Event Notification Report for March 14, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/13/2019 - 03/14/2019
EVENT NUMBERS
5394053935539365393353938
Agreement State
Event Number: 53940
Rep Org: CA DEPARTMENT OF PUBLIC HEALTH
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOANNA BRIDGE
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/15/2019
Notification Time: 17:37 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Notification Time: 17:37 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - UNDER-DOSAGE TO PATIENT
The following was received via e-mail:
"On March 15, 2019, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a medical event involving Y-90 TheraSphere had occurred on March 14, 2019. A patient was prescribed 120 Gy to the left lobe of their liver with Y-90 TheraSpheres. However, the authorized user (physician) was only able to deliver 80.9 Gy (67.4 percent of the prescribed dose) due to suspected complications with the delivery system. UCLA's Office of Environment, Health and Safety (EH&S) team will continue to investigate and notify the BTG Radiation Safety Officer (RSO) group to examine the delivery system.
"The patient was notified of the under-dosage and potential continuation of their treatment. The patient was discharged in a stable condition."
CA 5010 No.: 031419
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 was received via e-mail:
"On March 15, 2019, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a medical event involving Y-90 TheraSphere had occurred on March 14, 2019. A patient was prescribed 120 Gy to the left lobe of their liver with Y-90 TheraSpheres. However, the authorized user (physician) was only able to deliver 80.9 Gy (67.4 percent of the prescribed dose) due to suspected complications with the delivery system. UCLA's Office of Environment, Health and Safety (EH&S) team will continue to investigate and notify the BTG Radiation Safety Officer (RSO) group to examine the delivery system.
"The patient was notified of the under-dosage and potential continuation of their treatment. The patient was discharged in a stable condition."
CA 5010 No.: 031419
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: 53935
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CERTAIN TEED CORPORATION
Region: 1
City: OXFORD State: NC
County:
License #: 0411-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: CERTAIN TEED CORPORATION
Region: 1
City: OXFORD State: NC
County:
License #: 0411-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/15/2019
Notification Time: 10:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Notification Time: 10:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE SHUTTER STUCK IN CLOSED POSITION
The following report was received via e-mail:
"On 3/14/2019, NC Radioactive Materials Branch (RMB) was notified that a fixed nuclear gauge was stuck in the closed position (found that day). The reporting licensee had the vendor arrive on site, the same day, and repaired the gauge."
Source Sr-90, 100 milliCuries
North Carolina State Tracking ID: 190009
The following report was received via e-mail:
"On 3/14/2019, NC Radioactive Materials Branch (RMB) was notified that a fixed nuclear gauge was stuck in the closed position (found that day). The reporting licensee had the vendor arrive on site, the same day, and repaired the gauge."
Source Sr-90, 100 milliCuries
North Carolina State Tracking ID: 190009
Agreement State
Event Number: 53936
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KOURY ENGINEERING
Region: 4
City: CHINO State: CA
County:
License #: 6449
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: JEFF HERRERA
Licensee: KOURY ENGINEERING
Region: 4
City: CHINO State: CA
County:
License #: 6449
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/15/2019
Notification Time: 11:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Notification Time: 11:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED BY BACKHOE
The following report was received from the California Department of Public Health via email:
"A moisture density gauge was being used at a construction site when it was struck by a backhoe. The gauge operator had visual contact with the gauge, and had been assured by the backhoe operator that the gauge would not be impacted by the backhoe operation. However, that was not the case. The backhoe bucket struck the gauge source rod extension, bending it, and damaging the gauge casing. Due to the damage, the source rod could not be fully shielded and locked in the storage position."
CA 5010 Number: 031419
The following report was received from the California Department of Public Health via email:
"A moisture density gauge was being used at a construction site when it was struck by a backhoe. The gauge operator had visual contact with the gauge, and had been assured by the backhoe operator that the gauge would not be impacted by the backhoe operation. However, that was not the case. The backhoe bucket struck the gauge source rod extension, bending it, and damaging the gauge casing. Due to the damage, the source rod could not be fully shielded and locked in the storage position."
CA 5010 Number: 031419
Power Reactor
Event Number: 53933
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: PAUL BOKUS
HQ OPS Officer: JOANNA BRIDGE
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: PAUL BOKUS
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/14/2019
Notification Time: 17:08 [ET]
Event Date: 03/14/2019
Event Time: 09:34 [EDT]
Last Update Date: 03/14/2019
Notification Time: 17:08 [ET]
Event Date: 03/14/2019
Event Time: 09:34 [EDT]
Last Update Date: 03/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
FRED BOWER (R1DO)
FFD GROUP (EMAIL)
FRED BOWER (R1DO)
FFD GROUP (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT - LICENSED EMPLOYEE FAILED A RANDOM SCREENING
A licensed employee was determined to be under the influence of alcohol during a random test. The employee's access to the plant has been suspended pending an investigation.
The licensee notified the NRC Resident Inspector.
A licensed employee was determined to be under the influence of alcohol during a random test. The employee's access to the plant has been suspended pending an investigation.
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 53938
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CONSTRUCTION ENGINEERING CONSULTANTS
Region: 1
City: WHITE TOWNSHIP State: PA
County:
License #: PA-1034
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOANNA BRIDGE
Licensee: CONSTRUCTION ENGINEERING CONSULTANTS
Region: 1
City: WHITE TOWNSHIP State: PA
County:
License #: PA-1034
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/15/2019
Notification Time: 14:05 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Notification Time: 14:05 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - STUCK OPEN GAUGE SHUTTER
The following was received via e-mail:
"On March 14, 2019, the licensee informed the Department [Pennsylvania Department of Environmental Protection (DEP)] of a moisture/density nuclear gauge with a stuck open shutter. It is reportable per 10 CFR 30.50(b)(2).
"While at a temporary job site, a DEP inspector found a Troxler gauge with a stuck open shutter. The technician did not know how long the shutter had been open and was only able to get the Tungsten sliding block closed by tapping on the gauge. After it was closed the technician was unable to get the sliding block open again. The DEP will update this event as soon as more information is provided.
"The Department will perform a reactive inspection. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA190008
The following was received via e-mail:
"On March 14, 2019, the licensee informed the Department [Pennsylvania Department of Environmental Protection (DEP)] of a moisture/density nuclear gauge with a stuck open shutter. It is reportable per 10 CFR 30.50(b)(2).
"While at a temporary job site, a DEP inspector found a Troxler gauge with a stuck open shutter. The technician did not know how long the shutter had been open and was only able to get the Tungsten sliding block closed by tapping on the gauge. After it was closed the technician was unable to get the sliding block open again. The DEP will update this event as soon as more information is provided.
"The Department will perform a reactive inspection. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA190008