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Event Notification Report for April 5, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/04/2018 - 04/05/2018

** EVENT NUMBERS **


52779 53223 53292 53293 53295 53296

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 52779
Rep Org: VETERANS HEALTH ADMINISTRATION
Licensee: VETERANS HEALTH ADMINISTRATION
Region: 4
City: NORTH LITTLE ROCK State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/31/2017
Notification Time: 20:08 [ET]
Event Date: 05/30/2017
Event Time: 07:00 [CDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

EXTERNAL CONTAMINATION ON PACKAGE GREATER THAN ALLOWABLE LIMITS

"Pursuant to 10 CFR 20.1906, Veterans Health Administration (VHA) National Health Physics Program is notifying NRC of the receipt of two packages of radioactive material with removable surface contamination on the outside that exceeded NRC reporting limits.

"The packages were received on the morning of Tuesday, May 30, 2017, by the Robert J. Dole VA Medical Center in Wichita, Kansas. This facility is a site of use under the VA St. Louis Health Care System, St. Louis, Missouri, which holds VHA permit number 24-00144-05 under the VHA master materials license. The packages were surveyed at about 0700 CDT. The wipe tests performed on the external surfaces of the packages indicated removable contamination of about 1,450 and 1,390 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. The packages contained unit dosages of fluorine-18 fluorodeoxyglucose. The packages were shipped from Cardinal Health in Wichita, Kansas, which was also the final delivery carrier. A facility nuclear medicine technologist notified the final delivery carrier by telephone of the contaminated packages soon after discovery of the contamination. VHA National Health Physics Program, which manages the master materials license, was notified of the incident at about 1700 CDT on Wednesday May 31, 2017.

"The VHA is aware that this notification does not conform to the timeliness requirements in 10 CFR 20.1906. VHA will take appropriate action regarding this apparent noncompliance. VHA will notify our NRC Region III Project Manager of this incident."


* * * RETRACTION ON 4/4/18 AT 1330 EDT FROM LYNN GRAVES TO DONALD NORWOOD * * *

"On July 18, 2017, the review by the facility Radiation Safety Officer (RSO) determined the event was 'suspect' due to radiation levels from a dose calibrator inducing spurious results in the well counter used for package surveys. The package did not have external radioactive contamination.

"The root cause of the report of contamination was identified by the PET [Positron Emission Tomography] technologist. It was a result of counting the package wipes with a radioactive source in the adjacent dose calibrator causing crosstalk between the two instruments. Correct technique was discussed by the RSO with the PET technologist. In addition, staff training of the correct technique was provided for all department personnel. During an onsite inspection in January 2018, the root cause was verified with the inspector having a high degree of confidence that the Wichita facility did not receive an externally contaminated package on May 30, 2017."

The licensee notified R3 (Parker).

Notified R3DO (Orth) and NMSS Events Notification E-mail group.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53223
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: BRYAN PARKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/20/2018
Notification Time: 18:46 [ET]
Event Date: 02/20/2018
Event Time: 12:25 [CST]
Last Update Date: 04/04/2018
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)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

Event Text

ALL THREE AUXILIARY FEEDWATER PUMPS INOPERABLE DUE TO HELB DOOR BEING OPEN

"At 1225 CST, all three Auxiliary Feedwater [AFW] pumps were declared inoperable at the Callaway Plant upon discovery that a door (DSK13311) credited for protection of equipment from the effects of a high-energy line break (HELB) hazard had come partially open due to vibration harmonics from the running turbine-driven Auxiliary Feedwater pump (TDAFP). Immediate investigation identified that play in the mechanism that holds the door closed had rendered it susceptible to movement from the vibration harmonics.

"The affected HELB door specifically protects safety-related instruments that provide a swap-over signal upon detection of a low suction pressure condition for the AFW pumps and thereby automatically effect a suction transfer for the AFW pumps from the condensate storage tank (normal/standby source) to the Essential Service Water (ESW) system (credited safety-related source).

"All of the AFW pump suction transfer instrument channels were declared inoperable. Per Technical Specifications (TS) 3.3.2, 'Engineered Safety Feature Actuation System (ESFAS) Instrumentation,' the applicable Condition(s) and Required Action(s) for inoperable AFW pump suction transfer instrumentation only addresses a single channel being inoperable. Thus, the condition of having all three instrument channels inoperable required entry into TS Limiting Condition for Operation (LCO) 3.0.3. At the same time, however, with the automatic suction transfer capability rendered inoperable, all three AFW pumps, i.e., the TDAFP and the 'A' and 'B' motor-driven AFW pumps, were declared inoperable. Although LCO 3.0.3 was applicable, entry into the Required Actions of LCO 3.0.3 was suspended per the Note attached to Required Action E.1 of TS 3.7.5, 'Auxiliary Feedwater (AFW) System,' which states, 'LCO 3.0.3 and all other LCO Required Actions requiring MODE changes are suspended until one AFW train is restored to OPERABLE status.'

"At 1336 CST, Operations took actions to prevent the TDAFP from running, so the remaining [AFW Pumps] could be returned to Operable status. Operations then declared the affected instrumentation and the 'A' and 'B' motor-driven AFW pumps Operable. This allowed LCO 3.0.3 and Conditions A, B, D, and E under TS 3.7.5 to be exited. With only the TDAFP inoperable, TS 3.7.5 Condition C and its Required Actions remain in effect.

"Due to the degraded HELB door rendering all three AFW pumps inoperable, the unidentified condition is being reported as an unanalyzed condition that significantly degraded plant safety [per 10 CFR 50.72(b)(3)(ii)(B)] as well as a condition that could have prevented the fulfillment of the safety functions of structures or systems that are needed to shut down the reactor and maintain it in a safe shutdown condition, remove residual heat, and mitigate the consequences of an accident [per 10 CFR 50.72(b)(3)(v)(A), (B), and (D), respectively].

"The NRC Senior Resident Inspector has been notified."


* * * RETRACTION ON 4/4/2018 at 1109 EDT FROM JONATHAN LAUF TO DAVID AIRD * * *

"Event Notification (EN) # 53223, made on 2/20/2018, is being retracted because new information has been obtained that negates the original basis for reporting the unanalyzed condition. Specifically, an evaluation of the HELB that is postulated to occur in the TDAFP room has determined that without crediting door DSK13311 for protection, the affected safety-related instruments would not be exposed to environmental conditions beyond their analyzed capability.

"This resulted in a conclusion that the unanalyzed condition of door DSK13311 being open did not prevent the affected safety-related instruments or their supported AFW pumps from performing their required safety functions to shut down the reactor and maintain it in a safe shutdown condition, remove residual heat, and/or mitigate the consequences of an accident, nor did it significantly degrade plant safety. Consequently, the condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(A), (B), or (D)."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Drake).

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Agreement State Event Number: 53292
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF ILLINOIS - CHICAGO
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DAVID AIRD
Notification Date: 03/27/2018
Notification Time: 14:33 [ET]
Event Date: 03/27/2018
Event Time: [CDT]
Last Update Date: 03/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING SOURCE

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

"On March 27, 2018, the agency [Illinois Emergency Management Agency] was contacted by the licensee's radiation safety officer to report a missing 10 microCi Am-241 source. The source assay date was not immediately available. Reportedly, forms were distributed to the authorized users who would perform the physical inventory. An investigation is ongoing to determine the last physical inventory and responsible individuals. A full report is pending from the licensee by April 26, 2018. A comprehensive source inventory is to be completed within the week. Additional updates will be provided as they become available."

Item Number: IL 180024

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.

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Agreement State Event Number: 53293
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SUMMA HEALTH SYSTEMS
Region: 3
City: AKRON State: OH
County:
License #: 2120780022
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: DAVID AIRD
Notification Date: 03/27/2018
Notification Time: 15:59 [ET]
Event Date: 09/05/2017
Event Time: [EDT]
Last Update Date: 03/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

The following is an excerpt from a report received from the State of Ohio via email:

The criteria for a medical event supported by ODH (Ohio Department of Health) is if the 90% prostate volume receives less than 80% of the prescribed dose or more than 120% of the prescribed dose. Upon generating the post treatment plans for nine patients, the Dosimetry staff discovered that four were below 80%.

Summary of Prostate Implant Incidents:

Case #. Implant Date, Discovery Date, Prescribed Dose (Gy), Estimated D90 (Gy)

1. 9/05/2017, 3/26/2018, 110 Gy, 58.15 Gy
2. 9/28/2017, 3/26/2018, 145 Gy, 100.19 Gy
3. 2/13/2017, 3/26/2018, 110 Gy, 81.28 Gy
4. 2/19/2017, 3/26/2018, 145 Gy, 103.7 Gy

Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125

Item Number: OH180002

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: 53295
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: PHILLIP OLLIS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/28/2018
Notification Time: 14:07 [ET]
Event Date: 03/28/2018
Event Time: 13:30 [EDT]
Last Update Date: 03/28/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
STEVE ROSE (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

CONCURRENT REPORT DUE TO DAMAGED TRITIUM EXIT SIGN

"At approximately 1330 EDT, 3/28/2018, a report was sent to the State of North Carolina Department of Radiation Protection. The report is below:

"'Pursuant to 10A NCAC 15.0309, Global Nuclear Fuel Americas, LLC (GNF-A) is providing this report for discovery of a damaged self illuminated exit sign in the Fuel Manufacturing Operations (FMO) building.

On February 26, 2018, it was discovered that one tube out of the twelve originally installed tubes in a generally licensed exit sign was damaged. The sign was in storage and not being used at the time and there was no significant exposure as a result of the event.

The sign is believed to be a model number 101 or 201, originally containing a maximum of 25 Ci of tritium manufactured and distributed by:

Evenlite, Inc., 220 VFW Avenue.,Grasonville, MD 21638.

Arrangements were made to properly dispose of the sign. It was shipped offsite for recovery or disposal on March 23, 2018 to SRB Technologies (NC Radioactive Material License 034-0534-2).'

"This report to NRC is being made in accordance with 10 CFR 70 Appendix A (c) - Concurrent Reports (... notifications to other government agencies has been or will be made, shall be reported to the NRC Operations Center concurrent to the news release or other notification.)"

The Licensee has notified NRC Region 2.

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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Non-Agreement State Event Number: 53296
Rep Org: AUTOMATED PACKAGING SYSTEMS
Licensee: AUTOMATED PACKAGING SYSTEMS
Region: 1
City: KEYSER State: WV
County: MINERAL
License #: GL-657303-19
Agreement: N
Docket:
NRC Notified By: CHRIS KNOX
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/28/2018
Notification Time: 15:38 [ET]
Event Date: 03/28/2018
Event Time: [EDT]
Last Update Date: 03/28/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

NOTIFICATION OF A LOST THICKNESS GAUGE

The licensee determined today, 3/28/2018, that they had lost an Am-241 thickness gauge source. A few months ago the Am-241 thickness gauge source had been replaced with a non-radioactive thickness gauge source. The licensee had observed the Am-241 thickness gauge source at the plant after it was removed, but when they tried to locate it last week could not find it. They searched the site, including using a radiation detector to search with, and did not locate the Am-241 thickness gauge source.

The gauge is an NDC Technologies, probe Model 103, with an Am-241source. The device S/N is 12131, and the source S/N is 7199 LQ with an Assay date of 10/6/1998. No specific source strength was included in the data the licensee had, but they indicated the source strength was low. NDC Technologies license GL-657303-19 indicates the Am-241 source activity is 150 micro Ci.

The licensee stated that they are continuing to search for the Am-241 thickness gauge source, and they are preparing a written report. The licensee stated that they have revised their administrative policy for control of radioactive material and are scheduling retaining for their radiation safety officers.

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

Page Last Reviewed/Updated Thursday, April 05, 2018
Thursday, April 05, 2018