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Event Notification Report for January 16, 2018

U.S. Nuclear Regulatory Commission
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Event Reports For
01/12/2018 - 01/16/2018

** EVENT NUMBERS **


53148 53149 53150 53152 53155 53156

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Agreement State Event Number: 53148
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: IL
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 01/05/2018
Notification Time: 08:30 [ET]
Event Date: 01/04/2018
Event Time: [CST]
Last Update Date: 01/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

The following was received from the State of Wisconsin:

"On January 4, 2018, the Department [Wisconsin Radiation Protection Section] received a telephone call and email from the licensee's medical physicist that a medical event of a prostate brachytherapy procedure was identified on January 4, 2018. The total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS [Department of Health Services] 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 105 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 75% of the intended dose. The post-implant computed tomography scan occurred on December 6, 2017. The subsequent dosimetric analysis was on January 3, 2018. The department will perform a site investigation to determine the root cause of this medical event.

"DHS inspectors will investigate this medical event."

Wisconsin Event: WI180001

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: 53149
Rep Org: VIRGINIA OFFICE OF RAD HEALTH
Licensee: OLD DOMINION ELECTRIC COOPERATIVE/VIRGINIA POWER
Region: 1
City: CLOVER State: VA
County:
License #: 083-388-1
Agreement: Y
Docket:
NRC Notified By: STEVE HARRISON
HQ OPS Officer: DAVID AIRD
Notification Date: 01/05/2018
Notification Time: 12:16 [ET]
Event Date: 01/04/2018
Event Time: [EST]
Last Update Date: 01/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE IN DENSITY GAUGE

The following report was received via email from the Virginia Office of Radiological Health:

"On January 4, 2018, the Radiation Safety Officer of the licensee reported that the metal (insertion) rod that enables the source holder to move to its 'ON' position (moves the source in and out of the vessel) broke during routine periodic maintenance. The gauge is a Texas Nuclear Model 50315, serial number B0047, with a 100 milliCurie Cesium-137 source (effective 1993). The gauge is used to measure the density of material inside a process vessel. The gauge is currently in its normal operative state, which is to send a signal to the detector to control density in the vessel. The source was pushed back into the vessel to allow for normal operation after the rod broke, but it is not able to be removed. The licensee has contacted ThermoFisher Scientific for further actions."

Virginia Event Report ID No.: VA-18-001

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Agreement State Event Number: 53150
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: DOMTAR PAPER COMPANY
Region: 1
City: BENNETTSVILLE State: SC
County:
License #: SC 438
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: BETHANY CECERE
Notification Date: 01/05/2018
Notification Time: 16:12 [ET]
Event Date: 11/06/2017
Event Time: [EST]
Last Update Date: 01/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTERS ON FIXED NUCLEAR GAUGES

The following was excerpted from an email received from the state of South Carolina:

"On January 5, 2018, the licensee called [South Carolina Department of Health and Environmental Control] to provide notification of stuck shutters on 2 sets of three-rod Berthold Model LB300L fixed gauging devices. The shutters were stuck in the open position. The gauging devices contain Co-60 in amounts of 0.11, 0.41, and 1.81 milliCuries in one and 0.189, 0.5, and 1.50 milliCuries in the other. The [licensee's] Radiation Safety Officer found the shutter stuck in the open position on November 6, 2017 and the licensee notified the State on January 5, 2018. The licensee called Berthold to come out to evaluate corrective measures on the shutter mechanisms. Berthold technicians came to the plant on December 19, 2017. After being informed of proper procedures on reporting requirements, the licensee stated that a written report will be sent within 30 days of the event.

"Updates to this event will be made through the NMED system."

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Agreement State Event Number: 53152
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NDE, INC
Region: 1
City: TAMPA State: FL
County:
License #: 3404-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DAVID AIRD
Notification Date: 01/05/2018
Notification Time: 16:48 [ET]
Event Date: 11/01/2017
Event Time: [EST]
Last Update Date: 01/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE

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

"Received a notification letter from a licensee [NDE, Inc.] reporting a possible overexposure. According to the [Radiation Safety Officer] RSO for NDE, an employee had the leather pouch that his badge and his pocket dosimeter were in cut open resulting in his badge falling out near where radiography was taking place. The missing badge was discovered during a routine check of his pocket dosimeter which read 2 mRem for the shift. The badge was sent to Landauer for analysis and the recorded dose for the time period of Oct. 10 - Nov. 9, 2017 was 23.420 Rem. After conducting interviews, the RSO concluded that the overexposure was due to the badge being so close to the source, and the employee did not receive the recorded dose. After compiling the daily pocket dosimeter readings, the estimated dose to the employee would have been 57 mRem for that time period."

Incident Number: FL 18-003

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Agreement State Event Number: 53155
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ALBEMARLE CATALYSTS LP
Region: 4
City: PASADENA State: TX
County:
License #: L01743
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/08/2018
Notification Time: 16:40 [ET]
Event Date: 01/07/2018
Event Time: [CST]
Last Update Date: 01/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER FAILED TO SHUT

The following information was received via E-mail:

"On January 8, 2018, the Agency [Texas Department of State Health Services] received a report from the licensee's radiation safety officer (RSO) stating the shutter on an Ohmart Vega model SH-F1 gauge, containing a 60 milliCurie cesium-137 source, failed to shut during an operational check. Open is the normal operation position of the gauge shutter. No licensee employee received any exposure as a result of this event. The gauge was repaired the following morning. An investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9529

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Agreement State Event Number: 53156
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXONMOBIL REFINING & SUPPLY CO.
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-1345-L01,
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/08/2018
Notification Time: 17:36 [ET]
Event Date: 01/03/2018
Event Time: [CST]
Last Update Date: 01/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE INVOLVED IN A FIRE

The following information was received via E-mail:

"The Radiation Safety Officer (RSO), reported Friday, 1/5/2018 that a fire occurred on 1/3/2018 at the refinery in the Coker Unit Drum D. The RSO made the Department [Louisiana Department of Environmental Quality (LDEQ)] notification when the area cooled and he could assess the situation.

"The Louisiana State Police were notified on 1/3/2018 at approximately 1530 CST. The Department was notified at approximately 1330 CST on 1/5/2018 when the situation had been assessed after the unit cooled enough for entry.

"A level/density gauge on Coker Process Drum D was involved in a unit fire. The level/density gauge was an Ohmart-Vega device/source holder, model SHG1-45, S/N 3813CP housing 500 mCi of Cs-137 S/N 26165309.

"On 1/3/2018, ExxonMobil Refining & Supply had a fire on the Coker unit in Drum D. In the assessment process of the radiation sources from becoming a radiation exposure hazard, it was discovered that the gauge/device shielding was compromised through a melted opening in the lead shielding.

"ExxonMobil called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. The service contractor was unable to repair the device/source holder and determined the source holder would have to be replaced. This is not a radiation exposure hazard and does not pose a health and safety situation for the ExxonMobil employees or the general public.

"The source holder was intact for the most part with the exception of a degraded/melted spot on the shielding. The radiation exposure level from the opening was 30 mR/hr at 1 ft. BBP Sales was notified and called in to make an assessment and recommendation for corrective action of this situation. BBP Sales locked the shutter, secured the device, placed it in a storage container and isolated the storage container. Some additional lead was placed over the opening and the exposure reading was reduced to approximately 4 mR/hr. The storage container was placed behind a radiation labeled barricade. It is considered in storage until it is replaced and the damaged level gauge is shipped for disposal. The 500 mCi Cs-137 source did not appear damaged or compromised. The RSO performed wipes on the device and the wipes were sent to Suntrac Services for analysis.

"This event is considered closed for reporting requirements by LDEQ. This is not equipment failure. This event is a level/density gauge damaged in a refinery fire. This event is being reported to the NRC as required by Regulatory Requirement 10 CFR 30.50(b)(4) and LAC 33:XV.341.B.4"

Louisiana Event Report ID No.: LA-180001; SPOC T182036

Page Last Reviewed/Updated Tuesday, January 16, 2018
Tuesday, January 16, 2018