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Event Notification Report for November 30, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/29/2017 - 11/30/2017

** EVENT NUMBERS **


53002 53062 53082 53086 53087 53088 53096

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Part 21 Event Number: 53002
Rep Org: PARAGON ENERGY SOLUTIONS
Licensee: PARAGON ENERGY SOLUTIONS
Region: 1
City: OAK RIDGE State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RAY CHALIFOUX
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/06/2017
Notification Time: 15:29 [ET]
Event Date: 10/06/2017
Event Time: [EDT]
Last Update Date: 11/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
REBECCA NEASE (R2DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 INTERIM REPORT - SWITCH WITH UNACCEPTABLE CHATTER

The following information is excerpted from a report received via email:

"Seismic qualification testing revealed contact block (CB) chatter greater than 2 milliseconds (msec) contrary to the acceptance requirements of the seismic test procedure developed for the activity. This switch has not been provided to the customer, however, a second suspect switch with a similar configuration and parts is installed in the customer's facility.

"The condition is isolated to when OT2A CBs are configured in an alternating Normally Open (NO) / Normally Closed or Normally Closed (NC) / Normally Open (NO) arrangement. The CBs do not exhibit chatter when 3 or less CBs are configured this way. The chatter is not exhibited when configured in a NO/NC, NO/NC, configuration. When the fourth CB is added to the switch assembly in an alternating configuration is when the contact chatter exceeds greater than 2 msec.

"Paragon Engineering has requested TVA Engineering to provide a reduced spectra specific to the installed location for further evaluation. Paragon Engineering has not been able to complete this activity within the 60-day period allowed under 10 CFR 21.

"One suspect switch has been provided to and installed at the customer's facility. The customer's facility is TVA - Watts Bar Unit 2."

* * * UPDATE ON 11/29/17 AT 1648 EST FROM RAY CHALIFOUX TO DAVID AIRD * * *

The following is an excerpt from the final Part 21 report received via email:

"Paragon ES [Energy Solutions] successfully completed qualification of a seismic specimen to the originally provided spectra using older vintage contact blocks. A reduced response spectra was requested from the licensee to verify that this condition did not present a substantial safety hazard for the existing installed switch.

"The licensee alternatively completed an evaluation of the condition and determined a substantial safety hazard did not exist."

Notified R2DO (Blamey) and Part 21 Reactors Group via email.

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Agreement State Event Number: 53062
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: NOT SPECIFIED
Region: 3
City: AKRON State: OH
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: VINCE KLCO
Notification Date: 11/08/2017
Notification Time: 15:06 [ET]
Event Date: 09/02/2017
Event Time: [EST]
Last Update Date: 11/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MATERIAL STOLEN AND NOT RECOVERED

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

"A local Health District employee had a Niton Xlp 300 XRF with a 50 mCi Cadmium-109 source stolen overnight on Saturday, September 2, 2017. It was in the car in their garage and someone came in and took it. The employee had worked late at a job site that day and brought the gauge home instead of returning to the office. Employee's garage door did not close for some reason that night and they were unaware that it was open when they went to bed. There were several other cars broken into that night in employee's neighborhood. A report was filed with local police department. Device has not yet been recovered."

Source/Radioactive Material: Sealed Source; Radionuclide: Cd-109; Activity: 50mCi; Device Name: X-RAY Fluorescence (XRF); Model Number: Niton XLp 300; Manufacturer: Thermo Scientific Analytical; Serial Number: 98149.

Ohio Item Number: OH170007

* * * UPDATE AT 0919 ON 11/29/17 FROM STEPHEN JAMES TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"Note: According to device owner, the manufacturer told them that this incident was NOT reportable to their regulatory agency. The owner reported the event on 11/6/17 as a result of more research on their part.

"UPDATE: The gauge was found by a member of the public in their yard, where it had apparently been abandoned. The local health district was notified based on contact information on case. The case was still locked when found. The device is now back in the possession of the local health district as of 11/27/17."

Notified the R3DO (Duncan), NMSS Events Resources and CNSC (via e-mail) .

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: 53082
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: GOODYEAR
Region: 4
City: LAWTON State: OK
County:
License #: GLD0013
Agreement: Y
Docket:
NRC Notified By: JENNIFER McALLISTER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2017
Notification Time: 11:57 [ET]
Event Date: 11/20/2017
Event Time: [CST]
Last Update Date: 11/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE DAMAGED HOUSING

The following information was received via e-mail:

"The RSO [Radiation Safety Officer] for Goodyear contacted us [Oklahoma Department of Environmental Quality] yesterday afternoon. [The RSO] stated that a roller had broken loose from their line, and it damaged the housing for a registered generally licensed device (fixed gauge) they have on the property. The gauge is a Honeywell Measurex. 50 mCi Sr-90.

"There was no loss of control, but there was damage. They [Goodyear] took immediate action. The source is secure and shielded at this time."

* * * UPDATE AT 1049 EST ON 11/27/17 FROM JENNIFER McALLISTER TO S. SANDIN VIA EMAIL * * *

"Generally Licensed Device Site Registration Number: GLD0013

"Source Serial No.: 0953BG"

Notified R4DO (O'Keefe) and NMSS Events Notification via email.

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Agreement State Event Number: 53086
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: FAIRVIEW HOSPITAL
Region: 3
City: CLEVELAND State: OH
County:
License #: 02120180101
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 13:40 [ET]
Event Date: 11/20/2017
Event Time: [EST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL UNDERDOSE

The following information was received via e-mail:

"ODH [Ohio Department of Health] was notified of a potential medical event by Fairview Hospital. The licensee performed a permanent prostate seed implant using I-125 according to the treatment plan. When the post implant dosimetry was performed, the D90 coverage was calculated to be 73% of the prescribed dose. After an initial investigation by the licensee, it was determined the under dose was caused by an 18% increase in prostate size compared to the pre-plan, which was prescribed 6 weeks prior to treatment.

"At the time of reporting, the licensee had informed the referring physician but they did not inform the patient. The licensee believes that once the inflammation subsides the D90 coverage will be within the prescribe treatment plan.

"NMED will be updated once ODH receives additional information from the licensee and conducts an investigation of the event."

Ohio Event: OH170009

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: 53087
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: CO 902-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 14:37 [ET]
Event Date: 11/22/2017
Event Time: [CST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following report was received via e-mail:

"A crew with [Shawcor] experienced a malfunction on the evening of November 21, 2017, with the INC IR-100 exposure device they were using when performing radiographic operations at Ward Petroleum (10404 E. 146th, Thornton, CO).

"Exposure Device: INC IR-100 (s/n 6839)
"Source: INC (s/n T0799) 65 curies

"After completing a radiographic exposure, the crew attempted to crank the source back into the exposure device; however, they were still able to crank the source out even after the button on the exposure device popped up to indicate the source was fully retracted and locked in place. After an attempt to crank the source out and back into the exposure device, the button was still popping up prematurely. Realizing there was a problem with the locking mechanism, the crew ensured their 2 mR/hr boundary was properly established and immediately contacted the Site RSO/Branch Manager. The crew maintained visual surveillance of the area until [the RSO], along with [the Assistant Site RSO], arrived at the jobsite.

"When [the RSO and Assistant Site RSO] arrived at the jobsite, they also ensured the 2 mR/hr boundary was properly established and began to assess the situation. There was no visible damage to any associated equipment (guide tube, crank assembly, etc.). They attempted several times to crank the source out and back into the fully shielded position; each time the button popped up prematurely even though the source was not locked into the exposure device. While holding down the button on the exposure device, [the RSO] was able to crank the source back in and upon releasing the button, the source locked in place. Surveys were completed to ensure the source was fully shielded.

"At no time during the incident did any crew member's dosimeter go off-scale and there was no threat of overexposure at any time to our company's employees, nor un-monitored workers. All personnel involved were wearing and utilizing proper radiation detection equipment, including OSL [Optically Stimulated Luminescent] badges, pocket dosimeters, alarming rate meters, and they were properly utilizing survey meters.

"The INC exposure device will be sent back to the manufacturer for maintenance and repair, if necessary."

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Agreement State Event Number: 53088
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH AND SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 15:22 [ET]
Event Date: 11/17/2017
Event Time: [PST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered.

Oregon Report: 17-0073

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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Power Reactor Event Number: 53096
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHARLENE MILLER
HQ OPS Officer: STEVEN VITTO
Notification Date: 11/29/2017
Notification Time: 18:09 [ET]
Event Date: 11/29/2017
Event Time: 11:25 [PST]
Last Update Date: 11/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NEIL OKEEFE (R4DO)
FFD GROUP (EMAI)

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

FITNESS-FOR-DUTY REPORT INVOLVING DISCOVERY OF KOMBUCHA TEA INSIDE THE PROTECTED AREA

"On 11/29/2017, at approximately 1125 (Pacific Time), an employee reported finding a container of herbal tea (Kombucha) in a refrigerator in a warehouse building break room, which is located inside the Protected Area. Kombucha tea is a fermented tea containing trace amounts of alcohol. Based on the product labeling, which indicates the beverage may contain more than 0.5 percent alcohol by volume, and which also includes a government alcoholic beverage health warning label, this is being considered an alcoholic beverage, and is being reported under the requirements of 10 CFR Part 26.719.

"An investigation is under way to identify who may have brought the kombucha tea on-site.

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, November 30, 2017
Thursday, November 30, 2017