Event Notification Report for September 07, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/06/2018 - 09/07/2018
EVENT NUMBERS
53585535875358853589535905359153596
Agreement State
Event Number: 53585
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: ANDREW WAUGH
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 13:14 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2018
Notification Time: 13:14 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE
The following information was received from the Commonwealth of Kentucky via fax:
"At approximately 1045 [EDT] on September 7, 2018 an Authorized User at Hardin Memorial Hospital (HMH) called the RHB [Radiation Health Branch] supervisor to report a medical event. A HMH medical physicist determined a patient received 70 percent of an intended brachytherapy dose; the same Authorized User is adding seeds to bring the dose up to acceptable range. RHB staff have contacted the HMH Radiation Safety Officer and are awaiting further information on the possible medical event."
Kentucky Event Report ID No.: KY180003
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.
The following information was received from the Commonwealth of Kentucky via fax:
"At approximately 1045 [EDT] on September 7, 2018 an Authorized User at Hardin Memorial Hospital (HMH) called the RHB [Radiation Health Branch] supervisor to report a medical event. A HMH medical physicist determined a patient received 70 percent of an intended brachytherapy dose; the same Authorized User is adding seeds to bring the dose up to acceptable range. RHB staff have contacted the HMH Radiation Safety Officer and are awaiting further information on the possible medical event."
Kentucky Event Report ID No.: KY180003
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.
Agreement State
Event Number: 53587
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: KLEINFELDER, INC.
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800085
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: ANDREW WAUGH
Licensee: KLEINFELDER, INC.
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800085
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 16:00 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/07/2018
Notification Time: 16:00 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following was received from the State of Utah via fax:
"On September 5, 2018, a portable gauge user from Kleinfelder, Inc. (Radioactive Materials License UT 1800085) was performing compaction measurements at a field location in West Jordan, Utah. After performing a test, the operator placed the Troxler 3440 (s/n 19966) gauge on the tailgate of the licensee's vehicle to move to another location. The gauge fell off the tailgate of the truck, struck the pavement, and cracked the gauge case. The licensee performed exposure rate measurements of the gauge and incident site, and determined that the sealed sources were intact and that no contamination was present at the site. The licensee secured the damaged gauge in the transportation package, transported the gauge to the licensee's facility, and secured the gauge in the licensee's gauge storage cabinet. The licensee is conducting an investigation into the incident, and will submit a written report to the Division of Waste Management and Radiation Control (Division) within 30 days."
Utah Event Report ID No.: UT180007
The following was received from the State of Utah via fax:
"On September 5, 2018, a portable gauge user from Kleinfelder, Inc. (Radioactive Materials License UT 1800085) was performing compaction measurements at a field location in West Jordan, Utah. After performing a test, the operator placed the Troxler 3440 (s/n 19966) gauge on the tailgate of the licensee's vehicle to move to another location. The gauge fell off the tailgate of the truck, struck the pavement, and cracked the gauge case. The licensee performed exposure rate measurements of the gauge and incident site, and determined that the sealed sources were intact and that no contamination was present at the site. The licensee secured the damaged gauge in the transportation package, transported the gauge to the licensee's facility, and secured the gauge in the licensee's gauge storage cabinet. The licensee is conducting an investigation into the incident, and will submit a written report to the Division of Waste Management and Radiation Control (Division) within 30 days."
Utah Event Report ID No.: UT180007
Agreement State
Event Number: 53588
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT State: TX
County:
License #: L06443
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: ANDREW WAUGH
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT State: TX
County:
License #: L06443
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 17:11 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/07/2018
Notification Time: 17:11 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - GAUGE STUCK SHUTTER
The following information was received from the State of Texas via email:
"On September 7, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that during plant maintenance on a vessel, the handle on a Vega model SH-F2 nuclear gauge containing a 70 millicurie (original activity) Cesium-137 source was broken and the shutter was stuck in the half closed (half open) position. The license stated because of the location of the gauge on the vessel it does not create an exposure risk to any individual. The licensee has contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: 9611
The following information was received from the State of Texas via email:
"On September 7, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that during plant maintenance on a vessel, the handle on a Vega model SH-F2 nuclear gauge containing a 70 millicurie (original activity) Cesium-137 source was broken and the shutter was stuck in the half closed (half open) position. The license stated because of the location of the gauge on the vessel it does not create an exposure risk to any individual. The licensee has contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: 9611
Power Reactor
Event Number: 53589
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: ERIK SILKO
HQ OPS Officer: DONG HWA PARK
Region: 1 State: NY
Unit: [] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: ERIK SILKO
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/07/2018
Notification Time: 20:56 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2018
Notification Time: 20:56 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER LALLY (R1DO)
CHRISTOPHER LALLY (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 40 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
"[Indian Point Unit 3] entered Technical Specification 3.0.3 for Safety Injection Boron Injection Tank Header Inoperable due to a thru weld leak at the thermal well rendering two Safety Injection Pumps Inoperable. Plant shutdown was started 1803 hours EDT."
The licensee plans to be in Mode 4 at 0600 EDT on 9/8/2018. There is no impact to Unit 2.
The licensee notified the NRC Resident Inspector and the State of New York.
"[Indian Point Unit 3] entered Technical Specification 3.0.3 for Safety Injection Boron Injection Tank Header Inoperable due to a thru weld leak at the thermal well rendering two Safety Injection Pumps Inoperable. Plant shutdown was started 1803 hours EDT."
The licensee plans to be in Mode 4 at 0600 EDT on 9/8/2018. There is no impact to Unit 2.
The licensee notified the NRC Resident Inspector and the State of New York.
Power Reactor
Event Number: 53590
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: MICHELLE MALONEY
HQ OPS Officer: OSSY FONT
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: MICHELLE MALONEY
HQ OPS Officer: OSSY FONT
Notification Date: 09/08/2018
Notification Time: 01:38 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2018
Notification Time: 01:38 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ALAN BLAMEY (R2DO)
ALAN BLAMEY (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF ENVIRONMENTAL REPORT TO ANOTHER GOVERNMENT AGENCY
"At 2210 EDT on September 7, 2018, Duke Energy personnel determined that the following event required notification of a federal agency, North Carolina State agency and a local agency for a chemical spill exceedance.
"At 2140 EDT on September 7, 2018, plant personnel identified a sodium hypochlorite spill of more than the reportable quantity of 75.9 gallons. This notification is being made as a four-hour, non-emergency notification for a Notification of Other Government Agencies. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
"At 2210 EDT on September 7, 2018, Duke Energy personnel determined that the following event required notification of a federal agency, North Carolina State agency and a local agency for a chemical spill exceedance.
"At 2140 EDT on September 7, 2018, plant personnel identified a sodium hypochlorite spill of more than the reportable quantity of 75.9 gallons. This notification is being made as a four-hour, non-emergency notification for a Notification of Other Government Agencies. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 53591
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/08/2018
Notification Time: 17:44 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2018
Notification Time: 17:44 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE
The following information was received from the state of North Carolina via email:
"A patient being treated for liver tumors was prescribed to receive 47.6 mCi of Y-90 microspheres, but instead received only 11.9 mCi (about 25 percent of prescribed). The remainder was in the vial as residual.
"Because this under-dosing was not due to stasis or emergent patient conditions, and the delivered dose was less than 20 percent of that prescribed, this constitutes a reportable medical event according to the 2016 version (9) of the NRC guidance for Y-90 microspheres.
"Source: Microspheres
Radionuclide: Y-90
Manufacturer: Sirtex Medical
Model: Sir-Spheres
S/N: Aggregate
"Investigation is pending for the Medical Event."
North Carolina Tracking Number: 180039
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.
The following information was received from the state of North Carolina via email:
"A patient being treated for liver tumors was prescribed to receive 47.6 mCi of Y-90 microspheres, but instead received only 11.9 mCi (about 25 percent of prescribed). The remainder was in the vial as residual.
"Because this under-dosing was not due to stasis or emergent patient conditions, and the delivered dose was less than 20 percent of that prescribed, this constitutes a reportable medical event according to the 2016 version (9) of the NRC guidance for Y-90 microspheres.
"Source: Microspheres
Radionuclide: Y-90
Manufacturer: Sirtex Medical
Model: Sir-Spheres
S/N: Aggregate
"Investigation is pending for the Medical Event."
North Carolina Tracking Number: 180039
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.
Agreement State
Event Number: 53596
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HDT&I DBA AMERICAN ENGINEERING LABS, INC.
Region: 4
City: MONTEREY PARK State: CA
County:
License #: 5775-36
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: ANDREW WAUGH
Licensee: HDT&I DBA AMERICAN ENGINEERING LABS, INC.
Region: 4
City: MONTEREY PARK State: CA
County:
License #: 5775-36
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/11/2018
Notification Time: 18:23 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/11/2018
Notification Time: 18:23 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following information was received from the State of California via email:
"HDT&I doing business as American Engineering Laboratories, Inc. had a CPN moisture density gauge (MC39048771 containing nominally 10 mCi of Cs-137 and 50 mCi of Am-241/Be) run over by construction equipment at a temporary job site in Monterey Park on Friday, September 7, 2018 around 1400 PDT. The gauge operator notified his [radiation safety officer] RSO of the accident. He sent photographs of the broken handle and said the source rod was bent. In accordance with the RSO's instructions, the source rod was retracted, secured inside the transport box, and taken to their permanent storage site. Upon return from his travel, the RSO was able to visually inspect the damaged gauge on Sunday, September 9, 2018 and instructed the gauge operator to transport it to the CPN service center on Monday, September 10, 2018.
"On Monday, September 10, 2018, the damaged CPN gauge was brought to the CPN service center for evaluation and it was discovered that the tip containing the Cs-137 source had apparently broken off from the source rod in the accident. The Am-241/Be source was secure in place. The gauge operator and the RSO went to the accident site with a Geiger-Muller survey meter to search for the missing source after contacting the job site supervisor that they were returning to search for the lost radioactive source and to ensure personnel/equipment were not working in that area. The gauge operator was able to locate the Cs-137 sealed source at the job site, and used 8-inch long pliers to place it into the gauge's shielding. The gauge was then placed into the transport case and transported back to the service center for evaluation and emergency leak testing of the sealed source."
California Report No.: 5010-091018
The following information was received from the State of California via email:
"HDT&I doing business as American Engineering Laboratories, Inc. had a CPN moisture density gauge (MC39048771 containing nominally 10 mCi of Cs-137 and 50 mCi of Am-241/Be) run over by construction equipment at a temporary job site in Monterey Park on Friday, September 7, 2018 around 1400 PDT. The gauge operator notified his [radiation safety officer] RSO of the accident. He sent photographs of the broken handle and said the source rod was bent. In accordance with the RSO's instructions, the source rod was retracted, secured inside the transport box, and taken to their permanent storage site. Upon return from his travel, the RSO was able to visually inspect the damaged gauge on Sunday, September 9, 2018 and instructed the gauge operator to transport it to the CPN service center on Monday, September 10, 2018.
"On Monday, September 10, 2018, the damaged CPN gauge was brought to the CPN service center for evaluation and it was discovered that the tip containing the Cs-137 source had apparently broken off from the source rod in the accident. The Am-241/Be source was secure in place. The gauge operator and the RSO went to the accident site with a Geiger-Muller survey meter to search for the missing source after contacting the job site supervisor that they were returning to search for the lost radioactive source and to ensure personnel/equipment were not working in that area. The gauge operator was able to locate the Cs-137 sealed source at the job site, and used 8-inch long pliers to place it into the gauge's shielding. The gauge was then placed into the transport case and transported back to the service center for evaluation and emergency leak testing of the sealed source."
California Report No.: 5010-091018