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Event Notification Report for March 12, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/09/2018 - 03/12/2018

** EVENT NUMBERS **


53237 53238 53241 53243 53253

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Agreement State Event Number: 53237
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: AMARILLO TESTING & ENGINEERING INC.
Region: 4
City: AMARILLO State: TX
County:
License #: 02658
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: OSSY FONT
Notification Date: 03/01/2018
Notification Time: 15:51 [ET]
Event Date: 02/28/2018
Event Time: 16:30 [CST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE-DENSITY GAUGE

The following report was received from the Texas Department of State Health Services via email:

"On March 1, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that at approximately 1630 CST on February 28, 2018, one of its technicians was performing a density test at a job site when an equipment operator veered off of his path and over into the path where the technician was testing. The technician was barely able to get out of the way of the heavy equipment, but was unable to move a Troxler Model 3440 Plus gauge and it was run over.

"The gauge contains a 40 milliCurie Americium-241 source and an 8 milliCurie Cesium-137 source. The casing on the gauge was damaged and the Cesium source rod was bent. The technician straightened the rod and secured the gauge in its transport case.

"The licensee's radiation safety officer (RSO) responded to the site and performed a radiation survey of the ground where no elevated levels were identified. The RSO surveyed the device and radiation levels were between five and eight millirem/hour, which the RSO stated is higher than normal. The RSO has contacted the manufacturer for guidance. The gauge is in storage area at the licensee's facility. The gauge is not an exposure risk to any individual. The Agency will respond to the licensee's location to perform additional surveys. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9548

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Agreement State Event Number: 53238
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ENGEO INCORPORATED
Region: 4
City: SAN RAMON State: CA
County:
License #: 3016-07
Agreement: Y
Docket:
NRC Notified By: KAMANI HEWADIKARAM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/01/2018
Notification Time: 15:34 [ET]
Event Date: 02/28/2018
Event Time: [PST]
Last Update Date: 03/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN AND RECOVERED MOISTURE-DENSITY GAUGE

The following information was obtained from the State of Texas via email:

"On February 28, 2018, the radiation safety officer from ENGEO Incorporated, contacted RHB [California Radiologic Health Branch] to report a stolen moisture-density gauge. This is a Troxler moisture-density gauge, Model 3440, Serial Number 23533 containing 9 mCi of Cs-137 and 44 mCi of Am-241. According to the licensee, the operator left the gauge secured to the open bed truck at a job site, and upon his return noticed the gauge had been stolen. The gauge was stolen without the Type A container. The licensee immediately notified San Ramon Police Department (SRPD) of the incident.

"Note: On 03/01/18, at approximately 1100 PST, SRPD notified the licensee that they had recovered the gauge near the job site. The licensee is enroute to recover the gauge from SRPD. RHB will be following up on this incident."

California Report No.: 5010-022818

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Agreement State Event Number: 53241
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: CARTERSVILLE MEDICAL CENTER
Region: 1
City: CARTERSVILLE State: GA
County:
License #: 796-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/02/2018
Notification Time: 15:13 [ET]
Event Date: 02/22/2018
Event Time: [EST]
Last Update Date: 03/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the State of Georgia via email:

"On February 19, 2018, a patient was being treated with Y-90 SIR-Spheres. The targeted site was the liver. The prescribed dose was 39 mCi. The procedure appeared to go normally. A follow-up was performed on the same day. The physician thought the scan indicated there was no significant loss of material. On February 22, 2018, another intervention radiologist re-read the scan and noted approximately 30% entered the abdominal wall. On February 23, 2018, the patient was seen and complained of pain and reddening of the skin. The patient went through additional test to determine the cause. The RSO was notified on March 1, 2018 of the incident. The patient, physician, and manufacture were notified of the incident.

"The licensee will submit a more detailed report to determine the root cause, difference between the prescribed and delivered dose, dose to target organ and non-target organ."

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: 53243
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ADVANCED CORROSION TECHNOLOGIES & TRAINING LLC
Region: 4
City: PORT NECHES State: TX
County:
License #: 06508
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/03/2018
Notification Time: 18:39 [ET]
Event Date: 03/02/2018
Event Time: 12:00 [CST]
Last Update Date: 03/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE RETRACTION FAILURE

The following information was obtained from the State of Texas via email:

"On March 3, 2018, the Agency [Texas Department of State and Health Services] received notice that a source retraction failure had occurred on March 2, 2018 around 1200 CST. The camera was a QSA Global 880D with a 61 Curie Iridium-192 source. During source retrieval the crank cables snapped and the source was just outside the camera. The Radiation Safety Officer (RSO) reported to the scene and covered up the source with shielding. The RSO made multiple trips to cover the source with lead and after he completed the operation he noticed his 0-200 mrem pocket dosimeter was off scale. The RSO will send off his film badge for an emergency reading on March 5, 2018. No other personnel received any excessive dose from the event.

"Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident #: I-9550

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Power Reactor Event Number: 53253
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: RYAN LYNN
HQ OPS Officer: OSSY FONT
Notification Date: 03/10/2018
Notification Time: 13:54 [ET]
Event Date: 03/10/2018
Event Time: 07:09 [CST]
Last Update Date: 03/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL VASQUEZ (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

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"HPCI [High Pressure Coolant Injection] was removed from service (unplanned) on 3/10/2018 at time 0709 [CST] by closing HPCI-MO-15, STEAM SUPPLY INBOARD ISOLATION. The inboard steam supply isolation valve is inside Primary Containment. The steam supply valve was closed in an effort to isolate [unidentified] leakage to Primary Containment from a suspected packing leak from HPCI-MO-15. After closing the HPCI-MO-15, Reactor Coolant System Leakage parameters returned to within Technical Specification [TS] LCO [Limiting Condition of Operations] 3.4.4 limits.

"Entered into Technical Specification LCO 3.5.1 Condition C - HPCI System Inoperable.

"Required Actions for Condition 'C' are to verify by administrative means RCIC [Reactor Core Isolation Cooling] System is operable within 1 hour and restore HPCI System to operable status within 14 days. RCIC was verified operable by administrative means concurrent with declaration of HPCI inoperable.

"Normal plant shutdown activities are being planned [for 03/11/2018 at 1200 CDT] to support entry into Primary Containment to initiate any necessary repairs.

"HPCI is a single train safety system. This report is submitted as a condition that at time of discovery could prevent the fulfillment of the safety function of an SSC [System, Structure, or Component] needed to mitigate the consequences of an accident.

"This condition has been entered into the CNS [Cooper Nuclear Station] Corrective Action Program. CR-CNS-2018-01346"

LCO 3.4.4 was entered during unplanned maintenance of the HPCI system. When the HPCI-MO-15 was cycled from closed to open, unidentified leakage in the containment increased above 2 gallons per minute (gpm) in less than a 24 hour period. Also, total unidentified leakage exceeded 5 gpm. The licensee closed the HPCI-MO-15 valve resulting in a decrease in unidentified leakage below TS shutdown limit.

The NRC Resident Inspector was notified.

Page Last Reviewed/Updated Monday, March 12, 2018
Monday, March 12, 2018