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Event Notification Report for July 30, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/27/2018 - 7/30/2018

** EVENT NUMBERS **


53322 53518 53527 53528 53529

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Agreement State Event Number: 53322
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KAISER PERMANENTE MEDICAL CARE PROGRAM OF SOUTHERN CA
Region: 4
City: Los Angeles   State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/10/2018
Notification Time: 20:38 [ET]
Event Date: 03/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 07/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DOUGLAS BOLLOCK (NMSS)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE DID NOT FULLY RETRACT

The following was received from the State of California via E-mail.

"The Regional RSO, Kaiser Permanente Medical Care Program, contacted LA County Radiation Management (LA County) on April 10, 2018 to report a Medical Event that occurred at the Kaiser Therapy Department on March 28, 2018 located in Los Angeles, CA. The event occurred during a HDR [High-Dose Rate] brachytherapy procedure in which the iridium-192 (Ir-192) source did not fully retract post-treatment and remained in the transfer guide tube about 5 cm from the cylinder-transfer guide tube connector. The source remained in this position between the patient's thighs for approximately 15 minutes resulting in the patient receiving about 300 cGy (300 rad) to the thighs. It was later determined that the source wire was bent near the source which is suspected to be the reason the source did not retract fully.

"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, especially concerning the delay in removing the source from the immediate vicinity of the patient, the delay in reporting the event to the RSO, as well as to better understand the reason the source wire did not fully retract. "

California 5010 Number: 041018 (5010#)


* * * UPDATE ON 7/30/2018 AT 1746 EDT FROM ANA CASAJE TO ANDREW WAUGH * * *

The following was excerpted from an E-mail received from the State of California:

Kaiser Permanente contacted LA County Radiation Management on April 24, 2018 to update this medical event based on new information submitted by their primary medical physicist and corroborated by other HDR personnel present during the incident. The patient's exposure time has been revised from 15 minutes to 5 minutes, and the calculated unintended dose was revised from 300 cGy to 100 cGy.

Notified R4DO (Gaddy) and NMSS (Bollock) and NMSS Events Notification group via email.

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: 53518
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTEK ASSET INTEGRITY MANAGEMENT INC
Region: 4
City: LONGVIEW   State: TX
County:
License #: L06801
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/20/2018
Notification Time: 12:32 [ET]
Event Date: 07/20/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
PATRICIA MILLIGAN (INES)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

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

"On July 20, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that he had been contacted by their dosimetry processor and informed that one of his radiographer's dosimeter had read 37.5 rem for the previous month (June, 2018). The RSO stated the report indicated the dose was irregular. The RSO stated the individual had stated they had not lost their badge, but had left it in the radiography truck a few times on their day off. The RSO stated the individual has been removed from all duties that would give them any additional exposure to ionizing radiation. The individual's current dosimeter has been sent to the processor for reading. The RSO stated the exposure to the radiographer this individual had been working with was normal. The RSO stated they would contact Radiation Emergency Assistance Center/Training Site (REAC/TS) and seek assistance. The RSO does not believe the dose is real and is a badge only exposure. The RSO stated the radiographer has not displayed any signs of a high exposure. Additional information will be provided as it is received in accordance with SA-300."

* * * UPDATE FROM ARTHUR TUCKER TO VINCE KLCO ON 8/14/18 AT 1727 EDT * * *

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

"On August 14, 2018, the licensee reported they had received sample results for the blood samples sent to Radiation Emergency Assistance Center/Training Site (REAC/TS). The sample indicated a dose of 0.44 gray. The licensee stated the individual exposed has not complained of any unusual feelings in the hands. The licensee's Assistant Corporate Radiation Safety Officer is going to the location where the individual works to interview. The investigation into this event is on going. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #9597

Notified the R4DO (Deese). INES Coordinator (Milligan) and NMSS Events notified via email.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53527
Facility: GENERAL ELECTRIC CO.
RX Type: ADVANCED FUEL R&D AND PILOT PLANTS
Comments: HOT CELL R&D
Region: 4
City: PLEASANTON   State: CA
County: ALAMEDA
License #: SNM-960
Docket: 07000754
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/27/2018
Notification Time: 13:00 [ET]
Event Date: 07/26/2018
Event Time: 13:55 [PDT]
Last Update Date: 08/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
HEATHER GEPFORD (R4DO)

Event Text

DISABLED VENTILATION SYSTEM

"On 7/26/18 at approximately 1355 PDT, the Building 103 laboratory facility ventilation exhaust system was disabled during a scheduled evacuation drill at the Vallecitos Nuclear Center (VNC).

"The system was restored on 7/26/18 at approximately 1407 PDT. There were no active fissile material operations in Building 103, thus no unsafe condition existed, and no release of material occurred.

"This event is being reported pursuant to the requirements of 10 CFR 70.50 (b)(2)."

The licensee will notify the NRC Region 4 office.

* * * RETRACTION FROM SCOTT MURRAY TO HOWIE CROUCH AT 1031 EDT ON 8/7/2018 * * *

"EN53527, made July 27, 2018, reported an event in accordance with 10CFR70.50(b)(2) in which the Vallecitos Nuclear Center Building 103 facility ventilation exhaust system was disabled for approximately 12 minutes.

"At the time of the report, information regarding the special nuclear material (SNM) in the affected Building 103 areas was not available and a conservative decision was made that the ventilation system was required to prevent releases or exposures to radioactive materials exceeding regulatory limits or to mitigate the consequences of an accident.

"Based on a subsequent review of SNM inventory records and additional survey measurements, it has been determined the event report should be retracted due to the minimal amount of SNM that could have been affected.

"Notified R4 Fuel Cycle Decommissioning Branch and NMSS Enrichment and Conversion Branch."

Notified R4DO (Vasquez) and NMSS Events Notification (email).

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Power Reactor Event Number: 53528
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: CURTIS CASTELL
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/27/2018
Notification Time: 13:41 [ET]
Event Date: 07/27/2018
Event Time: 06:56 [EDT]
Last Update Date: 07/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (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

CONTRACTOR SUPERVISOR TESTS POSITIVE FOR ALCOHOL

A non-licensed contractor supervisor had a confirmed positive for alcohol during a random fitness-for-duty (FFD) test. The employee's unescorted access to the plant has been suspended.

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 53529
Rep Org: AMETEK SOLIDSTATE CONTROLS
Licensee: AMETEK SOLIDSTATE CONTROLS
Region: 3
City: COLUMBUS   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ETHAN SALSBURY
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/27/2018
Notification Time: 16:14 [ET]
Event Date: 05/01/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
SCOTT SHAEFFER (R2DO)
ANN MARIE STONE (R3DO)
HEATHER GEPFORD (R4DO)
PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - POTENTIAL DEFECT IN AC VOLTAGE SENSE BOARD

"COMPONENT DESCRIPTION:
277VAC Voltage Sense Board.

"PROBLEM YOU COULD SEE:
In May of 2018, AMETEK Solidstate Controls (SCI) experienced failures during preventative maintenance with the 80-210833-90 AC Voltage Sense board during the startup of a unit. While the failures were experienced on commercial equipment, a version of the AC Voltage Sense printed circuit board is used in safety-related equipment as well.

"CAUSE:
The failure of the AC Voltage Sense Boards is caused by the opening of the 100 OHM 2W R7 metal oxide resistor, AMETEK SCI part number 03-804103-00, due to insufficient peak power withstand capability for the application. In all instances of failures experienced, the peak inrush power dissipation during startup caused the 2W metal oxide resistor to open. Failures have been limited to the metal oxide resistor.

"EFFECT ON SYSTEM PERFORMANCE:
If the 100 OHM, 2W metal oxide resistor in the R7 position (PN: 03-804103-00) of the AC Voltage Sense board experiences peak power above its rating and opens, the AC Voltage Sense board may fail. This failure could cause a false low AC voltage alarm and an inoperable high AC voltage alarm condition. During steady state operation, the resistor will not be exposed to power dissipation significant enough to impact the resistor.

"This potential defect and 10 CFR 21 notification applies to SCI safety-related 277VAC version of the AC Voltage Sense printed circuit board:
80-9210842-90 - PCB ASSY, VLT SENSE 277VAC, 1PH.

"ACTION RECOMMENDED:
The R7 metal oxide resistor is being replaced in the 80-9210842-90 version of the AC voltage sense printed circuit board with a wire-wound resistor (PN: 03-804103-10). The AC Voltage Sense Board will be revised to revision level 'I'. AMETEK recommends replacing any prior revisions of the 277VAC AC Voltage Sense boards at the earliest convenience.

"AMETEK SOLIDSTATE CONTROLS CORRECTIVE ACTION:
If you wish to replace the 277 VAC AC Voltage Sense Board with the latest revision, AMETEK Solidstate Controls will work with you to arrange replacements. Please contact Mr. Mark Shreve of our Client Services group at 1-800-222-9079 or 1-614-846-7500 ext. 6332. mark.shreve@AMETEK.com.

"AFFECTED CUSTOMERS
The list below identifies all AMETEK Solidstate Controls customers who have purchased the printed circuit board 80-9210842-90 since 2008. Any purchases prior to 2008 should have been replaced according to the recommended preventative maintenance schedule and, therefore are not applicable to this 10 CFR 21 notification."

China Nuclear, Edison Material Supply, Energy Northwest, Jade Dragon Trading, Korea Hydro & Nuclear Power Company Limited, KRSKO, Exelon Business Services - Braidwood Warehouse, Exelon Business Services - Braidwood/ Byron Generating Station, Georgia Power Company - Vogtle 1 & 2, Shenzhen Chance New Energy Scientific Instrument Co.


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