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Event Notification Report for November 26, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/23/2018 - 11/26/2018

** EVENT NUMBERS **


53738 53739 53740 53742 53743 53751 53752 53754

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Agreement State Event Number: 53738
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: U.S. STEEL CORPORATION
Region: 1
City: WEST MIFFLIN   State: PA
County:
License #: PA-G0309
Agreement: Y
Docket:
NRC Notified By: JOHN S. CHIPPO
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/15/2018
Notification Time: 11:13 [ET]
Event Date: 10/18/2018
Event Time: 00:00 [EST]
Last Update Date: 11/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT- FAILED SHUTTER

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

"Notifications: On November 14, 2018, the licensee informed the Department [Pennsylvania Department of Environmental Protection] of a failed shutter. It is reportable per 10 CFR 30.50(b)(2).

"Event Description: The licensee reported that on October 18, 2018, a IRMS Model TG-2 gauge, serial number 00MO397-15, containing 3000 milliCuries of americium 241 did not properly perform following scheduled maintenance. Specifically, the shutter failed to open completely and then would not open at all. The gauge was taken out of service and a service provider was contacted, responded and corrected the problem. The licensee has since contacted the same service provider and, on November 2, 2018, transferred the device for proper disposal. Licensee and service provider survey results indicated no abnormal amounts of radiation in the area before, during or after the event or removal of the device. There were no overexposures related to this event.

"Cause of the Event: Equipment failure.

"Actions: The Department will perform a reactive inspection. More information will be provided upon receipt."

PA Event Report ID No: PA180020

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Agreement State Event Number: 53739
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: 3D IMAGING DRUG DESIGN DEVELOPMENT, LLC
Region: 4
City: LITTLE ROCK   State: AR
County:
License #: ARK-1008-03214
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/15/2018
Notification Time: 12:02 [ET]
Event Date: 11/14/2018
Event Time: 00:00 [CST]
Last Update Date: 12/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - RADIATION WORKER RECEIVES HIGH DOSIMETRY READING

The following report was received from the Arkansas Department of Health via email:

"The RSO reported at 1100 [CST], on November 14, 2018, that the dosimetry provider had reported to the licensee one radiation worker badge had received a possible exposure of 9,000 mR for the month of October. The dosimetry provider has stated the exposure was a dynamic exposure with atypical exposure to the badge.

"The licensee began to investigate the cause of the high reading. The worker had worked with other employees and had not worked independently during the month. Other workers had routine exposures for the month.

"The licensee requires workers to wear SRD's [Self Reading Dosimeter] while working in the restricted area. The worker's cumulative reading for the time period was 200 mR. The worker's ring badge had routine exposure readings.

"During investigation by the licensee, there was no recollection of the badge being separated from the worker during the month. During off hours, all dosimetry is stored with the worker's lab coats outside the restricted area.

"The licensee develops PET [Positron Emission Tomography] radionuclides for radiopharmaceutical research and development.

"Since the time period of the exposure cannot be determined, the Arkansas Program is reporting this event under RH-1502.b. of the Arkansas Regulations equivalent to 10 CFR 20.2202(b)(1) of the NRC Regulations.

"The licensee and the State continue to investigate.

"The State of Arkansas will update when additional information is known.

"Arkansas event number AR-2018-006."

* * * UPDATE ON 12/14/18 AT 1535 EST FROM STEVE MACK TO BETHANY CECERE * * *

The following update was received from the Arkansas Department of Health (Department) via email:

"The licensee provided a written report dated November 15, 2018, outlining the investigation performed to verify the overexposure reported.

"This report restated the requirements of additional dosimetry worn by the worker with no significant indication exposure above routine doses. The report also indicated that at no time during the month was contamination detected when conducting personnel surveys leaving the restricted area. The licensee continues to believe that the dose was only received by the badge and not to the whole body of the radiation worker.

"The licensee submitted its own dose estimate on December 3, 2018, in which the licensee calculated a possible contamination event of the badge that would provide the dose yet exclude dose to other measuring devices and could evade detection when exiting the restricted area.

"The Department has taken this dose estimate into consideration and is requesting that the October, 2018 dose for the radiation worker be reduced to 250 mrem.

"The Department considers this event closed."

Notified R4DO (Taylor), NMSS Events Notification group, and INES (Milligan) by email.

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Agreement State Event Number: 53740
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI   State: FL
County:
License #: 1319-2
Agreement: Y
Docket:
NRC Notified By: ED POMBIER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/15/2018
Notification Time: 13:13 [ET]
Event Date: 11/14/2018
Event Time: 00:00 [EST]
Last Update Date: 11/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EXPOSURE READ AS OCCUPATIONAL EXPOSURE

The following report was received via e-mail:

"On Wednesday, November 14, [the University of Miami Radiation Safety Officer (RSO)] received an Occupational Exposure Report from Mirion Technologies indicating that for wear dates July 1 through July 31, 2018, x-ray technologist [redacted] received the following doses: Deep: 8328 mR, Eye: 8328 mR, and Shallow: 8328 mR.

"Upon interviewing Mr. [redacted], in the presence of his supervisor, Mr. [redacted] indicated that he had a therapeutic Nuclear Medicine procedure for hyperthyroidism during the month of July in one of our facilities. Upon review of his medical records it was confirmed that Mr. [redacted] received 24 microCuries of iodine-131 for an uptake scan on July 10, 2018, and a therapeutic dose of 28.9 mCi of iodine-131 on July 17, 2018. It was noted that Mr. [redacted] wears his dosimeter high on the collar of his scrubs, very close to the area overlying his thyroid and continued to wear it throughout the period in question. Based on this information it is [the RSO's] professional judgement that this dose does not constitute an Occupational Dose but is rather a medical dose, and he will be requesting that his dosimetry provider remove it from Mr. [redacted] Occupational [dose]."

Florida Incident: FL18-139

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53742
Rep Org: EPA OFFICE OF RESEARCH AND DEVELOPM
Licensee: EPA OFFICE OF RESEARCH AND DEVELOPMENT
Region: 4
City: ADA   State: OK
County:
License #: 35-11581-02
Agreement: Y
Docket:
NRC Notified By: CHERRI ADAIR
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/16/2018
Notification Time: 16:08 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [CST]
Last Update Date: 11/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TROXLER GAUGE LOST IN TRANSIT

On 11/16/2018, a Troxler gauge was declared lost by the EPA while in transit from Ada, OK to the Troxler Corporation in Research Triangle Park, NC. The Troxler gauge departed from the EPA Office of Research and Development to the Troxler corporation for disposal on 11/8/2018. On 11/16/2018, the EPA Radiation Safety Officer contacted Troxler and determined that they had not yet received the gauge. The transportation company was then contacted and the transportation company records indicated that the gauge was still in transit to Memphis, TN, but could not be located. The EPA is still investigating to determine the location of the gauge. The gauge is a Troxler Model 4302, Serial Number 382, containing 10 milliCuries of Am-241/Be.

* * * RETRACTION ON 11/21/18 AT 0959 EST FROM CHERRI ADAIR TO BETHANY CECERE * * *

The intact gauge was located in Richmond, VA. The transportation company plans to deliver the gauge to Troxler, as originally intended.

Notified R4DO (Werner), NMSS Events Notification Group, and ILTAB by email.

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: 53743
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VHS SAN ANTONIO PARTNERS LLC
Region: 4
City: SAN ANTONIO   State: TX
County:
License #: LICEN-RAM-L00455
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/16/2018
Notification Time: 18:13 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [CST]
Last Update Date: 11/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF THERASPHERE MICROSPHERES

The following information was received via E-mail:

"On November 16, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that a medical event had occurred earlier that day.

"The event occurred when the licensee attempted to treat a patient with 220 grays of Yttrium-90 (TheraSphere) microspheres. After the treatment the injection catheter was removed from the device and placed in a storage container. A survey of the container indicated the dose rate was half of the dose rate prior to injection. The licensee stated they believe only 107.1 Grays of the spheres had been injected into the patient.

"The licensee did not provide the target organ, but will provide it in the written report. The licensee stated the patient would not experience any adverse effects from the event. The licensee stated no individual performing the treatment received any significant exposure. The licensee stated the area was not contaminated. The licensee did not have a cause for the event, but will provide it once determined. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I - 9636

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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Power Reactor Event Number: 53751
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW JUNGELS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/24/2018
Notification Time: 21:27 [ET]
Event Date: 11/24/2018
Event Time: 00:00 [EST]
Last Update Date: 11/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ROSE (R2DO)
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 Cold Shutdown 0 Cold Shutdown

Event Text

AUXILIARY BUILDING DOOR BLOCKED OPEN

"At 1420 [EST] on November 24, 2018, operators discovered that a door was blocked open creating a breach of the auxiliary building secondary containment enclosure (ABSCE) boundary that exceeded the allowed ABSCE breach margin [of three minutes]. As a result, Unit 1 entered Technical Specification Limiting Condition of Operation (LCO) 3.7.12 Condition B for two trains of Auxiliary Building Gas Treatment System (ABGTS) inoperable due to an inoperable ABSCE boundary in MODE 1, 2, 3, or 4, and both Units entered Condition E for one required ABGTS train inoperable with fuel stored in the spent fuel pool.

"In MODES 1, 2, 3, and 4, the analysis of the loss of coolant accident (LOCA) assumes that radioactive materials leaked from the Emergency Core Cooling System are filtered and absorbed by the ABGTS. For the fuel handling accident, the analysis assumes that the ABSCE boundary is capable of being established to ensure releases from the auxiliary and containment buildings are consistent with the dose consequence analysis.

"The event is reportable in accordance with 10 CFR 50.72(b)(3)(v) as an event or condition that could have prevented fulfillment of the safety function of structures or systems that are needed to: (C) control the release of radioactive material and (D) mitigate the consequences of an accident.

"No actual LOCA or fuel handling accident occurred while both trains of ABGTS were inoperable. The condition had no impact on the health and safety of the public.

"The NRC Resident Inspector has been notified."

This situation occurred because of maintenance activities. A breeching permit had been initiated however, the required personnel to ensure the door could be closed within the required three minutes were not assigned. The door was closed approximately 15 minutes after the situation was noticed.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53752
Facility: MILLSTONE
Region: 1     State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: RYAN ROBILLARD
HQ OPS Officer: DAN LIVERMORE
Notification Date: 11/25/2018
Notification Time: 02:47 [ET]
Event Date: 11/24/2018
Event Time: 20:15 [EST]
Last Update Date: 01/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY POWELL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF CONTROL ROOM ENVELOPE DUE TO DOOR FAILURE

"On 11/24/18 at 2015 EST, a loss of Control Room Envelope (CRE) was declared due to failure of the control room boundary door, 204-36-008. [Abnormal Operating Procedure 8588A Mitigating Actions for Control Boundary Breach was implemented]. The door was repaired at 2030 EST, restoring CRE to operable [status]."

A mechanical failure of the control room door latch prevented the door from closing.

The licensee notified the NRC Resident Inspector.



* * * RETRACTION ON 01/18/19 AT 1457 EST FROM GARY CLOSIUS TO JEFFREY WHITED * * *

"The purpose of this call is to retract a report made on November 25, 2018, NRC Event Number EN53752.

"NRC Event Report number EN53752 describes a condition at Millstone Power Station Unit 2 (MPS2) in which a control room envelope boundary door was discovered to not be able to fully close due to the latching mechanism being stuck in the extended position.

"The condition was reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) via an 8-hour prompt report as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"Upon further review, MPS2 determined that there was no loss of safety function. An engineering evaluation determined that even with the control room boundary door unable to be fully closed due to the latching mechanism being stuck in the extended position, control room air in-leakage would not have been sufficient to prevent the control room emergency ventilation system from performing its safety function.

"Therefore, this condition is not reportable and NRC Event Number EN53752 is being retracted.

"The basis for this conclusion has been provided to the NRC Resident Inspector."

Notified the R1DO (Carfang).

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53754
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEPHEN FRIESE
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/26/2018
Notification Time: 08:31 [ET]
Event Date: 11/26/2018
Event Time: 00:00 [EST]
Last Update Date: 11/29/2018
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ROSE (R2DO)
CATHY HANEY (R2 RA)
HO NIEH (NRR)
BILL GOTT (IRD MOC)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNUSUAL EVENT DECLARED FOR EXCESSIVE SMOKE IN CONTAINMENT

At 0816 EST, a Notification of Unusual Event was declared for Unit 2 under Emergency Action Level H.U.4 for excessive smoke in the lower level of containment with a heat signal. Onsite fire brigade is responding to the event. A command post is established. Offsite support is requested by the fire brigade. No flames have been observed as of this report.

The NRC Resident Inspector and State and Local government agencies will be notified.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 11/26/18 AT 1036 EST FROM BILL HARRIS TO JEFFREY WHITED * * *

At 1036 EST, Sequoyah Nuclear Station Unit 2 terminated the Notice of Unusual Event. The licensee determined that the source of the smoke in containment was oil on the pressurizer beneath the insulation, that heated up during plant heatup. The licensee did not see visible flame during the event. The licensee is still working to determine if there was any damage to the pressurizer.

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Rose), R2RA (Haney), NRR (Nieh), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 11/26/18 AT 1337 EST FROM STEPHEN FRIESE TO KARL DIEDERICH * * *

Following declaration of the Notification of Unusual Event, TVA media relations communicated with the local media regarding the event.

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Rose).

* * * UPDATE ON 11/26/18 AT 1551 EST FROM STEPHEN FRIESE TO DONG PARK * * *

"At 1036 EDT, Sequoyah Nuclear Plant (SQN) terminated the Notification Of Unusual Event (NOUE) due to initial report of heat and smoke in Unit 2 Lower Containment.

"At 1000 EDT, it was determined that no fire had occurred. Due to difficulty of access to some of the areas being searched, the source could not be identified prior to 1000 EDT. No visible flame (heat or light) was observed.

"The source of the smoke was determined to be residual oil from a hydraulic tool oil in contact with pressurizer piping. The pressurizer piping was being heated up to support Unit 2 start-up following U2R22 refueling outage. Once the residual oil dissipated, the smoke stopped. It has been concluded that no fire or emergency condition existed.

"Unit 2 is currently in Mode 5, maintaining reactor coolant temperature 160F-170F and pressure 325psig-350psig with 2A Residual Heat Removal (RHR) system in service in accordance with U2R22 refueling outage plan."

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Rose).

* * * RETRACTION ON 11/29/2018 AT 1358 EST FROM FRANCIS DECAMBRA TO ANDREW WAUGH * * *

"Sequoyah Nuclear Plant (SQN) is retracting this notification based on the following additional information not available at the time of the notification:

"Following a full Reactor Building inspection, it was concluded that a fire did not exist. The source of the smoke originally reported was later determined to be residual oil from a hydraulic tool in contact with pressurizer piping. Once the residual oil dissipated, the smoke stopped. The source of heat originally reported was normal heated conditions associated with the pressurizer commensurate with plant conditions. SQN reported initially based on the available information at the time and to ensure timeliness with emergency declaration and reporting notification requirements."

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Shaeffer).


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