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Event Notification Report for July 12, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/11/2018 - 7/12/2018

** EVENT NUMBERS **


53430 53439 53445 53487 53500

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Agreement State Event Number: 53430
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: STEVEN VITTO
Notification Date: 05/29/2018
Notification Time: 14:48 [ET]
Event Date: 05/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - PATIENT SKIN CONTAMINATION

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

"On May 29, 2018, the Department's [Bureau of Radiation Protection] staff in Central Office became aware of a medical event (ME) at U PENN hospital in Philadelphia. The ME is reportable as per 10 CFR 35.3045(a)(1)(i) and also meets criteria for an Abnormal Occurrence.

"On May 25, 2018, a 17 year old pediatric patient underwent an 834 millicurie metaiodobenzylguanidine (MIBG) lodine-131 (I-131) treatment for brain cancer. The dose was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medical technician present during the infusion reported seeing a small amount of blood, but other than that, nothing unusual was noted. However, upon completion of the infusion, meter readings noted high activities on the patient's clothing and bed linen. The possible reason given being a faulty connection line on the automatic pump. The contamination is believed to have also been present on the skin all weekend. Due to the large dose of I-131 infused, the licensee's staff were not able to see the contamination on the patient's skin until he developed erythema. The licensee is in the process of doing a dose reconstruction for the skin contamination. Based on the reading from the patient and estimated activity in the various contaminated items, the licensee currently estimates that approximately 50% of the intended dosage was successfully infused. The authorized user has been informed and is currently notifying the patient's parents and the referring physician.

"A reactive inspection is planned by the Department. More information will be provided upon receipt."

PA Event Report ID No: PA 180012

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 FROM JOHN CHIPPO TO DONALD NORWOOD AT 1451 EDT ON 7/12/2018 * * *

"The University of Pennsylvania (U Penn) reported that a patient's skin became contaminated during medical treatment on 5/25/2018. The 17-year-old pediatric patient was scheduled to receive 30.86 GBq (834 mCi) of 1-131 metaiodobenzylguanidine (MIBG) for treatment of brain cancer. The dosage was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medicine technician present during the infusion saw a small amount of blood, but nothing unusual other than that was noted. However, upon completion of the infusion, radiation surveys revealed high activities of 1-131 on the patient's clothing and bed linen.

"U Penn stated that the patient's upper right thigh was cleaned. On 5/27/2018, the patient reported discomfort and reddening (i.e. erythema) on the skin of his upper right thigh, which developed into a lesion and further into desquamation (grade 3) the next day. Radioactive contamination is believed to have been present on the patient's skin for 24 to 48 hours.

"Based on U Penn measurements, nuclear medicine imaging, and the patient's clinical symptoms, the dose to the skin was estimated to be between 50,000 and 120,000 cGy (rad) to a 15 cm2 area. Radiation safety staff consulted with U.S. DOE's REAC/TS in Oak Ridge TN, to verify dose calculations. Calculations of the activity in the waste and the exposure rate from the patient in previous treatments estimated the activity delivered at 15.54 GBq (420 mCi). It was calculated that approximately 7.77 GBq (210 mCi) went to the waste.

"The cause of the incident is believed to be a faulty connection line on the automatic pump. The patient was also disconnected from the infusion pump at the 'Spiros tube' to use the lavatory part way through the procedure. Due to the large dosage of 1-131 infused, U Penn staff were unable to detect the contamination on the patient's skin until he developed erythema.

"The authorized user was informed and notified the patient's parents and referring physician. Pennsylvania DEP, Bureau of Radiation Protection, performed a reactive inspection on 6/7 and 6/13/2018. U Penn is conducting a full root cause analysis to develop and implement corrective actions. Procedures that have already been implemented for 1-131 MIBG patients included placing absorbent chucks between all parts of the infusion line and the patient's body and requiring an authorized user to be contacted for approval if it is necessary to disconnect a patient during the infusion.

"Root Cause(s): possible equipment failure, training, and/or human error in connecting the line to the infusion pump.

"Actions: A reactive inspection has been completed by the Department. More information will be provided upon receipt from U Penn."

Notified R1DO (Bower), NMSS Events Notification E-mail Group, and INES Coordinator (Milligan).

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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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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53445
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE   State: NM
County: LEA
License #: SNM-2010
Docket: 70-3103
NRC Notified By: BLAKE BIXENMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/06/2018
Notification Time: 15:48 [ET]
Event Date: 06/05/2018
Event Time: 15:14 [MDT]
Last Update Date: 07/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
MIKE ERNSTES (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FUELS GROUP (EMAIL)

Event Text

UNANALYZED CONDITION RESULTING FROM INCORRECT IMPLEMENTATION OF ITEMS RELIED ON FOR SAFETY (IROFS)

"Appendix A to 10 CFR 70 (b)(1)

"An incorrect implementation of IROFS36c (Limit Cylinder Mover to Electric or Diesel with less than 280L [74 gallons] Fuel Load) has been identified as having occurred for feed deliveries into the Cylinder Receipt and Dispatch Building (CRDB). IROFS36c requires that UF6 transporters/movers inside CRDB truck bays utilize a tractor which has a limited fuel capacity of less than 74 gallons. This requires the Over the Road (OTR) tractor truck to disconnect the trailer in a designated staging area and a local tractor with a fuel tank capacity less than 74 gallons be utilized with the OTR trailers. Methods were used allowing an OTR truck trailer to access the CRDB with the OTR tractor and fuel tanks of the vehicle remaining outside. Activities involving OTR tractor trailers entering the CRDB truck bay in this manner have not been evaluated in the ISA.

"10 CFR 70.50 (c)(iii)

"(A) There was not a material release, no radiological or chemical hazards were present.
"(B) No exposure occurred
"(C) A condition exists which resulted in the facility being in a state that was different from that analyzed in the Integrated Safety Analysis. The method for cylinder transport into the CRDB truck bay by an OTR tractor, in proximity to cylinders inside the CRDB, has not been specifically evaluated as the evaluated condition prohibited the use of vehicles with fuel capacities in excess of 74 gallons within the CRDB truck bay. The only piece of equipment which entered the CRDB was the OTR trailer; the tractor remained connected and outside the CRDB.
"(D) IROFS36c remains available and reliable to perform its safety function. The identified deficiency only affects OTR tractors that could potentially expose UF6 cylinders in the CRDB to fuel sources greater than 74 gallons. UUSA [Urenco USA] has issued a stop work to prevent the introduction of excessive fuel capable of causing a release of UF6 inventory in the area of concern should a fire occur. The capabilities of existing IROFS are sufficient to meet the performance requirements of 10 CFR 70.61.
"(iv) No external conditions affect this event.
"(v) A stop work was issued to prevent the access of OTR tractor trucks to the CRDB where proximity to UF6 cylinders could occur.
"(vi) An event did not occur at UUSA. UUSA remains in a safe and stable condition.
"(vii) Current and planned site status is normal. No emergencies have been or will be declared.
"(viii) No local, state, or federal agencies will be notified.
"(ix) No press releases will occur.

"Condition has been entered into the UUSA Corrective Action Program. Event Record 125051."

The licensee will notify R2 (Lopez).


* * * RETRACTION ON 07/11/2018 AT 1534 EST FROM BLAKE BIXENMAN TO STEVEN VITTO * * *

"EN53445, made June 5th, 2018, reported a condition in accordance with Appendix A to 10 CFR 70 (b)(1) in which the facility was in a state different from that analyzed in the Integrated Safety Analysis, and which resulted in failure to meet the performance requirements of 10 CFR 70.61.

"This report was prompted by an incorrect implementation of IROFS36c (Limit Cylinder Mover to Electric or Diesel with <280L Fuel Load) during feed deliveries into the Cylinder Receipt and Dispatch Building (CRDB). An Over the Road (OTR) tractor containing greater than the maximum allowable fuel load was permitted access the CRDB Truck Bay with the OTR truck trailer.

"At the time of the report, this method for cylinder transport into the CRDB Truck Bay by an Over the Road (OTR) tractor in proximity to cylinders inside the CRDB had not been evaluated. URENCO USA conservatively assumed a failure in the performance requirements of 10 CFR 70.61 at the time of the 24 hour report. Since the time of the initial report, URENCO USA has completed an assessment of safety significance for the events reported in EN53445.

"With detailed results documented in the UUSA corrective action program, Event Record EV125051, the following conclusion has been made:

"The fuel delivery events using the OTR truck into the CRDB can be categorized as events with low safety significance since they would not result in breached/ruptures of UF6 cylinders and no uranic material would be released in the event of a fire involving UF6 cylinders in the CRDB Truck Bay. This correlates with a low consequence event.

"Based on calculations shown in the 'Assessment of Safety Significance for Events Documented in EV125051', the conditions reported in EN53445 did not result in failure to meet the performance requirements of 10 CFR 70.61. Therefore, the condition reported in EN53445 did not exceed the criteria which would necessitate an event be reported to the NRC. URENCO USA hereby retracts Event Notification 53445."

Notified R2DO(Rose), Fuels Group, and NMSS Events Notification email.

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Agreement State Event Number: 53487
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE   State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 07/04/2018
Notification Time: 23:19 [ET]
Event Date: 07/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT

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

"On July 4, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that one of their crews has experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 70 Curie Iridium - 192 source. The licensee did not have a lot of details on the event, but stated the source had been recovered and that no over exposures had occurred. The licensee stated the connector ball on the drive cable was tested after the event and failed the test. The RSO stated they would provide additional information on July 5, 2018. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident- I-9591

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Power Reactor Event Number: 53500
Facility: DUANE ARNOLD
Region: 3     State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DOUGLAS PETERSON
HQ OPS Officer: VINCE KLCO
Notification Date: 07/11/2018
Notification Time: 03:58 [ET]
Event Date: 07/11/2018
Event Time: 02:58 [CDT]
Last Update Date: 07/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK JEFFERS (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation

Event Text

METEOROLOGICAL DATA UNAVAILABLE

"On July 11, 2018, as part of pre-planned maintenance, the site meteorological tower will be removed from service. The tower will be out of service for approximately 11 days. As a result, this is reportable under 10CFR 50.72 (b)(3)(xiii). During the time the data is not available from the meteorological tower; compensatory measures will be in place to obtain the data from the National Weather Service if necessary.

"The [NRC] Resident Inspector has been notified."


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Friday, May 03, 2019