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Event Notification Report for June 11, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/8/2018 - 6/11/2018

** EVENT NUMBERS **


53014 53340 53415 53434 53436 53437 53439 53440 53441

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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 THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!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: 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.

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Agreement State Event Number: 53436
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL PRESSURE PUMPING, INC.
Region: 1
City: MEADVILLE   State: PA
County:
License #: PA-1446
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/01/2018
Notification Time: 11:39 [ET]
Event Date: 05/30/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - IN-LINE DENSITY GAUGE STUCK SHUTTER

The following information was received via E-mail:

"On May 31, 2018, the Department [PA DEP Bureau of Radiation Protection] was notified by the licensee that a malfunction of a roll pin on a shutter handle occurred at a temporary jobsite in Eighty Four, Pennsylvania. It is initially reportable per 10 CFR 30.50(b)(2).

"A roll pin, which holds the shutter handle to the shutter shaft on a Berthhold Model LB 8010 in-line density gauge containing 20 milliCuries of cesium-137 became sheared off during an attempt to move the shutter to the open position, rendering the gauge unusable. The gauge is currently being stored at their Punxsutawney, PA location. The shutter is in the closed position and the gauge is out of service awaiting repair from the manufacturer. There was no other damage to the gauge. No overexposures have occurred.

"Radionuclide: Cs-137
Manufacturer: Berthold
Model: LB 8010
Serial Number: 10485
Activity: 20 mCi

"The cause of the event has been attributed to normal wear and tear on the gauge. A reactive inspection is planned by the Department."

PA Event Report ID No: PA180013

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Non-Agreement State Event Number: 53437
Rep Org: CHRISTIANA CARE HOME SERVICES, INC
Licensee: CHRISTIANA CARE HOME SERVICES, INC.
Region: 1
City: NEWARK   State: DE
County:
License #:
Agreement: N
Docket:
NRC Notified By: XIAOQIAN WEN
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/01/2018
Notification Time: 13:05 [ET]
Event Date: 05/30/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Category 3" level of radioactive material.

Event Text

LOST IODINE-125 SEEDS

On 5/30/2018 a physicist for Christiana Care Home Services discovered that 50 Iodine-125 seeds were missing from the Hot Lab. The licensee began investigating to determine what happened to the seeds. The licensee determined that the seeds had been initially brought into the Hot Lab on 2/6/2018. The licensee believes that on 3/16/2018 an employee from Occupational Safety picked up empty trays from the Hot Lab to recycle them as part of their recycling program and that the Iodine-125 seeds may have been on two of the trays picked up. The trays were taken to a trailer where normal scrap metal is placed and were later picked up by the recycling company.

The licensee believes, but could not confirm that the recycling company picked up the trays along with the seeds which were then taken to universal waste disposal. The licensee interviewed the occupational safety individual and the individual could not confirm that he saw any Iodine-125 seeds in the trays he placed into the recycling box. The licensee has also contacted the recycling company to determine if the boxes can be retrieved, however, the recycling company stated that the box of scrap metal could not be retrieved at this point.

The licensee contacted the Iodine-125 vendor to confirm that the inventory that they have in their possession was correct. The quantity of seeds missing consisted of 50 Iodine-125 seeds with a total activity of 6 millicuries.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53439
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILINE   State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/01/2018
Notification Time: 14:45 [ET]
Event Date: 05/31/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY SOURCE TO RETRACT

The following information was received via E-mail:

"On June 1, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that a radiography crew was unable to retract a 50 Curie Iridium-192 source into an INC 100 exposure device. The crew was working in a remote area in West Texas when they could not get the source to go past the inlet nipple of the exposure device. After a few attempts, the crew contacted the licensee and an individual authorized to recover sources was sent to the site.

"The licensee did not have specific information on how the source was retracted, but stated it took the individual about 45 minutes to recover the source. The source was returned to the fully shielded position. The exposure device and source were returned to the licensee's storage area and will be sent to the manufacturer for inspection. The licensee stated the exposure device was surveyed and radiation levels were normal.

"The licensee reported that one individual's 0 - 200 millirem self-reading dosimeter did go off scale. The individual's OSL dosimeter has been sent to the licensee's dosimetry processor for reading. The licensee stated it calculated the individual's dose to be 400 millirem based on an interview with the individual. The licensee stated no individual involved received an exposure that exceeded any limit. No member of the general public received an exposure from this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9578

* * * UPDATE FROM ART TUCKER TO GEROND GEORGE ON 7/11/2018 AT 1125 EDT * * *

The following information was received from the State of Texas via email:

"On June 1, 2018, the licensee reported one of its crews were unable to retract a 50 curie iridium - 192 source to the fully shielded position. The licensee's written report received June 29, 2018, stated one of the radiographers had disconnected the guide tube from the exposure device and saw the source was not in the shielded position. The licensee stated the radiographer would have been in contact with the guide tube for 3-5 seconds. The individuals badge was sent for processing and had a reading of 312 millirem DDE. The licensee's initial calculation for the exposure to the individuals hands was 450 millirem. The Agency questioned the dose assessment to the hand. On July 11, 2018, the licensee's radiation safety officer stated they have contacted a service company to perform the dose calculations for the individuals hands. Pictures of the individuals hands taken on July 11, 2018, show no adverse effects from the exposure."

Notified the R4DO (Pick) and the NMSS Events Group via email.

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Agreement State Event Number: 53440
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GEOTECHNICAL CONSULTANTS, INC.
Region: 3
City: WESTERVILLE   State: OH
County:
License #: 31210250023
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/01/2018
Notification Time: 15:21 [ET]
Event Date: 05/31/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN AND RECOVERED DENSITY GAUGE

The following report was received from the Ohio Bureau of Environmental Health and Radiation Protection via email:

"The Licensee had a truck with a CPN Model MC1DR gauge in it, stolen at approximately [1330 EDT] on 5/31/18 from a convenience store in southeast Columbus. The gauge contains 10 mCi of Cs-137 and 50 mCi of Am-241 sealed sources. The truck and gauge were recovered by police several hours later. The Licensee got the truck and gauge back about [2100 EDT] that evening. The gauge case had been opened, but the gauge did not appear to be damaged. The Licensee is taking the gauge to Cline Technical Services (a licensed service provider) to have it checked out as a precautionary measure. An ODH [Ohio Department of Health] inspector [will be visiting the] licensee location on Monday, 6/4/18."

Ohio Item Number: OH180004

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: 53441
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CALCASIEU REFINING CO.
Region: 4
City: LAKE CHARLES   State: LA
County:
License #: GL-156 / AI# 3585
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/01/2018
Notification Time: 15:50 [ET]
Event Date: 05/31/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EXPOSURE TO MEMBERS OF THE PUBLIC

The following information was received via E-mail:

"On May 31, 2018, during a turn-around at Calcasieu Refining Co., lockout and tagout procedures were not performed for two fixed gauges. Two non-radiation workers were over-exposed for the limit of 2 mR/hr. External radiation exposures are currently estimated at between 20 to 40 millirem whole body.

"The two sources were 50 mCi Cs-137 sources in Ohmart Vega Model SH-F1 gauges with serial numbers 70012 and 69998.

"This event was reported by the facility on June 1, 2018."

LA Event Report ID No.: LA20180010


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