United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > April 9

Event Notification Report for April 9, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/06/2018 - 04/09/2018

** EVENT NUMBERS **


53297 53298 53301 53306 53318 53319

To top of page
Non-Agreement State Event Number: 53297
Rep Org: EISENHOWER ARMY MEDICAL CENTER
Licensee: EISENHOWER ARMY MEDICAL CENTER
Region: 1
City: FORT GORDON State: GA
County:
License #: 10-12044-03
Agreement: Y
Docket:
NRC Notified By: BRIAN CHAMPINE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/29/2018
Notification Time: 10:31 [ET]
Event Date: 03/28/2018
Event Time: 15:00 [EDT]
Last Update Date: 03/29/2018
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

MISSING I-125 SEED

On 3/27/2018, a patient was implanted with a 83 microCi I-125 seed marker in preparation for a breast tumor surgery. Following the surgery on 3/28/2018, at approximately 1500 EDT, the I-125 seed marker went missing. The operating room was surveyed, and the patient was imaged with no discovery of the I-125 seed marker.

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.p

To top of page
Non-Agreement State Event Number: 53298
Rep Org: GM COMPONENTS HOLDING, LLC
Licensee: GM COMPONENTS HOLDING, LLC
Region: 3
City: GRAND RAPIDS State: MI
County: KENT
License #: GL
Agreement: N
Docket:
NRC Notified By: ANNETTE WENDLAND
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/29/2018
Notification Time: 16:07 [ET]
Event Date: 03/28/2018
Event Time: [EDT]
Last Update Date: 03/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (EMAI)

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

Event Text

NOTIFICATION OF A LOST TRITIUM EXIT SIGN

During an annual audit on 3/28/2018, the licensee determined that a self luminous exit sign was missing. Through interviews the licensee determined that an employee had removed the sign during a safety walkdown, because it did not appear to be working, and likely disposed of in the trash. Through a records review the licensee determined the safety walkdown was most likely on 11/1/2017.

The licensee information on the self luminous exit sign is that it was a Isolite model SLX60, serial number Y60813, manufactured in 11/2008 with an activity of 7.4 curies of H(3).

The licensee continues to investigate this event and has counseled the employee to follow the procedures for these signs. The licensee is planning to put out a general communication on these signs, and for the eventual removal of all the self luminous exit signs. The licensee is preparing a written report.

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
Agreement State Event Number: 53301
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: OCEAN SPRINGS HOSPITAL
Region: 4
City: OCEAN SPRINGS State: MS
County: JACKSON
License #: MS-356-01
Agreement: Y
Docket:
NRC Notified By: BENJAMIN CULPEPPER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/30/2018
Notification Time: 12:18 [ET]
Event Date: 03/30/2018
Event Time: [CDT]
Last Update Date: 03/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GRETCHEN RIVERA-CAPE (NMSS)

Event Text

AGREEMENT STATE REPORT OF OVEREXPOSURE TO CARDIOLOGIST

The following report was received from the Mississippi Division of Radiological Health via email:

"It was reported, via phone, that an overexposure was received by a Cardiologist in the Ocean Springs Hospital's Catheterization Laboratory. The Cardiologist has received a dose of 5.1 R. The individual reported to the Division of Radiological Health (DRH) of Mississippi that corrective actions were being taken: an investigation was being implemented, dose report(s) were being gathered, and the Cardiologist was being trained on proper handling of ionizing radiation.

"DRH immediately responded by requesting the following information: a report detailing the overexposure, dosimetry reports for the current year, a report on the Radiation Safety Committee's investigation, corrective actions that were taken, and if the overexposure was due to radioactive material or an x-ray device.

"Licensee notified to send a written report of the initial findings by April 5, 2018."

Event Report ID: MS-180004

To top of page
Non-Agreement State Event Number: 53306
Rep Org: THE NACHER CORPORATION
Licensee: THE NACHER CORPORATION
Region: 4
City: OFFSHORE State: LA
County: OFFSHORE
License #: LA 13065-L01
Agreement: Y
Docket:
NRC Notified By: DAVID BOUDREAUX
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/31/2018
Notification Time: 20:57 [ET]
Event Date: 03/31/2018
Event Time: 16:30 [CDT]
Last Update Date: 03/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

GUIDE TUBE DISCONNECTED WITH RADIOGRAPHY SOURCE NOT RETRACTED

The following is a synopsis of the information received during phone notification:

On March 31, 2018 at about 1630 CDT, radiography was being conducted on an offshore platform at the +10 foot level. During an exposure the technician (radiographer) noted that the source did not appear to be retracting. The technician observed that the guide tube had become disconnected. The technician lifted the guide tube to align the source cable and the assistant (radiographer) cranked in the source. The technician estimated he held the guide tube for 2 to 5 seconds for the source to be retrieved. The whole evolution took an estimated 30 to 60 seconds. The technicians then shutdown the operation and called the Radiological Safety Officer (RSO).

The technician and assistant's whole body dosimetry was read and the technician received 7 mR, and the assistant no millirem (mR). The device that malfunctioned was a Source Product Equipment Company (SPEC) model 150 with a model G60 source of IR 192 with an activity of 77 curies. The RSO calculated the technician's dose to the hand to be 630 mR.

The RSO stated that since this is an offshore operation he was reporting this event to the NRC under a reciprocity agreement. The RSO stated that he would be making a report to the state of Louisiana, and to NRC Region 4 as a courtesy.

To top of page
Power Reactor Event Number: 53318
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: TASHA STEPHENS
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/07/2018
Notification Time: 11:59 [ET]
Event Date: 04/07/2018
Event Time: 04:51 [EDT]
Last Update Date: 04/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

AUTOMATIC ACTUATION OF AUXILIARY FEEDWATER SYSTEM (AFW)

"On April 7, 2018 at 0451 EDT, with Unit 1 in Mode 3 at 0 percent power, an auto actuation of 'A' and 'B' Motor Driven Auxiliary Feedwater (MDAFW) pumps occurred during the shutdown of Unit 1 for Harris Nuclear Plant's refueling outage. Plant Operators successfully took control of the AFW flow and noted the 'B' Main Feed pump was still running with proper suction and discharge pressures of 430 lbs. and 1000 lbs.

"The 'A' and 'B' Motor Driven Auxiliary Feedwater (MDAFW) pumps automatically started as designed when the 'Loss of Both Main Feedwater Pumps' signal was received. The cause of the actuation is still being evaluated.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

To top of page
Power Reactor Event Number: 53319
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MICHAEL LONG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/07/2018
Notification Time: 12:10 [ET]
Event Date: 04/07/2018
Event Time: 08:36 [EDT]
Last Update Date: 04/07/2018
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):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR TRIP AND PCIS ACTUATION DURING STATOR COOLING SYSTEM TESTING

"On April 7, 2018, at 0836 EDT, with Unit 1 in Mode 1 at approximately 100 percent power, the reactor automatically tripped during testing of the stator cooling system. The trip was uncomplicated with all systems responding normally. No safety-related equipment was inoperable at the time of the event. Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Operations responded using Emergency Operating Procedures and stabilized the plant in Mode 3. Reactor water level being maintained via normal feedwater system. Decay heat is being removed through the bypass valves.

"Reactor water level reached low level 1 (LL1) as a result of the reactor trip. The LL1 signal causes a Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves) and Group 8 (i.e., shutdown cooling isolation valves) isolations. The LL1 isolations occurred as designed; the Group 8 valves were closed at the time of the event. Due to the Primary Containment Isolation System (PCIS) actuation, this event is also being reported as an eight-hour, non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the PCIS.

"Unit 2 was not affected. There was no impact on the health and safety of the public or plant personnel. The safety significance of this event is minimal. The automatic reactor trip was not complicated and all safety-related systems operated as designed.

"Investigation of the cause of the Reactor Protection System actuation is in progress."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, April 09, 2018
Monday, April 09, 2018