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Event Notification Report for July 21, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/20/2017 - 07/21/2017

** EVENT NUMBERS **


52849 52851 52853 52854 52855 52856 52865

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Non-Agreement State Event Number: 52849
Rep Org: ACUREN INSPECTION
Licensee: ACUREN INSPECTION
Region: 1
City: MORGANTOWN State: WV
County:
License #: 22-27593-01
Agreement: N
Docket:
NRC Notified By: CHRIS DIXON
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/12/2017
Notification Time: 12:08 [ET]
Event Date: 06/28/2017
Event Time: 17:30 [EDT]
Last Update Date: 07/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

STUCK RADIOGRAPHY CAMERA SOURCE

"On June 28, 2017, at approximately 1725 EDT, a RT [Radiographic Testing] crew was performing radiography in Morgantown, WV. After completing a weld, they proceeded to move the exposure device to the next location. Due to the terrain and trench conditions, the crew was utilizing a 7 foot guide tube with a 7 foot extension tube with the exposure device on the top side of the trench.

"While exposing the source, the trench below the exposure device shifted causing the exposure device to barrel roll into the trench. The radiographer attempted to retract the source, but was unsuccessful. He then adjusted his boundaries and notified the RSO [Radiation Safety Officer] and Operations Manager [OM] of the situation.

"The RSO proceeded to the Akron, OH lab to gather the retrieval equipment while the OM discussed the situation with the technician over the phone. Multiple photos of the scene were sent to the OM, at which time, it was determined that the guide tube had most likely been damaged during the fall. Within 15 minutes of the initial notification, both the RSO and OM were on their way.

"Once in route to the job site, the OM notified the Assistant Director of Radiation Safety of the situation. He then contacted another RSO to assist in the retrieval.

"At approximately 2130 EDT, the retrieval team arrived on site and continued to assess the situation. The exposure device was at the bottom of a trench, on its side. The source was in an unshielded position. The team believed that the source was just outside of the exposure device due to readings that were taken with the Teletector.

"With multiple attempts of pulling the cranks, the team was eventually able to position the source into the 4 HVL [Half-Value Layer] collimator that was still strapped to the pipe. At this point, the team was able to get a better view of the front of the camera and confirmed that the extension tube had been crimped right at the connection to the bayonet. The exposure device was then pulled backwards by the cranks in an attempt to straighten the tubes. When challenging the cranks, the team confirmed that the source would not be able to be retracted by normal means.

"The team then planned to move the exposure device back to an area of the trench that gave them better access to the damaged tube. They noted that the bungie cord holding the collimator to the pipe was behind the set screw that holds it to the guide tube stop. Knowing that they did not want to lose the 4 HVL of shielding provided by the collimator, they decided that the bungie would need to be removed first.

"With the use of remote tongs and an extendable hook, the collimator was freed from the bungie. At this time, the team proceeded to pull the exposure device back approximately 10 feet to an area with adequate lighting and room to continue with the retrieval process. As the device was being pulled backwards, the guide tube remained over the pipe. The extendable hook was then used to move the remainder of the guide tube and collimator to the camera side of the pipe with the collimator pointing down into the ground.

"With the dose rates at ALARA, the team proceeded with lead shot bags. At first, the bags were walked by rope with one person on either side of the trench. Once the dose rates were lowered even further, the team applied several more until the dose rate at the front of the exposure device was less than 5 mR/hr. The team then approached the exposure device with tools in hand. The tube was unable to be uncrimped completely with the protective coating on the tube. The damaged area was then stripped and uncrimped to the best of the team's ability. Once complete, the area was cleared and the source was retracted back into its shielded position inside of the exposure device. Once the confirmatory surveys were made, [Assistant Director of Radiation Safety] was notified of the successful retrieval."

The three individuals involved in the source retrieval received 13, 5 and 4 mRem.

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Agreement State Event Number: 52851
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: VINCE KLCO
Notification Date: 07/13/2017
Notification Time: 10:33 [ET]
Event Date: 07/12/2017
Event Time: 11:00 [MDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF TREATMENT

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

"This is an initial report regarding a misadministration event in Colorado.

"University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached.

"Follow-up information will be provided after they are available."

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: 52853
Rep Org: NV DIV OF RAD HEALTH
Licensee: MET-CHEM TESTING LABS, INC.
Region: 4
City: CARLIN State: NV
County:
License #: UT1800146
Agreement: Y
Docket:
NRC Notified By: MICHAEL W, SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 08/07/2013
Event Time: [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY DEVICE

The following was received from the State of Nevada via email:

"A radiography device was involved in a structural collapse at Barrick Goldstrike Mines, north of Carlin. A wind gust collapsed a steel tank and the scaffolding around it where a radiographer (met chem reciprocity) was working. The device fell approx. 60 ft., damaging the shutter end. The radiographer was not seriously injured and determined that the radiation source was secure and there was no leakage. He packaged the camera and returned to Utah."

Item Number: NV130013

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Agreement State Event Number: 52854
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VEGAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0720-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 01/27/2016
Event Time: 16:35 [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING AND RECOVERED TROXLER GAUGE

The following was received from the State of Nevada via email:

"Incident involving a lost Troxler Portable gauge, Model 3430, S/N 23626 was reported to the State of Nevada Radiation Control Program on 01/27/2016 at 1635 [PST].

"The RSO of Las Vegas Valley Water District reported the gauge missing. An operator was distracted before the transportation of the gauge and failed to block and brace the gauge or close the tailgate of the transport vehicle. The operator had forgotten the pound plate on-site and walked to where he left it, retrieved the plate but then was distracted and did not secure the gauge. He then started back to the office but realized part way back he had lost the gauge from the back of his vehicle. He retraced his steps, called the RSO and asked another operator to help find the gauge. The gauge was not found at that time. The RSO call the Las Vegas Metropolitan Police [LVMPD]. The Duty Officer for the State of NV, RCP [Radiation Control Program] was notified.

"Update 01/28/2016: The RCP Duty Officer received a call from LVMPD ARMOR that the General Contractor on site found the gauge on 01/27/2016 and took it his storage and secured it over night.

"Update 01/29/16: The person who found it was non English speaking and locked it up at his work. He brought it back in the morning to the general contractor who called Armor the next morning. John and I gave 3 violations for security, blocking & bracing and type A container breach (pop rivets with their license information).

"We [Radiation Control Program] leak tested the gauge and it was negative, and they are having either Troxler or the local InstroTek repair it next week. It is tagged out of service right now.

"Update 05/10/2016: The LVWD has retrained all staff on properly securing device prior to driving vehicles. Investigation is considered closed."

The Troxler Model 3430 usually contains 8mCi of Cs-137 and 40 mCi of Am241/Be.

Item Number: NV160002

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: 52855
Rep Org: NV DIV OF RAD HEALTH
Licensee: CONSTRUCTION MATERIALS ENGINEERS
Region: 4
City: RENO State: NV
County:
License #: 00-11-0009-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 06/27/2016
Event Time: 18:45 [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING AND RECOVERED TROXLER GAUGE

The following was received from the State of Nevada via email:

"On 06/27/2016 at 1845 [PDT], it was reported to the State of Nevada, Radiation Control Program that a moisture/density gauge, Troxler model 3440, containing 40mCi of Am-241/Be and 8mCi of Cs-137 was missing/lost. The gauge fell out of the back of a transport vehicle and was lost in Reno, Nevada. The gauge user set the gauge on the tailgate of his truck and took a phone call. He was distracted by the phone call and did not place the gauge in it's transport case or secure the gauge and drove back to the office where he realized the gauge had fallen out of the transport vehicle. The gauge user immediately called the RSO and retraced his route to find the gauge. The gauge was not found and it was reported to the Nevada Highway patrol, Washoe County Sheriff and Reno Police Department. The State is following the incident and working with local authorities to develop a press release. Follow-up information will be provided to NRC on the recovery of the lost gauge and entered into NMED.

"Update 6/29/2016: 2 hours following the press release, the gauge was recovered and returned to the owner."

Item Number: NV160010

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: 52856
Rep Org: NV DIV OF RAD HEALTH
Licensee: ROBINSON NEVADA MINING COMPANY
Region: 4
City: RUTH State: NV
County:
License #: 17-11-0372-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL W. SCHMIDT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/13/2017
Notification Time: 16:05 [ET]
Event Date: 11/02/2015
Event Time: [PDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER MALFUNCTION

The following was received from the State of Nevada via email:

"Report of an equipment failure incident to the State of Nevada Radiation Control Program, fixed gauge malfunctioning shutter, Ohmart model SR-A, S/N: 1015GK at the Robinson Mine, Ruth, Nevada phoned in on 01/26/2016 at 1400 [PST].

"The RSO of Robinson Mine reported the shutter malfunction. He called the vendor to come on site and force the shutter closed. They were successful. The gauge was locked out/tagged out, but not removed from the service area in the mill central processing plant. The vendor stated the shutter malfunctioned because the shielding shifted due to process vibrations. The RSO has been instructed to submit a plan for the gauge."

Gauge contained 1.85 MBq of Cs-137.

Item Number: NV160003

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Power Reactor Event Number: 52865
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: WARREN CLEVELAND
HQ OPS Officer: DAN LIVERMORE
Notification Date: 07/20/2017
Notification Time: 13:30 [ET]
Event Date: 07/20/2017
Event Time: 12:30 [EDT]
Last Update Date: 07/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
LAURA KOZAK (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

Event Text

POTENTIAL TORNADO MISSILE VULNERABILITIES

"In order to address the concerns outlined in RIS 2015-06 'TORNADO MISSILE PROTECTION,' an evaluation of tornado missile vulnerabilities and their potential impact on Technical Specification (TS) plant equipment was conducted. This evaluation concluded that the following Structures, Systems, and Components (SSCs) are potentially vulnerable to tornado generated missiles:

"The Davis-Besse Nuclear Power Station (DBNPS) Unit 1 Emergency Diesel Generator (EDG) Fuel Oil Storage Tanks (FOST) (DB-Tl53-l, DB-T-153-2) support the EDG operation for 7 days. The vents on the FOST are necessary to support the transfer of fuel from the FOST to the EDG day tank. These vents are not protected and are vulnerable to a potential tornado-generated missile impact. This postulated strike could impact fuel transfer to the EDG day tank and, therefore does not support operability of both EDGs for Technical Specification 3.8.1.

"Tornado generated missiles striking the FOST vent piping could potentially affect pump performance and challenge the structural integrity of the tank. This would render both the FOST and corresponding EDG inoperable. This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(A).

"The potential vulnerabilities for the FOST vents (as discussed above) are being addressed in accordance with NRC EGM-15-002 Revision 1 and DSS-ISG-2016-01 NRC enforcement discretion and interim guidance documents. Immediate compensatory measures were taken to mitigate the potential consequences of an onsite tornado generated missile impact on the FOST vents."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, July 21, 2017
Friday, July 21, 2017