| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
8/30/2018 - 8/31/2018 ** EVENT NUMBERS ** |
| Agreement State | Event Number: 53532 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALARON NUCLEAR SOLUTIONS
Region: 1
City: WAMPUM State: PA
County:
License #: PA-0678
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: BRIAN LIN | Notification Date: 08/02/2018
Notification Time: 11:48 [ET]
Event Date: 07/26/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/30/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
ANNE DEFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION EVENT
The following information was received via E-mail:
"During the process of shredding filters for cement solidification, the licensee had an unplanned contamination event. Loose surface contamination was spread throughout the building with an estimate of total activity being 2 milliCuries and the primary isotope being Cobalt-60. In addition to building surfaces, several personnel who were working in the area at the time were contaminated. It is unclear at this time the extent of the personnel contamination but inhalation and skin contamination are believed to have occurred. The licensee is currently decontaminating the area using protective clothing and respiratory protection, monitoring the individuals who were working in the area during the time of the event, and has sent a sample of the material to an independent lab for isotopic analysis. The licensee will be performing a root cause analysis and the state will perform a reactive inspection. The cause of the event is unknown at this time."
PA Event Report ID No: PA180016
* * * UPDATE ON 8/29/2018 AT 1354 EDT FROM JOHN CHIPPO TO BRIAN LIN * * *
The following update was provided via E-mail:
"During the process for cement solidification of shredded filter materials the licensee's mixing unit auger became stuck. Technicians eventually, through the use of various manual and air tools, were able to remove the blockage and resume the solidification process. At this time the unit was run again with only a cement mixture with no filter media to create a cap in the disposal container. Upon completion of this procedure a crane operator entered the containment area to remove the filter media hopper from atop the unit. He had forgotten his hard hat and immediately left containment and the H-1 building to retrieve his hat. Upon entering the Personnel Contamination Monitor (PCM) he then set off the alarm. This was the first indication of contamination. The RSO was immediately contacted and all remaining personnel exited the building and were found to be contaminated. Immediately upon discovery of the incident, all doors to the contaminated building (the H-1 building) were locked, all operations equipment was placed in the off position, and the building was secured. Building access was then restricted. The plant manager stopped all work at the site and informed his chain of command. In the days following the event the licensee performed a detailed survey to assess the extent of contamination. The survey showed general distributed contamination of the horizontal surfaces within the building. The maximum contamination level identified with this survey was 800,000 dpm/100cm2. The primary isotope was Co-60 (-90%), with Mn-54 and Sb-125 as other contributors.
"Seven personnel exhibited general distributed contamination of varying amounts on their exterior clothing and/or shoes and had indication of inhalation of radioactive material. All showered in the onsite Decontamination Room and then were monitored with an extended count in the PCM and all were released with only gamma related upper torso activity. Nasal swabs from affected personnel were analyzed, however the license has yet to share these or any other personnel dose data. Daily extended PCM counts continue for available personnel who exhibit upper torso gamma activity. Four individuals continue to exhibit this activity. In addition, in-vivo and in-vitro bioassay measurements were initiated and are in progress to complete the internal dose assessment process. It is expected that the offsite laboratory bioassay measurement data will be available in 2-3 weeks and the internal dose assessment will then be completed.
"The H-1 Building Containment itself remains restricted. The H-1 Building Containment will remain restricted and the work activities related to the encapsulation of materials inside this containment have been suspended indefinitely. This status will continue until corrective actions have been implemented in order to prevent a reoccurrence of this incident. The licensee contends the initial root cause of the incident was inadequate procedure implementation and training regarding radiological containment inspection and certification.
Corrective actions that are planned include:
"1. H-1 Building Containment program overhaul.
2. Upgrade procedures to include routine containment inspections to be conducted and implement additional independent verification by Alaron's Radiation Safety staff.
3. Highlight Operational procedures to require signature requirement verifying proper ventilation alignment is functioning prior to commencement of work.
4. Alarming differential pressure gauges will be installed on the HEPA units to provide warning of both HEPA buildup and/or breakthrough.
5. The RSO will review the current application of constant air monitors against problematic conditions such as radon gas buildup to ensure alarm setpoints can adequately protect workers from excessive derived air concentrations in the work zone and retrain all staff.
6. The RSO will review and upgrade shield frisking stations to ensure proper contamination control in areas that have a high dose background.
7. Implement a recurring refresher training program in addition to the recertification training programs.
8. General Manager to conduct an all hands 1-day stand down to communicate priorities (i.e. Safety, Health and environmental stewardship are the top priorities; anyone can stop a job if they feel any of these are being compromised, etc.)
"The cause of the event is believed to be inadequate procedure implementation and training."
RIDO (Lilliendahl) and NMSS were notified. |
| Agreement State | Event Number: 53560 | Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK | Notification Date: 08/23/2018
Notification Time: 18:12 [ET]
Event Date: 08/23/2018
Event Time: 16:00 [CDT]
Last Update Date: 08/23/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the State of Illinois via email:
"The RSO [Radiation Safety Officer] for Rush University Medical Center in Chicago (IL-01766-01) notified the Agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] at approximately 1600 [CDT] today that a reportable event transpired while attempting to administer Y-90 TheraSpheres. The licensee attempted to administer Y-90 to a patient this morning and was unable to move the dose through the tubing to the patient. A different administration route was selected and also met with inability to deliver the dose. This treatment was aborted.
"A second patient was scheduled for Y-90 administration this afternoon. The licensee encountered resistance in the second delivery system and was unable to deliver the Y-90 dose. This treatment was also aborted. Both patients were imaged and verified to not have been administered any Y-90. The licensee is currently performing a PET [Positron Emission Tomography] scan on the delivery systems to look for occlusions that may have impeded delivery. IEMA [Illinois Emergency Management Agency] staff has requested information on lot numbers for the individual doses.
"Details are pending from the licensee on root cause and lot numbers. The licensee will not administer any additional doses from this lot number until root cause is identified. Further details are pending."
Illinois Item No.: IL180033
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. |
| Power Reactor | Event Number: 53575 | Facility: PALO VERDE
Region: 4 State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID HECKMAN
HQ OPS Officer: BETHANY CECERE | Notification Date: 08/31/2018
Notification Time: 16:04 [ET]
Event Date: 08/31/2018
Event Time: 05:44 [MST]
Last Update Date: 08/31/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
GEOFFREY MILLER (R4DO) | | 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 UNPLANNED LOSS OF STEAM LINE MONITOR CHANNELS
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) as a Loss of Emergency Preparedness Capabilities at Palo Verde Nuclear Generating Station (PVNGS) Unit 2. On August 31, 2018, at approximately 0544 Mountain Standard Time (MST), the Unit 2 control room experienced an unplanned loss of Steam Generator #1 steam line monitor (RU-139), Channels A and B.
"This main steam line monitor is used in the PVNGS Emergency Plan to perform dose assessment in the event of a steam generator tube rupture.
"The NRC Resident Inspectors have been notified." |
| Power Reactor | Event Number: 53576 | Facility: LASALLE
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: RICHARD CALVIN
HQ OPS Officer: BETHANY CECERE | Notification Date: 08/31/2018
Notification Time: 23:26 [ET]
Event Date: 08/31/2018
Event Time: 21:05 [CDT]
Last Update Date: 08/31/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
| Person (Organization):
RICHARD SKOKOWSKI (R3DO) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | M/R | Y | 29 | Power Operation | 0 | Hot Shutdown | Event Text MANUAL REACTOR SCRAM DUE TO MAIN CONDENSER DEGRADATION
"This notification is being provided in accordance with 10 CFR 50.72(b)(2)(iv)(B).
"On August 31, 2018 at 2105 CDT, Unit 2 Reactor Manual Scram signal was inserted due to Main Condenser vacuum degrading. The turbine was tripped following the scram. Main Condenser vacuum is at 6 inches of backpressure slowly improving following the scram and turbine trip. During the scram, one Control Rod (30-31) did not fully insert. Control Rod 30-31 has been manually inserted to position 00 with the first position identified as position 24. Plant is in a stable condition with reactor pressure being maintained by the Turbine Bypass valves. Reactor water level is being controlled with feedwater. Investigation into the cause of the elevated condenser in leakage is in progress.
"The Senior NRC Resident has been notified." | |