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Event Notification Report for October 11, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/10/2018 - 10/11/2018

** EVENT NUMBERS **


53638 53639 53640 53641 53656 53657

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Agreement State Event Number: 53638
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOCON, INC.
Region: 4
City: SAN DIEGO   State: CA
County:
License #: 3924-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/03/2018
Notification Time: 10:57 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE - STOLEN DENSITY GAUGE

The following was received via email from the State of California:

"On October 2, 2018, at approximately 0830 [PDT] the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted [California Radiologic Health Branch] RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 [PDT], on Friday morning, September 28, 2018.

"The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 [PDT] on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material."

California Report No. 5010-100218

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: 53639
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SANTA CLARA VALLEY HEALTH AND HOSPITAL SYSTEM
Region: 4
City: SAN JOSE   State: CA
County:
License #: 0741-43
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/03/2018
Notification Time: 12:06 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - UNDERDOSAGE OF YTTRIUM 90 THERASPHERES

The following was received via email from the State of California:

"On 09/28/18, [the Radiation Safety Officer] RSO initially contacted [Radiologic Health Branch] RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter).

"On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis.

"The licensee will submit a written report in accordance with 10 CFR 35.3945(d)."

California Report No. 5010-092818

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: 53640
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: TERRACO CONSULTANTS INC
Region: 4
City: OMAHA   State: NE
County:
License #: 01-58-01
Agreement: Y
Docket:
NRC Notified By: JULIA SCHMITT
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/03/2018
Notification Time: 15:16 [ET]
Event Date: 10/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/09/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - LOSS OF CONTROL AND POSSIBLE DAMAGE OF MOISTURE DENSITY GAUGE

At 1355 CDT on 10/3/18, the Nebraska Office of Radiological Health was notified by the Corporate Radiation Safety Officer (RSO) that a licensed moisture density gauge was run over by a large piece of construction equipment on a construction site in Omaha, NE. At the time of the notification to the State, the Corporate RSO did not know which of the licensee's gauges was involved in the incident, nor the device model number, isotope, or quantity.

Staff from the Nebraska Office of Radiological Health were dispatched and are enroute to the event site to meet the licensee's Assistant RSO to assess the possible damage to the gauge and obtain further information. No injuries related to the event were reported to the State and no offsite emergency services support were requested.

* * * UPDATE ON 10/5/2018 AT 0945 EDT FROM HOWARD SHUMAN TO ANDREW WAUGH * * *

Contamination swipes verified the source of the gauge to be intact. The gauge's source rod was broken during the event and the source had to be manually retracted into the shielded position. The gauge is currently at Terraco.

The moisture density gauge is a Troxler Model 3440 (serial number: 30122).

Notified R4DO (Farnholtz) and NMSS Event Notifications (email).

* * * UPDATE ON 10/5/2018 AT 1725 EDT FROM LARRY HARISIS TO DONG PARK * * *

The following was received via email from the State of Nebraska:

"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on October 3, 2018, by the Radiation Safety Officer (RSO) from Terracon, Inc (Nebraska license 01-58-01) that a portable nuclear moisture density gauge was damaged at a temporary job site. [The licensee authorized user] said that he arrived on the jobsite in Omaha, NE to perform moisture density measurements for Peter Kiewit Construction (general contractor) that was going to be pouring concrete later that afternoon by JR Barger & Sons Concrete Contractors (subcontractor). When [the licensee authorized user] arrived, he parked his vehicle near the work area and assessed the work area. He noticed that there were trucks and other heavy machinery working in the area. [The licensee authorized user] proceeded to take the Troxler portable nuclear moisture density gauge (model 3440, serial number 30122 containing 9 mCi of Cs-137 and 44 mCi of Am-241:Be) out of his vehicle and placed it on the ground where moisture density measurements were to be made. While performing a moisture density measurement with the Cs-137 source deployed from the protective housing, a skid loader backed up and hit the portable gauge. Fortunately, [the licensee authorized user] was able to dive out of the way with the back of the skid loader hitting the back of [the licensee authorized user's] arm. The extent of [the licensee authorized user's] injury is unknown.

"[The licensee authorized user] indicated he then proceeded to inform the skid loader to stop but said he continued without acknowledgement. [The licensee authorized user] was then able to get the attention of [the construction project supervisor] to inform him what just transpired. [The licensee authorized user] said that [the construction project supervisor] was not interested in stopping work for the damaged gauge and proceeded to tell [the licensee authorized user] [profanity] or we will call your boss . At this time, [the licensee authorized user] indicated that [an employee] picked up the damaged gauge and threw it to an area outside the work location. An assumption was made of the [the employee's] whole body dose of 571.1 millirem, assuming that he carried the gauge at one centimeter from the trunk of the body and that it took him one minute to move the gauge.

"[The licensee authorized user] said he then called [the Omaha RSO] and informed him of what just happened. [The Omaha RSO] then called the Corporate RSO. [The Omaha RSO] was then dispatched to the area with a survey meter and to assist [the licensee authorized user]. [The Corporate RSO] informed [the Nebraska Department of Health and Human Services (DHHS), Office of Radiological Health Manager]. [The Nebraska DHHS, Office of Radiological Health Manager] dispatched [personnel] to the scene.

"Meanwhile at the jobsite, [the licensee authorized user] maintained surveillance of the gauge and informed personnel to stay away from where the gauge was located. [The Omaha RSO] said that when he arrived, a radiation survey of the surveillance area and gauge was made. Radiation levels at the surveillance area was about 0.5 mR/hr and the gauge was 10 mR/hr, nearest to the extended Cs-137 source and the source was stuck into the ground to provide additional shielding. Calculations indicated that the exposure rate at the 15 foot exclusion boundary would have been 0.04 mR/hr.

"When Nebraska DHHS, Office of Radiological Health staff arrived, another confirmatory radiation survey of the gauge was completed with a result of 10.5 mR/hr. The gauge was also observed to have the source rod extended into the ground and part of the trigger mechanism was broken and sheared off. A wipe test was performed on the source rod with nip tongs and was reading the same as background. The portable gauge was then manipulated to place the Cs-137 source rod assembly back into the shielded position. After an unsuccessful attempt was made, the sliding spring lock was still open and was emitting 385 mR/hr on contact of the port hole. [The Omaha RSO] was able to clear off the excess mud and dirt on the port hole using the nip tongs and the sliding spring lock was shut. Another wipe test was completed and read at background. A radiation survey of the portable gauge confirmed that the Cs-137 source was in the shielded position and measured 20.8 mR/hr.

"[The Omaha RSO] placed the portable gauge back in the shipping container and duct tape was applied to prevent any movement of the source rod from the shielded position. A radiation survey of the transport case was performed with the portable gauge inside and the highest was 8.9 mR/hr on contact and 0.4 mR/hr at 3 feet. The listed TI [Transportation Index] of the package was labeled as 0.6 mR/hr. [The Omaha RSO] stated that he will contact InstroTek to either repair or dispose of the gauge upon their return to the Omaha office.

"An investigation is currently underway and the event is not closed."

Notified R4DO (Farnholtz) and NMSS Event Notifications (email).

* * * UPDATE ON 10/9/2018 AT 1624 EDT FROM HOWARD SHUMAN TO OSSY FONT * * *

The State of Nebraska submitted the full report. The detailed information was previously provided via email. The item is still open pending a reconstruction of the dose received by the employee who picked up the damaged gauge.

Incident Report No: NE180006

Notified R4DO (Gepford) and NMSS Event Notifications (email).

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Agreement State Event Number: 53641
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE   State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 10/03/2018
Notification Time: 15:11 [ET]
Event Date: 10/02/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY SOURCE

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

"On October 3, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that one of their radiography crews had reported they could not retract a 22 Curie Iridium-192 source into a SPEC 150 exposure device. The crew was working at a remote job site [in Carrizo Springs, TX]. The exposure device was sitting on a pipe rack. During an exposure (not the first one) the device fell off the pipe rack, hitting the guide tube, and crimping the tube to a point where the source could not be retracted back into the device.

"The crew contacted the RSO and a retrieval team was sent to the location. The source was positioned in the collimator and covered with bags of lead shot. The retrieval team was able to cut the protective coating off of the guide tube and, using a pair of pliers, reshape the guide tube until the source could be retracted to the fully locked position.

"No member of the general public received an exposure from this event. The highest dose received by an individual responding to this event was 40 millirem."

Texas Incident: I-9616

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Power Reactor Event Number: 53656
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SILVESTRE ROMERO JR.
HQ OPS Officer: STEVEN VITTO
Notification Date: 10/10/2018
Notification Time: 01:29 [ET]
Event Date: 10/09/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HEATHER GEPFORD (R4DO)
CYBER ASSESSMENT (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNPLANNED LOSS OF EMERGENCY RESPONSE EQUIPMENT

"At 2115 CST on October 9, 2018, South Texas Project Electric Generating Station (STPEGS) experienced an unplanned loss of the Integrated Computer System (ICS) to the Emergency Operations Facility (EOF). The loss of ICS resulted in a major loss of emergency assessment capability to the STPEGS Emergency Operations Facility (EOF) for greater than 75 minutes. Assessment capability has been verified to be available in the Unit 1 and Unit 2 Technical Support Centers (TSC) and the Unit 1 and Unit 2 Control Rooms.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability, off site response capability, or off site communications ability.

"The NRC Resident Inspector has been informed."

The cause of the unplanned loss is currently being investigated and compensatory measures are in place.


* * * UPDATE ON 10/10/18 AT 0951 EDT FROM RICK NANCE TO PHIL NATIVIDAD * * *

Integrated Computer System was returned to service as of 0810 CDT on October 10, 2018.

Notified R4DO (Gepford) and CAT via email.

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Power Reactor Event Number: 53657
Facility: QUAD CITIES
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JEFFREY EASLEY
HQ OPS Officer: STEVEN VITTO
Notification Date: 10/10/2018
Notification Time: 03:26 [ET]
Event Date: 10/09/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM EMERGENCY VENTILATION AC SYSTEM INOPERABLE

"On October 9, 2018 at 2002 CDT the Control Room Emergency Ventilation Air Condition (CREV AC) system was in the process of being returned to service following maintenance. During the return to service, the end bell on the CREV AC Condenser developed a significant leak requiring isolation. No work was performed on the CREV AC Condenser during the work window.

"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.

"This notification is being made in accordance with 10CFR50.72(b)(3)(v)(D), "Event or Condition That Could Have Prevented Fulfillment of a Safety Function " because the CREV system is a single train system required to mitigate the consequences of an accident."

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Thursday, October 11, 2018
Thursday, October 11, 2018