| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
12/28/2018 - 12/31/2018 ** EVENT NUMBERS ** |
| !!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!! | | Power Reactor | Event Number: 53712 | Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: JEFFREY MYERS
HQ OPS Officer: JEFF HERRERA | Notification Date: 11/01/2018
Notification Time: 20:10 [ET]
Event Date: 11/01/2018
Event Time: 13:00 [EDT]
Last Update Date: 12/28/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
KARLA STOEDTER (R3DO) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text UNANALYZED CONDITION DUE TO MODIFICATION NOT ADDED TO PROCEDURE
"On November 1, 2018, at approximately 1300 EDT, Fermi 2 identified that a Station Blackout (SBO) procedure was deficient as a result of a modification installed during a recent refueling outage. A review identified that the performance of the SBO procedure could have resulted in a challenge to having an alternate AC source available within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2. The alternate AC source was always available to be manually aligned in accordance with other standard operating procedures. The modification did not affect the function for Appendix R alternative shutdown.
"Immediate actions are underway to revise the impacted procedure. The health and safety of the public was not affected as offsite power has remained available since the modification was installed. Investigation into the cause and corrective actions is ongoing.
"Fermi 2 is reporting this event as an unanalyzed condition pursuant to the requirements of 10 CFR 50.72(b)(3)(ii)(B)."
The licensee notified the NRC Resident Inspector.
* * * RETRACTION ON 12/28/18 AT 1228 EST FROM JEFFREY MYERS TO JEFFREY WHITED * * *
"The purpose of this notification is to retract a previous report made on November 1, 2018 (EN 53712) under 10 CFR 50.72(b)(3)(ii)(B). Subsequent to the initial notification, the event, site procedures, and the NRC guidance in NUREG-1022 pertaining to 10 CFR 50.72(b)(3)(ii)(B) were reviewed further. The evaluation determined that at the time of the event, there were multiple methods defined in existing station procedures to establish an available alternate AC source within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2.
"Under these circumstances, the event does not represent an unanalyzed condition under 10 CFR 50.72(b)(3)(ii)(B). Therefore, EN 53712 can be retracted and no Licensee Event Report (LER) under 10 CFR 50.73(a)(2)(ii)(B) is required to be submitted.
"The licensee has notified the NRC Resident Inspector."
Notified R3DO (Riemer). |
| !!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!! | | Power Reactor | Event Number: 53750 | Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: ANGEL YARBROUGH
HQ OPS Officer: DAN LIVERMORE | Notification Date: 11/22/2018
Notification Time: 03:56 [ET]
Event Date: 11/21/2018
Event Time: 21:25 [CST]
Last Update Date: 12/28/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
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 | 13 | Power Operation | 13 | Power Operation | Event Text HPCI UNEXPECTEDLY TRANSFERRED TO ALTERNATE SUCTION SOURCE DURING TESTING
"At 2125 [CST] on 11/21/2018, it was discovered that U1 High Pressure Coolant Injection System (HPCI) was inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), 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.
"During performance of a routine surveillance, HPCI automatically transferred from its normal suction source to the alternate suction source. The control room operator then manually tripped the HPCI turbine. HPCI was already inoperable in accordance with Technical Specifications (TS) Limiting Condition for Operability (LCO) 3.5.1, ECCS Operating, Condition C during performance of the surveillance. However, this condition was not expected nor induced by the testing.
"There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"CR 1469109 documents this condition in the Corrective Action Program."
* * * RETRACTION ON 12/28/18 AT 1300 EST FROM MARK MOEBES TO JEFFREY WHITED * * *
"ENS Event Number 53750, made on November 22, 2018, is being retracted.
"NRC notification 53750 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72(b)(3)(v)(D) were met when the licensee discovered 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.
"During performance of a routine surveillance, the High Pressure Coolant Injection (HPCI) System automatically transferred from its normal suction source to the alternate suction source. As a result, Unit 1 HPCI was declared inoperable.
"On December 20, 2018, a Past Operability Evaluation was completed which determined that the HPCI System remained operable. The evaluation determined that the HPCI System could have performed its specified safety function of vessel injection throughout the time that the suction path was aligned to the torus. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D).
"TVA's evaluation of this event is documented in the Corrective Action Program in Condition Report 1469109.
"The licensee has notified the NRC Resident Inspector."
Notified R2DO (Desai). |
| Agreement State | Event Number: 53797 | Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: PASADENA REFINING SYSTEM
Region: 4
City: PASADENA State: TX
County:
License #: L01344
Agreement: Y
Docket:
NRC Notified By: Irene Casares
HQ OPS Officer: BRIAN P. SMITH | Notification Date: 12/20/2018
Notification Time: 10:24 [ET]
Event Date: 12/19/2018
Event Time: 10:49 [CST]
Last Update Date: 01/30/2019 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER
The following was received from the State of Texas via email:
"On December 19, 2018 at 10:49 am, the licensee's radiation safety officer reported a stuck shutter on a fixed gauge, found during routine maintenance. Gauge is in the open operating position; no employee or public exposures are anticipated. Gauge is attached to a vessel located several feet off the ground. Device information: source SN 8423CN, model SH-F1B, Cs-137, 100 mCi. A service company has been called to repair the gauge. Update will be sent in accordance with SA300 guidelines."
Texas Incident #: I-9646
* * * UPDATE ON 01/30/2019 AT 1135 EST FROM MATTHEW KENNINGTON TO JEFFREY WHITED * * *
The following update was received from the State of Texas via email:
"On January 29, 2019, the licensee's Radiation Safety Officer (RSO) reported to the [Texas Department of State Health Services] that after further investigation two additional gauges were found on December 19, 2018, with shutters stuck in the open position. Open is the normal operating position. The gauges are Ohmart Vega model SH-F1B serial number 8431CN and 8443CN, both containing 100 mCi of cesium (Cs)-137. The RSO stated he discovered the additional shutter failures after reviewing reports received on January 21, 2019. The gauges are located on towers, not easily accessible, and are unlikely to cause unintended exposure. The RSO has contacted a service company and is anticipating the repairs completed to all three gauges in the next week. The RSO intends to apply grease to O-rings to prevent moisture from entering and fouling the shutter mechanism."
Notified R4DO (Werner) and NMSS Events Notification via email. |
| Non-Agreement State | Event Number: 53799 | Rep Org: FROEHLING AND ROBERTSON
Licensee: FROEHLING AND ROBERTSON
Region: 1
City: FORT BRAGG State: NC
County:
License #: 45-08890-02
Agreement: Y
Docket:
NRC Notified By: BRETT CLARKE
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 12/20/2018
Notification Time: 14:12 [ET]
Event Date: 02/27/2017
Event Time: 00:00 [EST]
Last Update Date: 12/20/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text DAMAGED MOISTURE DENSITY GAUGE
A technician did not secure the Troxler Moisture Density Gauge in his truck before moving from one job site to the next. The tailgate was open and the gauge fell from the truck onto the dirt road. Someone subsequently found the gauge and returned it to the technician approximately 20 minutes after losing the gauge. The sources remained in the stored position. Subsequent surveys and wipe tests determined that no damage had occurred to the sources however the case itself was cracked. The gauge was sent back to the manufacturer and the case was replaced.
Troxler model 3430 (S/N 23714)
Sources: Cs-137 at 8 mCi and Am-241 at 40 mCi |
| Agreement State | Event Number: 53800 | Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MINISHIELLO BROTHER SCRAP IT
Region: 1
City: EVERETT State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWARD SALOMON
HQ OPS Officer: JEFFREY WHITED | Notification Date: 12/20/2018
Notification Time: 16:32 [ET]
Event Date: 12/18/2018
Event Time: 00:00 [EST]
Last Update Date: 12/20/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | | This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - REPORT OF LOST METAL DISC CONTAINING RA-226 FOUND WITHIN SCRAP LOAD
The following was received from the State of Massachusetts via e-mail:
"On December 18, 2018, the Massachusetts Radiation Control Program (MARCP) was informed by Schnitzer Steel Metal Recycling Facility that a scrap metal load shipment from Minichiello Brothers Scrap It (431 Second Street, Everett, MA 02149) set off the radiation monitor alarms. The vehicle returned back to Minichiello Brothers Scrap It for radiation consultant follow-up survey via MARCP Department of Transportation Special Scrap Permit MA-MA-18-4. On December 20, 2018, this material was identified, removed and segregated from this scrap load by the radiation consultant. The radioactive material found is an abandoned metal disc (three inch in diameter) containing Radium-226. The radiation consultant's direct radiation dose rate reading was 1.2 mR/hour at 30 cm from the metal disc. The Radium-226 activity was estimated to be approximately 5.55 MBq (150 uCi) based on the dose rate taken. This material is being held in a secured location at the Minichiello Brothers Scrap It Facility awaiting appropriate disposal.
"This activity meets the immediate event report requirements where report of lost or abandoned RAM [Radioactive Material] is found to be greater than 1,000 times the quantities specified in 10 CFR 20 Appendix C or MA equivalent 105 CMR 120.297 Appendix C. (The 1000 times reportable quantity for Radium-226 is 100 uCi.)
"The MARCP considers this event to be open until proper disposal of this metal disc is confirmed."
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 |
| Agreement State | Event Number: 53802 | Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: REGIONAL WEST MEDICAL CENTER
Region: 4
City: SCOTTSBLUFF State: NE
County:
License #: 21-01-03
Agreement: Y
Docket:
NRC Notified By: LARRY HARISIS
HQ OPS Officer: THOMAS KENDZIA | Notification Date: 12/21/2018
Notification Time: 10:05 [ET]
Event Date: 12/13/2018
Event Time: 00:00 [CST]
Last Update Date: 02/07/2019 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | | This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - REPORT OF LOST I-125 SEED DURING MEDICAL PROCEDURE
"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on December 21, 2018 at 8:50 am CST by the Radiation Safety Officer (RSO) from Regional West Medical Center (Nebraska license 21-01-03) that one I-125 seed is lost and still missing at this time. The I-125 seed was part of a manual brachytherapy procedure that involved one hundred permanently implanted I-125 seeds in the patient's prostate. The procedure occurred in a surgery suite at approximately 9 am MST, the patient was then transported to a recovery room and then to a CT suite to confirm the placement of the seeds at approximately 12:19 pm MST. During the review of the CT, the licensee observed that only ninety nine seeds were implanted. The licensee then conducted a search for the missing I-125 seed.
"During the search of the missing I-125 seed on December 13, 2018, licensee staff surveyed the surgical suite and recovery room of the patient. The licensee staff were not able to find the missing seed. During the survey, licensee staff also questioned the nursing staff and it was noted that a nurse emptied a catheter bag into a toilet shortly following the completion of surgery. Licensee staff believe that the missing I-125 seed may have been flushed and disposed in the sanitary sewage system.
"The missing I-125 seed was a Bard Medical product, serial number 7815544SO, containing 283 uCi and was one of many seeds preloaded into a needle to be injected into the patient. On December 13, 2018 at 9:30 am CST, the RSO was contacted to report the search results in the adjacent hallways, the CT suite, and if possible, any sewage holding areas. The RSO has dispatched staff to conduct a new search of all areas and transport beds that the patient was in and in contact areas. The RSO expects this to be completed later in the day of 12/21/2018.
"The State is awaiting the results of this new survey and will be following up with the licensee and US NRC."
Nebraska Report: NE-18-0009
* * * UPDATE AT 1721 EST ON 02/07/2019 FROM LARRY HARISIS TO JEFF HERRERA * * *
The following update was received from the Nebraska Department of Health and Human Services (DHHS) via email:
"On 01/16/2019, Nebraska DHHS Office of Radiological Health staff arrived at the licensee's facility. Discussions, reenactments, radiological surveys, and presentations were performed and given to assess if the I-125 seed was disposed of in the sanitary system. A review of the licensee's training of oncology staff and nursing personnel, policies and procedures for specific seed implantation for oncology and nursing staff, and interviews of all involved personnel were completed.
"It was determined that all 100 I-125 seeds were implanted into the patient as ordered and the bladder was verified as emptied by a cystoscope after removing an inflated balloon to prevent seeds from entering the bladder. After the inflatable balloon device was removed from the patient, a seed near the urethra was dislodged and entered the urethra then into a urinary catheter bag. When the oncology personnel arrived at the patient's recovery room, they noticed that the urinary catheter bag was abnormally low. Oncology personnel found that a nurse in the recovery room emptied the urinary catheter bag without approval from Oncology personnel, inadvertently disposing of the seed in a sink in the recovery room. Oncology personnel surveyed the surgical suite, recovery room, and sink with no results above background. A review of the policies and procedures of radioactive seed implantation with the nursing staff was also completed.
"The licensee's implementation of corrective measures to prevent a reoccurrence will be reviewed on the next inspection."
Notified the R4DO (Werner) and NMSS Events (via 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.
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 |
| Non-Agreement State | Event Number: 53803 | Rep Org: IRIS NDT
Licensee: IRIS NDT
Region: 3
City: WHITING State: IN
County:
License #: 13-32791-01
Agreement: N
Docket:
NRC Notified By: KYLE LEDBETTER
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 12/21/2018
Notification Time: 14:46 [ET]
Event Date: 02/24/2018
Event Time: 00:00 [EST]
Last Update Date: 12/21/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
ANN MARIE STONE (R3DO)
ROBERT GATONE (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text RADIOGRAPHY CAMERA GUIDE TUBE DISCONNECTED DURING USE
The following is a synopsis of the report received via email:
The quick connect fitting on the guide tube came apart when the source was being cranked out. When the source was cranked out beyond where the end of the guide tube was supposed to be the technicians stopped and tried to crank the source back into the camera. The source rod became stuck because the control cable had become entangled. The RSO (Radiation Safety Officer) was later able to disconnect the source's pigtail, unkink the control cable, reconnect the guide tube, and reconnect the control cable to retrieve the source. The maximum doses received were 114 mRem whole body and 260 mRem to the right hand.
Camera: model SPEC-300 with model G-70 source assembly
Source: 88 Ci Co-60 |
| Agreement State | Event Number: 53804 | Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 12/21/2018
Notification Time: 15:55 [ET]
Event Date: 12/19/2018
Event Time: 00:00 [PST]
Last Update Date: 01/17/2019 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - RADIOACTIVE SOURCE FAILS LEAK TEST
The following report was received via e-mail:
"A routine leak test at the Swedish Cancer Institute found a leaking Cs-137 e-vial source in the Physics Lab. The initial leak test was taken 12/19/2018 and analyzed on 12/20/2018. It revealed an activity of approximately 10 nanoCuries, and additional confirmation tests found contamination above the regulatory threshold for a leaking source.
"The source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a larger pig while it is being held for disposal. Surveys of the original storage pig and the hot lab where the source was utilized found no removable contamination and there was no personnel contamination detected.
"The RSO [Radiation Safety Officer] was notified of the positive results the morning of 12/21/2018 and provided notification to DOH [Washington State Department of Health] at 1114 PST on 12/21/2018."
* * * UPDATE ON 01/17/2019 AT 1201 EST FROM ANDREW HALLORAN TO JEFFREY WHITED * * *
The following report was received via e-mail:
"A leaking sealed source was discovered at The Swedish Cancer Institute during periodic leak tests performed by the health physics staff. The source (MED3550 Gamma Reference Standard, SN 11345, Cs-137, initial activity 209.6 micro-Ci, reference date 8/1/2001) was used in the A Level Physics Lab as part of routine radiation oncology operations. The source was initially received by Swedish 12/6/2007.
"The sample was collected on 12/19/2018 using an alcohol wipe, and analyzed on 12/20/2018 using a Ludlum 261 single channel analyzer coupled with a NaI well detector. The system was set to detect the 662 keV photon energy for Cs-137, with a calculated efficiency of 11.71 percent. The result of the wipe test analysis was a removable activity of 9.92 Nano-Ci, above the 5 Nano-Ci threshold for a leaking source.
"After the RSO was notified of the positive result on 12/21/2018, the source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a lead pig. The pig is currently being stored in the Radiation Safety Office Lab awaiting disposal. Wipes of the A Level Physics Lab source storage cabinet and all surfaces of the pig used to house the source when it was in service yielded no detectable removable contamination.
"After reviewing the final report of the licensee, this event is now closed as of 1/3/2018. DOH will verify that the source has been disposed of during the next routine inspection of the licensee."
Washington Event Report ID: WA-18-031
Notified R4DO (Drake) and NMSS Event Notification (e-mail). |
| Power Reactor | Event Number: 53809 | Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: CASEY WOODS
HQ OPS Officer: ANDREW WAUGH | Notification Date: 12/29/2018
Notification Time: 10:27 [ET]
Event Date: 12/29/2018
Event Time: 09:04 [CST]
Last Update Date: 12/29/2018 | Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
| Person (Organization):
NICK TAYLOR (R4DO)
WILLIAM GOTT (IRD)
KRISS KENNEDY (R4RA)
HO NIEH (NRR) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text NOTICE OF UNUSUAL EVENT DUE TO TOXIC GAS AND FIRE
At 0904 CST, on December 29, 2018, Cooper declared a Notice of Unusual Event under emergency action level HU 3.1. The emergency declaration was due to a toxic gas asphyxiant as a result of a fire. The fire is contained and the fire brigade continues to extinguishing the fire. Offsite support has not been requested.
The licensee notified the NRC Resident Inspector. Additionally, State and Local government agencies were also notified.
Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
* * * UPDATE ON 12/29/2018 AT 1655 EST FROM JIM FLORENCE TO JEFFREY WHITED * * *
At 1544 CST, on December 29, 2018, Cooper terminated the Notice of Unusual Event under emergency action level HU 3.1. The fire was verified to be extinguished and the flammable material was removed. The plant remained at 100% power for the duration of the event.
The licensee issued a press release regarding the event at 1202 CST, on December 29, 2018.
The license notified the NRC Resident Inspector.
Notified R4DO (Taylor), NRR EO (Groom), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email). | |