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Event Notification Report for October 04, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/3/2018 - 10/4/2018

** EVENT NUMBERS **


53616 53620 53621 53624 53637 53642 53643 53644

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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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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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: 53624
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: KENNETH GREER
HQ OPS Officer: OSSY FONT
Notification Date: 09/26/2018
Notification Time: 16:29 [ET]
Event Date: 09/26/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NICOLE COOVERT (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FFD GROUP (EMAIL)
FUELS OUO (EMAIL)

Event Text

FITNESS FOR DUTY - DISCOVERY OF KOMBUCHA TEA INSIDE THE PROTECTED AREA

"An unopened (sealed) container of Herbal Tea (Kombucha) was found in a refrigerator located within a common office break area inside the protected area. Kombucha Tea is a fermented tea, which contains at least 0.5 percent alcohol by volume. Alcohol is a prohibited item per the requirements of 10 CFR Part 26.719(1).

"The incident was entered into the NFS corrective action program and an investigation is in progress

"The licensee notified the NRC Resident Inspector."

NFS Event (PIRCS) Number: 67184.

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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."

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Power Reactor Event Number: 53643
Facility: VOGTLE
Region: 2     State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN LOWE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/04/2018
Notification Time: 07:57 [ET]
Event Date: 10/04/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
OMAR LOPEZ (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 0 Startup 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DURING LOW POWER PHYSICS TESTING

"At 0544 EDT on October 4, 2018, with Unit 1 in Mode 2 with reactor power in the intermediate range performing low power physics testing, the reactor was manually tripped due to a rod control urgent failure alarm. The trip was not complex, with all systems responding normally. Operations stabilized the plant in Mode 3. Decay heat is being removed through the main steam system.

"Unit 2 was not affected.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC Resident Inspectors have been notified.

"All control rods inserted as expected. The cause of the rod control urgent failure is being investigated."


* * * UPDATE FROM KEVIN LOWE TO DONALD NORWOOD AT 1408 EDT ON 10/19/2018 * * *

"This Event Notification is being updated to clarify that the reactor was not critical when this event occurred. Therefore, the reporting requirement is changed from 10 CFR 50.72(b)(2)(iv)(B) to 10 CFR 50.72 (b)(3)(iv)(A).

"During Dynamic Rod Worth Measurement testing, Control Bank Charlie was inserted approximately 153 steps when the urgent failure occurred (CBC positioned at 75 steps out). Following the scram, additional analysis concluded that the reactor was subcritical when the Reactor Protection System was actuated."

The licensee notified the NRC Resident Inspector.

Notified the R2DO (McCoy).

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Power Reactor Event Number: 53644
Facility: PERRY
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ALEX HALLMARK
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/04/2018
Notification Time: 12:29 [ET]
Event Date: 10/04/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
STEVE ORTH (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

POSTULATED HOT SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"Degraded or unanalyzed condition due to the possibility for a postulated fire induced hot short to cause a secondary fire in a different fire area, which would be outside the boundaries analyzed for safe shutdown in calculation SSC-001 due to an unfused circuit associated with the 1M43C0001A, Diesel Generator Building Ventilation Fan. This condition is not bounded by existing design and licensing documents.

"Without overcurrent protection for this circuit, the potential exists that an initial fire event affecting this circuit could cause a short circuit without protection that would cause excessive current through the circuit beyond the capacity rating of the conductors. This could lead to a secondary fire in another plant area where this circuit is routed challenging the ability to achieve and maintain safe shutdown.

"The postulated event would affect the following fire zones: 1CC-3c (Unit 1, Division 1 4160V and 480V Switchgear Room, 620 feet 6 inch elevation), 1CC-3e (Unit 1 West Corridor North of Elevator, 620 feet 6 inch elevation), DG-1d (Hallway Diesel Generator Building 620 feet 6 inch elevation), and 1DG-1c (Unit 1, Division 1 Diesel Generator Building 620 feet 6 inch elevation).

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). Interim compensatory measures (i.e., fire watches) have been implemented for affected areas of the plant.

"The licensee has notified the NRC Senior Resident Inspector."


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