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Event Notification Report for January 8, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/05/2018 - 01/08/2018

** EVENT NUMBERS **


53138 53139 53151 53153 53154

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Agreement State Event Number: 53138
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE-ELMBROOK MEMORIAL
Region: 3
City: BROOKFIELD State: WI
County:
License #: 079-1092-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/28/2017
Notification Time: 12:50 [ET]
Event Date: 11/01/2017
Event Time: [CST]
Last Update Date: 12/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - TOTAL DOSE DELIVERED DIFFERED FROM PRESCRIBED DOSE BY GREATER THAN 20%

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

"On December 28, 2017, the Wisconsin Department of Health Services (DHS) received notice that the licensee identified a prostate manual brachytherapy procedure where the total dose delivered differed from the prescribed dose by 20% or more. The implant occurred in November 2017 and post-implant dosimetric analysis was performed on December 27, 2017. The prescribed dose was 110 Gy; the dose delivered to the treatment site (D90) was 56.5% of the intended dose.

"DHS inspectors will investigate this medical event.

"Event Report ID No.: WI170023"

The licensee will compensate for the underdose with subsequent scheduled beam therapy.

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: 53139
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VERSA INTEGRITY GROUP INC
Region: 4
City: HOUSTON State: TX
County:
License #: 06669
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/29/2017
Notification Time: 12:13 [ET]
Event Date: 12/29/2017
Event Time: [CST]
Last Update Date: 12/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
GRETCHEN RIVERA-CAPE (NMSS)
JEFFERY GRANT (IRD)
NMSS_EVENTS_NOTIFICA (EMAI)
DESIREE DAVIS (ILTA)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST CATEGORY 2 RADIOGRAPHY EXPOSURE DEVICE

The following information was received via E-mail:

"On December 29, 2017, the Agency [Texas Department of State Health Services] received a call from the licensee's corporate radiation safety officer (CRSO) reporting a lost exposure device. The CRSO stated one of the licensee's radiographers at one of their licensed storage locations had placed a QA model D880 exposure device (serial # D15021) containing a 40.9 curie iridium-192 source on the tailgate of the truck at the licensee's Beaumont location. The radiographer left the licensee's location and headed to their work location. When the radiographer reached Groves, Texas, they realized they had not secured the device and pulled over. The device was not on the tailgate. The radiographer contacted the radiation safety officer and a search was begun. The CRSO stated at least two teams are searching the route looking for the device. The distance to be searched is about 20 miles based on the current information. The CRSO stated the device did have both storage caps on the device. The CRSO stated the dose rate on the device was 17 millirem on contact with a TI [Transportation Index] of 0.4. The CRSO stated they have contacted local law enforcement who are responding to the licensee's location. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9528

Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC.

Notified External via E-mail: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC.


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1638 EST ON 12/29/2017 * * *

The following information was received via E-mail:

"The missing device has been found. Additional information will be provided in accordance with SA-300."


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1700 EST ON 12/29/2017 * * *

The following information was received via E-mail:

"The Agency received the following information on the event. The radiographers did not go to Grove Texas, but only made it to Nederland, Texas making the search area between 8 and 10 miles. At the time the device was recovered approximately 40 people were searching for it on foot. The searchers included firefighters, emergency response personnel, and licensee personnel. Pictures of the device show the outer coating was scratched, but the device itself did not appear damaged. Additional information will be provided as it is received in accordance wit SA-300."

Notified Internal NRC: R4DO (Haire), NMSS Regional/INES Coordinator (Rivera-Capella), IRD MOC (Grant), ILTAB (Davis), and NMSS Events Notification.

Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC.

Notified External via E-mail: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Part 21 Event Number: 53151
Rep Org: ENGINE SYSTEMS, INC
Licensee: ENGINE SYSTEMS, INC
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOM HORNER
HQ OPS Officer: DAVID AIRD
Notification Date: 01/05/2018
Notification Time: 17:16 [ET]
Event Date: 11/22/2017
Event Time: [EST]
Last Update Date: 01/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
BINOY DESAI (R2DO)
ROBERT DALEY (R3DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - DEFECT IN THERMOSTATIC VALVE ASSEMBLIES

The following information was excerpted from a facsimile received from Engine Systems, Inc.:

"Two thermostatic valve assemblies were supplied by [Engine Systems, Inc.] ESI that were found to have retaining straps, subcomponents of the internal thermostatic element, detached from the correct position. For each valve assembly, one of the thermostatic elements (the centrally located element) contained this defect. The straps are used in conjunction with a spring to retain the element in a closed position. As the temperature of the sensed fluid increases, a temperature sensitive wax expands to open the element while acting against the spring. As the temperature of the fluid decreases, the wax contracts and the spring returns the element to its closed position. Absence or failure of the straps would prevent proper operation of the element.

"The thermostatic valve assembly is used on an emergency diesel generator [EDG] set to regulate the temperature of lubricating oil (other EDGs use this same type of valve for jacket water temperature regulation). If one of the elements within the assembly were to fail, as is the case with a missing strap, regulating capacity of the thermostatic valve could be affected. However, the failure mode in the case of missing straps is in the open position (element does not return closed) and the remaining eight elements would compensate by closing to regulate the fluid temperature. More importantly, detached retaining straps could migrate to other components in the lube oil system. Acting as foreign material, the straps could adversely affect the ability of these critical components to perform their safety-related function within the emergency diesel generator's lube oil piping. The foreign material aspect of this defect makes it a reportable issue.

"Information of such defect or failure to comply was obtained on November 22, 2017.

"This issue is an isolated incident affecting two thermostatic valves supplied to one nuclear plant [DC Cook]. The nuclear plant detected the issue during inspection and returned the assemblies to ESI. No further action is required on the part of DC Cook.

"ESI's investigation revealed that this issue was induced by a test technician who, in an effort to minimize the amount of test fluid remaining in the assembly after pressure testing, manually actuated the center thermostatic element (there are 9 total elements) to drain a small pocket of residual fluid. This effort to prevent the formation of oxidation had an unintended consequence and resulted in a more serious issue. Though this is an isolated incident as it pertains to items supplied from ESI, this same model thermostatic valve assembly is used extensively on EDGs in the nuclear industry. Those customers that perform valve maintenance, including thermostatic element replacement, should be aware of the possibility of the straps becoming detached if care is not taken."

If you have any questions, you may call:

Tom Horner
Quality Assurance Manager
Tel: (252) 977-2720

ESI Report ID: 10CFR21-0120, Rev. 0, dated 01/05/18

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Power Reactor Event Number: 53153
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JAMES RITCHIE
HQ OPS Officer: VINCE KLCO
Notification Date: 01/06/2018
Notification Time: 06:05 [ET]
Event Date: 01/06/2018
Event Time: 05:24 [EST]
Last Update Date: 01/06/2018
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVE WERKHEISER (R1DO)
BRIAN HOLIAN (NRR)
DAVID LEW (R1RA)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 70 Power Operation

Event Text

DECLARATION OF UNUSUAL EVENT DUE TO ABNORMAL INTAKE STRUCTURE LEVEL

"Oyster Creek Declared an Unusual Event HU 6 Hazardous Event for an Abnormal Intake Structure Level Less than or equal to -3.0 feet MSL [Mean Sea Level] on points 23 and 24 in the Main Control Room at time 0524 [EST]."

The licensee notified the NRC Resident Inspector, State, and local authorities.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 1/6/18 AT 2325 EST FROM JAMES RITCHIE TO BETHANY CECERE * * *

"Oyster Creek Terminated Unusual Event HU 6 Hazardous Event for an Abnormal Intake Structure Level at time 2308 [EST]."

The licensee notified the NRC Resident Inspector, State, and local authorities.

Notified R1DO (Werkheiser), NRR EO (King), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

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Power Reactor Event Number: 53154
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LAUREN NEUBURGER
HQ OPS Officer: DAVID AIRD
Notification Date: 01/06/2018
Notification Time: 18:14 [ET]
Event Date: 01/06/2018
Event Time: 11:26 [CST]
Last Update Date: 01/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DRAKE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

MAIN STEAM LINE RADIATION MONITOR DETERMINED TO BE NON-FUNCTIONAL

"At 1126 [CST], main steamline radiation monitor 2-RE-2326 (Main Steamline 2-02) reading was determined to be erratic and was declared non-functional.

"With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 2-02 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii).

"Comanche Peak Nuclear Power Plant [CPNPP] has assurance of steam generator integrity and fuel cladding integrity and there is a negligible safety significance to the current condition from a public health and safety perspective.

"Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator or fuel cladding. The N16 [Nitrogen-16] radiation monitor serves as a backup with alarm function and Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL [Main Steam Line] 2-02.

"Corrective actions are being pursued to restore 2-RE-2326 to functional status.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, January 08, 2018
Monday, January 08, 2018