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Event Notification Report for November 27, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2018 - 11/27/2018

** EVENT NUMBERS **


53742 53743 53744 53754

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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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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Fuel Cycle Facility Event Number: 53744
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: OSSY FONT
Notification Date: 11/19/2018
Notification Time: 13:59 [ET]
Event Date: 11/17/2018
Event Time: 00:00 [EST]
Last Update Date: 11/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
SHANE SANDAL (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS EO)

Event Text

UNPLANNED CONTAMINATION DUE TO KILN SEAL LEAK

"On 11/17/2018, at approximately 1445 EST, it was discovered that the Fuel Manufacturing Operation (FMO) Dry Conversion Line 1 kiln seal began to leak and caused an alarm on the Hydrogen Fluoride (HF) room detection system. This manufacturing process equipment is within an established FMO contamination-controlled area which is designed to contain and control this type of release. The area was not occupied at the time, there were no personnel exposures or releases from the area and the affected process was shut-down.

"As a precautionary measure consistent with current NRC radiation protection requirements, an appropriate, additional radiological control was imposed by requiring respiratory protection for entry into the room to keep personnel exposures as low as reasonably achievable until the area could be decontaminated in a safe and timely manner. Although the affected equipment remains shutdown, this additional radiological control remained in place for more than 24 hours.

"NRC Fuel Cycle Safety and Safeguards staff recently clarified its position for this type of reportability determination in a letter sent to the Nuclear Energy Institute dated October 5, 2018. Because of this letter, this event is conservatively being reported pursuant to the requirements of 10 CFR 70.50 (b)(1)."

The NRC region will be notified. Additionally, the North Carolina Radiation Protection Commission and New Hanover County Emergency Management will also be notified.

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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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