera and magnetic stand to become crimped at the camera connection point. The licensee's radiography supervisor was notified and the restricted area boundary was increased by the two (2) radiographers.
"Source retrieval was performed by the radiography supervisor with assistance from the radiography crew. A survey was performed using a NDS, ND-2000, SN: 20113, Calibration date: 1/15/2016, at the opposite end of the vessel thirty two (32) feet away from the source revealing a reading of two hundred twenty (220) mR/hr. A decision was made to pull the camera to one opening of the vessel by the camera cranks. The restricted area was then readjusted for two (2) mR/hr.
"While the camera was being lowered to the ground with a guide rope out of the vessel opening, the guide tube became straight enough to allow for source retraction. The guide tube and magnetic stand hung at the opening of the vessel causing the guide tube to straighten out from the weight of the camera below the vessel opening. The radiographers made another attempt to retract the source with success when the guide tube was straight. Once the camera was on the ground, the Licensee's survey of 46 mR/hr confirmed the source was retracted back into the camera.
"Doses to the radiography crew and supervisor were all below 60 millirems (mR). Instadose radiation badges were used with the highest dose reported of thirty nine (39) mR to both radiographers. Pocket dosimeters were also used with the highest dose reported by the radiography supervisor of fifty five (55) mR.
"Licensee's written report was received on 3/7/2016. The camera has been removed from service pending a sealed source and DU wipe test. Implemented corrective actions included adequate lighting at night and tying the camera off when it is used over twelve (12) inches off the ground."
The radiography camera contains a 79.9 Ci Ir-192 Source, model A424-9, serial number 28799G.
The State of Mississippi instructed the licensee to submit a 30 day written report and considers this case to be closed.
Mississippi State Report number: MS-16002. |
| Power Reactor | Event Number: 51792 | Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: HOWIE CROUCH | Notification Date: 03/15/2016
Notification Time: 15:14 [ET]
Event Date: 03/15/2016
Event Time: 06:49 [CDT]
Last Update Date: 03/15/2016 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
| Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Cold Shutdown | 0 | Refueling | Event Text IDENTIFIED PRESSURE BOUNDARY LEAKAGE
"During a scheduled refueling outage, an inspection of containment components revealed a suspected through wall leak on 1CV-200B, Letdown Orifice 'B' Outlet Control. Non-destructive engineering inspection has been completed and determined that an indication exists.
"10 CFR 50.2(2)(i) defines the reactor coolant pressure boundary as being connected to the reactor coolant system, up to and including the outermost containment isolation valve in system piping which penetrates primary reactor containment. 1CV-200B is isolable from the Reactor Coolant System (RCS) by a single motor operated valve, 1RC-427, Reactor Coolant Loop 'B' Leg to CVCS Letdown Isolation valve.
1CV-200B is located inside of containment between 1RC-427 and the two containment isolation valves for the letdown line, 1CV-371 and 1CV-371A. Based on the definition provided in 10 CFR 50.2, the condition is considered pressure boundary leakage and is considered reportable under 10 CFR 50.72(b)(3)(ii).
Unit 1 is currently in Mode 6. Repairs for the condition are being determined.
The NRC Resident Inspector has been notified. | |