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Event Notification Report for April 11, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/10/2017 - 04/11/2017

** EVENT NUMBERS **


52345 52638 52653 52654 52656 52659 52660 52661

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 52345
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTEK ASSET INTEGRITY MANAGEMENT INC
Region: 4
City: LONGVIEW State: TX
County:
License #: 06801
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/03/2016
Notification Time: 12:36 [ET]
Event Date: 11/02/2016
Event Time: [CDT]
Last Update Date: 04/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DID NOT RETRACT CAUSING DOSIMETER ALARM

The following report was received from the Texas Department of State Health Services via email:

"On November 3, 2016, the Agency [Texas Department of State Health Services] was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The camera had a 36 curie Ir-192 source. The crew could not hear the alarming rate meters due to excessive noise. The radiographers noticed the source had not retracted completely into the camera while trying to disconnect the guide tube to move the camera to another location. The radiographer reported to the RSO that the source was retracted immediately after finding the source extended. The time reported to the RSO with the source exposing the radiographer was less than 3 minutes. The pocket dosimeters were checked outside the area and found off scale. The RSO stopped all work, requested radiographers return to the shop and he checked the camera to find no defects. The RSO has sent the monitoring badges in for processing and is in the process of completing an investigation to determine exposure dose. A complete report will be provided by the RSO. Updates will be provided in accordance with SA 300 guidelines."

Texas Incident #: I 9437

* * * UPDATE FROM IRENE CASARES TO JOHN SHOEMAKER AT 1613 EST ON 12/13/16 * * *

"On November 3, 2016, the Agency received a call stating that a radiography crew had experienced an incident on November 2, 2016. The crew had been working at a Power Plant near Franklin, Texas when they experienced an incident involving a possible overexposure. The radiographers were working in a noisy area with all monitoring devices on their person. They had performed several exposure shots and were completing the last shot on a pipe before moving the camera to the next weld area. The radiographer had cranked in the source and both walked to the weld to discuss the next shot position. They were about five feet from the camera and behind the camera which was partially shielded by conduit and piping. Then one radiographer walked to the camera and using the quick disconnect, disconnected the guide tube. When he did this he noticed he source protruding from the camera about six inches and yelled at the other radiographer to get back away from the area. Both ran to the crank, one grabbed the survey meter and the other then cranked in the source, about a turn and half on the crank to secure the source in the camera. The source was in the camera. Both checked their alarming rate meters which were alarming and the pocket dosimeters were off scale. They called the RSO and then packed up their equipment for the day. An incident report was completed at the power plant before leaving the site. Once back at the radiography headquarters the badges were collected and mailed for processing. Both radiographers were interviewed by the RSO and then suspended until monitoring results were received. The RSO calculated the dose to be 1593 mrem for the one radiographer's hand dose.

"Monitoring badge results were reported to the Agency on November 10, 2016, with a whole body dose of 309 mrem and a whole body dose of 317 mrem. The annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem. The November badges had been worn for two days when the incident occurred.

"A re-enactment investigation was conducted on November 29, 2016, due to limited details on the report provided by the RSO and the calculations appeared to be short in dose. The investigation and interviews with the radiographers on November 29, 2016, revealed the dose to the hand, foot, gonads, knee, and whole body were slightly higher dose but still under the limits for an overexposure. We had calculated the dose to the hand to be approximately 29 rem instead of 15.9 rem reported by the RSO. The distance of the hand dose was provide by the RSO at 4 inches, during the re- enactment, a smaller distance of one half inch during the time the radiographer removed the guide tube was more accurate. His hand passed directly over the source when he pulled the guide tube over the source when it was extended from the camera. The shorter distance increased the dose, however was still under the 50 rem limit for an overexposure. The radiographer has not experienced any redness, blisters or soreness to his hand. He has been viewing his hands daily and has not notice any radiation burn or injury. During the investigation his hands were viewed and no noticeable damage was seen (26 days after the incident).

"The cause of the incident was not retracting the source completely into the shielded position and not using a survey meter to ensure the source was shielded. The two radiographers had changed positions during this job. One usually worked the crank and the other collected the film. Neither radiographer heard the alarms on the rate meters due to the noise. Both radiographers commented during the investigation, that they weren't using the meter like they should and it was their fault for not doing the required survey. Violations were cited to company and radiographers."

Notified R4DO (Kellar) and NMSS Events Notification via email.

* * * RETRACTION FROM IRENE CASARES TO VINCE KLCO ON 4/10/17 AT 1253 EDT * * *

The following information was received from the State of Texas via email:

"[The Texas Department of State Health Services] would like to retract NRC event number 52345. At the initial reporting from the regulated entity, it was believed two radiographers had received an overexposure from a non-retractable source. After further investigation, it was not a non-retractable source, such as equipment failure. It was human error and the source was retracted by the radiographer. There was no equipment failure. It was operator error and the dose that both radiographers received was not over the reporting limits. Please retract this event.

"Summary:
On November 3, 2016, the Agency was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The device was a Spec 150, serial 1500, Spec source G60, serial XG2601 with of Ir-192 with 36 curies of activity. The monitoring badges were sent for processing with results of 317 and 309 mrem doses. The annual dose for both radiographers was below the 5 rem limit. The calculations for the extremity dose (hand, foot, and knee) were below the 50 rem overexposure limit. The annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem. A re-enactment investigation was conducted on November 29, 2016 due to limited details provided by the RSO. The dose was calculated at 29 rem to the extremities which is under the limit 50 rem for reportable event. The cause of the incident was not retracting the source completely into the shielded position and not using a survey meter to ensure the source was shielded. To prevent recurrence, the company had a meeting (training) with employees stressing the importance of safety, following procedures, and being aware of surroundings. One violation cited to the company and each radiographer."

Notified the R4DO (Kramer) and NMSS Events Notification via email

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52638
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DON HARTINGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/24/2017
Notification Time: 17:15 [ET]
Event Date: 03/20/2017
Event Time: 16:39 [CDT]
Last Update Date: 04/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)

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

Event Text

HISTORICAL EVENT RELATED TO PAST OPERABILITY

"On February 3, 2017, Prairie Island staff performed maintenance on the transom above Battery Room Door 225. This activity resulted in the transom being unlatched for approximately five minutes. On February 6, 2017, a question from the NRC Resident Inspector resulted in an evaluation of this condition for past operability. On March 20, 2017, the past operability evaluation of Door 225 concluded that, in the event of a postulated HELB [High Energy Line Break], the transom being unlatched during the five minute maintenance period resulted in the inoperability of multiple systems in the Unit 1 and Unit 2 battery, auxiliary feedwater, and Unit 1 safeguards bus rooms that would be required to mitigate the postulated HELB.

"The loss of safety functions required to mitigate the postulated HELB make the condition reportable under 50.72(b)(3)(ii) for an unanalyzed condition that significantly degrades plant safety.

"Unlatching the transom above the Battery Room Door creates an opening not accounted for in design bases documents. This occurred due to an improperly prepared work permit. Corrective actions are in place to preclude recurrence."

The licensee informed the NRC Resident Inspector.

* * * RETRACTION FROM MARK LOOSBROCK TO JEFF ROTTON AT 1559 EDT ON 04/10/2017 * * *

"Further analysis determined that an unlatched transom would result in a relative humidity of 100 percent in 11 Battery Room for about 10 minutes following a postulated HELB. Since the equipment in the Battery Rooms is not qualified for a harsh environment, the components in 11 Battery Room would have been inoperable. Temperature and relative humidity in the other Battery Rooms, Auxiliary Feedwater Rooms, and the Unit 1 Safeguards Bus Rooms would have remained within the allowable limits.

"Therefore, for the five minutes the strike was removed from the transom, only equipment in 11 Battery Room and supported A Train components would have been inoperable. This event was not an Unanalyzed Condition that significantly degraded plant safety, under 10 CFR 50.72(b)(3)(ii), as no safety function would have been lost."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Skokowski).

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Agreement State Event Number: 52653
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: INTERNATIONAL PAPER
Region: 1
City: GEORGETOWN State: SC
County:
License #: 060
Agreement: Y
Docket:
NRC Notified By: LELAND R. CAVE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/31/2017
Notification Time: 11:21 [ET]
Event Date: 03/22/2017
Event Time: [EDT]
Last Update Date: 03/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILL COOK (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER

The following report was received from the South Carolina Department of Health and Environmental Control via email:

"The licensee provided notification of a stuck shutter on a Berthold Model LB7440 fixed gauging device. The shutter was stuck in the open position. The gauging device contains 100 mCi of Cs-137. A licensed contractor found the shutter stuck in the open position on March 22, 2017, and the licensee notified the State [of South Carolina] on March 30, 2017. The contractor proceeded with corrective maintenance on the shutter mechanism. The licensee stated that a written report will be sent within 30 days of the event. Updates to this event will be made through the NMED system."

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Agreement State Event Number: 52654
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: RADIATION HEALTH BRANCH
Region: 1
City: LOUISVILLE State: KY
County:
License #: 201-501-90
Agreement: Y
Docket:
NRC Notified By: CURT PRENDERGRASS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2017
Notification Time: 16:15 [ET]
Event Date: 03/28/2017
Event Time: [CDT]
Last Update Date: 03/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILL COOK (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF CONTROL OF A SEALED SOURCE

The following information was received from the Commonwealth of Kentucky via facsimile:

"On 3/28/2017 the licensee left a Cs-137 brachytherapy sealed source at [address provided]. On 3/30/2017 the licensee discovered the source was not in its shielded container and immediately determined the location of the source and took steps to retrieve and secure it. This event is actively being investigated by the licensee."

Kentucky Event: KY170003

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

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)

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Agreement State Event Number: 52656
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: JRT CONSTRUCTION COMPANY
Region: 4
City: MERLIN State: OR
County:
License #: 91180
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/02/2017
Notification Time: 10:36 [ET]
Event Date: 04/02/2017
Event Time: [PDT]
Last Update Date: 04/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

OREGON AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

An Oregon state licensee reported that a Campbell Pacific moisture density gauge model CPN-MC3 (serial number MC380304170) was stolen from a jobsite in Merlin, OR sometime late last night or early this morning. The licensee reported that the gauge was properly secured in a temporary storage building when the building was burglarized. The gauge and other equipment were stolen during the burglary. The licensee has contacted the local police department.

The gauge contains 10 mCi of Cs-137 and 10 mCi of Am-241/Be.

The state of Oregon will be contacting state and county officials to request public notification about the stolen gauge.

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

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Agreement State Event Number: 52659
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: 02500250000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 14:33 [ET]
Event Date: 03/22/2017
Event Time: [EDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - PACKAGE LOST DURING SHIPMENT

The following information was provided by the State of Ohio via email:

"On 3/31/17 the licensee (Cardinal Health) notified ODH [Ohio Department of Health] that a package containing a Ge [Germanium] Generator was being returned to the manufacturer (IRE Elit) in Belgium.

"The package was sent on 3/7/17 and on 3/22/17 Cardinal was notified by IRE that the package had not arrived. Cardinal immediately contacted the shipper [common carrier] concerning the package and at that time they had indication that it was stuck in customs in Paris, France.

"On 3/31/17 Cardinal was told by [common carrier] that the package has not been located in customs and they are continually searching for the package.

"On 4/3/17 licensee told by [common carrier] that there was no record that the package had ever left the [common carrier] hub in . . . and still have not located the package.

"Package is labeled as a Yellow II DOT Type A container with 1371 MBq (37 mCi) of Germanium 68. Solid/self-shielded container with a TI at shipment of 0.3.

"Item No.: OH170002

"Reference Number: OH 2017-017"

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

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Agreement State Event Number: 52660
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNIVERSITY OF VIRGINIA OFFICE OF ENVIRONMENTAL HEALTH AND SA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 16:07 [ET]
Event Date: 03/22/2017
Event Time: [EDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - WRITTEN DIRECTIVE INCORRECTLY IDENTIFIED THE TARGET ORGAN

The following information was received from the Commonwealth of Virginia via fax:

"On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive.

"The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated.

"ORH will review the licensee's written report and determine additional actions to be taken.

"Event Report ID No.: VA-17-004"

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.

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Agreement State Event Number: 52661
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KIRKHAM MICHAEL & ASSOCIATES, INC
Region: 4
City: ELLSWORTH State: KS
County:
License #: 22-B683-01
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 16:37 [ET]
Event Date: 04/03/2017
Event Time: 13:48 [CDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE DAMAGED BY HEAVY EQUIPMENT AT CONSTRUCTION SITE

An in-use Troxler gauge was damaged at a construction site on US 83 near Garden City, KS. The gauge, a Troxler model 3430, S/N 28271, contains a 0.3 GBq [8 mCi] Cs-137 source and a 1.48 GBq [40 mCi] Am-241/Be source. The Cs-137 source rod was extended at the time of the incident and could not be withdrawn into the shielded volume. Rad surveys on-site confirmed that both sources were intact [No contamination at the jobsite]. The gauge was returned to its case and temporary shielding used to prevent personnel exposure during transport back to the licensee's Ellsworth Office. The licensee will return the gauge to the manufacturer for disposition.

Item Number: KS170004

Page Last Reviewed/Updated Tuesday, April 11, 2017
Tuesday, April 11, 2017