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Event Notification Report for July 31, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/30/2018 - 7/31/2018

** EVENT NUMBERS **


53322 53485 53518 53521

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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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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53485
Facility: CALLAWAY
Region: 4     State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: JEREMY CZESCHIN
HQ OPS Officer: VINCE KLCO
Notification Date: 07/03/2018
Notification Time: 19:07 [ET]
Event Date: 07/03/2018
Event Time: 15:15 [CDT]
Last Update Date: 07/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEOFFREY MILLER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

DISCOVERY OF AN UNANALYZED CONDITION THAT SIGNIFICANTLY DEGRADES PLANT SAFETY

"On July 3, 2018, while performing a review of Emergency Operating Procedures, a concern was identified regarding the potential for excessive loss of ultimate heat sink inventory (UHS) through the auxiliary feedwater (AFW) system mini-flow recirculation pathway. This condition would have the potential to prevent the ultimate heat sink from providing an adequate inventory of water for a 30-day mission time.

"The normal water supply for the Callaway AFW system is the condensate storage tank (CST). The CST is a non-safety grade component. The safety-grade supply for AFW is the essential service water (ESW) system. The ESW system is supplied by the UHS. The UHS thermal performance analysis accounts for a loss of UHS inventory to the AFW system up until the point of the accident sequence that the AFW pumps would be secured. The analysis did not include an allowance for loss of UHS inventory through the AFW mini-flow recirculation pathway following the AFW pumps being secured. The EOP guidance that secures the AFW pumps does not isolate the mini-flow recirculation pathway.

"Initial estimates indicate that loss of UHS inventory through the mini-flow recirculation pathway, if not isolated, would preclude the UHS from completing its 30-day mission time. This potential for depletion of the UHS placed the plant in an unanalyzed condition that significantly degraded safety.

"Callaway has issued interim guidance to the on-shift personnel regarding this concern to ensure that the ultimate heat sink water level is maintained at a level that will be adequate to mitigate the potential loss of inventory.

"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety.

"The NRC Resident Inspectors have been notified of this condition."

* * * RETRACTION ON 07/31/2018 AT 1430 EDT FROM LEE YOUNG TO ANDREW WAUGH * * *

"Event Notification (EN) 53485, made on July 3, 2018, is being retracted because re-evaluation performed subsequent to the notification has demonstrated, based on actual plant equipment and environmental conditions, that the unanalyzed inventory losses previously reported by EN 53485 would not have depleted the UHS inventory to an unacceptable level during its 30-day mission time.

"The re-evaluation has led to the conclusion that the previously unanalyzed losses of UHS inventory would not have prevented the UHS from performing its specified safety functions and meeting its 30-day mission time requirements. With the UHS capable of performing its specified safety functions and meeting its 30-day mission time requirements, the systems supported by the UHS would have remained capable of performing their specified safety functions. Based on these considerations, it has been determined that the condition reported in EN 53485 did not result in the plant being in an unanalyzed condition that significantly degraded safety. Consequently, the condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety.

"The NRC Resident Inspector has been notified of the Event Notification retraction."

Notified R4DO (Gaddy).

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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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Agreement State Event Number: 53521
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: AVILES ENGINEERING CORPORATION
Region: 4
City: HOUSTON   State: TX
County:
License #: L03016
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/23/2018
Notification Time: 18:33 [ET]
Event Date: 07/23/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE-DENSITY GAUGE

The following was received from the State of Texas via email.

"On July 23, 2018, the licensee reported that one of its Troxler model 3430 moisture/density gauges (SN: 68529) had been run over and damaged by a dozer at a temporary job site. The licensee's technician was performing a moisture test when he saw a dozer moving backward into the area and toward the gauge. The technician yelled at the dozer driver but was unable to get his attention and there was not enough time for the technician to move the gauge. The gauge was severely damaged. The 40 milliCurie americium-241/beryllium source (SN: 47-21269) remained secure in its shielding. The source insertion rod was bent and broken and the 8 milliCurie cesium-137 source, which was still attached to the rod, could not be retracted. The licensee wrapped the exposed cesium source in lead blankets and placed the gauge back into its transport case. The area and dozer tracks were surveyed--there were no readings above background. The exterior of the transport case was surveyed and the highest reading was 0.4 mR/hr at the blanketed source. The damaged gauge was transported to the manufacturer's service center where a technician made the determination it was not repairable. The licensee is storing the gauge at its facility until arrangements can be made for disposal. An investigation into this event is ongoing. More information will be provided as it becomes available in accordance with SA-300."

Texas Incident #: 9600


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Friday, May 03, 2019