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Event Notification Report for June 08, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/7/2018 - 6/8/2018

** EVENT NUMBERS **


53014 53340 53415 53432 53434

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53014
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: STEWART WETZEL
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 22:46 [ET]
Event Date: 10/13/2017
Event Time: 17:00 [CDT]
Last Update Date: 06/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ROSE (R2DO)
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

ACCIDENT MITIGATION - HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"On October 13, 2017 at 1700 CDT, Unit 1 High Pressure Coolant Injection (HPCI) was declared Inoperable due to discovery of a leak on a sensing line to 1-PCV-073-0043, Lube Oil Cooler & Gland Seal Condenser Pressure Control Valve. The leak is a steady stream located where the sense line connects to the valve.

"This constitutes an unplanned HPCI System inoperability and requires an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(D), due to the failure of a single train system affecting accident mitigation and a 60 day written report in accordance with 10 CFR 50.73(a)(2)(v)(D)."

The NRC Resident Inspector has been notified by the Licensee.

* * * RETRACTION ON 6/8/18 AT 1500 EDT FROM BILL BALL TO BETHANY CECERE * * *

"ENS Event Number 53014, made on 10/13/2017 is being retracted.

"NRC notification 53014 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 were met when a leak on a threaded union, along with piping vibration, was identified on U1 HPCls Lube Oil Cooler & Gland Seal Condenser Pressure Control Valve sensing line (1-PCV-073-0043).

"A Past Operability Evaluation [POE] was performed under CR# 1347736. The evaluation concluded that HPCI was degraded, but met the threshold for TS operability. Specifically the vibrations shown were evaluated and deemed to not impact pipe integrity. These vibrations were also evaluated for seismic events. Based on this the POE concluded that HPCI was capable of performing its intended safety function for its designed mission time.

"As such, the circumstances discussed in the report did not result in any condition that at the time of discovery could have prevented the fulfillment of the safety function of structures of system that are needed to remove residual heat. Thus, there was no impact on nuclear safety. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(B).

"TVA's evaluation of this event notification is documented in the corrective action program.

"The licensee has notified the NRC Resident lnspector."

Notified R2DO (Ernstes).

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53340
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: CHRISTOPHER BENNETT
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/17/2018
Notification Time: 12:02 [ET]
Event Date: 04/17/2018
Event Time: 04:16 [CDT]
Last Update Date: 06/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ALAN BLAMEY (R2DO)
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 INOPERABLE

"At 0416 CDT on April 17, 2018, the High Pressure Coolant Injection System (HPCI) was isolated due to a water side leak from the gland seal condenser. Unit 1 HPCI remains inoperable pending repairs to the gland seal condenser.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(V)(D), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(V)(D).

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

* * * RETRACTION ON 6/8/18 AT 1500 EDT FROM BILL BALL TO BETHANY CECERE * * *

"ENS Event Number 53340, made on 4/17/2018 is being retracted.

"NRC notification 53340 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 were met when a leak was identified on U1 HPCls Gland Seal Condenser.

"A Past Operability Evaluation [POE] was performed under CR# 1406178. The evaluation concluded that HPCI was degraded, but met the threshold for TS operability. Specifically the POE states that if the leak was left unaddressed for 8 hours (mission time) with HPCI in operation, the additional volume of water that would accumulate on the HPCI room floor would be approximately 5520 gallons which would be within the capacity of the floor drain pumps and spill over into Torus area to prevent water level from reaching a value which would preclude operation of HPCI critical components. Additionally the leak was upstream of the system flow controller, so the leakage rate of 11.5 gpm would not affect the ability of the HPCI pump to provide rated flow of 5000gpm.

"As such, the circumstances discussed in the report did not result in any condition that at the time of discovery could have prevented the fulfillment of the safety function of structures of system that are needed to remove residual heat. Thus, there was no impact on nuclear safety. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(B).

"TVA's evaluation of this event notification is documented in the corrective action program.

"The licensee has notified the NRC Resident lnspector."

Notified R2DO (Ernstes).

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Agreement State Event Number: 53415
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NOT APPLICABLE
Region: 1
City: ORLANDO   State: FL
County: ORANGE
License #:
Agreement: Y
Docket:
NRC Notified By: PAUL NORMAN
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/21/2018
Notification Time: 21:49 [ET]
Event Date: 05/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
JEFFERY GRANT (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POSSIBLE PLUTONIUM SPHERE FOUND

Received the following by email from Florida Bureau of Radiation Control.

"[A] resident at Waterford [Senior Living Center], recently passed away. His son contacted a licensed Firearms Dealer and Estate Appraiser, to assess his father's estate value. [The appraiser] discovered a metal canister containing a grayish-silver marble-sized sphere. A certificate in the [deceased's] personal effects states that the sphere is Pu, and is a gift given in appreciation of the [deceased's] contributions to The Manhattan Project. Also included in the [deceased] personal effects is a piece of glass said to be from Atomic Bomb Testing. The Certificate is signed by Robert Oppenheimer. [The Estate Appraiser], contacted the ATF. The ATF Special Agent contacted the Bureau of Radiation Control (BRC) Duty Officer. A preliminary investigation is scheduled for Tuesday, May 22, 2018."

Florida report # FL18-062.

* * * UPDATE ON 05/22/2018 AT 13:32 EDT FROM PAUL NORMAN TO THOMAS KENDZIA * * *

"Phone conversation with appraiser and son revealed the following:

"Deceased passed away years ago, and his wife, who has had her spouse's possessions since then, is moving from the Senior Center. Their son was given the name of an Estate Liquidator, to assess their belongings. The appraiser came across a metal shoe shine sized canister containing what he described as marble sized pellets and sandy glass, that had Plutonium marked on it. There also was a framed Reference letter addressed to the deceased from Robert Oppenheimer, thanking him for his contributions to The Manhattan Project. Unbeknownst to the son, the appraiser then contacted the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) with his concerns.

"The son stated that the material in the canister was fused sand from the Trinity test site, and did not know why the appraiser was concerned about it."

Florida report # FL18-062.

Notified R1DO (Dimitriadis), IRD MOC (Pham), and NMSS Events Notification (email).

* * * UPDATE ON 06/08/2018 AT 09:17 EDT FROM TIM DUNN TO OSSY FONT * * *

"[Florida Bureau of Radiation Control] would like to update [NMED] item #180240, regarding the Manhattan Project memorabilia thought to be Plutonium:

"Lab Results
34.76 grams (spherical shape)
0.623 inches (15.82 mm) diameter
Calculated density 16.75 g per cm3 (Uranium is 19.1), so this is some type of alloy.

"Analysis of spectra by DOE indicates natural uranium."

Florida report # FL18-062.

Notified R1DO (Jackson), IRD MOC (Grant), and NMSS Events Notification (email).

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Agreement State Event Number: 53432
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TERRACON CONSULTANTS INC
Region: 4
City: HOUSTON   State: TX
County:
License #: 05268
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: KENNETH MOTT
Notification Date: 05/30/2018
Notification Time: 11:14 [ET]
Event Date: 05/29/2018
Event Time: 00:00 [CDT]
Last Update Date: 05/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

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

"On May 30, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that on May 29, 2018, a Troxler model 3440 moisture/density gauge was damaged at a field site. The gauge contains an 8 millicurie cesium-137 source and a 40 millicurie americium-241 source. While the gauge was in taking a measurement and the technician and the job site foreman were talking, a bobcat operator working in the area failed to see the gauge and ran over it. The RSO stated the foreman and technician attempted to stop the operator of the bobcat, but were unable to get his attention. The RSO stated the operating rod for the cesium source was slightly bent, but the technician was able to return the source to the shielded position. The RSO stated the gauge was surveyed and radiation levels were normal. The gauge was returned to the licensee's location in San Antonio, Texas, for storage. The manufacturer has been contacted for guidance on what to do with the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # - 9577


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: 53434
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: SANFORD MEDICAL CENTER
Region: 4
City: FARGO   State: ND
County:
License #: ND 33-10227-02
Agreement: Y
Docket:
NRC Notified By: BROOKE OLSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/31/2018
Notification Time: 13:59 [ET]
Event Date: 04/04/2018
Event Time: 00:00 [MDT]
Last Update Date: 06/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - PATIENT SKIN CONTAMINATED WITH FLOURINE-18

The following summary was received from the North Dakota Department of Health via telephone:

On April 4, 2018 the licensee reported that a patient undergoing a PET (Positron Emission Tomography) scan was squirted with 15 millicuries of FDG (Fluorodeoxyglucose) - Flourine-18, by the technologist administering the dose. A peak skin dose of 2 Gray was calculated by the licensee Radiation Safety Officer.

The North Dakota Department of Health is awaiting additional information from the licensee regarding the event.

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.

* * * UPDATE ON 06/01/2018 AT 09:17 FROM BROOKE OLSON TO THOMAS KENDZIA * * *

"On April 4, 2018 a patient was imaged with ~15 millicuries of FDG. At the time of the injection, it is now believed that ~15 millicuries dose was inadvertently delivered on the patient's shirt. Since the first dose wasn't administered as intended, a second ~15 millicuries dose was administered into the patient. Per protocol the patient rested for an hour and was imaged. The patient was released from the scan room and was discharged and went to the cafeteria. The [study] physician reviewed the images and found them non-diagnostic due to external contamination. The [study] physician ordered that the images be repeated. The patient was located in the cafeteria and returned to Nuclear Medicine and his shirt was removed. Patient was reimaged approximately an hour after the start of the first scan (approximately 2 hours after the shirt was contaminated) and the second set of images were deemed to be diagnostic.

"On May 15, 2018 the RSO [Radiation Safety Officer] learned of the event and began an investigation. The skin dose is estimated to be approximately 2.8 Gy to 100 cm2 of tissue. This exposed tissue was on the patient's torso. The uncertainty in the skin dose calculation is great. Due to the complexity of the calculation, the skin dose was estimated on May 31, 2018.

"The study physician is aware of the incident and will notify the referring physician. The patient is unlikely to have noticeable negative effects from the incident, however if the patient did have a tissue reaction, it would have been mild and transient. The patient has not yet been notified of any of the findings since the RSO was made aware, however the patient was aware that he was spilled on and that his shirt was kept for decay. Notice will be sent to the patient offering the ability to obtain a written description of the event.

"Continued investigation is in process and will start with a review of reporting requirements and event management related to radioactive spills."

Notified the R4DO (Farnholtz), INES (Milligan), and the NMSS Events Notification email group.

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.


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019