United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > January 31

Event Notification Report for January 31, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/30/2018 - 01/31/2018

** EVENT NUMBERS **


53072 53179 53181 53188

To top of page
Agreement State Event Number: 53072
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: ST. VINCENTS
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-91014
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/14/2017
Notification Time: 17:35 [ET]
Event Date: 11/14/2017
Event Time: 11:30 [PST]
Last Update Date: 01/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION FOUND DURING SOURCE EXCHANGE

On 11/14/2017, during a source exchange, a radiation technician discovered contamination on an High Dose Rate [HDR] device located inside a pig container. The device was located inside the vault. The Radiation Safety Officer [RSO] isolated and roped off the area to prevent unauthorized entry and contacted the vendor: Varian. The vendor is expected to arrive tomorrow to continue the investigation.

Device: Varian HDR 600333
Source: IR-192
Activity: 11 Curies

Oregon Event Report ID: 17-0071

* * * UPDATE AT1655 EST ON 11/22/2017 FROM DARYL LEON TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"The radiation technician who found the contamination is the Varian field service engineer (FSE) who performed the HDR source exchange. The decayed Ir-192 source was removed from the HDR and placed into a transport container. The new container with the new Ir-192 source was surveyed and a contamination wipe performed with all readings within normal range for a new source. The new source wire was wiped and no contamination found and it was loaded into the HDR. A dose rate survey was performed around the afterloader and the new transport container to confirm the source transfer was successful. However, the measurement inside the empty container indicated a dose rate of 35 microSv/hr (background in the vault given at 0.1 microSv/hr). The Varian RSO was called at this time (11:30 AM PT). The FSE placed the lid onto the new transport container and the dose rate dropped to 2.4 microSv/hr. Per company procedure, the new Ir-192 source was unloaded from the HDR and placed back into the new transport container and a confirmation survey and wipe performed on the HDR to ensure no contamination was transferred into the machine. The FSE then performed a contamination wipe on the new source wire and found the count rate at 6.35 cps with a background of 0.62 cps. This was a second indication of contamination. The FSE was instructed by the Varian RSO to leave the room and secure it. The FSE was surveyed by the facility AMP [Authorized Medical Physicist] upon exit to ensure no spread of contamination. The Varian RSO then contacted Oregon Radiation Protection Services [RPS] to report the event as well as the source manufacturer, Alpha-Omega Services, Inc. (AOS) to plan a response.

"The Varian RSO and AOS RSO came to the Oregon site on November 15th. Oregon RPS also responded and observed the procedure by the Varian RSO to clear any contamination from the HDR vault. No contamination was found outside the new transport container. The new transport container was prepared and shipped by the AOS RSO for return to their licensed facility in Louisiana, the Louisiana Agreement State agency was notified by Oregon RPS of the event. Oregon RPS requested a copy of the AOS investigation report stating what radionuclide is identified in this contamination event and potential source of the contamination. The Varian FSE indicated that similar contamination events, 'four (including this one) since 2013 where a hot particle has been found' in the container of AOS shipments containing HDR sealed sources of Ir-192."

Notified the R4DO (Hay) and NMSS (via e-mail).

* * * UPDATE AT1452 EST ON 01/30/2018 FROM DARYL LEON TO DONG PARK * * *

The following report was received via e-mail:

"On November 14, 2017, a contracted Varian field service engineer (FSE) was at the licensee's facility performing a routine Ir-192 source exchange on a Varisource IX High Dose Rate brachytherapy afterloader (HDR), serial number H600333. The 'old' sealed source (Source #1) was removed from the HDR and placed in the 'old' shielded transport safe (Safe #1). The 'new' shielded transport safe (Safe #2) was wiped and surveyed and no unusual readings noted. The 'new' sealed source (Source #2=Varian model VS2000, 11 mCi, Ir-192, serial number 02-01-9216-001-110117-11206-32) was removed from Safe #2, wiped and surveyed with no issues and placed into the HDR. The FSE surveyed the HDR and inside the unloaded Safe #2 and found a dose rate of 35 uSv (3.5 mrem) per hour inside the container. The FSE stopped work and immediately phoned the Varian RSO. Per the RSO instructions, the FSE replaced the lid on Safe #2 and took another dose reading outside and found a maximum of 2.4 uSv (240 urem) per hour. An exterior wipe of the 'new' container was at background which was 0.62 cps indicating contamination was inside the container. Per Varian procedure, the FSE then removed Source #2 from the HDR and placed into Safe #2. A wipe was performed of the source wire and the measurement was found to be 6.35 cps, well above background (background noted previously). This wipe was placed into a nitrile glove for analysis. Based on elevated contamination and dose readings, the Varian RSO instructed the FSE to exit the room and leave all tools in the HDR vault. The FSE was then surveyed by the HDR facility Authorized Medical Physicist (AMP) and the vault secured to prevent entry. The Varian RSO contacted the Oregon Agreement State program office, Radiation Protection Services (RPS), to report the event. The Varian RSO then contacted and coordinated a response plan with the source manufacturer, Alpha Omega Services, Inc (AOS). RPS contacted the HOO at 2:35 hours to initially report a potential leaking medical sealed source.

"On November 15, 2017, the Varian RSO, the Varian FSE, facility RSO, and an inspector with Oregon RPS arrived on site. The Varian RSO and FSE established a radiation control zone and the RSO performed wipes and surveys of the vault and all tools and equipment and ensured Safe #2 plus transport bucket had no exterior contamination while RPS observed the work. No new contamination was found. RPS performed an independent survey and found no contamination. The AOS RSO arrived in the afternoon and performed additional surveys and no contamination was found. That RSO packaged up Safe #2 and transport bucket with contaminated wipe (inside glove) and Source #2 with contaminated wire for shipment back to the AOS manufacturing facility in Louisiana. This shipment occurred that day. The Varian FSE prepared Source #1 for shipment to AOS in the uncontaminated transport container which was also shipped that day. Entry access to the vault was permitted in the afternoon. A new source was ordered for the facility HDR which was installed on November 17th with no issues.

"On November 21, 2017, Safe #2 was received by the AOS Louisiana facility and surveys/wipes performed. The Varian FSE contamination field wipe taken on November 14th showed activity of 2.91 nCi, Source #2 wire showed activity of 344 nCi, and a contamination wipe taken by AOS personnel at the top of Safe #2 exterior under the metal bracket showed activity of 5.62 uCi. The first two items were further sent off to an independent laboratory on December 6, 2017 to determine nuclide identity.

"On January 2, 2018, the laboratory reported to AOS that the nuclide was Ir-192. Results showed the Varian FSE field wipe at 942 pCi and Source #2 wire at 562 pCi. AOS reported the lab findings and their full report on January 4, 2018. The report indicated three potential causes (all human error, not following correct procedures) for the contamination:

"(1) The handling tools used in the hot cell, specifically the manipulator fingers, did not always have their rubber covers replaced between receipt/opening of irradiated targets and the start of sealed source manufacturing in the same cell.
(2) Observation of personnel performing contamination wipes on the shielded transport safes after loaded with a sealed source showed that not all surfaces were being wiped, specifically under the top metal bracket.
(3) After the loaded transport safes are placed into shipping packages (buckets), they are stored in the same manufacturing facility and when ready to be shipped, personnel perform another contamination wipe but again, not all surfaces were being wiped, specifically the bottom of the bucket and some areas on the lid.

"Procedural changes for the hot cell and contamination wipes have been implemented by the Louisiana licensee to address the issue. The licensee indicates that separation of manufacturing processes (target opening and sealed source manufacturing) into dedicated cells will be a long-term solution."

Notified the R4DO (Deese) and NMSS (via e-mail).

To top of page
Agreement State Event Number: 53179
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ROANE MEDICAL CENTER
Region: 1
City: HARRIMAN State: TN
County:
License #: R-73003
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/22/2018
Notification Time: 15:16 [ET]
Event Date: 02/19/2014
Event Time: [EST]
Last Update Date: 01/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FACILITY FAILED TO REPORT SUSPECTED OVEREXPOSURE

The following was received via email:

"On 1/19/18, while conducting an inspection at [Roane Medical Center] RMC of a standard diagnostic nuclear medicine program with no written directive, an inspector identified, in review of facility dose records, evidence of an overexposure to a nuclear medicine technician of a dose of 118.425 Rem for period of January 20, 2014 to February 19, 2014. Investigation by the facility subsequently determined that the exposure was not likely a real exposure to the individual. However, facility failed to report the suspected overexposure. Dose was subsequently removed from the individual's dose history based on their investigation."

State Event Report ID NO.: TN-18-012

To top of page
Agreement State Event Number: 53181
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: CRETE COLD STORAGE
Region: 4
City: CRETE State: NE
County:
License #: GL0635
Agreement: Y
Docket:
NRC Notified By: MALISA MCCOWN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2018
Notification Time: 16:03 [ET]
Event Date: 01/19/2018
Event Time: [CST]
Last Update Date: 01/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the state of Nebraska via email:

"On 1/19/18, GL0635 [General License] Crete Cold Storage called NEDHHS [Nebraska Department of Health and Human Services], Office of Radiological Health to inquire about reporting requirements if they could not locate GL [generally licensed] devices. Licensee assumed devices were lost during a renovation. Licensee was given reporting instructions via e-mail. On 1/23/18, NEDHHS Office of Radiological Health was notified via letter by GL0635 that four (4) tritium exit signs were reported lost."

All four signs were manufactured by Safety Light Corporation, Model 2040, Serial numbers 252778, 252779, 252781 and 252774. Nominal material content is 11.5 Ci of tritium per sign.

Nebraska NMED Report No.: NE180001

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.

To top of page
Power Reactor Event Number: 53188
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RALPH FLICKINGER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/30/2018
Notification Time: 21:56 [ET]
Event Date: 01/30/2018
Event Time: 18:22 [CST]
Last Update Date: 01/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 91 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO MAIN TURBINE LOAD OSCILLATIONS

"On 1/30/2018 at 1750 [CST], the Reactor Pressure Control Malfunctions ONEP [Off Normal Event Procedure] was entered due to main turbine load oscillations of approximately 30 MWe peak to peak. At 1822 [CST], a manual reactor scram was inserted by placing the Reactor Mode Switch in Shutdown due to continued main turbine load oscillations.

"Reactor SCRAM ONEP, Turbine Trip ONEP, and EP-2 were entered. Reactor water level was stabilized at 36 inches narrow range on startup level and reactor pressure stabilized at 933 psig using main turbine bypass valves.

"Reactor Water Level 3 (11.4 inches) was reached which is the setpoint for Group 2 (RHR to Radwaste Isolation) and Group 3 (Shutdown Cooling Isolation). No valve isolated in these systems due to all isolation valves in these groups being in their normally closed position. The lowest Reactor Water level reached was -36 inches wide range.

"No other safety system actuations occurred and all systems performed as designed.

"That event is being reported under 10CFR 50.72(b)(2)(iv)(B) as any event or condition that results in actuation of the Reactor Protection System (RPS), when the reactor is critical and also reported under 10CFR 50.72(b)(3)(iv)(A), as any event or condition that results in actuation of RPS."

The MSIVs are open with decay heat being removed via steam to the main condenser using the bypass valves. Off site power is stable, and the plant is in a normal shutdown electrical lineup. RCIC (Reactor Core Isolation Cooling) was out of service for maintenance, and the reactor water level did not reach the system activation level. The cause of the main turbine load oscillations being investigated.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, January 31, 2018
Wednesday, January 31, 2018