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Event Notification Report for July 24, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/23/2018 - 7/24/2018

** EVENT NUMBERS **


53234 53363 53505 53506 53507 53522

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Agreement State Event Number: 53234
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GEORGIA-PACIFIC CONSUMER OPERATIONS
Region: 4
City: CROSSETT   State: AR
County:
License #: ARK-0321-03120
Agreement: Y
Docket:
NRC Notified By: DAVID STEPHENS
HQ OPS Officer: DAVID AIRD
Notification Date: 02/28/2018
Notification Time: 14:45 [ET]
Event Date: 02/28/2018
Event Time: 11:27 [CST]
Last Update Date: 07/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

The following report was received from the State of Arkansas via e-mail:

"At approximately 1127 CST on 2/28/2018, the Arkansas Department of Health [ADH] Radioactive Materials Program received a phone call from the licensee stating that during routine shutter tests the gauge shutter handle fell off and the shutter is stuck open. The gauge is a Vega America Corporation (Ohmart) Model A-2102, serial number 6997, originally containing 1.5 Curies [Cesium-137] on 4/30/1968 (calculated current activity approximately 475 milliCuries).

"Discussion with the licensee indicates that the gauge is mounted on a digester, outside of normal employee traffic. It is normally open during operations and is only closed during maintenance of the digester, which is not planned. Cautionary signage is already present. The licensee representative stated that the staff will be made aware of the situation. Licensee maintenance is assessing the situation and will advise the ADH Radioactive Materials program of the plan for handling this situation.

"The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge. The State's event number is AR-2018-003."

* * * UPDATE FROM DAVID STEPHENS TO VINCE KLCO ON 7/24/2018 AT 1043 EDT * * *

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

"Communication with the licensee on March 28, 2018 indicated the licensee was working with the manufacturer to effect replacement of the gauge, and on April 26, 2018 the licensee communicated that a replacement quote from the vendor had been obtained and logistics were being arranged. On May 30, 2018, the licensee amended their license to obtain the replacement, and on June 15, 2018, a contractor replaced the gauge, placing the old gauge in storage. On June 19, 2018, possession of the old gauge was assumed by QSA Global.

"The licensee attributes the failure of the shutter handle to the age of the gauge and the environmental conditions (heat, humidity) it was exposed to in the paper plant.

"The State of Arkansas considers this incident closed."

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

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Agreement State Event Number: 53363
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: ALBEMARLE CORPORATION
Region: 4
City: MAGNOLIA   State: AR
County:
License #: ARK-0717-03120
Agreement: Y
Docket:
NRC Notified By: DAVID STEPHENS
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/26/2018
Notification Time: 10:31 [ET]
Event Date: 04/24/2018
Event Time: 14:00 [CDT]
Last Update Date: 07/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following was received from the State of Arkansas via email:

"At approximately 1400 [CDT] on 4/24/2018 the Arkansas Department of Heath Radioactive Materials Program received a phone call from the licensee stating that during routine shutter tests two fixed gauge shutters were not functioning properly; one had a stuck shutter and the other was stiff and might become stuck. The gauges are Thermo MeasureTech Model 7063S, source serial numbers S97D2112 (stuck shutter) and S97D2109 (stiff shutter), each originally containing 2 Ci of Cs137.

"Discussion with the licensee indicates that the gauges are mounted on a reactor, outside of normal employee traffic. It is normally open during operations and is only closed during maintenance of the reactor, which is not planned. Cautionary signage is already present. The licensee representative stated that the staff will be made aware of the situation. Licensee maintenance is assessing the situation and will advise the ADH Radioactive Materials program of the plan for handling this situation.

"The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge. The State's event number is AR-2018-004."

* * * UPDATE FROM DAVID STEPHENS TO VINCE KLCO ON 7/24/2018 AT 1025 EDT * * *

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

"Subsequent to the previous communication, the licensee wrote on April 25, 2018, that Thermo-Fisher had been contacted to schedule a field service visit to address the situation. [Surveys taken indicated readings below 2 mR/hr. at 1 foot for the suspect gauges]. It has been decided by the licensee to have the service technician inspect all three gauges on site that are of the same model.

"On May 21, 2018, a letter from the licensee indicated that on May 8, a field service engineer with Thermo-Fisher Scientific was able to lubricate and unstick the affected shutters using a graphite lubricant. Leak tests indicated no contamination above the threshold. The field service engineer advised the licensee that a plan should be developed for replacement of these gauges as spare parts are no longer available. The licensee will be attempting to replace the affected gauges within the next year; meanwhile, the shutters of the affected gauges will be lubricated and checked once a month.

"In an email on July 20, 2018, the licensee stated that they had been informed by Thermo-Fisher that the 7063S model source holder was notorious for having stiff shutters. The pin/spring assembly apparently has very tight tolerances, and any dust or particulates in the mechanism can stiffen shutter function. The licensee stated that they attributed this event to this mechanism being exposed to the elements for over 20 years.

"The state of Arkansas considers this incident closed."

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

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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-Agreement State Event Number: 53507
Rep Org: FLEIS & VANDENBRINK ENGINEERING
Licensee: FLEIS & VANDENBRINK ENGINEERING
Region: 3
City: GRAND RAPIDS   State: MI
County:
License #: 21-26580-01
Agreement: N
Docket:
NRC Notified By: RICK THORNE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/16/2018
Notification Time: 21:24 [ET]
Event Date: 07/16/2018
Event Time: 18:00 [EDT]
Last Update Date: 07/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
AARON MCCRAW (R3DNMS)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

While performing measurements at a construction site in Big Rapids, MI, a Troxler Model 3430 was struck by a bulldozer while the source rod was extended. While attempting to retract the source, the 9 mCi Cs-137 source disconnected from the source rod. The RSO covered the source and established boundaries around the source.

The licensee contacted the NRC Operations Center to get authorization to transport the source back to their storage facility. Notified R3DO (Reimer) and R3DNMS (McCraw) and placed them on a conference call with the licensee. The licensee was authorized to transport the source, in a sand-filled bucket, back to their facility.

The Troxler serial number is 23659 and also contained a 44 mCi AmBe source. The AmBe source is in the shield.

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Power Reactor Event Number: 53522
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JUSTIN GUNTHER
HQ OPS Officer: VINCE KLCO
Notification Date: 07/24/2018
Notification Time: 00:57 [ET]
Event Date: 07/23/2018
Event Time: 16:31 [MST]
Last Update Date: 07/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HEATHER GEPFORD (R4DO)
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

UNPLANNED LOSS OF STEAM LINE MONITOR CHANNELS

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS [Emergency Notification System] or under the reporting requirements of 10CFR50.73.

"This event is being reported pursuant to 10CFR50.72(b)(3)(xiii) as a Loss of Emergency Preparedness Capabilities at Palo Verde Nuclear Generating Station (PVNGS) Unit 2. On July 23, 2018, at approximately 1631 Mountain Standard Time (MST), the Unit 2 control room experienced an unplanned loss of Steam Generator #1 steam line monitor (RU-139), channels A and B.

"This monitor is used to assess dose projections for Main Steam line exhaust while in Modes 1-4 and is used in the PVNGS Emergency Plan to perform classification of Initiating Conditions 'RS1' and' RG1' and Emergency Action Levels (EALs) 'RS1.2' and 'RG1.2'. The PVNGS Emergency Plan does have two additional EALs that can be assessed for each Initiating Condition. The loss of this monitor constitutes a reportable loss of emergency assessment capability.

"The NRC Resident Inspector has been informed of this condition."


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