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Event Notification Report for July 20, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/19/2018 - 7/20/2018

** EVENT NUMBERS **


53488 53501 53502 53503 53504 53517

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Agreement State Event Number: 53488
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: STANLEY
Region: 4
City: TULSA   State: OK
County:
License #: LOK-32187-0
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/05/2018
Notification Time: 18:02 [ET]
Event Date: 07/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
KEVIN WILLIAMS (NMSS)
GRETCHEN RIVERA-CAPELLA (EMAIL)
PATRICIA MILLIGAN (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE EVENT

The following information was obtained from the state of Texas via email:

"On July 5, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's [Stanley out of Tulsa, OK] consultant that an overexposure event may have occurred involving radiographers working in the state of Texas, under reciprocity, at a field site near Midland, Texas, but offered no actionable information. At 1620 hours [CDT], the consultant called back and stated that a crew was performing radiography in a pit using a 99.6 Curie iridium - 192 source. The individual who received the high exposure had been working in the dark room. He completed the task he was working on and exited the dark room and went straight to the pit. He picked up the collimator and started to move it while the source was still in the collimator. The other radiographers yelled at him and he dropped the source and left the pit.

"The consultant stated the calculations for the dose to the individual's hand provided by the licensee is 284 rem. The consultant stated the radiographer held the source for about 3 seconds and the dose calculation was based on no shielding. The consultant stated there is currently no apparent injury to the individual's hand. The consultant stated the licensee is contacting REAC/TS in Oak Ridge, Tennessee, for assistance. The licensee's radiation safety officer is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #9592

* * * UPDATE FROM THE STATE OF OKLAHOMA TO HOWIE CROUCH ON 7/6/18 AT 1032 EDT * * *

The following information is excerpted from an email that was received from the state of Oklahoma:

Oklahoma DEQ [Department of Environmental Quality] Radiation Management was contacted by the radiation safety officer (RSO) of Stanley Inspection, License No.: OK-32187-01, after hours on 7/5/2018. Stanley Inspection, a radiography company, was working in Midland, TX under reciprocity, and one of the radiographers potentially overexposed his hand. Stanley Inspection was instructed by Texas to do medical monitoring for the radiographer, including bloodwork and photographs of his overexposed extremity.

Notified R4DO (Miller) and NMSS Events Notifications (email).

* * * UPDATE FROM IRENE CASARES TO DONG PARK ON 7/19/18 AT 1158 EDT * * *

The following information was obtained from the state of Texas via email:

"Stanley Inspection Services reported that a radiation overexposure may have occurred involving radiographers working in Texas, under reciprocity, at a field site on 7/3/2018 near Midland, Texas. Reported to NRC as update on July 19, 2018. After complete investigation and reenactment of the incident the following information was obtained and being provided as an update of the incident.

"On July 3, 2018, a radiographer working a temporary field site project under reciprocity (OK licensee in TX) with another crew had an incident. The radiographer was working in the dark room and was developing film. He completed this task and exited the darkroom. This was the last shot of the day in which this crew was working. It was the last image for this shot in which four images are taken for this weld of a 36 inch pipe at a time of 6.5 minutes each image. They were about to end the workday. It was at dusk and his assistant went to the front of the vehicle to get a flashlight while a member of the other crew showed up. The time of day was between 9 and 10 pm. When this person showed up, the radiographer was exiting the darkroom. These two radiographers both walked down into the pit to retrieve the film, when they were walking to the film, the assistant arrived at the back of the truck, stating that the source was still out and at that time the survey meter being carried by the other crew member (RDS-30, Mirion technologies) was alarming. The person carrying the survey meter was about 2-3 feet behind the first radiographer. The first radiographer had already put his fingers (index and middle) and thumb on the collimator for estimated 3 seconds as he was checking to ensure it had not moved from the mark/film while imaging. He explained that he heard the alarms from the survey and dosimetry meters and they both ran out of the pit. It was reenacted on 16 July to confirm how he placed his fingers on the collimator and estimated the time. The Delta 880, sn D15456, camera was loaded with, QSA, A424-9, 66225G, Ir-192, at an activity of 101.5 curies. The calculated dose to the hand for 3 seconds with a collimator made of tungsten rated at 4 HVL was 25.54 rem for the extremity dose. The initial whole body dose was estimated to be unshielded at 109 mrem. The radiographer had been wearing an electronic dosimeter (Tracerco) which was acting as an alarming rate meter and dosimeter. The film badge was processed with results of 18 mrem. And the dosimetry was reported to have read 24 mrem by the radiographer for that day's work. The dosimeter was sent for verification/accuracy checks. The radiographer had his blood drawn as instructed by REAC/TS and the RSO photographed his fingers/hands for 3 weeks. The radiographer stated he had no abnormal redness, tingling or sensations in the tissue of the hand. The supporting documents and reenactment support an estimated dose of 25.54 rem to the extremity and approximately 20 mrem to the whole body.

"The company is completing its documentation of the incident and will be providing its detailed report with corrective actions, another update will be forthcoming."

Notified R4DO (Young), INES (Milligan) and NMSS Events Notifications via email.

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Agreement State Event Number: 53501
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CENTRAL TEXAS MEDICAL SPECIALISTS PLLC
Region: 4
City: AUSTIN   State: TX
County:
License #: L 06618
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: STEVEN VITTO
Notification Date: 07/11/2018
Notification Time: 15:58 [ET]
Event Date: 07/10/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the State of Texas via E-mail:

"On July 11, 2018, a license notified the Agency [Texas Department of State Health Services] that a medical event had occurred. On July 10, 2018, a patient received the first fraction of a treatment plan delivered by a high dose rate afterloader (HDR) utilizing iridium-192. On July 11, 2018, the medical physicist noticed that the dose per fraction entered in the treatment plan of the 1st fraction was incorrect. Instead of a 350 cGy/fraction for 6 fractions, a value of 2100 cGy was entered for one fraction (which was the total dose for the brachytherapy course). The Radiation Oncologist (RO) was notified and he notified the referring physician and patient that day. RO will follow the patient closely and make all possible interventions to minimize potential adverse effects. The Agency is awaiting answers to multiple questions including identification of target area. More information will be provided as it is obtained and in accordance with SA-300.

"Texas Incident #: I-9594"


* * * UPDATE FROM CHRIS MOORE TO DONALD NORWOOD AT 1621 EDT ON 7/13/2018 * * *

The following was received from the State of Texas via E-mail:

"The patient was treated for vaginal cancer using HDR (High Dose Rate) brachytherapy using a 6 Curie Iridium-192 source. A written report was received from the licensee indicating several factors contributed to the medical event including a busy work day, mental fatigue, verbal description of the intended dose instead of written direction, and unavailability of another medical physicist (MP) to independently review the dose/fraction entered in the treatment planning system. The overall brachytherapy plan was modified and the volume treated in the first fraction was considered completed and [the patient] will not receive further treatment. The Radiation Oncologist will follow the patient closely and make all possible interventions to minimize potential adverse effects. Immediate changes implemented at the facility include: no HDR treatment will start without a written prescription in the patient electronic medical record and an independent check of the prescription entry and radiation dosimetry will be conducted by an Authorized User, other than the MP who generated the treatment plan. An Agency team will conduct an onsite investigation in early August 2018 when all parties involved are available. Additional information will be provided as it is obtained and in accordance with SA-300."

Notified R4DO (Pick) and NMSS Events Notification E-mail 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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Fuel Cycle Facility Event Number: 53502
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
Region: 2
City: ERWIN   State: TN
County: UNICOI
License #: SNM-124
Docket: 07000143
NRC Notified By: RON RICE
HQ OPS Officer: BRIAN LIN
Notification Date: 07/12/2018
Notification Time: 09:23 [ET]
Event Date: 07/11/2018
Event Time: 06:45 [EDT]
Last Update Date: 07/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
STEVE ROSE (R2DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
- FUELS GROUP (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNPLANNED CONTAMINATION EVENT

"On July 11, 2018, at approximately 0645 [EDT] a radiological spill occurred in Building 333 Uranium Metal Dissolution area due to a glass column leak. This area is controlled as a Radiologically controlled Area. Cleanup and evaluation activities were initiated, but later suspended when it was determined the column had failed and additional evaluation for structural stability was necessary prior to safely performing additional recovery and decontamination activities.

"There were no radiological or chemical exposures. There were no releases to the environment or public areas.

"The licensee has notified the NRC Resident Inspector."

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Non-Agreement State Event Number: 53503
Rep Org: TETRA TECH EC, INC.
Licensee: TETRA TECH EC, INC.
Region: 1
City: BRUNSWICK   State: ME
County:
License #: 29-31396-01
Agreement: Y
Docket:
NRC Notified By: STEVEN ADAMS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/12/2018
Notification Time: 13:30 [ET]
Event Date: 06/04/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARK MACDONALD (ILTAB)
CANADA (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

STOLEN RADIOACTIVE CALIBRATION CHECK SOURCES

The following is a synopsis of information received:

This event notification is being made in reference to seven radioactive calibration check sources that were stolen from the Tetra Tech EC, Inc. (TtEC) temporary job site at the former Naval Air Station Brunswick (NASB) in Brunswick, Maine. TtEC currently is performing work at NASB for the U.S. Department of the Navy, Naval Facilities Engineering Command

On the morning of June 4, 2018, Sites 1 and 3 were inspected as part of the follow-up to a May 25, 2018 break-in of the TtEC field trailer. It was observed and reported to the TtEC Project Manager at approximately 0825 EDT that the Navy-owned, locked bunkers (three total), the abandoned Navy warehouse, and TtEC conex box had been broken into sometime after May 25, 2018. The TtEC Project Manager was informed that they were likely broken into during the weekend of June 2 and 3, 2018. Missing from one bunker was a locked safe that contained seven low-level radioactive check sources (five leased from subcontractor RSRS, and two owned by TtEC). The safe had a label bearing the radiation symbol and the words 'CAUTION, RADIOACTIVE MATERIAL,' as was each of the source holders.

At the time of the theft, the sources were locked inside a secure safe, and the safe was, in turn, locked inside a former munitions bunker. The entire safe was stolen from the munitions bunker. The bunker was locked with a heavy-duty keyed padlock issued by the Navy.

The following is a listing of the stolen sources:
ID No. 109402, Sr-90, 0.00065 microCuries
ID No. A2-575, Sr-90, 0.00563 microCuries
ID No. 019-456, Cs-137, 2.72463 microCuries
ID No. 079-705, Cs-137, 5.80465 microCuries
ID No. 129-6119, Cs-137, 2.74557 microCuries
ID No. H7-605, Th-230, 0.01060 microCuries
ID No. 119-706, Th-230, 0.00957 microCuries.

The exposure rate, at 30 centimeters from the safe, is 15 to 16 microroentgens per hour and is not distinguishable from background. If the thieves are successful at opening the safe, they might handle the sources. Of the seven radioactive sources, the cesium-137 source (Identification No. 079-705) would result in the maximum dose to a member of public. An individual would receive a dose of approximately 6 millirem (mrem)/hour if this source was left in a backpack or jacket pocket. The dose rate to an individual 1 foot from this source is 0.041 mrem/hour, and the dose rate to an individual 1 yard from this source is 0.0046 mrem/hour.

A thorough search of the TtEC temporary job site at NASB, including all buildings, bins, and grounds, has been performed in an attempt to recover the sources, but none of the sources were found. The local police have been notified of the theft, and a formal police report was filed. As of today, the sources have not been recovered.

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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Fuel Cycle Facility Event Number: 53504
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA   State: SC
County: RICHLAND
License #: SNM-1107
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/12/2018
Notification Time: 16:13 [ET]
Event Date: 07/12/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
STEVE ROSE (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

OFFSITE NOTIFICATION TO SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

"For this event, notification was made to the South Carolina (SC) Department of Health and Environmental Control (DHEC) per R 61-68 E.4.b which requires 24 hour notification upon discovery of an 'unauthorized discharge into waters of the State which may cause or contribute to an excursion of a water quality standard.' While it was not conclusively determined that the leak migrated to the groundwater, Columbia made the notification based on discussions with SCDHEC. SCDHEC was notified by phone on July 12, 2018 at 1530 EDT.

"An equipment issue was noted on July 10, 2018 during ongoing maintenance activities to repair the liner associated with Hydrofluoric Acid Spiking Station No. 2 in the conversion process area of the Columbia plant. While the polypropylene liner was removed for repair work, a crack was noticed in the epoxy coating covering the diked area at the spiking station. Upon further investigation, a hole approximately 3 inches in diameter was found penetrating the concrete floor and into the soil beneath. Measurements taken reflect the depth of the hole as approximately 6 feet into the soil. Several samples of soil were obtained from the immediate area the morning of July 11, 2018. These samples were analyzed at the Columbia Plant Chemical Laboratory with results obtained the morning of July 12. The highest measurements reported from the samples are 4,000 ppm Uranium and 24 ppm Fluoride, with a pH of 2.84.

"The Hydrofluoric Acid Spiking Station No. 2 remains out of service. This is a localized issue underneath the floor of the existing structure and well within the boundaries of the site, thus there is no impact to public health and safety or facility workers.

"The spiking station remains removed from service while the event is being fully evaluated. Maintenance has placed a metal plate over the hole as an interim measure to protect the environment from any potential leaks from associated piping. Monitoring of closest downgradient well will be performed within the next seven days. Appropriate repairs or modifications will be completed to the concrete pad and protective layers before the equipment is returned to service. Issue Report 2018-12123 was entered into the Corrective Action Program."

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Power Reactor Event Number: 53517
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: DANIEL MICKINAC
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/19/2018
Notification Time: 12:36 [ET]
Event Date: 07/18/2018
Event Time: 13:00 [EDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

NON-LICENSED CONTRACT SUPERVISOR SUBVERTS FITNESS FOR DUTY TEST

"At 1300 [EDT] on July 18, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD) program by subverting the Fitness for Duty process. The contractor's site access has been terminated. The NRC Resident Inspector was notified."


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