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Event Notification Report for March 5, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/01/2018 - 03/05/2018

** EVENT NUMBERS **


53194 53224 53225 53226 53235 53236 53239 53240 53242

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Agreement State Event Number: 53194
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: TEAM INDUSTRIAL SERVICE
Region: 1
City: SAVANNAH State: GA
County:
License #: FL 3721-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/02/2018
Notification Time: 13:50 [ET]
Event Date: 02/01/2018
Event Time: 12:16 [EST]
Last Update Date: 03/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPH CAMERA

The following report was received via email:

"The radiographers placed the camera on a pipe, several feet from the ground, to take a shot. They did not secure the camera to the pipe. During the crank out process the camera fell off the pipe, face first, crimping the guide tube and causing the source to become stuck. The company called their radiographer crew located in Jacksonville, FL, to assist them in the retrieval of the source. The RSO and the helper from that office are trained in source retrieval. In the meantime, the area was cordoned off and secured until assistance could arrive. The incident occurred at approximately 1216 EST and completed the source retrieval at approximately 1900 EST. The source was not damaged. The exposure device and drive cable were put out of service and sent to the manufacturer for inspection/repair. The guide tube was damaged due to the fall and was disposed.

"The licensee will be submitting a report within a few days with detailed information. The licensee will be in the State for the remainder of the month providing us an opportunity to do an on-site inspection."

Camera: QSA Model 880 Delta
Source: Ir-192, 91 Ci
RSO dose: 310 mrem,
Helper dose: 118 mrem

* * * UPDATE FROM IRVIN GIBSON (VIA EMAIL) TO HOWIE CROUCH AT 1541 EST ON 3/2/18 * * *

"After receiving the final report from the licensee, it was concluded that appropriate measures had been taken to limit overexposure from the source and corrective actions were set in place to reduce the likelihood of this incident reoccurring."

The state of Georgia now considers this incident closed.

Notified R1DO (Bickett) and NMSS Events (email).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53224
Rep Org: SAINT MARY'S HEALTH CARE
Licensee: SAINT MARY'S HEALTH CARE
Region: 3
City: GRAND RAPIDS State: MI
County:
License #: 21-01078-01
Agreement: N
Docket:
NRC Notified By: TRISTON DOUGALL
HQ OPS Officer: OSSY FONT
Notification Date: 02/21/2018
Notification Time: 15:33 [ET]
Event Date: 02/20/2018
Event Time: 12:00 [EST]
Last Update Date: 02/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

DOSE TO PATIENT LESS THAN THE INTENDED DOSE

A patient was administered the radiopharmaceutical Xofigo which contains Radium Dichloride (Ra-223 CL2). The dosage is based on patient weight. The patient was administered 119.1 microCi. The patient was then weighed and found to weigh greater than 25 percent more than the weight used to calculate the dosage. This was the fourth treatment session of six prescribed. The referring physician's intended dose would have been 159 microCi, based on the patient's actual weight. This misadministration is being characterized as a personnel error.

The patient and the physician have been notified and treatment will continue.

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.


* * * RETRACTION ON 02/22/2018 AT 1541EST FROM TRISTON DOUGALL TO STEVEN VITTO * * *

The Licensee determined that the written directive was followed and therefore this event does not qualify as a misadministration.

Notified R3DO(Peterson) and NMSS Events Notification email.

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Agreement State Event Number: 53225
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: KEANE FRAC LP
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/21/2018
Notification Time: 16:20 [ET]
Event Date: 02/20/2018
Event Time: [CST]
Last Update Date: 02/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK

The following information was received via E-mail:

On February 21, 2018, the licensee notified the Agency that on February 20, 2018, routine inspection and maintenance was being performed on a Berthold model LB 8010 gauge containing a 20 millicurie cesium-137 source that was in storage at its facility. During shutter check, the shutter was stiff during opening and then it would not close. The shutter was stuck in the open position. The licensee reported that the storage area is segregated from work areas and no one has received any exposure as a result of this event. The few employees with access to the area where the gauge is located have been notified of the situation. The manufacturer was contacted and repair scheduled. Information will be provided as it is obtained and in accordance with SA-300.

Texas Incident #: I-9544

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Agreement State Event Number: 53226
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN State: TX
County:
License #: 06090
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/22/2018
Notification Time: 18:51 [ET]
Event Date: 02/21/2018
Event Time: [CST]
Last Update Date: 02/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On February 22, 2018, the licensee notified the Agency [Texas Department of State Health Services] that it had made the determination a medical event had occurred. On February 19, 2018, a patient received first fraction of treatment plan delivered by high dose rate afterloader (HDR) utilizing iridium-192. The patient returned on February 21st for the second fraction. The physicist was reviewing the information prior to treatment and found an error had occurred with the first treatment.

"The licensee investigated and conducted dose reconstruction. The licensee's investigation revealed that the physicist performing the digitization of the 13 channels on HDR applicator had digitized channel #12 and when he went to channel #13 he failed to 'tell' the machine, which added the 5.5 centimeters that should have been in channel #13 onto channel #12. There was a high dwell time at the end of the extended 5.5 centimeters which resulted in a dose to tissue outside the target volume that exceeds 50 rem and 50% or more of the dose expected. The licensee reported a small amount of tissue received, and should tolerate, the extra dose. The referring physician has been notified. More information will be provided as it is obtained and in accordance with SA-300."

Texas Incident #: I -9546

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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Power Reactor Event Number: 53235
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: PHILIP FOWLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/01/2018
Notification Time: 13:43 [ET]
Event Date: 03/01/2018
Event Time: 12:10 [CST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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 85 Power Operation 85 Power Operation

Event Text

UNANALYZED CONDITION FOR TORNADO GENERATED MISSILES

"On March 1, 2018, during evaluation of protection for Technical Specifications (TS) equipment from the damaging effects of tornado generated missiles, Quad Cities Station identified a non-conforming condition in the plant design such that specific TS equipment is considered to not be adequately protected from tornado generated missiles. Tornado generated missiles could strike the Unit l, Unit 1/2, and Unit 2 Emergency Diesel Generator intake and exhaust stacks, day tank vents, and main fuel oil tank vents. This could result in crimping of the intake/exhaust stacks and vents, which would affect the ability of the Emergency Diesel Generators to perform their function if a tornado would occur.

"This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B) as a condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and 10 CFR 50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"This condition is being addressed in accordance with NRC enforcement guidance provided in Enforcement Guidance Memorandum (EGM) 15-002, 'Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' Revision 1, and DSS-ISG-2016-01, 'Clarification of Licensee Actions in Receipt of Enforcement Discretion per Enforcement Guidance Memorandum EGM 15-002, Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' Revision 1. Compensatory measures have been implemented in accordance with these documents.

"The NRC Resident Inspector has been informed of this notification."

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Power Reactor Event Number: 53236
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: CYNTHIA BOMYEA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/01/2018
Notification Time: 13:53 [ET]
Event Date: 03/01/2018
Event Time: 07:51 [EST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FFD GROUP (EMAI)

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

FITNESS FOR DUTY - POSITIVE RESULT FOR ALCOHOL

A non-licensed, supervisory employee was determined to be under the influence of alcohol during a random test. The employee's unescorted access was terminated.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 53239
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RICK ROBBINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/01/2018
Notification Time: 20:05 [ET]
Event Date: 03/01/2018
Event Time: 16:43 [CST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

POTENTIAL TORNADO MISSILE VULNERABILITIES

"During review of protection of equipment from damaging effects of tornados, Point Beach Nuclear Plant identified a potential vulnerability for the turbine driven auxiliary feedwater pumps due to steam supply piping that is not routed through a Class 1 structure. Immediate compensatory measures were taken to mitigate the potential consequences of a tornado generated missile impact.

"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) and per 10 CFR 50.72(b)(3)(v)(A) and (D). The identified vulnerability is being addressed in accordance with EGM 15-002 and DSS-ISG-2016-01, enforcement discretion memorandum and interim guidance document for resolution of noncompliance with tornado-generated missile protection.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 53240
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANDREW SMITH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/01/2018
Notification Time: 20:34 [ET]
Event Date: 03/01/2018
Event Time: 15:55 [EST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC MICHEL (R2DO)

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

UNPLANNED LOSS OF TECHNICAL SUPPORT CENTER

"This is an eight-hour, non-emergency notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the discovered condition affects the functionality of an emergency response facility. Due to the discovery of a breaker coordination issue during an NRC Inspection, the power supply breakers to the Technical Support Center (TSC), including the ventilation system, has been opened to address the condition. This will make the TSC non-functional.

"If an emergency is declared requiring TSC activation during this period, the Alternate TSC will be staffed and activated using existing emergency planning procedures. The Emergency Response Organization team has been notified to respond to the Alternate TSC in the event of an ERO [Emergency Response Organization] activation.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 53242
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KENNETH GRACIA
HQ OPS Officer: VINCE KLCO
Notification Date: 03/03/2018
Notification Time: 02:19 [ET]
Event Date: 03/02/2018
Event Time: 23:15 [EST]
Last Update Date: 03/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRICE BICKETT (R1DO)
BO PHAM (IRD)

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

POTENTIAL LOSS OF OFFSITE RESPONSE CAPABILITIES

"At 2315 EST on March 2, 2018, Pilgrim Nuclear Power Station (PNPS) determined, based on information received from the Commonwealth of Massachusetts, that there may be a potential loss of offsite response capabilities due to ongoing severe natural hazard conditions (i.e., major winter storm) along the coast of Massachusetts. According to information received by PNPS, towns within the 10 Mile EP Radius could be hampered in implementing some protective actions specified in the emergency plan in the unlikely event an emergency were to occur. There is no condition at the Station that would warrant implementation of any emergency plan at this time. PNPS continues to operate safely and is monitoring the weather conditions closely. The Station maintains emergency assessment, response, and communication capability.

"This report is being made conservatively in accordance with 10 CFR 50.72(b)(3)(xiii) which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As stated previously, the Station maintains emergency assessment, response, and communication capability.

"The licensee notified the NRC Resident Inspector."

Page Last Reviewed/Updated Monday, March 05, 2018
Monday, March 05, 2018