Event Notification Report for March 05, 2019

AUTOMATIC ACTUATION OF THE PRIMARY CONTAINMENT ISOLATION SYSTEM

"At 05:35 Eastern Standard Time (EST) on March 5, 2019, with Unit 2 in Mode 5 at 0% power, an actuation of the Primary Containment Isolation System occurred during hydrolazing of the reactor water level variable leg instrumentation line nozzle N011B in the reactor cavity. The hydrolazing activity caused low reactor water level to be sensed on Division II of the shutdown range level instrumentation. Per design, the low level 1 signal resulted in Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves) and Group 8 (i.e., shutdown cooling isolation valves) isolations.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Primary Containment Isolation System.

"There was no impact on the health and safety of the public or plant personnel. The Group 8 was reset and shutdown cooling was restored at approximately 05:45 EST.

"The safety significance of this event was minimal. Although there was a brief interruption of the shutdown cooling, the Residual Heat Removal (RHR) shutdown cooling system operation was restored in approximately 10 minutes without extensive troubleshooting or maintenance, and remained operable. The RHR shutdown cooling system is not credited in any Updated Final Safety Analysis Report Chapter 6 or 15 accidents or transients.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - SCRAP METAL WITH RADIUM DISCOVERED

The following was received from the state of New Jersey by email:

"The Pennsylvania Department of Environmental Protection informed the New Jersey Department of Environmental Protection that a load of scrap metal from the John Blewett company in Howell, New Jersey set off the radiation alarm at Sims Metal Management in Morrisville, Pennsylvania. Sims rejected the load and it was returned to Blewett in Howell via a U.S. DOT special permit. Once returned to Blewitt, the load was dumped and what appeared to be the instrument panel from a World War II era plane was found to be the cause of the elevated readings. Based on readings taken at the site, it is estimated that the panel contains 61 microCi of Ra-226. The highest reading seen was 12.5 mR/hr on contact. Some of the glass covering over a gauge was broken. A gross wipe test indicated removable contamination was present. Those individuals who had touched the panel were checked for contamination or advised to check. The area where the panel had been originally placed was also checked, with slightly elevated readings discovered. All surfaces were cleaned to background levels, as well as the area where the panel had been originally secured. The panel and all items involved in the clean-up were placed in a five-gallon bucket and will be secured pending proper disposition through a waste broker."

AGREEMENT STATE REPORT - LOST IR-192 SOURCE

The following is a summary of the phone call with the state of Oregon:

On March 5, 2019, the licensee realized that a 9.4 Curie Ir-192 industrial radiography source was missing when the scheduled shipment was not received on March 4, 2019. Last known location was Memphis, TN on March 1, 2019.

* * * UPDATE AT 1110 EDT ON 3/13/2019 FROM DARYL LEON TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On March 11 at 11:38 AM (PDT), the licensee (OWL) emailed and stated that the lost package and source have been found after an extended telecon (1 hour) with the carrier. No location given in email but a statement that [the common carrier] had held the shipment because they needed a copy of the shipping papers to send it on to its destination (QSA in Baton Rouge, LA). OWL emailed a copy of the shipping papers to [the common carrier] and the package was released to continue on to QSA.

"On March 12 at 9:15 AM (PDT), [the state of Oregon] contacted the licensee (OWL) by phone. The package and source were found by [the common carrier] in their Memphis, TN shipping center. [The common carrier] did not have shipping papers for the package when received in Memphis and placed it into their 'Overgoods' department where 'lost dangerous goods' are taken and held if there is a paperwork issue preventing a shipment from continuing on its way. The package in this case was released on March 11th as previously indicated and arrived at QSA in Baton Rouge at 10:02 AM (CDT)."

Notified the R4DO (Groom), and NMSS Events Resource and ILTAB (via e-mail).


THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

AGREEMENT STATE REPORT - INCORRECT SOURCE STRENGTH ENTERED RESULTING IN OVERDOSE OF 20 PERCENT

The following report was received from the North Carolina Division of Health Service Regulation via email:

"A prostate patient returned for a 30 day post treatment review and CT scan. Licensee Physics Group reviewed the Post Op Plan with the Intended Plan. It was found that when the Intended Plan was entered into the planning software, a dosimetrist entered an incorrect source strength into the planning system, causing the planning system to appear to be implanting weaker seeds than were being implanted resulting in an over dose of 20 percent.

"Event Date: 3/5/19
Discovered Date: 3/28/1
Prescribed dose: 164.85 mCi
Administered dose: 213.15 mCi
Isotope: PD-103.
Target organ: Prostate
Referring Physician notified on: 3/28/19
Patient notified on: 3/28/19
Effects/Outcome to the Patient: None anticipated. Physician will monitor patient for side effects.
Notifications & Generic Implications: None.
Corrective Action: Procedure revision.

"A reactive inspection was conducted today [by the North Carolina Division of Health Service Regulation]. Following this entry into NMED we [the North Carolina Division of Health Service Regulation] would like to request the event be closed and complete. We [the North Carolina Division of Health Service Regulation] have concluded our investigation.

"NC Tracking Number: 190011"

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 REPORT - TROXLER GAUGE DESTROYED WHEN RUN OVER

The following was received from the Arkansas Department of Health via e-mail:

"The Department [Arkansas Department of Health Radioactive Materials Program] received notification on March 5, 2019, from licensee GTS, Inc. that a Troxler gauge model 3440 [serial number: 73390, 40 mCi Am-241, 8 mCi Cs-137] had been struck by a skid steer while performing routine measurements at a road construction site. As a result of the incident, the source had been pulled from its testing position and become partially exposed.

"Upon review of the event, it was noted that the technician quickly created a thirty (30) foot containment barrier and notified his company's Radiation Safety Officer [RSO]. The [RSO] for GTS mobilized to the event location and contacted the [Department].

"Upon receiving an exemption from the Department, the RSO was able to manipulate the source into the shielded position and place the remnants into the transportation container for transport to the permanent storage location. The gauge was returned to the permanent storage location at approximately 1330 [CST] on March 5, 2019. The licensee performed leak tests of the sources, surveys of the gauge transport container, and surveys of the storage location.

"[Department] inspectors visited the licensee on March 6, 2019, to investigate the event. Surveys at the exterior of the transport container were determined to be 3-5 mR/hr. Surveys performed inside of the transport container were measured to be a maximum of 15 mR/hr at a location close to the surface of the shielded source.

"The [Department] considers this investigation open pending receipt and review of the licensee's 30 day report"

State of Arkansas Event Report No. : AR-2019-002

* * * UPDATE AT 1437 EDT ON 4/10/19 FROM CHRISTOPHER TALLEY TO KARL DIEDERICH * * *

The following was received via e-mail:

"Upon review of the licensee's 30 day report, received April 5, 2019, it was noted that the dosimetry badge worn by the RSO during the retraction and transportation of the source showed no measurable dose. The dosimetry badge was new for the month of March.

"The report also contained leak test results for the sources both prior to the event, January 19, 2019, and after the event, March 6, 2019. The results for the leak tests in both instances were measured to be below 185 Bq (0.005 microCuries), considering the sources to be non-leaking sources.

"The company conducted mandatory safety meetings with all staff who work with the portable gauges and also sent a companywide e-mail to all employees as a result of the event. Topics discussed during the meetings and e-mail included radiation safety, worksite safety, portable gauge specific safety and use, emergency response procedures, and gauge security. The contractor responsible for the skid steer also conducted an on-site safety meeting immediately following the event on March 5, 2019.

"The Department now considers this event to be closed providing that no new information is received by the Department."

Notified R4DO (Werner) and NMSS Events (via e-mail).

* * * UPDATE ON 5/31/19 AT 1037 EDT FROM CHRISTOPHER TALLEY TO THOMAS KENDZIA * * *

The following was received via e-mail:

"The Licensee has transferred the radioactive sources and associated nuclear gauge remnants to the manufacturer for disposal/repair. The sources are now listed under North Carolina Radioactive Materials License #032-0182-1."

The Department now considers this event to be closed.

Notified R4DO (Kozal) and NMSS Events (via e-mail).