United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2017 > March 28

Event Notification Report for March 28, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2017 - 03/28/2017

** EVENT NUMBERS **


52616 52617 52620 52622 52626 52641 52642 52643

To top of page
Agreement State Event Number: 52616
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THE AMERICAN ONCOLOGY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0293
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/17/2017
Notification Time: 12:52 [ET]
Event Date: 03/16/2017
Event Time: [EDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT DOSAGE LOWER THAN PRESCRIBED

The following report was received via email:

"On March 16, 2017, a patient was prescribed a 12.16 milliCurie treatment dosage of Y-90 Sirspheres. As the AU [Authorized User] was pushing on the syringe he noticed a strong resistance, as did the interventional radiologist. Therefore, the administration was stopped to prevent any further safety issues. The micro catheter was pulled from the patient and the vial with the micro catheter and other radioactive waste was put in the jar for measuring. As the micro catheter was pulled, a very small defect was observed. The activity administered was 53% less than the prescribed dosage (5.64 milliCuries). The outer wrapping of the catheter was kept. The patient will be notified once recovered from the anesthesia. The licensee is investigating.

"The cause of the event may be a potential manufacturing defect.

"A reactive inspection is planned by the Department [Pennsylvania Bureau of Radiation Protection]. More information will be provided upon receipt."

PA Event Report ID No: PA 170005

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.

To top of page
Agreement State Event Number: 52617
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: PA-0415
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/17/2017
Notification Time: 13:14 [ET]
Event Date: 03/17/2017
Event Time: 07:00 [EDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
HAROLD GRAY (R1DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
BERNARD STAPLETON (IRD)

Event Text

AGREEMENT STATE REPORT - TRANSPORTATION ACCIDENT DAMAGING LICENSED MATERIAL

The following report was received via email:

"At about 0700 [EDT] on March 17, 2017, the Department [Pennsylvania Bureau of Radiation Protection] received notification through the Pennsylvania Emergency Management Agency of a vehicle fire near mile marker 286 on I-76 (PA Turnpike) [near Reading, PA]. The vehicle was carrying approximately 0.6 Ci (22 GBq) Tc-99m and 1 Ci (37 GBq) of F-18 for Cardinal Health (PA licensee PA-0415). Department emergency response and radiological health physics staff responded to the scene. The vehicle was entirely engulfed in flames and allowed to burn itself out. There are no reports of injuries. A representative from the licensee was on scene and collected contaminated debris and ash which was returned to their facility for decay.

"The vehicle will be removed from the scene and isolated to allow any remaining material to decay. Departmental health physics inspector will oversee operations."

PA Event Report ID No: PA 170006

To top of page
Agreement State Event Number: 52620
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GFK & ASSOCIATES
Region: 4
City: DUBLIN State: CA
County:
License #: 6810-01
Agreement: Y
Docket:
NRC Notified By: EPHRIME MEKURIA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/17/2017
Notification Time: 16:45 [ET]
Event Date: 03/16/2017
Event Time: 16:04 [PDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"RHB-North [Radiologic Health Branch - North] received an email from CDPH [California Department of Public Health], Emergency Preparedness Office, Disaster Information Coordinator that they received a message from CAL OES [California Office of Emergency Services] stating that a nuclear density gauge was run over and damaged by earth moving equipment.

"Incident location: 308 Love Lane, Danville, CA 94526 - Contra Costa County, time 16:04 [PDT].

"RHB North contacted the Manager, Pacific Nuclear Technology (PNT), to survey the area and collect the damaged gauge. [He] went to the incident location, evaluated the moisture density gauge, and confirmed that the sealed sources Cs-137 and Am-241:Be were intact and were in the shielded position. In addition [he] surveyed the gauge and the surrounding area with a Ludlum Model 3, PR 44-9 and found no contamination, [he] further verified that exposure at 1 meter was 0.4 mRem/hr.

"Because the source was not damaged and the TI [Transportation Index] was within the limit, the licensee owner/operator insisted in taking the damaged gauge to the storage location . . . . [The owner/operator] said that the following day he will take the damaged gauge to CPN InstroTek Inc. for exchange or disposal.

"On March 17, 2017 RHB-North verified that CPN InstroTek Inc. has received the damaged gauge and the leak test result was negative.

"PNT equipment: Ludlum Model 3, PR 44-9, Calibration date 04/28/2016."

5010 Number: 031617

To top of page
Agreement State Event Number: 52622
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: RANGER EXCAVATING LP
Region: 4
City: AUSTIN State: TX
County:
License #: 06314
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/18/2017
Notification Time: 13:54 [ET]
Event Date: 03/18/2017
Event Time: 06:15 [CDT]
Last Update Date: 03/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
DESIREE DAVIS (ILTA)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the state of Texas via email:

"On March 18, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that a Troxler model 3440 moisture density gauge, serial #64732, containing a 1.48 GBq (40 mCi) Am-Be source and a 0.3 GBq (8 mCi) Cs-137 source was stolen. The licensee stated a technician improperly took the gauge home and left it in the back of his pickup truck. The sources were locked and inside their case. The case was secured by two locking mechanisms, both were cut sometime during the night before 0615 [CDT]. Local law enforcement was notified. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9472

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

To top of page
Agreement State Event Number: 52626
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: JOHNSON, MIRMIRAN & THOMPSON, INC.
Region: 1
City: FORT LAUDERDALE State: FL
County:
License #: 4418-1
Agreement: Y
Docket:
NRC Notified By: RENO FABII
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/20/2017
Notification Time: 11:37 [ET]
Event Date: 03/20/2017
Event Time: [EDT]
Last Update Date: 03/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following report was received from the State of Florida Bureau of Radiation Control via email:

"[The licensee] called to inform the BRC [Bureau of Radiation Control] that a Troxler gauge, Model 3430, in use at a construction site on Midway Rd. in Ft. Pierce had been run over by a pick up truck. The gauge was not in the transport case. The source rod was retracted. The outer plastic case and the screen are damaged. Reading of unit taken with a TroxAlert, Model 3105B indicated source / shielding is intact. All reading around the meter were normal background. Gauge will be taken to Atlantic Drill Supply, Rivera Beach, FL for repairs.

"Florida Incident Number: FL17-089"

To top of page
Power Reactor Event Number: 52641
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: AMANDA PUGH
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/27/2017
Notification Time: 16:02 [ET]
Event Date: 03/27/2017
Event Time: 09:40 [EDT]
Last Update Date: 03/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
EUGENE GUTHRIE (R2DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS-FOR- DUTY TEST POSITIVE FOR NON-LICENSED CONTRACTOR

A non-licensed contractor employee had a confirmed positive for a controlled substance during a random fitness-for-duty test. The employee's access to the site has been terminated.

The licensee notified the NRC Resident Inspector.

To top of page
Part 21 Event Number: 52642
Rep Org: ENGINE SYSTEMS, INC.
Licensee: ENGINE SYSTEMS, INC.
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOM HORNER
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/27/2017
Notification Time: 16:51 [ET]
Event Date: 03/27/2017
Event Time: [EDT]
Last Update Date: 03/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
EUGENE GUTHRIE (R2DO)
JAMNES CAMERON (R3DO)
THOMAS HIPSCHMAN (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - IDENTIFICATION OF FAILED DIODE SURGE SUPPRESSOR WITH INTERNAL MANUFACTURING DEFECT

The following information is excerpted from an Engine Systems, Inc. (ESI) report received via fax:

"COMPONENT:

"Diode Surge Suppressor
"Allen-Bradley P/N: 199-FSMZ-1

"SUMMARY:

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on February 10, 2017 after receiving notification from FirstEnergy Corp - Perry Nuclear Power Plant (PNPP) of a manufacturing defect in a diode supplied by ESI. The evaluation was concluded on March 27, 2017 and it was determined that this issue is a reportable defect as defined by 10CFR21. The manufacturing defect identified was in a diode of the same date code as two diodes that failed while installed at PNPP. The failed diodes resulted In loss of class 1E control power which could have prevented the emergency diesel generator set from performing its safety related function.

"Discussion:

In January 2007, ESI supplied a governor system upgrade to PNPP. The upgrade replaced the existing Woodward EGB-35C governor/actuator, EGA control (w/ resistor box), and MOP with an EGB-35P governor/actuator, 2301A control, and DRU. The electrical components were housed in a control panel assembly. To support the slow start feature of the new system, 4 relays were used, each of which used a surge suppressor (flyback) diode.

"PNPP experienced two failures in 2016 of the aforementioned diodes supplied by ESI. The diodes are Allen Bradley part number 199-FSMZ-1 and they were installed across the coils of Allen-Bradley 700DC series relays. The Allen-Bradley date code stamped on the side of the diodes is BX9. The failure in both cases resulted in a short circuit condition that resulted in a loss of class 1E control power to the EDG.

"Root cause evaluation:

"The root cause of the failure is determined to be a manufacturing defect internal to the diode. Though an analysis of the diodes that failed at PNPP was unable to be performed due to their condition, the analysis performed on a degraded diode of the same date code, BX9, detected an internal manufacturing defect.

Affected Users:

A listing of users with suspect diodes includes FirstEnergy - Perry, Entergy - Grand Gulf, Progress - Shearon Harris, and Duke - Shearon Harris. A total quantity of 34 diodes are suspect.

"Corrective Action:

"All affected users . . . [identified above] . . . should perform the following:

"1. Review their inventory for suspect diodes listed in Table 1. Any suspect diodes should be removed from inventory and discarded.

"2. Determine if suspect diodes listed in Table 1 have been installed. Thus far, ESI has identified degraded diodes from date codes BX9 and ZX9 and it is possible that diodes from the other date codes are degraded as well. ESI has been unable to determine an expected service life. Therefore, the recommendation is to remove or replace any installed suspect diodes as soon as possible. Note that the applications for which this diode has been supplied (Enterprise engine control panels) used the same style Allen-Bradley relays as original equipment but without diode surge suppressors. It is therefore acceptable to remove the diodes and expect no change or impact to the existing equipment.

"To prevent recurrence of this issue, the following has been Implemented by ESI:

"1. The test procedure for the diode has been enhanced to increase the test voltage and decrease the allowable leakage current. Although this was not the cause of the failure, it may have prevented identification of a degraded condition. This corrective action has already been implemented.

"2. A review has been performed of other diodes supplied by ESI and at this time only this one part number is affected. A typical diode would be procured and/or sold under the diode manufacturer part number; whereas in this case it was procured from the relay manufacturer. Testing was performed using typical relay values in lieu of the diode manufacturer's acceptance criteria."

If you have any questions, you may call:

Tom Horner
Quality Assurance Manager
Tel: (252) 977-2720

ESI Report ID: 10CFR21-0116, dated 03/27/17

To top of page
Power Reactor Event Number: 52643
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KEVIN OROURKE
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/27/2017
Notification Time: 21:54 [ET]
Event Date: 03/27/2017
Event Time: 18:25 [EDT]
Last Update Date: 03/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILL COOK (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HPCI DECLARED INOPERABLE DUE TO INADVERTENT ISOLATION

"On March 27, 2017, at 1825 hours EDT, with the reactor at 100 percent core thermal power and steady state conditions, technicians inadvertently caused a High Pressure Coolant Injection (HPCI) System isolation, by testing the incorrect temperature switches in the TIP [Traversing In-core Probe] room. Pilgrim Nuclear Power Station (PNPS) was performing testing on the temperature switches for Reactor Core Isolation Cooling (RCIC), but the HPCI temperature switches were inadvertently actuated causing HPCI to isolate.

"The Limiting Condition for Operation (LCO) Action Statement 3.5.c.2 has been entered and the planned testing has been secured pending further investigation. PNPS is providing an 8-hour non-emergency notification that the HPCI System was declared inoperable in accordance with 10 CFR 50.72(b)(3)(v)(D), an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. HPCI was returned to Operable within 40 minutes."

The licensee notified the NRC Resident Inspector and the Commonwealth of Massachusetts.

Page Last Reviewed/Updated Tuesday, March 28, 2017
Tuesday, March 28, 2017