Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for April 19, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/18/2018 - 04/19/2018

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 52047
Facility: SAN ONOFRE Region: 4 State: CA Unit: [1] [2] [3] RX Type: [1] W-3-LP,[2] CE,[3] CE NRC Notified By: PHYLLIS DOMINGUEZ HQ OPS Officer: VINCE KLCO	Notification Date: 06/27/2016 Notification Time: 22:14 [ET] Event Date: 06/27/2016 Event Time: 07:29 [PDT] Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): THOMAS HIPSCHMAN (R4DO) FFD GROUP (EMAI)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	N	0	Decommissioned	0	Decommissioned
2	N	N	0	Defueled	0	Defueled
3	N	N	0	Defueled	0	Defueled

Event Text

FITNESS FOR DUTY

A non-licensed contract employee had a confirmed positive for alcohol following a for-cause fitness-for-duty test. The employee's access to the plant has been terminated.

This information will be sent to the NRC Region 4 Office as San Onofre no longer has a resident.

* * * RETRACTION ON 4/18/2018 AT 1308 EDT FROM TIM CUSICK TO STEVEN VITTO * * *

"In the event report, the individual was described as a contract supervisor, thus meeting the reporting threshold. (the violation of the FFD policy was that he failed a for-cause test for alcohol). Recently, an NRC review of SONGS' 2016 Annual Fitness for Duty report found that SONGS described that test failure as 'not reportable' and that the labor category was 'Maintenance
(Craft).' After reviewing the data, Access Authorization confirmed that the individual was a Union Maintenance Foreman (not a supervisor). The event was not reportable."

SONGS will be notifying NRC Region 4.

Notified R4DO (O'KEEFE) and FFD E-mail Group.

Agreement State	Event Number: 53322
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: KAISER PERMANENTE MEDICAL CARE PROGRAM OF SOUTHERN CA Region: 4 City: Los Angeles State: CA County: License #: 0372-19 Agreement: Y Docket: NRC Notified By: ROBERT GREGER HQ OPS Officer: STEVEN VITTO	Notification Date: 04/10/2018 Notification Time: 20:38 [ET] Event Date: 03/28/2018 Event Time: [PDT] Last Update Date: 04/10/2018
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICA (EMAI) DOUGLAS BOLLOCK (NMSS)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE DID NOT FULLY RETRACT

The following was received from the State of California via E-mail.

"The Regional RSO, Kaiser Permanente Medical Care Program, contacted LA County Radiation Management (LA County) on April 10, 2018 to report a Medical Event that occurred at the Kaiser Therapy Department on March 28, 2018 located in Los Angeles, CA. The event occurred during a HDR [High-Dose Rate] brachytherapy procedure in which the iridium-192 (Ir-192) source did not fully retract post-treatment and remained in the transfer guide tube about 5 cm from the cylinder-transfer guide tube connector. The source remained in this position between the patient's thighs for approximately 15 minutes resulting in the patient receiving about 300 cGy (300 rad) to the thighs. It was later determined that the source wire was bent near the source which is suspected to be the reason the source did not retract fully.

"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, especially concerning the delay in removing the source from the immediate vicinity of the patient, the delay in reporting the event to the RSO, as well as to better understand the reason the source wire did not fully retract. "

California 5010 Number: 041018 (5010#)

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.

Non-Agreement State	Event Number: 53325
Rep Org: UNITED STATES NAVY Licensee: UNITED STATES NAVY Region: 1 City: State: VA County: License #: 45-23645-01NA Agreement: Y Docket: NRC Notified By: LINO FRAGOSO HQ OPS Officer: STEVEN VITTO	Notification Date: 04/11/2018 Notification Time: 11:38 [ET] Event Date: 04/05/2018 Event Time: 14:35 [EDT] Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): DON JACKSON (R1DO) NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST RADIOACTIVE MATERIAL

"A Marine Corps CH-53 helicopter crashed around 1453 PDT on 5 April 2018 at the outlying landing field of Naval Air Facility El Centro, California. This helicopter carries seven in-blade-inspection-systems (IBIS), one per blade, and each one carries a strontium-90 source with an activity of 0.5 milliCuries. The U.S. Navy was able to retrieve five of the IBIS, but two of them were not located after several surveys of the aircraft and the surrounding area. The U.S. Navy is reporting those two sources as lost for a total 1 milliCurie of strontium-90."

The Licensee has notified NRC Region 1 (Seeley) and (Elliott).

* * * UPDATE FROM L.L. FRAGOSO (VIA EMAIL) TO HOWIE CROUCH AT 1242 EDT ON 4/12/18 * * *

"The sixth strontium-90 source has been found buried under the fuselage wreckage. That leaves only one strontium-90 source missing for a total of 0.5 mCi lost."

Notified R1DO (Jackson) and NMSS Events Notification (email).

* * * UPDATE FROM L.L. FRAGOSO (VIA EMAIL) TO ANDREW WAUGH AT 0902 EDT ON 4/18/18 * * *

"The last report was made in error. Upon evaluation of the sixth IBIS (buried underneath a gear box), they found no source pin, hence we still have two missing IBIS sources. Personnel will be surveying the area in the next couple of days in the hope of finding the two missing sources."

Notified R1DO (Lilliendahl) and NMSS Events Notification (email).

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

Power Reactor	Event Number: 53342
Facility: COOK Region: 3 State: MI Unit: [1] [2] [ ] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: CORY SHIMULUNAS HQ OPS Officer: THOMAS KENDZIA	Notification Date: 04/18/2018 Notification Time: 09:29 [ET] Event Date: 04/18/2018 Event Time: 03:00 [EDT] Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): KENNETH RIEMER (R3DO) FFD GROUP (EMAI)

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	N	0	Defueled	0	Defueled

Event Text

FITNESS FOR DUTY - DISCOVERY OF PARAPHERNALIA THAT COULD BE USED TO FALSIFY URINE TEST

On 4/18/2018, at approximately 0300 EDT, a contract cleaning employee notified her supervisor that she had found an oven mitt and a bottle containing a liquid that was possibly urine. The bottle had a temperature strip and heating element attached to it. These items were found in the trash in a bathroom in the training center located near the bathroom used for Fitness-for-Duty testing. The supervisor notified Security. Security responded and took possession of the objects.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, March 24, 2021