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Event Notification Report for June 19, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/18/2018 - 6/19/2018

** EVENT NUMBERS **


53438 53450 53451 53452 53453

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Power Reactor Event Number: 53438
Facility: SALEM
Region: 1     State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW D. MOG
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/01/2018
Notification Time: 14:42 [ET]
Event Date: 06/01/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/19/2018
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):
GLENN DENTEL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

TORNADO MISSILE VULNERABILITIES

"During the period of evaluation of tornado missile vulnerabilities and the potential impacts to technical specification (TS) plant equipment, it was determined that the power cables to a safety related motor control center (MCC) in the service water (SW) intake structure are not adequately protected from tornado generated missiles. During walk downs, it was identified that the installed SW pipe tunnel barrier is not adequate. A tornado could generate missiles capable of striking the power cables and rendering a SW MCC inoperable.

"These conditions are reportable per 10 CFR 50.72(b)(3)(ii)(B) and per 10 CFR 50.72(b)(3)(v)(D).

"This condition is being addressed in accordance with NRC enforcement guidance provided in Enforcement Guidance Memorandum (EGM) 15-002, 'Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' Revision 1, and DSS-ISG-2016-01, 'Clarification of Licensee Actions in Receipt of Enforcement Discretion per Enforcement Guidance Memorandum EGM 15-002, Enforcement Discretion for Tornado- Generated Missile Protection Noncompliance,' Revision 1. Compensatory measures have been implemented in accordance with these documents.

"The NRC Resident Inspector has been notified."

The licensee will be notifying the Lower Alloways Creek Township.

* * * UPDATE ON 6/18/2018 AT 1604 EDT FROM JUSTIN HARGRAVE TO RICHARD SMITH * * *

"During subsequent walk downs, PSEG [Public Service Enterprise Group] identified that both the Unit 1 and Unit 2 turbine driven auxiliary feedwater pumps are also not adequately protected from tornado generated missiles. The steam exhaust pipe could be potentially impacted and cause crimping that could reduce steam exhaust flow and pump capacity. EN 53438 is updated to include both Salem units and these additional components.

"This condition is being addressed in accordance with NRC enforcement guidance provided in enforcement Guidance Memorandum (EGM) 15-002, 'Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' Revision 1, and DSS-ISG-2016-01, 'Clarification of Licensee Actions in Receipt of Enforcement Discretion per Enforcement Guidance Memorandum EGM 15-002, Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' Revision 1. Compensatory measures have been implemented in accordance with these documents."

The NRC Resident Inspector has been notified.

The licensee will be notifying the Lower Alloways Creek Township.

Notified R1DO (Burritt).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53450
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: WESTERN TUMOR MEDICAL GROUP
Region: 4
City: LOS ANGELES   State: CA
County: LOS ANGELES
License #: 7954-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/09/2018
Notification Time: 10:48 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION

The following report was received from the State of California by email:

"[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.

"The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.

"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, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification."

* * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *

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

"Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose)."

California ID # 060818

Notified the R4DO (Deese) and NMSS Events Notifications via email.

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: 53451
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: APPLIED GEOTECHNICAL ENGINEERING CONSULTANTS, INC.
Region: 4
City: SALT LAKE CITY   State: UT
County:
License #: UT1800298
Agreement: Y
Docket:
NRC Notified By: PHIL GOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/11/2018
Notification Time: 10:21 [ET]
Event Date: 06/10/2018
Event Time: 10:00 [MDT]
Last Update Date: 06/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
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 MOISTURE-DENSITY GAUGE

The following was received from the State of Utah via email.

"The morning of June 10, 2018, the licensee discovered that a portable nuclear density gauge had been stolen from one of their work trucks. The truck had been parked in the driveway of the AGEC's [Applied Geotechnical Engineering Consultants, Inc.] employee's house. The license claims that the gauge was properly stored in storage container that was bolted to the bed of the truck and the tailgate was locked. The licensee explained that the perpetrator broke through the locked tailgate, cut the barriers around the Troxler box, cut the locks on the Troxler box and removed the portable gauge. The Salt Lake City Police Department was also contacted. The licensee will continue to investigate the incident and will submit a written report to the DWMRC [Division of Waste Management and Radiation Control]."

Event Report ID No.: UT180002

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: 53452
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BEYOND ENGINEERING AND TESTING LLC
Region: 4
City: ROUND ROCK   State: TX
County:
License #: L-06924
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/11/2018
Notification Time: 13:27 [ET]
Event Date: 06/11/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE-DENSITY GAUGE

The following was received from the State of Texas via email.

"On June 11, 2018, the licensee's radiation safety officer (RSO) notified the Agency [Texas Department of State Health Services] that one of their Troxler 3440 moisture/density gauges (SN: 67091), containing a 40 milliCurie americium 241 source and an 8 milliCurie cesium-137 source, could not be accounted for. The gauge was last used at a temporary job site on May 25, 2018. The technician that used the gauge stated to the RSO that he had returned the gauge to the storage area at their facility in Midland, Texas, that afternoon. He further stated the insertion rod was locked. The gauge, along with another, were to have been picked up by, and transferred to, another licensee (a company associated with the licensee) the week of May 28th. On June 4, 2018, the RSO discovered the gauge had not been picked up/transferred nor was it in the storage area. He began an investigation. The RSO interviewed the technician and facility supervisor and reviewed documentation. The gauge had not been used by the licensee since May 25th. The associated licensee conducted a physical inventory of all of its gauges. The associated licensee's RSO was on vacation and could not be reached until June 11th. After it was confirmed with him that the associated company did not have possession or any further knowledge of the gauge, the RSO made the notification. The RSO is continuing his investigation. More information will be provided as it is
obtained in accordance with SA-300."

Texas Incident #: 9583

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: 53453
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TOLUNAY-WONG ENGINEERS INCORPORATED
Region: 4
City: BEAUMONT   State: TX
County:
License #: L 04848
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/11/2018
Notification Time: 14:29 [ET]
Event Date: 06/11/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE-DENSITY GAUGE

The following was received from the State of Texas via email.

"On June 11, 2018, the licensee's radiation safety officer (RSO) reported to the Agency [Texas Department of State Health Services] that one of its Humboldt 5001-EZ moisture/density gauges (serial number 4097) containing a 40 milliCurie americium-241/Beryllium source (NJ04418) and a 8 milliCurie cesium-137 source (7146GQ) had been run over by a dump truck at a temporary job site. The upper casing on the gauge was damaged and the guide bar broke off as the rod was taking a reading. The rod was in the ground when hit by the truck. The technician was taking readings when he noticed a dump truck backing up close to his location. He moved to the side and tried to wave the person driving to stop. The truck didn't stop and hit the gauge. The incident was reported by the RSO and stated the area has been restricted access until the device can be recovered. The RSO traveled to the site and accessed the device. The source was successfully pulled/retrieved into the shielded position, surveyed and being transported to a servicing company for possible repair or disposal. The company will provide full details of the incident within the next few days. Investigation ongoing."

Texas Incident #: 9584


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Friday, May 03, 2019