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Event Notification Report for January 26, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/25/2018 - 01/26/2018

** EVENT NUMBERS **


53169 53171 53172 53175 53183 53184

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Non-Agreement State Event Number: 53169
Rep Org: RADIATION SAFETY ASSOCIATES, INC
Licensee: ULBRICH STAINLESS STEELS AND SPECIAL METALS, INC.
Region: 1
City: WALLINGFORD State: CT
County:
License #: 06-12357-01
Agreement: N
Docket:
NRC Notified By: PAUL STEINMEYER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/17/2018
Notification Time: 11:13 [ET]
Event Date: 01/16/2018
Event Time: 14:00 [EST]
Last Update Date: 01/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

NUCLEAR INSTRUMENT WITH RADIOACTIVE SOURCE DISPOSED OF IN LOAD OF SCRAP METAL - RECOVERED

A load of scrap metal was returned by the recycler to the originator (Ulbrich Stainless Steels and Special Metals, Inc.) after their radiation detector alarmed on the load of metal. After arriving back at Ulbrich, the load was checked and a Dickey-John Dewpointer instrument containing a 7 microCurie Radium-226 source was found.

The Dewpointer instrument is believed to have been purchased by Ulbrich more than 20 years ago. The Dewpointer instrument had no stickers or warning labels indicating that it contained a radioactive source. The Dewpointer instrument had been surplused and tossed in the trash.

The Dewpointer instrument is currently in the possession of Radiation Safety Associates, Inc. (license number: 06-30007-01). Ulbrich has taken responsibility for assuring proper disposal of the instrument.

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: 53171
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: KAISER FOUNDATION HOSPITAL
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90464
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DAVID AIRD
Notification Date: 01/17/2018
Notification Time: 16:45 [ET]
Event Date: 01/15/2018
Event Time: [PST]
Last Update Date: 01/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

On January 15, 2018 a medical event occurred at the licensed facility in which a patient received a prescribed dose less than 80 percent of the target dose to the liver. The dose was delivered via Y-90 microspheres.

The State will investigate this medical event.

* * * UPDATE FROM DARYL LEON TO HOWIE CROUCH VIA EMAIL AT 1616 EST ON 1/19/18 * * *

"On January 15, 2018, a patient was prescribed a dose of 130 Gy (2.789 GBq) for the left lobe of the liver involving two dose vials of Y-90 MDS Nordion TheraSphere microspheres. The first dose vial was administered without issue. The second dose vial was then primed and prepped as normal, however, a train of bubbles was noted in the line between the dose vial and the patient prior to administration. Due to the proximity of gastric artery relative to point of administration and the possibility that the bubbles could cause the flow to reflux into this artery (which could permanently damage the stomach), the AU [Authorized User] determined the best course of action was not to administer the second dose vial. The therapy procedure was then halted and rescheduled to complete on Thursday, January 18th.

"The administered dose was 84.9 Gy (1.760 GBq) to the left lobe of the liver. The dose was therefore 65% of the prescribed dose, a 35% difference. The difference between the prescribed and administered dose to the liver is 45.1 Gy (4510 rem). Therefore, the dose administered exceeds +/- 20% of prescribed dose and differs from the prescribed dose by more than 50 rem to an organ (liver).

"The referring physician has been notified as well as the patient.

"This event was reported to the Oregon Agreement State program on January 16, 2018.

"The licensee has removed all Y-90 therapy tubing sets from the same lot number for return and analysis by the vendor. Tubing sets from a different lot number were provided to interventional radiology for future cases."

Notified R4DO (Proulx) and NMSS Events Resource (email).

State Event Report ID No.: OR-18-0001

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: 53172
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AS METALS
Region: 4
City: CASTROVILLE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: DAVID AIRD
Notification Date: 01/17/2018
Notification Time: 19:42 [ET]
Event Date: 01/12/2018
Event Time: [PST]
Last Update Date: 01/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - GAUGE WITH RADIOACTIVE SOURCE DISPOSED OF IN LOAD OF SCRAP METAL - RECOVERED

The following information was received from the State of California via E-mail:

"The California Radiation Control Program (CDPH-RHB) was notified by US CBP [Customs and Border Patrol] on 1/12/18 that a shipping container that had arrived at the Oakland port triggered a radiation detector upon attempting to depart the port. The shipping container contained scrap metal that was later determined to have been rejected at a South Korea port due to radiation detected upon receipt there.

"The Oakland port CBP personnel detected Cs-137, with a maximum dose rate on the outside of the shipping container of 86 microR/hr (gross). The radiation apparently had not been detected when the container was shipped out of the Oakland port to South Korea.

"The shipping container was held at the Oakland port by CBP until Tuesday 1/16/18, when it was released to AS Metals with the provision that CDPH-RHB would be present when the container was opened to determine the source of the radiation and subsequent disposition. CDPH-RHB went to a scrap yard site on 1/16/18 and found the source of the radiation was a gauge that was labeled (in handwriting as the original gauge label was missing) as containing 100 mCi of Cs-137. The gauge shutter was locked in the closed position. Dose rates were measured as approximately 40 mR/hr contact and 3 mR/hr at one foot distance, and the radioactive material was confirmed to be Cs-137.

"The apparent generally licensed gauge, which appeared very old, is being held in secure storage by AS Metals pending an attempt by CDPH-RHB to identify the general licensee who lost control of the gauge. This may be difficult due to the missing original label on the gauge, and because AS Metals has not been able to determine how or where they came into possession of the gauge."

California 5010 Number: 011618

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: 53175
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ST. FRANCIS MEDICAL CENTER
Region: 3
City: PEORIA State: IL
County:
License #: IL-01361-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2018
Notification Time: 12:39 [ET]
Event Date: 01/09/2018
Event Time: [CST]
Last Update Date: 01/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] was notified on 1/16/18 of a medical event that occurred on 1/9/18. Agency personnel were able to contact the licensee and obtain details on 1/17/18. The licensee's RSO advised that he was out of state for a training class and was not informed by his staff until he returned.

"Licensee administered Y-90 Theraspheres to a patient in 2 doses, each treating a separate lobe of the liver. The physician wrote two prescriptions, one for each lobe. One lobe required 10 mCi, in which the entire 10 mCi dose was delivered. The second prescribed dose was for 7 mCi. Upon performing residual measurements, it was discovered that the delivered dose was 28 percent less than the 7mCi specified in the written directive. There were no equipment malfunctions reported, nor were there any medical reasons for the underdose (stasis was not reached). The AU [Authorized User] was notified, as was the referring physician.

"When considering the organ as a whole, three separate fractions were prescribed, under three separate written directives (34 mCi + 10 mCi +7 mCi), yielding a total dose of 94.44 Gy. The administered dose was 93.94 Gy. The resultant composite differential is 50 rem, with 99.5% of the desired dose administered to the organ. A written report is pending from the licensee."

Illinois Item No.: IL180012

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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Fuel Cycle Facility Event Number: 53183
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: NORMA WELLS
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/25/2018
Notification Time: 18:20 [ET]
Event Date: 01/25/2018
Event Time: 12:00 [MST]
Last Update Date: 01/25/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
EUGENE GUTHRIE (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

POTENTIAL DEFICIENCY ASSOCIATED WITH AN ITEM RELIED UPON FOR SAFETY

"During a self initiated review, ISA [Integrated Safety Analysis] Staff performed a preliminary review of the ISA to determine whether or not there was a chemical safety issue concerning the proximity of combustible fuel to the yard tractors/shuttle lifts that UUSA's [Urenco USA] Logistics organization uses to move UF6 [Uranium Hexa Fluoride] cylinders around outside on site.

"ISA staff determined that the ISA lacked sufficient information regarding the proximity of combustible fuel to the IROFS36c [Item Relied Upon for Safety] controlled yard tractors/shuttle lifts. ISA determined that revisions to one, or more, of the applicable IROFS Boundary Definition Documents was necessary to establish operator actions to ensure that the volumetric fuel limit is not compromised due to the proximity of other fuel sources, therefore UUSA is conservatively making this report.

"UUSA remains in a safe and stable condition. UUSA Logistics has issued a stop work that prohibits applicable cylinders from traveling where proximity to combustible fuel could occur.

"10 CFR 70.50(c)(iii)
(A) There was not a material release, no radiological or chemical hazards were present.
(B) No exposure occurred
(C) A deficiency exists in the ISA in which the limiting of external fuel sources near IROFS36c controlled yard tractors/shuttle lifts was not discussed
(D) IROFS36c remains operable and available to perform its safety function. The identified deficiency only affects applicable UF6 cylinders that could be moved in proximity to other fuel sources. UUSA has issued a stop work to adequately address the deficiency.
(iv) No external conditions affect this event
(v) A stop work was issued to prevent the movement of applicable UF6 cylinders where proximity to other fuel sources could occur
(vi) An event did not occur at UUSA. UUSA remains in a safe and stable condition
(vii) No emergencies have been, nor will any be declared
(viii) No state or other federal agencies will be notified
(ix) No press releases are planned."

The licensee will be contacting the NRC Region 2 office (Ortiz).

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Power Reactor Event Number: 53184
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC THOMAS
HQ OPS Officer: DAVID AIRD
Notification Date: 01/26/2018
Notification Time: 01:37 [ET]
Event Date: 01/25/2018
Event Time: 19:01 [PST]
Last Update Date: 01/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO SCREEN WASH PUMP MOTOR FIRE

"At 1901 PST on January 25, 2018, the Control Room received a fire alarm, followed by screen wash and 480v load center alarms a few minutes later. The intake operator and on-site fire department personnel were promptly dispatched to the scene and confirmed within 15 minutes there was no active fire. As a conservative measure, off-site fire assistance was initially requested, however [this request] was canceled a short time later. While on-site fire personnel were locally assessing the damage to screen wash pump 1-2, a brief flare-up occurred at the pump motor which was immediately extinguished. Units 1 and 2 remained stable and two screen wash pumps remain available. There is no risk to plant safety or personnel and both units continue to operate at power. Current efforts are focused on determining the cause of the situation."

The licensee notified the NRC Resident Inspector and CAL FIRE. The licensee issued a media/press release.

Page Last Reviewed/Updated Friday, January 26, 2018
Friday, January 26, 2018