Event Notification Report for July 23, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/20/2018 - 7/23/2018

** EVENT NUMBERS **


53502 53503 53504 53505 53506 53520

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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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Agreement State Event Number: 53505
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: RESOLUTE FOREST PRODUCTS
Region: 1
City: CATAWBA   State: SC
County:
License #: 030
Agreement: Y
Docket:
NRC Notified By: ANDREW ROXBURGH
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/13/2018
Notification Time: 11:27 [ET]
Event Date: 07/13/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE STUCK SHUTTER

The following information was received from the state of South Carolina via email:

"On July 13, 2018 the Department [South Carolina Division of Health and Environmental Control] was notified by the licensee that it had discovered a stuck shutter on one of its gauges while performing a lockout procedure in order to do maintenance on a rotary valve located near the gauge. The gauge is a Kay-Ray Model 7462BP s/n 22425 containing 50 mCi of Cesium 137. The licensee has contacted Systems Services who is specifically licensed to repair the damaged shutter. The RSO [Radiation Safety Officer] stated that the gauge is located 20 feet above areas where individuals normally work. The RSO also surveyed the gauge and found a reading of less than 2 mR/hr. Access to the gauge is made via a catwalk which will be roped off by the RSO until the service provider comes to fix the shutter. The service provider is scheduled to come July 17, 2018."

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53506
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: SE GEORGIA HEALTH SYSTEMS
Region: 1
City: BRUNSWICK   State: GA
County:
License #: 45-309857-01
Agreement: Y
Docket:
NRC Notified By: KATHARINE ARZATE
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 07/13/2018
Notification Time: 16:21 [ET]
Event Date: 07/13/2018
Event Time: 11:25 [EDT]
Last Update Date: 08/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
30.50(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
STEVE ROSE (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG PICK (R4DO)
FRED BOWER (R1DO)

Event Text

MEDICAL EVENT

The following information is a synopsis of information received via E-mail:

A HDR [high dose rate] brachytherapy incident occurred in Brunswick, Georgia, on July 13, 2018. No one, including the patient, was exposed to excessive radiation. SE Georgia Health Systems treated a Gyn [gynecology] patient using the GammaMed Plus HDR unit and a Tandem and Ring applicator set, both supplied by Varian. Upon completion of the treatment, the source wire retracts back into the shielded HDR unit for safe storage. At that time the room was checked with a survey meter and no exposure readings above background were measured. The HDR unit was surveyed to ensure that the source wire had retracted. The exposure reading on the surface demonstrated that the wire had retracted, and the room was safe. Upon scanning the patient's surface, however, a reading of approximately 2.5mR/hr was measured, which was higher than the expected background reading. The applicator was removed from the patient and scanned, the increased exposure reading was in the applicator. The applicator was placed into a large shielded container provided by Varian and immediately placed in safe storage. The patient, the bedding, and all other materials associated with the implant were re-scanned with no readings above background. The patient was removed from the room, deemed safe and released. The time was recorded to be approximately 5 to 6 minutes and will be used for dose estimates.

The HDR unit was re-scanned along with the Linac vault. All were deemed clear and safe. The HDR unit was locked and secured. Patient treatments in the Linac continued.

The applicator device was then scanned one piece at a time and it was determined that the Ring portion of the Tandem and Ring set was contaminated. It was assumed that the contamination was secure inside the ring which is a rounded hollow metal tube. Exposure readings at the surface of the ring were 96 mR/hr at the surface and approximately 30 mR/hr at 6 inches.

SE Georgia Health Systems notified the Georgia Radiation Protection Programs, and Varian Medical Systems of this incident.

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.

* * * RETRACTION FROM KATHY ARZATE TO HOWIE CROUCH AT 1050 EDT ON 8/7/18 * * *

"After investigation and arrival on site to determine the cause of the contamination, it was found there was no contamination on the patient's body. It was not a failure of the device. We [Varian] inspected the device. We attempted to remove the contamination from the applicator, but were unable to. Therefore, the manufacturer of the source took the applicator back to their facility and were able to remove the contamination there. Ultimately, there was no equipment failure per 10 CFR 30.50(b)(2) or (b)(3)."

Notified R1DO (Cahill), R2DO (Sykes), R4DO (Vasquez), and NMSS Events (by email).

* * * UPDATE FROM KATHY ARZATE TO OSSY FONT AT 1127 EDT ON 8/20/18 * * *

The following was received via email from Varian and is part of their retraction on 8/7/18:

"The Varian Radiation Safety Officer (VRSO), the Varian Field Service Engineer (VFSE), and the AOS Radiation Safety Officer (ARSO) arrived on the site on July 15, 2018 at 0830 EDT. They were met by the site Radiation Safety Officer and medical physicist.

"Utilizing a RADEYE B20-ER Geiger meter, an initial contamination wipe was performed on the afterloader turret. No results above background were found. The VFSE began the process of transferring the potentially contaminated wire from the afterloader to the transport safe. The VRSO then began decontamination steps to remove the particle from the applicator.

"The decontamination effort involved running a dummy cable completely through the applicator to the closed end. Once the cable reached the end of the applicator, the wire was moved back-and-forth in the location of the contamination while rotating the applicator. Once the site was agitated for an appropriate amount of time, the cable was slowly pulled from the applicator while holding a wipe on the wire. This action was performed for approximately 45 minutes without success.

"Once the old source wire was removed from the afterloader, the afterloader was scanned to determine if any contamination was present in the source wire tubing. No results above background were found. The new wire was installed into the afterloader. The plastic transfer catheter was wiped. No results above background were found. All gloves, wipes, and dummy cable were scanned for potential contamination prior to placement in the biohazard waste stream. No results above background were found.

"The ARSO took the contaminated applicator back to the AOS facility. Further efforts at that facility allowed the applicator to be cleaned and returned to the customer site.

"The results of all testing indicate that the afterloader was clear of possible radiological contamination. A new source wire was installed and the customer was able to resume treatments as scheduled. There was no indication that the contamination was from a leaking sealed source, but rather external contamination on the wire. There is no indication of patient contamination or equipment failure. Therefore, the NRC Event Report 53506 has been retracted."

Notified R1DO (Young) and R2DO (Sandal), R4DO (Taylor) and NMSS Events by email.

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Non-Power Reactor Event Number: 53520
Facility: KANSAS STATE UNIVERSITY
RX Type: 250 KW TRIGA MARK II
Comments:
Region: 0
City: MANHATTAN   State: KS
County: RILEY
License #: R-88
Agreement: Y
Docket: 05000188
NRC Notified By: MAX NAGER
HQ OPS Officer: KENNETH MOTT
Notification Date: 07/21/2018
Notification Time: 23:30 [ET]
Event Date: 07/21/2018
Event Time: 20:00 [CDT]
Last Update Date: 07/22/2018
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MICHELE EVANS (NRR)
SPYROS TRAIFOROS (NRR)
JEFFERY GRANT (IRD)

Event Text

UNUSUAL EVENT DECLARED AT A NON-POWER REACTOR SITE DUE TO A CAMPUS GAS LEAK

The licensee declared an Unusual Event on 7/21/2018 at 2000 CDT due to a detected gas leak near a campus dormitory. The reactor was not impacted. Local authorities and the gas company are on location in order to identify and repair the source of the gas leak. The Kansas State University non-power reactor is in a safe shutdown condition.

* * * UPDATE FROM ALLEN CEBULA TO OSSY FONT ON 7/22/2018 AT 0051 EDT * * *

The Unusual Event was terminated on July 21, 2018 at 2348 CDT. The source of the gas leak was identified and isolated.

Notified NRR (Evans), NRR PM (Traiforos), NRR (Reed), IRD (Grant), DHS SWO, DHS NICC, FEMA OPS AND FEMA NATIONAL WATCH CENTER, FEMA NRCC SASC AND NUCLEAR SSA via email.

Page Last Reviewed/Updated Thursday, March 25, 2021