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Event Notification Report for September 5, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/01/2017 - 09/05/2017

** EVENT NUMBERS **


52923 52925 52928 52929 52931 52933 52945 52946

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Agreement State Event Number: 52923
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EAGLE US 2 LLC
Region: 4
City: LAKE CHARLES State: LA
County:
License #: LA-2257-L01;
Agreement: Y
Docket:
NRC Notified By: JUDITH SCHUERMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2017
Notification Time: 12:19 [ET]
Event Date: 08/23/2017
Event Time: 16:00 [CDT]
Last Update Date: 08/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST SOURCE FROM A DENSITY GAUGE

The following information was received via E-mail:

"Eagle US 2 LLC in Lake Charles (formerly Westlake Chemicals) called to say they lost a Cs-137 source from a density gauge at 1600 [CDT] Wednesday, August 23, 2017. At purchase, the source was 200 mCi. The source is no longer in the device holder/housing. They surveyed for it and have not located it yet. They are continuing to search for it. Source housing is Ronan Model # SAIC10 and Source Serial Number is Ronan # 9527GG."

Louisiana Event Report ID No.: LA20170014

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: 52925
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0253-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2017
Notification Time: 22:09 [ET]
Event Date: 08/24/2017
Event Time: 18:00 [EDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

NORTH CAROLINA AGREEMENT STATE REPORT - MISSING PORTABLE NUCLEAR GAUGE

The following information was obtained from the state of North Carolina via email:

"North Carolina Radioactive Materials Branch (RMB) was notified on 8/24/17 at 7:58 PM [EDT] that a portable nuclear gauge went missing at around 6:00 PM at a job site at Ten-Ten Road in Garner, NC 27603.

"Licensee: ECS Southeast, LLP
License Number: 092-0253-1
Gauge Manufacturer: Instrotek Xplorer
Model #: 3500
Serial #: 3194

"The gauge contains 11 milliCuries of cesium-137 and 44 milliCuries of americium-241: beryllium. The gauge was not trigger locked and not locked in its original carrying case at the time it went missing. RMB is investigating the incident and working with local authorities to develop a press release. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC as this investigation is ongoing."

* * * UPDATE AT 1058EDT ON 08/25/17 FROM TRAVIS CARTOSKI TO S. SANDIN VIA EMAIL * * *

"NC Radioactive Materials Branch (RMB) would like to report that the missing gauge has been found this morning 8/25. Three members of the RMB were dispatched last night to initiate an investigation and reconvened this morning to continue. The gauge appeared to have no damage and is being returned to the manufacturer for verification. Surveys were taken on and around the gauge once it was found and all surveys appeared normal indicating the sources were still intact within the gauge.

"Through interviews of personnel on-site, it was determined that source rod was never extended from when the gauge went missing to when it was found. An on-site construction worker found the gauge unattended yesterday afternoon and secured it until this morning.

"RMB is continuing its investigation from a compliance stand point. Further details will be provided to satisfy the details of this incident following conclusion of this investigation."

Notified R1DO (Kennedy) and NMSS Events Notification and ILTAB via email.

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: 52928
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: UNIVERSITY OF KANSAS HOSPITAL
Region: 4
City: KANSAS CITY State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2017
Notification Time: 15:20 [ET]
Event Date: 08/24/2017
Event Time: 15:15 [CDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN COLLINS (NMSS)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION RESULTING FROM Y-90 SETUP

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

"During Therasphere setup, a technician forgot to prime the syringe and inserted it into the vial of Y-90. She realized the syringe was not primed, but because the syringe cannot be removed, her attempt at priming it opened the vial inadvertently. It got tracked all over the room and to some extent all around the Interventional Radiology (IR) department. IR is now completely closed. She was put in a bunny suit immediately and sent to emergency to get deconned at the shower. There was no risk of internal contamination due to the rapidity of the decon after the incident. Highest contamination is at 90k on her scrubs. Most of the contamination was on her lead apron. The clothes are currently sequestered and lacking skin contamination, she was sent home. They are currently in the process of cleaning up and recovering to get IR back in business.

"An investigator will be sent on Monday to gain first-hand knowledge of the incident. The RSO and ARSO were at a conference, arriving home last night, and were not present during the incident.

"Reporting under 10 CFR 30.50(b) (corresponding to K.A.R. 28-35-184b in Kansas Annotated Regulations), area closed to workers and public for more than 24 hours due to an unplanned contamination."

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Agreement State Event Number: 52929
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNKNOWN
Region: 1
City: MEMPHIS State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2017
Notification Time: 16:02 [ET]
Event Date: 08/24/2017
Event Time: [EDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)

Event Text

AGREEMENT STATE REPORT - DAMAGED SOURCE

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

"The corporate RSO [Radiation Safety Officer] for [common carrier] contacted the agency [Illinois Emergency Management Agency] at approximately 1300 [CDT] on August 25, 2017 to notify that last night (August 24, 2017) a Type A package containing 140 GBq of high dose rate brachytherapy lr-192 seeds had suffered physical damage at a [common carrier] facility in South Holland, IL. The package was en route from Community Hospital in Munster, IN to an out of state site for Alpha Omega and shifted during transit. The impact resulted in a cracked rim of the Type A package; however, there was no loss of contents, contamination, or exposure to personnel. Exposure rate surveys verified package contents but no contamination surveys were completed. The incident is being reported to the National Response Center concurrently."

Item number: IL177027
National Response Center Incident Report # 1188386

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Agreement State Event Number: 52931
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TURNER SPECIALTY SERVICES, LLC
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-10185-L01,
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2017
Notification Time: 15:32 [ET]
Event Date: 08/15/2017
Event Time: 22:15 [CDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE

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

"[On] 08/16/2017, [at] 1315 [CDT], [the RSO for Turner Specialty Services] called the Radiation Section of LDEQ [Louisiana Department of Environmental Quality] to report a source retrieval that occurred on 08/15/2017 [at] 2215 [CDT] at SALSOL CHEMICALS. The report was forwarded to the inspection staff on 08/17/2017.

"The camera was being setup initially to be used on this temporary jobsite at the Chemical Plant. The equipment evaluation and jobsite was being prepared for the radiographic exposures. The exposure device mis-connect/disconnect incident happened on the initial exposure crankout. The source remained in the collimator until the source could be manually returned to the shielded position. The equipment is a QSA Global Exposure device, Model 880 Delta, S/N D6149 loaded with 61.2 Ci Ir-192 source. The source is an AEA Technology Model A-424-9.

"This licensee is approved for source retrievals under their O&E Safety Procedures. The RSO and associates were able to return the source to the shielded position with minimal personnel exposures. A retrieval crew was assembled and they were able to retrieve the source and return it to the shielded position. After the source was in the shielded position, a Go/NoGo test and a misconnect test were performed on the controls and exposure device. Two radiographers and a site RSO conducted the retrieval activities. The retrieval process was safely completed later on the night of 08/15/2017. The individuals involved in the retrieval were wearing Instadose Personnel monitors that recorded exposures of [approximately] 250 mRem. The source assembly was sent to QSA Global, Inc. for further evaluation. Any adverse results of the evaluation will be forwarded as additional information.

"There was no threat of radiation exposures to the SALSOL CHEMICALS employees or any adverse threat to the Health and Safety to the general public."

Event Report ID No.: LA170013

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Non-Agreement State Event Number: 52933
Rep Org: HENRY FORD HOSPITAL
Licensee: HENRY FORD HOSPITAL
Region: 3
City: WEST BLOOMFIELD State: MI
County:
License #: 21-04109-16
Agreement: N
Docket:
NRC Notified By: ALAN JACKSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/28/2017
Notification Time: 12:39 [ET]
Event Date: 08/28/2017
Event Time: 07:00 [EDT]
Last Update Date: 08/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

RECEIPT OF A CONTAMINATED PACKAGE

This incident is being reported under 10CFR20.1906(d) and 10CFR71.87(i).

A contaminated package was received from Cardinal Health at approximately 0700 EDT on 8/28/17. The package contained 49.41 mCi of I-131 and had removable surface contamination. The first wipe test exhibited 0.4 microCi/300 sq. cm Tc-99m and the second wipe was 0.25 microCi Tc-99m/300 sq. cm. The interior of the package was not contaminated. The package was isolated pending disposition.

Cardinal Health was contacted. Their delivery van and driver were surveyed and exhibited no contamination.

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Power Reactor Event Number: 52945
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM PEREZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/02/2017
Notification Time: 01:36 [ET]
Event Date: 09/01/2017
Event Time: 21:40 [CDT]
Last Update Date: 09/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO TWO DROPPED RODS

"At time 2140 [CDT] on September 1, 2017, CPNPP [Comanche Peak Nuclear Power Plant] Unit 2 experienced two (2) dropped rods, one control, one shutdown. The reactor was then manually tripped.

"This event is being reported in accordance with 10CFR50.72(b)(2)(iv)(B) for reactor trip and 10CFR 50.72(b)(3)(iv)(A) for an actuation of auxiliary feedwater.

"Currently Unit 2 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IP0-007B, Emergency Response Guideline Procedure Network has been exited. Decay Heat is being rejected to the Main Condenser via Steam Dump Valves (Turbine Bypass Valves).

"The NRC Resident Inspector has been notified."

All rods inserted into the core during the trip. No relief or safety valves actuated during the plant transient. The electrical grid is stable and supplying plant loads. Unit 1 was not affected by the transient.

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Power Reactor Event Number: 52946
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: THOMAS JOACHIMCZYK
HQ OPS Officer: BETHANY CECERE
Notification Date: 09/02/2017
Notification Time: 19:36 [ET]
Event Date: 09/02/2017
Event Time: 11:48 [EDT]
Last Update Date: 09/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JON LILLIENDAHL (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

AREA RADIATION MONITOR FAILURE

"MCR (Main Control Room) area radiation monitor R-1 failed at 1148 [EDT on] 9/2/2017. This caused a loss of capability to classify EAL [Emergency Action Level] RA3.1, Dose Rates greater than 15 mrem/hr in either of the following areas requiring continuous occupancy to maintain plant safety functions: Control Room (R-1) or CAS [Central Alarm Station]. Compensatory measures are currently in place with a portable radiation monitor in the MCR with alarm setpoints consistent with R-1. Priority maintenance is being planned to restore R-1 to service."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, September 05, 2017
Tuesday, September 05, 2017