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Event Notification Report for April 12, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/11/2018 - 04/12/2018

** EVENT NUMBERS **


53233 53311 53312 53313 53314 53323 53324 53326

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Agreement State Event Number: 53233
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: DAVID AIRD
Notification Date: 02/28/2018
Notification Time: 14:33 [ET]
Event Date: 02/28/2018
Event Time: 10:30 [EST]
Last Update Date: 04/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
DESIREE DAVIS (ILTA)
JEFFERY GRANT (IRD)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - PACKAGE CONTAINING CATEGORY 2 SEALED SOURCES MISSING IN TRANSIT

The following information was received via E-mail:

"QSA Global reported via telephone on 2/28/2018 that a package shipped via [a common carrier] on 2/19/2018 (shipping documents prepared on 2/16/2018), containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by [the common carrier] at 1030 EST on 2/28/2018. [The common carrier] trace was already initiated and in progress, and tracking indicates last known package location was [the common carrier] hub in Memphis, TN. This was a RQ UN2916, Yellow-III, Type B package with a Transport Index of 1.9 at time of shipment. Package dimensions were 26x22x34 cm. Source changer SN 263. Sources - SN 63782G (111.6 Ci on 2/14/2018) and 73783G (108.0 Ci on 2/14/2018).

"This situation is an immediately reportable event per regulation.

"The search for the missing package is ongoing.

"Agency [Massachusetts Radiation Control Program] currently considers this docket to still be OPEN."

Package Origin: Burlington, MA, USA
Intended Destination: Bogota, Columbia

Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC.

Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.


* * * UPDATE FROM ANTHONY CARPENITO (VIA EMAIL) TO HOWIE CROUCH AT 1119 EST ON 3/1/2018 * * *

QSA Global reported to the Agency that the package was received at its intended destination on 2/26/2018. Agency considers this event to still be OPEN.

Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health.

Notified R1DO (Bickett), NMSS EO (Rivera-Capella), ILTAB (English), IRD MOC (Pham), and NMSS Events (email).

Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC.

Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.


* * * UPDATE FROM ANTHONY CARPENITO TO ANDREW WAUGH AT 1406 EDT ON 4/11/2018 * * *

The following was received from the Commonwealth of Massachusetts via email:

"QSA Global provided a 30-day written report received by the Agency on 3/9/18. Agency telephone discussions with QSA Global and [the common carrier] were held on 3/12/18. The following information is provided in order to report previously unreported details: (1) QSA Global confirmed that the 650-L Source Changer is itself a Type B package and was not shipped in an overpack container and therefore was the shipping container, (2) [the common carrier] indicated, as a corrective action, this situation would be included in the lessons learned portion of annual refresher training presented to [the common carrier] employees. In this case, although QSA Global had contact with the international customer on 2/21/18 and 2/23/18, the customer did not follow-up to inform QSA Global when the item actually arrived on 2/26/18 (two days before it was reported to Agency as missing by QSA Global on 2/28/18).

"Agency considers this event to be CLOSED."

Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health.

NMED number: 180099

Massachusetts Event: 15-3140

Notified R1DO (Jackson), NMSS EO (Rivera-Capella), ILTAB (Ahern), IRD MOC (Pham), and NMSS Events (email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.

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Agreement State Event Number: 53311
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ALADDIN TEMP-RITE LLC
Region: 1
City: HENDERSONVILLE State: TN
County:
License #: GL #14
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/03/2018
Notification Time: 11:48 [ET]
Event Date: 04/02/2018
Event Time: 15:41 [CDT]
Last Update Date: 04/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING GENERALLY LICENSED AM-241 SOURCE

The following information was received via E-mail:

"On 4/2/18, while conducting an inventory at Aladdin Temp-rite LLC, the licensee discovered that one of their generally licensed devices was missing. The device information includes the following:

"Manufacturer: Amersham
Model: AMCP6
Model #: 103
Serial #: 11070
Isotope: Am-241 (150 mCi)

"A follow-up report will be submitted within 30 days."

State Event Report ID No.: TN-18-064

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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Agreement State Event Number: 53312
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH RADIATION SAFETY
Region: 4
City: SALT LAKE CITY State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: TIM BUTLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/03/2018
Notification Time: 18:29 [ET]
Event Date: 03/05/2018
Event Time: [MDT]
Last Update Date: 04/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING GENERALLY LICENSED NI-63 SOURCE

The following information was received via E-mail:

"The licensee indicated that during a lab remodel, an employee removed a Gas Chromatograph (GC) containing a 13.81 mCi, Ni-63 source, Serial Number M2093, a license distributed under general license. The GC was then sent to surplus. The device was then purchased by an unknown party, on an as yet to be determined date. The radiation safety team last physically inventoried the device on August 2, 2017. The current location of the device is unknown."

Utah Event Report ID No.: UT180001

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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Agreement State Event Number: 53313
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MEDICAL UNIVERSITY OF SC
Region: 1
City: CHARLESTON State: SC
County:
License #: SC 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/04/2018
Notification Time: 10:10 [ET]
Event Date: 03/06/2018
Event Time: [EDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG TREATMENT SITE

A patient was prescribed treatment by High Dose Rate (HDR) brachytherapy to a breast keloid in two fractions on 3/6/18 and 3/7/18 of 600 cGy per fraction. The patient contacted the oncologist when a skin/tissue reaction was discovered on 4/2/18. The reaction was not an anticipated response to the treatment plan.

The fractions were likely directed to the wrong treatment site due to an improper length HDR catheter.

The patient will be evaluated by the oncologist this week.

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: 53314
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA SAN DIEGO
Region: 4
City: LA JOLLA State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/04/2018
Notification Time: 14:20 [ET]
Event Date: 04/02/2018
Event Time: 16:00 [PDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RECEIVED DOSE LESS THAN PRESCRIBED DOSE

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

"A medical event per 10 CFR 35.3045 was determined to have occurred on April 2, 2018 during a University of California San Diego (UCSD) Y-90 liver therapy procedure. The total delivered dosage was greater than 20 percent less than the prescribed dosage.

"The authorized user prescribed MDS Nordion Theraspheres Y-90 activity of 22.7 mCi to be delivered to the left lobe of the patient's liver. During the medical procedure, blockage occurred in the delivery apparatus, and the authorized user was unable to complete the administration of the Y-90 Therasphere dosage. Post-procedural dosage vial chamber measurements were performed that indicated only 32.5 percent (7.4 mCi) of the prescribed Y-90 dosage was delivered.

"An MDS Nordion representative was observing the procedure.

"The UCSD campus Radiation Safety office was notified that the administration resulted in a medical event and the California Radiation Health Branch was notified. The patient and their referring physician were notified on April 2, 2018. The patient will be scheduled for another Therasphere administration in the near future to complete the treatment plan."

California 5010 Number: 040218


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: 53323
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: JOSH EVANS
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/11/2018
Notification Time: 09:09 [ET]
Event Date: 04/11/2018
Event Time: 05:42 [EDT]
Last Update Date: 04/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DON JACKSON (R1DO)

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

OFFSITE NOTIFICATION DUE TO HYDRAZINE SPILL

"On April 11, 2018, a hydrazine spill resulted in measurable hydrazine levels released at the station outfall to the Susquehanna River over an approximately 16 minute time period. The hydrazine levels exceeded the station NPDES [National Pollutant Discharge Elimination System] permit effluent limitations. The Industrial Waste Treatment system release to the river was secured and no further hydrazine was released to the river.

"The concentrations released did not threaten the downstream users or the environment. Pennsylvania Department of Environmental Protection was notified of the NPDES non-compliance on April 11, 2018 at 0542 EDT.

"Pursuant to 10 CFR 50.72(b)(2)(xi), this notification satisfies the requirement to notify the NRC of the occurrence of any event or situation related to the health and safety of the public or onsite personnel, or protection of the environment, for which notification to other government agencies has been made.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 53324
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANNY JAMES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/11/2018
Notification Time: 10:14 [ET]
Event Date: 04/11/2018
Event Time: 01:50 [CDT]
Last Update Date: 04/11/2018
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):
RAY KELLAR (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

CONDITION THAT COULD IMPAIR FUNCTION OF CONTROL BUILDING AC SYSTEM

"At time 0150 CDT on April 11, 2018, a condition was identified that could impair the ability of the Control Building Air Conditioning System to perform its design function.

"Engineering determined that the time delay relays HVKA11-80YB or HVKA11-80YD (Division II chilled water LOW FLOW relays) could fail in a manner that challenges the design safety function of the Control Building Chilled Water System during a Loss of Offsite Power (LOP) Event. A failure of the time delay relay HVKA11-80YB or HVKA11-80YD (Division II chilled water LOW FLOW relays) to provide the time delay function would cause both the Division I and Division II HVK chilled water pumps to start after a LOP, which in turn could hinder the auto start of either Division I or Division II chillers.

"Currently the Chilled Water System is otherwise operating as designed. All operator actions are in place to ensure the plant meets all required designed safety system functions. Work is currently underway to correct this design vulnerability.

"The NRC Resident Inspector has been notified of this condition."

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Power Reactor Event Number: 53326
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: SARAH MCDANIEL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/11/2018
Notification Time: 20:56 [ET]
Event Date: 04/11/2018
Event Time: 14:30 [EDT]
Last Update Date: 04/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MARVIN SYKES (R2DO)

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

Event Text

DEGRADED CONDITION DUE TO INDICATION DURING ULTRASONIC EXAMINATION OF REACTOR NOZZLE PENETRATION

"On April 11, 2018, while the Harris Nuclear Plant was shut down for a scheduled refueling outage, the reactor vessel head penetrations were being examined in accordance with the lnservice Inspection Program. Ultrasonic examinations identified a flaw in the head penetration nozzle number 33. The unit is in a safe and stable condition. The flaw will be repaired prior to startup from the refueling outage.

"The flaw and repair have no impact on the health and safety of the public or station employees. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, April 12, 2018
Thursday, April 12, 2018