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Event Notification Report for December 20, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/19/2017 - 12/20/2017

** EVENT NUMBERS **


53013 53097 53103 53113 53114 53126 53128

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Agreement State Event Number: 53013
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SOUTHERN RECYCLING
Region: 4
City: WALLS State: MS
County: DESOTO
License #: GL-397
Agreement: Y
Docket:
NRC Notified By: BENJAMIN CULPEPPER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 15:38 [ET]
Event Date: 09/08/2017
Event Time: [CDT]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOSS OR THEFT OF LICENSED NUCLEAR MATERIAL

The following was reported from the State of Mississippi:

Description of Incident: Licensee reported that their Niton gun was discovered to be misplaced or stolen on September 8, 2017. A letter was received by Mississippi State Department of Health: Division of Radiological Health (DRH) from the licensee on October 13, 2017 briefly detailing that their equipment had been lost or stolen.

DRH intends to issue a violation letter to Southern Recycling due to the late notification. Also, due to lacking information, DRH cannot confirm if the device reported to have been stolen/lost contains radioactive material.

DRH has attempted to contact the Licensee a number of times to acquire more information; however, there has been no response. DRH will continue contacting the licensee for more information and will update this report once complete.

Isotope(s): Cd-109 (potentially lost source not confirmed), with an activity of 10 mCi.

The DRH Health Physicist stated that this would give a reading of approximately 20 mRem at one foot if unshielded.

Mississippi has assigned an incident number of MS17006.

* * * UPDATE AT 1055 EDT ON 10/31/17 FROM H. BENJAMIN CULPEPPER TO S. SANDIN VIA EMAIL * * *

"DRH was able to contact Licensee regarding the lost source. Licensee originally bought the device in 2007 to use at their facility. After a period of time, the device was more ineffective than effective, causing the Licensee to send the Niton gun for repairs. Licensee was informed that the source would have to be changed in order to alleviate the issue, but Licensee did not seek that avenue due to high costs. Even with the Niton gun being ineffective, Licensee maintained possession of the device until losing it three (3) years ago.

"The Licensee's coworker recently reminded them that DRH should be informed about the missing source.

"After contacting DRH about the missing source, DRH contacted a representative from Thermo Scientific to discuss the lifetime of the source. It was discovered that the source's assay date is 2/1/2006 and was shipped to the first owner on 12/6/2006. No other radioactive material was shipped to the Licensee in question from Thermo Scientific.

"Knowing that the lost source is Cd-109, which has a half-life = 462.6 days, it was discovered that the 10 mCi source will have decayed (as of today) to an activity level of 0.01618 mCi. Also, if the source was one (1) foot away from the target, the target would receive a dose-rate = 33.86 microR/hr."

DRH closed this case on 10/30/2017.

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


* * * UPDATE ON 12/19/2017 AT 0945 EST FROM H. BENJAMIN CULPEPPER TO ANDREW WAUGH * * *

The following report was received via email:

"The Source Serial Number for the Cd-109 source is U3134."

Notified R4DO (Pick) and NMSS Events Notification 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: 53097
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTECK ASSET INTEGRITY MANAGEMENT, INC.
Region: 4
City: LONGVIEW State: TX
County:
License #: 06801
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/30/2017
Notification Time: 08:49 [ET]
Event Date: 11/28/2017
Event Time: [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY TRAINEE OVEREXPOSURE

The following report was received via e-mail:

"On November 28, 2017, the Agency [Texas Department of State Health Services] was contacted by the licensee's Radiation Safety Officer (RSO) who reported that on November 28, 2017, they were notified by their dosimetry processor that one of their radiographer trainee's exposure badges was reported to read 62 Rem. The RSO stated the trainee was returning to the Longview office from West Texas to be interviewed. The badge reading was for the month of October 2017. The RSO stated the trainee had operated the radiography camera crank out device, but had not changed out any film. It is believed the dose is to the badge only. The RSO stated they had not observed any adverse health effects in the trainee. On November 29, 2017, the Agency contacted the RSO and requested additional information. The RSO stated the trainee stated that they had not dropped their dosimeter and accidently exposed it. The trainee had stated that they had been wearing an alarming rate meter and it had never alarmed. The trainee's daily exposure record did not indicate any abnormal exposures. The radiographer supervising the trainee did not recall any abnormal operations while supervising the trainee. The RSO stated the trainee had not received any type of medical treatments during the exposure period. The RSO stated they were considering sending blood samples to REAC/TS for analysis. The RSO stated the dosimetry processor reported the exposure to the badge was angular. The RSO stated the trainee has been assigned duties that would not give them any additional exposure.

"The licensee will provide the Agency [Texas Department of State Health Services] any information gathered in the interview with the trainee. The RSO cannot state with certainty that the exposure is not real, therefore the Agency is providing this report to the Nuclear Regulatory Commission. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9523


* * * UPDATE ON 12/12/2017 AT 0955 EST FROM ART TUCKER TO STEVEN VITTO * * *

The following report was received via e-mail:

"On November 28, 2017, the Agency was contacted by the licensee's RSO who reported that the OSL [Optically stimulated luminescence] badge reading for one of their radiographer trainees was reported to read 62 rem. On December 8, 2017, the Agency interviewed the individual with the high badge reading and the licensee's radiation safety officer (RSO). The interviews did not provide any additional information that would explain the high badge reading. The RSO stated a blood sample from the individual was submitted to Radiation Emergency Assistance Center/Training Site (REAC/TS) on December 5, 2017. Additional information will be provided as it is received in accordance with SA-300."

R4DO (Deese), INES Officer (Milligan), and NMSS Events Group have been notified.


* * * UPDATE ON 12/19/2017 AT 0828 EST FROM ART TUCKER TO ANDREW WAUGH * * *

The following report was received via e-mail:

"On December 18, 2017, the licensee [Interteck Asset Integrity Management Inc.] reported 'I have received the test report and the result is negative. No dicentric chromosome was observed in a total of 500 metaphase cells analyzed.' indicating the exposure was to the badge only. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Pick), INES Officer (Milligan), and NMSS Events Group via email.

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Agreement State Event Number: 53103
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CARE SOUTHERN LAKES, INC
Region: 3
City: KENOSHA State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: DAVID REINDL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/04/2017
Notification Time: 16:52 [ET]
Event Date: 12/04/2017
Event Time: 11:00 [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED Y-90 DOSE

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

"On December 4, 2017, the department [State of Wisconsin Department of Health Services] received a telephone call and email from the licensee's lead nuclear medicine technologist about a Y-90 TheraSphere dose that was not delivered as prescribed to the patient. The procedure occurred at 11:00 AM on December 4, 2017. The written directive stated that the dose delivered should be 120 Gy. The estimated dose delivered to the liver was 17.7 Gy. The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment. The licensee is suspecting that there was an issue with the administration kit. The licensee has contacted the manufacturer and the manufacturer is planning a site visit. The licensee has removed the contaminated administration kit and placed it in a waste bag for decay in storage. The room where the administration occurred has also been cleaned. The department [State of Wisconsin Department of Health Services] will follow up with a site visit to investigate the incident.

"Event Report ID No.: WI170019"

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.

* * * UPDATE FROM DAVID REINDL TO VINCE KLCO ON 12/19/17 AT 1217 EST * * *

The following information was excerpted from an email received from the State of Wisconsin:

". . . After performing a site visit on December 14, 2017 it was determined that there was actually no contamination resulting from this event. The licensee requested that we amend the notice to reflect this change . . . . In the publicly available text there are two statements that should be changed. The text 'The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment' should be changed to 'The nuclear medicine technologist discovered no contamination in the operating room where the procedure took place'. Additionally the following text should be deleted, 'The room where the administration occurred has also been cleaned'."

Notified the R3DO (Dickson) and NMSS Events Notification Group via email.

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Agreement State Event Number: 53113
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GEORGIA-PACIFIC CONSUMER PRODUCTS, LLC
Region: 4
City: ZACHARY State: LA
County:
License #: LA-2162-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/11/2017
Notification Time: 14:43 [ET]
Event Date: 12/06/2017
Event Time: [CST]
Last Update Date: 12/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION - STUCK SHUTTER

The following was received via fax:

"On Wednesday, December 6, 2017, a contract technician from BBP Sales conducted Georgia-Pacific semiannual shutter checks. It was found that a handle would not turn to close a shutter for a level gauge. The gauge was a Ronan holder model SAI-F37 manufactured in 1987. The sealed source serial number is MI104. This is a 150 mCi Cesium-137 source.

"Louisiana Department of Environmental Quality (LDEQ) was notified on December 11, 2017.

"The source holder will have to be replaced as there is no way to remove the shutter for repair."

LA Report ID: LA20170018

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Agreement State Event Number: 53114
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: STERIS ISOMEDIX SERVICES
Region: 1
City: SPARTANBURG State: SC
County:
License #: 267
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: VINCE KLCO
Notification Date: 12/11/2017
Notification Time: 16:29 [ET]
Event Date: 12/09/2017
Event Time: 03:28 [EST]
Last Update Date: 12/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR DISABLED SOURCE RACK

The following information was received from the State of South Carolina by email:

"On Monday, December 11, 2017 at [1100 CST], the Department [South Carolina Department of Health and Environmental Control] was notified by [the] Corporate RSO [Radiation Safety Officer] of STERIS Isomedix Services that one of the source racks had been stuck in the 'up' position. The incident happened at [0328 CST] on Saturday, December 8, 2017. The worker saw that there was an unload fault on the system indicating that the rack was stuck so he called maintenance to try to correct the problem. At [0340 CST] the Radiation Safety Officer [and then the corporate RSO were notified] about the event. [The RSO] called and left a message on an employee voicemail rather than calling the 24 hour emergency phone number.

"The workers were able to go into the penthouse to correct the problem and lower the source rack back into the pool. The workers found that a carrier had a cracked hinge. They checked all of their other carriers and replaced a total of two carrier doors. The RSO informed the CRSO [Corporate Radiation Safety Officer] that the situation was resolved at [0724 CST]. The licensee stated that a written report will be sent within 30 days of the event."

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Part 21 Event Number: 53126
Rep Org: CRANE NUCLEAR INC.
Licensee: CRANE NUCLEAR INC.
Region: 3
City: BOLINGBROOK State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOYCE HAMMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 12:46 [ET]
Event Date: 11/17/2017
Event Time: 20:17 [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BILLY DICKSON (R3DO)
ERIC MICHEL (R2DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - CHAPMAN GATE VALVE WEAK LINK ANALYSIS DEFECT

The following information was excerpted from a facsimile received from Crane Nuclear:

"This letter provides notification of a defect in a Weak Link Analysis provided to the Tennessee Valley Authority (TVA) by Crane-Aloyco, Inc. (CAI), a Crane Nuclear, Inc. (CNI) predecessor business unit, for a Chapman Gate Valve, Figure L900, Item # 18, Drawing CC05307, Revision B for the Browns Ferry Nuclear (BFN) plant.

"The subject valve was originally procured from Crane Chapman in 1968. In 1988, TVA requested Crane to supply a Weak Leak Analysis for the original valve. A Weak Link Analysis (OTC-258 Rev.0) was developed by CAI, which identified a maximum thrust capacity of approximately 112,000 lbf.

"In November 2017, Crane Nuclear, Inc. developed a new Weak Link Analysis for the valve. Crane Nuclear, Inc. provided the new Weak Link Analysis (WL-103 Rev. 0) to TVA on November 17th, 2017. Crane Nuclear. Inc. identified in the new Weak Link Analysis a maximum thrust capacity of approximately 96,000 lbf.

"CNI is reviewing our records to determine if the maximum thrust rating in any other Weak Link Analyses provided by CNI for gate valve designs with an SMB-4T or SMB-5T actuator exceeds the rating for the thrust bearings.

"Should you have any questions regarding this matter, please contact me, Joyce Hamman, Director, Safety & Quality at (678) 451-2280, Burt Anderson, Site Leader, at (630) 226-4990, or Samson Kay, Engineering Manager at (630) 226-4983."

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Power Reactor Event Number: 53128
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ROY GILES
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 17:17 [ET]
Event Date: 12/19/2017
Event Time: 13:40 [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GREG PICK (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

Event Text

DIESEL GENERATORS (DGs) DECLARED INOPERABLE DUE TO A COMMON ISSUE

"During regular power operations at 100% power, DG#1 and DG#2 were declared inoperable due to a common issue associated with indicating lights and the associated sockets installed in various control and auxiliary circuits for both DG's.

"The indicating lights in question are incandescent 120V AC style 120MB bulbs in a socket with a 550 ohm resistor. Style 120MB light bulbs have a failure mechanism where the bulb can cause a short circuit rather than the more common open circuit that is expected when an incandescent bulb filament fails. Cooper originally believed that the socket's integral resistor was sufficient to protect the circuit. In testing performed by an outside laboratory and confirmed on-site using warehouse stock, it was determined that the integral resistor may not have the power dissipation capability to protect the circuit ln which the light and socket are installed if a bulb fails in short circuit.

"This condition resulted in both DG's being declared inoperable at 1340 [CST] due to a loss of reasonable expectation that they would meet their safety function required action to start, load and run to support loads required to mitigate the consequences of an accident. This is a loss of safety function under 10CFR 50.72(b)(3)(v)(D) subject to an 8 hour report.

"As a result of both DG's being inoperable, the Control Room Emergency Filtration System is also inoperable. This is also a loss of safety function subject to an 8 hour report for the same criterion.

"The Senior Resident has been notified."

Page Last Reviewed/Updated Wednesday, December 20, 2017
Wednesday, December 20, 2017