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Event Notification Report for November 16, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/15/2018 - 11/16/2018

** EVENT NUMBERS **


53650 53653 53718 53719 53720 53721 53722 53723 53724 53741

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53650
Facility: COOPER
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: NATE BEGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/06/2018
Notification Time: 05:56 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 11/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

CONTROL ROOM EMERGENCY FILTER SYSTEM INOPERABLE

"On 10/5/2018, at 2219 CDT, the Control Room Emergency Filter (CREF) System was determined to be inoperable during a required condition of applicability due to being aligned to a Division 2 power source with its associated emergency power supply (Diesel Generator #2) removed from service earlier in the day. The power supply alignment was not identified at the time Diesel Generator #2 was removed from service (Diesel Generator #2 was rendered inoperable on 10/5/2018 at 1728 CDT). Movement of lately irradiated fuel assemblies in the Secondary Containment was in progress at the time of discovery of this condition. This condition represents an unplanned loss of safety function for a single train system during its specified condition of applicability. Movement of irradiated fuel was suspended until the power supplies to CREFs could be realigned to Division 1 which was completed at 0004 CDT on 10/6/2018.

"This represents a condition that could have prevented the fulfillment of the safety function of CREFs needed to mitigate the consequences of a fuel handling accident."

The NRC Resident Inspector has been notified.

* * * RETRACTION AT 1533 EST ON 11/15/18 FROM THOMAS FORLAND TO JEFFREY WHITED * * *

"CNS [Cooper Nuclear Station] is retracting the 8-hour non-emergency notification made on October 5, 2018 at 2219 CDT (EN# 53650). A subsequent evaluation concluded that the Control Room Emergency Filter (CREF) system remained operable in accordance with the applicable Cooper Nuclear Station Technical Specification Requirements 3.7.4 CREF System, 3.8.2 AC Sources - Shutdown, and 3.8.8 Distribution Systems - Shutdown. As a result of CREFs remaining operable throughout this period, no loss of safety function occurred. The NRC Senior Resident Inspector has been notified."

Notified R4DO (Haire)

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Part 21 Event Number: 53653
Rep Org: CURTISS WRIGHT
Licensee: CURTISS WRIGHT
Region: 3
City: CINCINNATI   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TIM FRANCHUK
HQ OPS Officer: OSSY FONT
Notification Date: 10/08/2018
Notification Time: 14:54 [ET]
Event Date: 08/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 11/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
STEVE ORTH (R3DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - NAMCO LIMIT SWITCH FAILED TEST DUE TO INSUFFICIENT LUBRICATION

The following information was received via email from Curtiss Wright:

"Curtiss-Wright was notified on August 7, 2018 by Exelon's Dresden Plant that a Curtiss-Wright Supplied Namco Limit Switch, P/N: EA700-90964 had failed during a planned maintenance test.

"The switch contacts were found to be sluggish in returning to the normal shelf state after actuation, or would not return at all. The switch was identified as Curtiss-Wright Tag Number 5T34603 and was provided as a safety related component to Exelon in September 2005. According to Exelon, the item was stored for 8 years, then failure occurred approximately 5 years into service. The part has a manufacturer date coded as August 2005.

"The switch was subsequently sent to Exelon Powerlabs where a detailed failure evaluation was performed. Exelon Powerlabs confirmed the failure mode and determined that there was insufficient lubrication in place to support normal switch function. The switch was then sent to Namco for further evaluation and Namco confirmed the lack of lubricant was the likely cause of the failure.

"Curtiss-Wright is currently investigating this issue and will provide a follow up report by November 15, 2018."


* * * UPDATE FROM TIM FRANCHUK TO DONALD NORWOOD AT 1335 EST ON 11/16/2018 * * *

The following information was received via E-mail:

"In reference to the Curtiss-Wright Interim Notification Report dated 10/8/2018 for an EA700-90964 limit switch failure, the following clarifications and updates are provided.

"The subject switch was originally supplied by Curtiss-Wright to Exelon's Dresden plant. Subsequently Dresden transferred the switch to Quad Cities where it was installed and found degraded and inoperable during a planned maintenance test. The initial notification of failure to Curtiss-Wright was by Quad Cities personnel, and not Dresden personnel. The switch was previously identified as Curtiss-Wright Tag Number 5T34603, which was incorrect. The actual Tag Number of the failed unit is 5T36403.

"The failure is still under investigation and Curtiss-Wright has been in communication with the manufacturer, Quad Cities personnel and Exelon Powerlabs personnel concerning the failure and application. A key factor in the failure appears to be heat related, specifically the switches operating temperature. As such, additional operating temperature data is being taken by Exelon personnel which will conclude in late February or early March 2019. Once this data is made available, a final conclusion as to the root cause of the failure can be determined.

"We therefore request additional time to complete our evaluation and should have our final report issued by March 8th, 2019."

Notified R3DO (Peterson) and Part 21/50.55 Reactors E-mail group.

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Agreement State Event Number: 53718
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTEC
Region: 4
City: SAN ANTONIO   State: TX
County:
License #: Licen-RAM-L05150
Agreement: Y
Docket:
NRC Notified By: MATTHEW KENNINGTON
HQ OPS Officer: RICHARD SMITH
Notification Date: 11/07/2018
Notification Time: 14:49 [ET]
Event Date: 11/07/2018
Event Time: 00:00 [CST]
Last Update Date: 11/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED DENSITY GAUGE

The following was received via email from Texas Department of State Health Services:

"On November 7th, 2018, the Agency [Texas Department Of State Health Services] was notified by the licensee's radiation safety officer that a moisture density gauge was damaged by heavy equipment [at a construction site in San Antonio, TX]. The gauge was manufactured by Troxler, serial number 38348, with Cs-137 (S/N:77-5682) and Am-241:Be (S/N:47-8792) sources of 8 mCi and 40 mCi respectively. The technician was operating the gauge at a construction site and a heavy equipment operator failed to notice the technicians attempts to stop him, and subsequently ran the gauge over. The source rod remained intact, however it could not be retracted into the shielded position. The licensee contacted the manufacturer and received shielding instructions. The gauge and the soil surrounding it were removed and transported to the licensee's office. The gauge will be sent back to Troxler for repair in an approved type package. No overexposures to the technician or to the public were reported."

Texas Incident #: I-9631

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Agreement State Event Number: 53719
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: VERSO CORPORATION
Region: 1
City: Wickliffe   State: KY
County:
License #: 201-705-56
Agreement: Y
Docket:
NRC Notified By: ERIC PERRY
HQ OPS Officer: VINCE KLCO
Notification Date: 11/07/2018
Notification Time: 17:28 [ET]
Event Date: 11/06/2018
Event Time: 00:00 [CST]
Last Update Date: 11/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - GAUGE LOST AND THEN FOUND

The following information was received from the Commonwealth of Kentucky by email:

"On 11/6/2018, a former licensee [formerly licensed as Wickliffe Paper Co.] reported discovery of a nuclear gauging device (TN [Texas Nuclear] model 5036 originally containing 200 mCi assayed 12/94) that it was unaware it possessed. The license was terminated on August 9, 2016 and at that time, the former licensee provided information related to the disposition of all devices the licensee was aware it possessed. License termination was due to plant closure. During engineering surveys to assess plant conditions for restart, personnel discovered the device still mounted on plant equipment. The former licensee is taking steps to have the device transferred to a licensed manufacturer for disposal. There is no reason to believe any individuals received any exposure at levels which would exceed the regulatory limits."

Kentucky Event: KY180004

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: 53720
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: AKUMIN
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: 4510-4,6
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: VINCE KLCO
Notification Date: 11/07/2018
Notification Time: 15:44 [ET]
Event Date: 11/01/2018
Event Time: 00:00 [EST]
Last Update Date: 11/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION DUE TO BATCH ERROR

The following information was received by the State of Florida:

"At noon [on 11/7/18], [Akumin] called [the State of FL Bureau of Radiation Control] to report that both Akumin Hollywood and Akumin Aventura View ordered F-18 Fluciclovine, and received packages that were labeled as F-18 Fluciclovine, but were subsequently notified by their radiopharmaceutical vendor PET NET Solutions-Ft Lauderdale, on Thursday, November 1, 2018 that due to a 'batch error,' the packages actually contained F-18 FDG [Fludeoxyglucose]."

Three patients were reported as receiving the incorrect radiopharmaceutical. Activity reported as approximately 10 mCi.

Florida Incident: FL18-137

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: 53721
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ALPHA TESTING INC
Region: 4
City: DALLAS   State: TX
County:
License #: Licen-RAM - L 03411
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: OSSY FONT
Notification Date: 11/08/2018
Notification Time: 12:19 [ET]
Event Date: 11/06/2018
Event Time: 00:00 [CST]
Last Update Date: 11/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

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

"On November 6, 2018, the licensee notified the Agency [Texas Department of State Health Services] that one of its Troxler model 3411 moisture/density gauges had been damaged at a temporary work site. The gauge contains an 8 milliCurie Cesium - 137 source and a 40 milliCurie Americium source. The initial report stated the casing and electronics were damaged but the shielding and insertion rod were not damaged.

"The licensee's Radiation Safety Officer (RSO) stated that at approximately 1430 [CST] on November 6, 2018, one of their technicians was working at a temporary job site. He had left the Troxler model 3411 moisture/density gauge on the ground about 10 feet behind him while he was preparing the test hole. A front end loader came into the area and struck the gauge with its back tire. The outer casing/shell of the device was broken as were the electronics. The source had been inside the gauge at the time. The insertion rod did not appear to be bent (didn't push it out to make sure), the shielding was not damaged, and survey did not detect any radiation above the same levels when sources are known to be fully shielded. The gauge was placed inside its transport case and transported to the licensee's facility for storage. The RSO stated the gauge would be taken to the service company for repair or disposal.

"On November 7, 2018, the Agency contacted the RSO and requested a picture of the device. The Agency received the pictures later that day. The Agency reviewed the pictures and the insertion rod for the cesium source appeared to have a slight bend in it. The Agency sent an e-mail request to the RSO and asked if the rod was operable.

"On November 8, 2018, the RSO responded to the Agency and stated they had not operated the source rod and he believed it would not be operable because of a slight curving bend in the operating rod. The gauge is still in storage at the licensee's location. The Agency will not ask the licensee to try and operate the rod as there is the risk that the source could get stuck in an unshielded position.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9630

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Agreement State Event Number: 53722
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DEPARTMENT STATE HEALTH SERVICES
Region: 4
City: AUSTIN   State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFFREY WHITED
Notification Date: 11/08/2018
Notification Time: 13:07 [ET]
Event Date: 11/08/2018
Event Time: 00:00 [CST]
Last Update Date: 11/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

This report was received by the State of Texas via e-mail:

"On November 8, 2018, the Agency [Texas Department of State Health Services] was notified by the radiation safety officer that a gauge used to calibrate Agency equipment had a stuck shutter. The Agency owns the gauge and it is not listed under a license. The port was stuck in the closed position. It did not and does not pose a health risk or exposure to individuals/public. The gauge is manufactured by JL Shepherd, Calibrator Model 28-6A SN:10239, 120 mCi Cs-[137] source. A service company has been contacted to schedule repairs. Additional information will provided in accordance with SA 300."

Texas Incident #: I-9632.

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Agreement State Event Number: 53723
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: KEANE FRAC LP
Region: 4
City: HOUSTON   State: TX
County:
License #: Licen-RAM-L06829
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFFREY WHITED
Notification Date: 11/08/2018
Notification Time: 14:19 [ET]
Event Date: 11/08/2018
Event Time: 00:00 [CST]
Last Update Date: 11/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

This report was received by the State of Texas via e-mail:

"On November 8, 2018, the Agency [Texas Department of State Health Services] received notification from a licensee's radiation safety officer that a gauge was found in the stuck open position on a blender truck at a well site. The gauge was checked and the shutter arm was broken off. The shutter was adjusted into the closed position and removed from the truck. The gauge is in storage until repaired. Another gauge was mounted to the truck. The gauge was manufactured by Berthold, model 8010, serial 12097, with source serial number 0108/12, isotope Cs-137, activity 20 mCi. The gauge will be sent to the manufacture for repair. No exposures were reported or expected from the position the gauge was mounted and used during the frac operation. Update will be sent in accordance with SA-300."

Texas Incident #: I-9633

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Agreement State Event Number: 53724
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: HINSDALE HOSPITAL
Region: 3
City: HINSDALE   State: IL
County:
License #: IL-01403001
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 11/08/2018
Notification Time: 16:19 [ET]
Event Date: 11/07/2018
Event Time: 00:00 [CST]
Last Update Date: 11/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RESIDUAL CONTAMINATION FOUND DURING SOURCE EXCHANGE

This report was received by the State of Illinois via e-mail:

"Varian Medical Systems reported that during a routine [high dose rate] HDR source exchange on 11/7/18, at Hinsdale Hospital, IL, they found residual contamination on a wipe sample of the wire from the source being removed from the device. The wipe activity measured less than leak test limits of 0.005 microCurie and measured 7.87 cps (40 Bq) with background measuring 0.45 cps. The source and wire were removed from the device. The wire was wiped prior to shipment to return the source to Alpha Omega. The area was immediately cordoned off by the engineer. Varian assumes this is a contaminated particle on the wire and that the source itself is not leaking. The wire is wiped prior to shipment from Alpha Omega and if contaminated it should not have been installed in the field. The source activity is now approximately 4.0 Ci of lr-192. The investigation is ongoing by the licensee and Varian."

Illinois Item Number: IL180039

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Power Reactor Event Number: 53741
Facility: SURRY
Region: 2     State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BEN EVANS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/16/2018
Notification Time: 05:16 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [EST]
Last Update Date: 11/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
SHANE SANDAL (R2DO)
CHRIS MILLER (NRR EO)
WILLIAM GOTT (IRD)
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 N 0 Defueled 0 Defueled

Event Text

TRANSPORT OF POTENTIALLY CONTAMINATED WORKER AND SUBSEQUENT FATALITY

"On November 16, 2018 at 0202 EST, a potentially contaminated Dominion worker was transported offsite for medical attention. The individual was initially found unresponsive in a contaminated area. A partial survey was performed prior to the individual being transported offsite, and no contamination was found. The individual passed away in transit to the hospital. Follow-up surveys to verify no contamination are ongoing. A notification to OSHA (Occupational Safety and Health Administration) is planned.

"This event is being reported pursuant to 10CFR50.72(b)(2)(xi) due to notification of an offsite organization and 10CFR50.72(b)(3)(xii) due to a potentially contaminated worker transported offsite.

"The NRC Resident Inspector was notified."


* * * UPDATE FROM ALAN BIALOWAS TO DONALD NORWOOD AT 1640 EST ON 11/16/2018 * * *

"Follow-up radiological surveys were performed and determined that there was no contamination on the worker, response personnel, or ambulance. The Occupation Safety and Health Administration was notified on 11/16/18. No media release is planned."

The NRC Resident Inspector was notified.

Notified the R2DO (Sandal) and via E-mail the NRR EO (Miller) and IRD MOC (Gott).


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