United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2017 > May 8

Event Notification Report for May 8, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/05/2017 - 05/08/2017

** EVENT NUMBERS **


52712 52714 52717 52719 52733 52734

To top of page
Agreement State Event Number: 52712
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BLANCHARD REFINING COMPANY LLC
Region: 4
City: TEXAS CITY State: TX
County:
License #: 06526
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2017
Notification Time: 12:58 [ET]
Event Date: 04/27/2017
Event Time: [CDT]
Last Update Date: 04/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED NUCLEAR GAUGE

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

"On April 27, 2017, the Agency [Texas Department of State Health Services] was notified by the radiation safety officer of a licensee that a fixed gauge was discovered with a stuck shutter. The gauge is a line level indicator on a hydrogen fluoride tank and was stuck in the normal operating position. The gauge is a Vega SHLG containing cesium-137, 300 milliCuries, serial number 321300. The gauge is scheduled for repair and an amendment to the license is in process to operate the gauge in the open position until repaired. There is no risk of exposure to an individual. Updates will be provided as acquired."

Texas Incident No.: I-9481

To top of page
Agreement State Event Number: 52714
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: COMPASS ONCOLOGY
Region: 4
City: PORTLAND State: OR
County:
License #: 91121
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/28/2017
Notification Time: 17:30 [ET]
Event Date: 04/28/2017
Event Time: [PDT]
Last Update Date: 04/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - HIGH DOSERATE AFTERLOADER CHECK SOURCE CABLE FAILURE

The following is an excerpt of a report received from the Oregon Department of Health via email:

Yesterday, April 27, 2017, while treating a patient with a 2 channel plan the licensee received the fault that the 'dummy' cable could not extend to the end of the applicator on the second channel. The licensee's procedure is to go into the HDR vault, check connections and position of the transfer tubes and then retry. The retry failed as well.

Because this was a 2 channel treatment, the patient had received only half of the treatment. The licensee explained what was going on to the patient and gave them the option of ending the treatment that day or waiting while the licensee did some testing and, if all went well, would finish the treatment. The patient opted to wait.

The licensee changed some of the applicators and transfer tubes, tested without failure, then brought the patient back into the vault to finish the treatment without any issues.

After the patient completed treatment and left, the licensee was able to extend the check source cable out of the afterloader and could see right away that the dummy source/end of cable had a bend in it. The licensee inspected the applicator that was used during the fault and thought there was a slight 'burr' in it. Between the bent cable and burr, there might have been snagging, leading to a fault.

The licensee called service (ELEKTA, Inc.) to come change the check source cable, which was done today, April 28, 2017.

After the check source cable change was completed, the licensee ran all combinations of transfer tubes and applicators without any failures. The licensee believed their theory about the burr and snag may have been wrong as that particular combination ran multiple times without any issues. Therefore, the bent cable caused the fault.

There were no adverse or unintended results for the patient, other than waiting 15 minutes while the licensee did some equipment testing. The patient received the prescribed dose. The system is designed so that if the check source/dummy cable cannot extend all the way to the end of the applicator you cannot proceed with the treatment so no possible way in this event to deliver an unintended dose to the patient.

To top of page
Agreement State Event Number: 52717
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VERSA INTEGRITY
Region: 4
City: HOUSTON State: TX
County:
License #: L06669
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 19:27 [ET]
Event Date: 04/28/2017
Event Time: [CDT]
Last Update Date: 04/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER TRAINEE BADGE READ GREATER THAN 5 REM

"On April 29, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that on April 28, 2017, one of its radiographer trainees had reported their self-reading dosimeter had gone off-scale. The licensee stopped all work and sent the trainee's OSL [Optically Stimulated Luminescence] dosimeter to be processed. The licensee received a verbal report from the processer on April 29, 2017, and the dose was reported as 5.392 REM. The licensee did not know if the dose was static or dynamic. The licensee stated that the trainee had not operated the exposure device and did not know how the trainee could have received the exposure. The licensee stated there was a chance that the dose was to the badge only. The licensee is conducting a formal investigation into the event. No other individual reported an unusual exposure. The exposure device was a QSA 880D camera containing a 51 Ci Ir-192 source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9482

To top of page
Agreement State Event Number: 52719
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: JANX
Region: 4
City: PARMA State: TX
County:
License #: 21-16560-01
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/30/2017
Notification Time: 22:05 [ET]
Event Date: 04/29/2017
Event Time: [CDT]
Last Update Date: 04/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

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

"On April 30, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew working at a temporary field site was unable to retract a 101 Curie iridium-192 source into a SPEC 150 exposure device (camera). The failure occurred after the radiography crew had moved the camera from one location to another at the same job site. The radiography crew notified the licensee of the event. The licensee sent an individual to the site to retrieve the source. The individual found that the guide tube had disconnected from the front of the camera and the flex in the cable was causing the connector to hang up on the camera inlet port. The recovery individual straightened the cable by pulling on the crank out cables and was able to fully retract the source. The RSO stated no over exposures occurred from this event. The RSO stated he believes sand had gotten into the guide tube to camera connection preventing the guide tube from fully latching on the camera outlet connection. The licensee possesses a license issued by the Nuclear Regulatory Commission and is operating under reciprocity in the State of Texas. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9483

To top of page
Power Reactor Event Number: 52733
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARC HILL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/05/2017
Notification Time: 00:45 [ET]
Event Date: 05/04/2017
Event Time: 21:03 [CDT]
Last Update Date: 05/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK HAIRE (R4DO)

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

OFFSITE NOTIFICATION DUE TO MISCOMMUNICATION DURING ON-THE-JOB TRAINING

"On 5/4/17 at 2103 CDT, the South Texas Project [STP] Security Department was conducting on-the-job training for Bomb Threat response. While simulating the Bomb Threat Checklist via phone call, the trainer mistakenly contacted the Brazoria County, TX Child Protective Services (CPS) and reported a bomb threat. In response, the Child Protective Services notified the City of Brazoria, TX Police Department of the threat. The Brazoria Police Dept. then contacted both the Bay City, TX Police Department and the STP Security Department. By approximately 2130 CDT, all agencies had been notified by the STP Security Department of the mistaken phone call and that no actual bomb threat existed.

"The NRC Senior Resident Inspector was notified of the issue."

To top of page
Part 21 Event Number: 52734
Rep Org: SUMMERILL TUBE CORPORATION
Licensee: SUMMERILL TUBE CORPORATION
Region: 1
City: SCOTTDALE State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SCOTT SALVATORE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/05/2017
Notification Time: 14:38 [ET]
Event Date: 03/08/2017
Event Time: [EDT]
Last Update Date: 05/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
JAMES DWYER (R1DO)
RANDY MUSSER (R2DO)
ROBERT ORLIKOWSKI (R3DO)
MARK HAIRE (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

INTERIM PART 21 - UNQUALIFIED SOURCE MATERIAL FOR NUCLEAR APPLICATIONS

During a Vendor Audit by Consolidated Power Supply located in Birmingham, AL, it was discovered that three (3) orders had been received from Summerill Tube Corporation that did not meet the ASME BPVC, Section III, NCA-3800 criteria.

Management Systems Analysis, Inc. completed a Supplier Quality Audit Report for Consolidated Power Supply which is described, in part, below:

"SUPPLIER QUALITY AUDIT REPORT

"SUPPLIER NAME/LOCATION: Summerill Tube Corp., Franklin Street, P.O. Box 302, Scottdale, Pa 15683, Phone: 724-887-9700

"PRODUCT: Ferrous & Nonferrous Tubing

"SPECIFICATIONS: ASME SECT III Div 1NCA3800 15 Ed, 10CFR50 APP 'B', ANSIN45.2, NQA-1 94 Ed thru & including 08 Ed/09 Ad Basic Requirements, 10CFR21, SNT-TC-1a ASME Nx 5500

"AUDIT SCOPE

"Summerill Tube is a Material Organization manufacturing Ferrous and Nonferrous Tubing in accordance with their Quality Assurance Manual Rev 04 dated 10/22/12 and Nuclear Code Manual Rev 03 dated 12/19/12 that supplements the program in accordance with the ASME Code.

"QUALITY ASSURANCE SUMMARY: On March 2, 2017 an audit was conducted of Summerill Tube in Scottdale, Pennsylvania. The primary contact during the investigation was Scott Salvatore Quality Assurance Manager.

"Summerill was procuring qualified materials from approved sources, typically ASME QSC holders for extrusion into its final form. Once material is accepted at their facility it is entered into inventory and stored in a lay down area outside. Upon acceptance of an order materials are allocated the job, a work order is issued detailing the sequence of operations to be performed and the customer's requirements. Testing is performed on each heat of material issued for code work using qualified materials. During the past year this has changed as documented in Audit Finding No 1.

"The material is annealed to remove work hardening, passivated to remove any scale or contamination and tested. Testing typically consists of eddy current testing, hydrostatic testing and ultrasonic examination as required. The completed materials are then line marked packaged and shipped.

"The following orders were reviewed as the primary basis of the investigation including certification of the material by Summerill material certifications, associated Shop Orders, testing performed to qualify the material, hydro testing, flare testing, heat treatment and final inspection of the parts prior shipment.

"Reviewed the following orders:

"Order 32422 Lot 32422 SA213 316L 5/17/16 ASME III NC 15 Ed Ht 541455 from Sandvik dated 7/7/15 Penn State Metals 5/12/16 Chem Analysis by LTI dated 5/13/16 Solution Anneal 5/3/16. Dim Inspection dated 5/16/16 Certification dated 5/17/16

"Order 32675 Lot 32675 SA213 to ASME III Cl 2 15Ed Ht 541366 from Sandvik dated 11/4/15 Tensile by Penn State dated 9/26/16 & Chem by Lab Testing dated 9/26/16 Solution Anneal dated 9/21/16. Dim Inspection dated 10/3/16 Certification dated 10/6/16

"Order 32676 Lot 32676 SA213 316L ASME III NC 15 Ed Ht 541028 from Sandvik dated 5/19/15 Tensile by Penn State dated 9/30/16 Chem by LTI 9/26/16 Solution Anneal dated 9/21/16. Dim Inspection dated 10/11/16 Certification dated 10/12/16

"Order 32120 Lot 32120 SA213 304L to ASME III Cl 1 15 Ed Ht 531223 from Sandvik dated 4/18/12 Tensile by Penn dated 9/1116 Chem by Lab Testing dated 8/31/16 UT by LTI 9/21/16 Solution Anneal dated 8/22/16. Dim Inspection dated 10/1/16 Certification dated 11/22/16

"As a part of the investigation corrective action to previous audit deficiencies was reviewed with the following results.

"Audit Finding No. 1 (V16-7) Contrary to NCA 1140.g STC does not have a copy of the 2015 Edition of the ASME Code and consequently has not reviewed the edition for changes that would impact their program. A copy of the 2015 Ed of Section III was obtained and reviewed. Actions taken found to be satisfactory.

"Based on the investigation the supplier program was found to be adequate and effective.

"RESULTS

"As a result of the investigation performed at Summerill revealed the following deficiency was noted.

"Audit Finding No. 1

"Two suppliers appear on the Approved Suppliers List, Walsin Specialty dated 4/15/16 and Shanghai Maxmount dated 4/13/16, as ASME III NCA 3800 suppliers. Audits of each of these suppliers performed by AccuInspection. The checklist sections covering NCA 3800 indicate 'Minor NC' and 'N/A' as a result without further explanation. Materials from these supplier were purchased from Krupala in Canada and unaudited source.

"Audit Finding No. 2

"Contrary to NCA 3855.5 and Section 7.3 of the manual only one chemistry was performed by Lab Testing on Ht E110462 Sa213 316L unqualified source material from Outokumpu via Krupalu and Walsin to represent 18 pieces used on order 32132. This material was certified as ASME Section III NC 2015 Ed."

Summerill identified three (3) additional unqualified orders that were shipped to Tioga who was notified on 04/28/2017.

For additional information, you may contact:

Scott Salvatore
Quality Manager
Summerill Tube Corp.
P. O. Box 302
220 Franklin Street
Scottdale, PA 15683
Work: 724.887.1412 / Cell: 412.901.9643 / Fax: 724.887.1450/Email: scotts@summerilltube.com
http://www.summerilltube.com/

Page Last Reviewed/Updated Monday, May 08, 2017
Monday, May 08, 2017