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Event Notification Report for October 03, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/2/2018 - 10/3/2018

** EVENT NUMBERS **


53573 53616 53618 53620 53621 53637 53642

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53573
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: TIM KNOWLES
HQ OPS Officer: OSSY FONT
Notification Date: 08/30/2018
Notification Time: 09:58 [ET]
Event Date: 08/29/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
BINOY DESAI (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FUELS GROUP (EMAIL)

Event Text

CONCURRENT REPORT FOR AN OFFSITE NOTIFICATION MADE TO THE STATE OF TENNESSEE

"This is a concurrent report of a 24-hour report that was made to the Tennessee Department of Environment and Conservation (TDEC) regarding an unauthorized storm water discharge. As permitted by the State of Tennessee, emulsified vegetable oil was being injected into ground water wells located on the North Site of NFS property. At approximately 11:00 [EDT], Environmental Safety was notified of a cloudy oil substance that was observed in the west storm water ditch. Injections were immediately ceased and immediate corrective actions were implemented. Oil absorbent pads and socks were deployed and samples were collected. Before noon on 8/29/2018, the cloudy substance was observed at the discharge of the storm water ditch into Martins Creek. Because of the discoloration observed at the entrance to Martins Creek, this event required a 24-hour notification to TDEC (made at 16:15 on. 8/29/18) and a five day written report will be submitted. Analysis of the grab samples indicated no radioactive material release.

"The licensee notified the NRC Resident Inspector."

* * * RETRACTION AT 1039 EDT ON 10/02/18 FROM TIMOTHY KNOWLES TO JEFF HERRERA * * *

"On 8/30/2018, NFS made an event report to the NRC Operations Center regarding a concurrent report of a 24-hour report that was made to the Tennessee Department of Environment and Conservation (TDEC) regarding an unauthorized stormwater discharge. Based on the determination that the unauthorized stormwater discharge involved a minor non-radioactive chemical spill that did not affect the safety of NRC licensed material, NFS is retracting the event report. This is consistent with guidance provided in FCSS Interim Staff Guidance - 12, 10 CFR Part 70, Appendix A - Reportable Safety Events, Section 3.5.2 Other Government Notifications."

Notified the R2DO (Coovert), NMSS and Fuels Group (via email).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53616
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: RSO   State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: AMY ETTLING
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2018
Notification Time: 17:40 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

POSSIBLE EXTRAVASATION OF RA-223

"The patient's first dose of 110.3 microCuries, 4.3 mL, of Ra-223 (Xofigo) was administered today, 9/21/18 at 1040 CDT. An IV was placed by RN [Registered Nurse] in the patient's left wrist. The IV was flushed with saline and blood return was checked and present prior to administration of Ra-223 by [the] MD [medical doctor]. The Ra-223 was delivered by MD. After delivery, the MD began [a] saline flush and after approximately 5cc of saline, noted resistance and a cold bulge near the infusion site. He was not able to get blood return. The RN was called in to check the IV and was not able to get blood return. It was noted an infiltration/extravasation had occurred. The IV was removed with catheter noted to be intact. Prior to the infusion the patient was told that the infusion should not be painful and he did not acknowledge any pain or discomfort during or after infusion. At this time it is not known if there was an extravasation of Ra-223 because the infiltration/extravasation was not noted until during the second saline flush. The patient and patient's family were notified at the time of the incident."

* * * RETRACTION ON 10/03/18 AT 1525 EDT FROM TOM MOENSTER TO RICHARD SMITH * * *

The licensee does not believe there was more than 10 percent of therapy dose that was not infiltrated. Based on the fact that the swelling went down in less than 45 minutes post imaging of the wrist, compared to the body, leads the Radiation Safety Officer (RSO) to believe most of the therapy dose went throughout the body.

Notified R3DO (Orth) and NMSS vis 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: 53618
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON REGIONAL HOSPITAL WOMEN'S IMAGING CENTER
Region: 1
City: BOCA RATON   State: FL
County:
License #: 0550-1
Agreement: Y
Docket:
NRC Notified By: RENO FABII
HQ OPS Officer: BETHANY CECERE
Notification Date: 09/24/2018
Notification Time: 11:29 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - POTENTIAL LOSS OF I-125 SEED

The following was received by the State of Florida by email:

"[Boca Raton Regional Hospital Women's Imaging Center] Radiation Safety Officer, contacted [the State of Florida Bureau of Radiation Control] by phone on Friday, September 21, 2018 at approximately 1500 EDT to report the potential loss of a 170 microCurie Iodine-125 seed, from Boca Raton Regional Hospital Women's Imaging Center. ISOAID Seed Company has been contacted to assure the seed was not received in an earlier shipment. Seed can be tracked to the Nuc Med Hot lab. Staff has confirmed it is not in the patient or in the Pathology lab. Sealed source certificate will be sent later. Full investigation report will be submitted within 30 days."

Florida Incident Number: FL18-124

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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Non-Agreement State Event Number: 53620
Rep Org: ACCUREN INSPECTION INC
Licensee: ACCUREN INSPECTION INC
Region: 4
City: SINCLAIR   State: WY
County: CARBON
License #: 222759301
Agreement: N
Docket:
NRC Notified By: BRETT PAYTON
HQ OPS Officer: OSSY FONT
Notification Date: 09/25/2018
Notification Time: 11:10 [ET]
Event Date: 09/23/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

RADIOGRAPHY SOURCE STUCK OUT DUE TO BENT GUIDE TUBE

"On 9/23/18, a worker reported an equipment failure while conducting radiographic operations at a refinery in Wyoming. A magnetic stand was used to support a 2.28TBq (61.8 Ci) Ir-192 source while performing internal tank radiography. The magnetic stand disconnected from the wall of the tank during crank out, falling and striking the 7ft guide tube and preventing the source from being retracted. The workers immediately backed up, expanded the boundary, and called the RSO [radiation safety officer]. The RSO advised the crew to return the source to the collimator, backup, and monitor the area while he contacted management since he was out of state. The RSO received a second call from the workers where they stated they successfully retracted the source into the exposure device after pulling the crank to relieve the kink caused by the magnetic stand.

"The crew surveyed the scene, verified the source was secure in the device, and ended their shift at the refinery. The crew arrived back in Colorado at 2100 MDT on 9/23/18, and management performed an initial assessment of the guide tube and cranks at 0715 MDT on 9/24/18.

"The RSO returned from vacation on 9/25/18 and inspected the guide tube, guide tube extension, cranks, and exposure device. The RSO concluded the exposure device and cranks were operational but removed the guide tube from service because it was involved in the strike incident.

"The RSO reviewed the statements from the workers and contacted the State of Colorado and the NRC. The workers statements revealed that one of the workers performed a source retrieval by dropping lead shot bags on the collimator and pulling the guide tube and extension (not the crank) to relieve the kink in guide tube. As a result, one of the employee's dosimeters went off scale. Both film badges were overnighted for processing on 9/25/18.

"The root cause was determined to be the equipment failure of the magnetic stand. Employees and management discussed the incident and reminded the individuals that source retrievals should be performed by the RSO or trained management as stated in Acuren Inspection Inc. procedures, and to always properly secure magnetic stands with a safe line while performing radiography at any elevation."

* * * BRETT PAYTON TO VINCE KLCO ON 9/26/18 AT 1445 EDT * * *

The licensee received the dosimetry report. Dose to the workers was 103 mRem and 76 mRem.

Notified R4DO (Alexander) and NMSS Events Group via email.

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Agreement State Event Number: 53621
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: GRAPHIC PACKAGING
Region: 4
City: QUEEN CITY   State: TX
County:
License #: L06934
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: OSSY FONT
Notification Date: 09/25/2018
Notification Time: 15:47 [ET]
Event Date: 09/25/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER

The following was received via email from the state of Texas:

"On September 25, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee [Graphic Packaging] that the shutter on a Berthold model P2602-100 gauge containing 100 milliCuries of Cobalt-60 failed to close during the required maintenance check. The gauge shutter is stuck in the open position, which is the normal operating position for the gauge and does not pose an increased exposure risk to any individual. The gauge is attached to a second floor crystallizer ash tank recirc line and is not accessed during system operation.

"The licensee stated that they were in the process of contacting the manufacturer for repairs or replacement of the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Report #: I-9614

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Fuel Cycle Facility Event Number: 53637
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON   State: NC
County: NEW HANOVER
License #: SNM-1097
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/02/2018
Notification Time: 14:38 [ET]
Event Date: 10/01/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
OMAR LOPEZ (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT NOTIFICATION

"At approximately 1525 [EDT] on October 1st, 2018, Fire Riser 318 which serves both non-contaminated and contaminated areas in [Fuel Manufacturing Operations] (FMO), was taken out of service due to a pin hole leak in the pipe. Water was contained and surveys were completed to ensure no contamination was released into non-contaminated areas. The New Hanover County Deputy Fire Marshall was notified at 1655 [EDT] on October 1st, 2018, per State code requirements. An hourly fire watch was implemented for surveillance of the affected areas. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will notify NRC Region 2 and the State of North Carolina Radiation Protection Section.

* * * UPDATE ON 10/4/18 AT 1335 EDT FROM PHILLIP TO OLLIS * * *

"The leaking sprinkler pipe fitting was replaced this morning and the system was restored to service at approximately 11 AM, 10/4/18. The NHC [New Hanover County] Deputy Fire Marshal was notified via telephone of the return to service at 11:50 AM, 10/4/18."

Notified the R2DO (Lopez), NMSS Events Notification via email.

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Power Reactor Event Number: 53642
Facility: SAN ONOFRE
Region: 4     State: CA
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CHRIS DIMENTO
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/03/2018
Notification Time: 19:39 [ET]
Event Date: 10/03/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Defueled 0 Defueled
3 N N 0 Defueled 0 Defueled

Event Text

FITNESS FOR DUTY - SUPERVISOR TESTS POSITIVE

"At 1135 PDT on October 3, 2018, Southern California Edison (SCE) determined a SCE supervisor failed a random breathalyzer test for alcohol during a random Fitness-for-Duty (FFD) test. The employee's unescorted access to San Onofre Nuclear Power Plant has been suspended."


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019