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Event Notification Report for July 25, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/24/2018 - 7/25/2018

** EVENT NUMBERS **


53234 53363 53507 53508 53509 53510 53512 53513 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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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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Agreement State Event Number: 53508
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: APPLIED TECHNICAL SERVICES
Region: 1
City: STONEVILLE   State: NC
County:
License #: 1510-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: OSSY FONT
Notification Date: 07/17/2018
Notification Time: 08:58 [ET]
Event Date: 06/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

The following information was received via email.

"North Carolina (NC) Radioactive Materials Branch (RMB) is submitting the following reportable event: Radiography Camera Source Unable to Retract.

Reportable per: 10 CFR 30.50(b)(2) & 10 CFR 34.101(a)(2)
Event Date & Discovered Date: 6/25/18
Date Reported to RMB: 6/26/18
Location where event took place: Stoneville, NC
Reporting Licensee: Applied Technical Services [ATS]
NC License Number: 1510-1
Radiography Camera Manufacturer: QSA Global, Inc.
Radiography Camera Model #: Delta 880
Radiography Camera S/N: D5059
Source: Ir-192
Source Activity: 71.4 Ci
Source Manufacturer: QSA Global, Inc.
Source Model #: A424-9
Source S/N: 65909G

"While conducting radiography shots at a water tank construction site, ATS radiography crew experienced a source hang up. Radiographers initially believed the cause to be a crimped guide tube due to source not moving in either direction. While maintaining a 2 mR/hr boundary, additional personnel were dispatched to the work site by ATS with additional shielding material and [the] RSO [radiation safety officer] who is responsible for source retrievals. Lead blankets were placed on the guide tube and the RSO determined that the guide tube was not compromised, kinked, crimped or otherwise damaged. Probable cause was determined to be in the control assembly. RSO unthreaded the guide from the outlet adapter and exercised the controls with no effect. Guide tube was reconnected and RSO began to troubleshoot the connection side of the camera by removing the housing from the connection to observe the cable while again exercising the controls. Cable would flex but was observed to be either wedged or pinned at the connector. During this process, it was observed that since the cable would not flex on the outlet side of the camera it was determined that extreme force on the controls side would not result in the cable being disconnected from the pig tail. The housing was reattached, and extreme force was used on the controls to break the cable free and the source was returned to its secured and shielded position. The RSO observed the control assembly crank did have more movement than usual, and root cause was determined to be debris from a damaged bearing that had moved down the control cable housing and locked up the controls. This equipment had quarterly maintenance and weekly inspections conducted on it. [The] controls were shipped to QSA for repair or disposal. All personnel involved in the source retrieval received doses well within annual limits for radiation workers.

"RMB has concluded its investigation and consider this event Closed & Complete. No other agencies were informed of this event and no other generic issues identified."

NMED Event ID: 180329
NC Tracking ID: 180029

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Agreement State Event Number: 53509
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: TOWER PLASTICS MFG., INC.
Region: 3
City: BURR RIDGE   State: IL
County:
License #: 9210428
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/17/2018
Notification Time: 12:20 [ET]
Event Date: 12/03/2015
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TWO GAUGES DESTROYED IN A FIRE

The following information was received via email.

"Tower Plastics Mfg., Inc. reported that their two remaining generally licensed NDC Model 103 gauges (SN's 2160 and 2161 containing 150 mCi/Am-241 each) were destroyed in a fire on December 3, 2015. This was reported during the IEMA [Illinois Emergency Management Agency] 2018 annual source reconciliation. The licensee reported that the site was completely destroyed in the fire and debris was hauled to a landfill. Records of the disposal and an IEMA survey of the site are pending."

Item Number: IL180030

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: 53510
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: DBI INC
Region: 4
City: OVERLAND PARK   State: KS
County:
License #: 21-B805
Agreement: Y
Docket:
NRC Notified By: JIMMY UHLEMEYER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/17/2018
Notification Time: 12:34 [ET]
Event Date: 05/06/2015
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

POTENTIAL OVER EXPOSURE FROM RADIOGRAPHY OPERATION

The following information was summarized from an email received from the state of Kansas:

[The licensee RSO] (DBI) reported to the KDEM [Kansas Division of Emergency Management] 24-hour number that they had a potential over exposure during a radiography operation.

The radiographer was in the process of setting up the last shot of the day. While returning to the crank, the radiographer was radioed by the refinery's QC person. At the same time, he was adjusting the collimator, which had shifted. The QC person called over the radio 'come on' which the radiographer's assistant (on the same radio channel) took to mean to crank out the source. When the radiographer felt the vibration of the source being cranked out, he dropped the collimator, exited the area immediately, and got the source retracted.

Preliminary worst case calculations indicated a possible extremity over exposure. The radiographer's badge was sent in for processing and the report came back with 33 mR for the period since April 9. With this information, the extremity dose will be recalculated to determine the actual exposure to the individual.

PQT Services Inc. and REAC/TS consulted on the incident. The worst case scenario is that the radiographer could have received a dose from 50 - 100R to the hands. Pictures of the radiographers were inspected for signs of radiation burns. No signs at this time. The plan is to continue to monitor his hands until June 20, 2015. Both PQT Services and REAC/TS agree that this should be a sufficient time to assure the safety of radiographer. The radiographer's annual dose was DDE 262 mR.

Root cause of incident was determined to be weakness in the communication procedures established between personnel during radiographic operations. A visual 'ALL CLEAR' confirmation from the radiographer setting up the exposures must be made with the person operating the exposure device before the source is exposed.

All DBI Inc. employees have been notified of this incident and the importance of a visual confirmation prior to exposing the source. This has been implemented in DBI's protocol.

This event is considered closed.

Item Number: KS150004

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Agreement State Event Number: 53512
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY   State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: BRIAN LIN
Notification Date: 07/17/2018
Notification Time: 17:54 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TOTAL DOSE DELIVERED DIFFERED FROM PRESCRIBED DOSE BY GREATER THAN 20 PERCENT

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

"On July 17, 2018, the licensee identified a medical event where the total dose delivered differed from the prescribed dose by 20 percent or more. The licensee implanted 83 seeds containing Pd-103 for prostate brachytherapy. The prescribed dose to the prostate was 125 Gy; the dose delivered was 96.25 Gy. The dose received by the prostate (D90) was 77 percent of the intended dose. The patient has been notified. The implant occurred on June 8, 2018, and post-implant dosimetry was completed on July 17, 2018. The department will perform a site investigation to determine the root cause of this medical event."

Event Report ID No.: WI180011

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: 53513
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TRC
Region: 4
City: MOUNTAIN VIEW   State: CA
County:
License #: 2536-43
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/17/2018
Notification Time: 20:32 [ET]
Event Date: 07/16/2018
Event Time: 00:00 [PDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

RECOVERY OF A STOLEN TROXLER MOISTURE DENSITY GAUGE

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

"On July 16, 2018, the California Office of Emergency Services (OES) contacted RHB [California Radiation Health Branch] to report the recovery of a stolen moisture density gauge. The gauge recovery was reported to OES by the San Jose Police Department. The service truck containing the moisture density gauge was stolen from a private residence sometime over the weekend, and was found by the San Jose Police Department during patrol early on July 16, with the gauge still chained to the bed of the truck. The San Jose Police Department cut the chain and stored the gauge at the station. The moisture density gauge is a CPN Model MC-1DR-P, S/N MD60508312, containing 10 mCi of Cs-137 and 50 mCi of Am-241. The gauge was collected by RHB and put in RHB storage on July 16. RHB will be following up with the licensee concerning adherence to regulatory and license requirements."

California report no.: 5010-071618

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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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