United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2019 > March 08

Event Notification Report for March 08, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/7/2019 - 3/8/2019

** EVENT NUMBERS **


53824 53869 53879 53899 53900 53901 53902

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53824
Facility: CLINTON
Region: 3     State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: TIM LANIER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/13/2019
Notification Time: 17:49 [ET]
Event Date: 01/13/2019
Event Time: 08:30 [CST]
Last Update Date: 03/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text



EN Revision Imported Date : 3/8/2019

EN Revision Text: HIGH PRESSURE CORE SPRAY SELF TEST FAILURE

"On January 13, 2019, the Self Test System reported a fault associated with the logic system for the High Pressure Core Spray (HPCS) high reactor water level closure function that could prevent the system from performing its safety function. The HPCS system was subsequently declared inoperable with actions taken per LCO [Limiting Condition for Operation] 3.6.1.3 to close and deactivate the 1E12-F004 valve, a primary containment isolation valve.

"Since HPCS is an emergency core cooling system and is a single train safety system, this condition is reportable under 10 CFR 50.72(b)(3)(v)(D) 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.'

"The NRC Resident Inspector has been notified."

HPCS is in a 14-day technical specification LCO action statement.

* * * RETRACTION AT 1908 EST ON 3/7/19 FROM JAMES FORMAN TO JEFF HERRERA * * *

"Testing of the logic system load driver card for the High Pressure Core Spray (HPCS) high reactor water level closure function was completed both on site and at General Electric Hitachi (GEH). This testing determined the cause of the self-test system fault report was limited to the self-test portion of the load driver card and did not impact the ability of HPCS system to perform its specified safety function.

"Based on the testing results, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D), 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' Therefore, EN 53824 is being retracted.

"The NRC Resident Inspector has been notified."

Notified the R3DO (Hills).

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53869
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE   State: NM
County: LEA
License #: SNM-2010
Docket: 70-3103
NRC Notified By: RICARDO MEDINA
HQ OPS Officer: RICHARD SMITH
Notification Date: 02/12/2019
Notification Time: 13:55 [ET]
Event Date: 02/11/2019
Event Time: 15:19 [MST]
Last Update Date: 03/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
ERIC MICHEL (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 3/8/2019

EN Revision Text: LOSS OR DEGRADATION OF SAFETY ITEMS

"[On February 11, 2019 at 1519 MST,] it was discovered that the calibration certificates for Measuring and Testing Equipment (M&TE) used to perform temperature trip IROFS [Items Relied On For Safety] surveillances, only had 1 set of calibration data. The instruments have an internal temperature sensor and an external input for temperature. Previously, the IROFS surveillances for IROFS 1, 2, 4, 5, 11, 43, C15, and C16 were performed using the external input.

"An external vendor, that performs the calibration for this M&TE, confirmed that the calibration had only been performed on the internal temperature sensor. This issue of how ATC-1 and ATC-2 (Jofra brand dry-block temperature calibrators) were calibrated is not currently an issue, as UUSA [URENCO USA] now only uses the Jofras as a heat source and uses a separately calibrated resistance temperature detector (RTD) and display for IROFS surveillances.

"Further investigation findings showed that a number of UF6 stations had not had their scheduled surveillance with the new method using a separately calibrated RTD. In total, 25 stations had their required annual IROFS surveillances performed with M&TE equipment which used an input that was not properly calibrated.

"The plant is in a safe condition."

The licensee will be contacting Region II.

* * * RETRACTION ON 3/7/2019 AT 1518 EST FROM BLAKE BIXENMAN TO ANDREW WAUGH * * *

"Event Notification (EN) 53869, made February 11, 2019, reported a condition in accordance with Appendix A to 10 CFR 70 (b)(2). The notification described degradation of items relied on for safety (IROFS) that could potentially result in failure to meet the performance requirements of 10 CFR 70.61.

"This notification was prompted by improperly calibrated Measuring and Testing Equipment (M&TE) which was used to perform surveillance activities for IROFS 1, 2, 4, 5, 11, 43, C15, and C16. At the time of the report, functionality of the IROFS' Active Engineered Controls within the acceptable parameters could not be verified. Therefore, URENCO USA (UUSA) conservatively assumed a degradation of IROFS resulting in failure to meet the performance requirements of 10 CFR 70.61.

"Since the time of the initial report, UUSA has re-performed surveillance activities using approved methods and obtained as found tolerances of the Active Engineered Controls for all of the affected stations. With this supporting data, UUSA has concluded that the affected IROFS were, at all times, operating below the maximum IROFS trip set point.

"The operating events using improperly calibrated M&TE can be categorized as events with low safety significance since they would not have resulted in breached/ruptured UF6 cylinders. Cylinder integrity would not have been compromised, as the temperature sensors were found to be available and reliable to perform their safety function. This correlates with a low consequence event.

"Based on engineering determinations and as found trip set points, the condition reported in EN 53869 did not result in failure to meet the performance requirements of 10 CFR 70.61. Therefore, the reported condition did not exceed the criteria which would necessitate an event be reported to the NRC. URENCO USA hereby retracts EN 53869."

The licensee has notified Region II.

Notified R2DO (Desai) and NMSS Events Notification (email).

To top of page
Agreement State Event Number: 53879
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK   State: AR
County:
License #: ARK-0001-02110
Agreement: Y
Docket:
NRC Notified By: ANGIE HALL
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/15/2019
Notification Time: 17:07 [ET]
Event Date: 02/13/2019
Event Time: 07:24 [CST]
Last Update Date: 03/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 3/8/2019

EN Revision Text: AGREEMENT STATE REPORT - DOSE DELIVERED WAS LESS THAN PRESCRIBED

The following was received from the Arkansas Department of Health, Radiation Control Program (the Department) via email:

"The treatment prescribed activity was for 0.54 GBq (14.5 mCi) on February 13, 2019. The calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter Terumo-Progreat Microcatheter (2.0 French Catheter). The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST].

"The Department performed exposure surveys of the connector confirming activity stuck at the connector site. The connector site read the highest and in that concentrated area, reading 430 mR/hr, on February 15, 2019, at approximately 1415 [CST].

"There were no spills and/or contamination during this event.

"The licensee notified the manufacturer and the manufacturer will be performing an investigation on the tubing and radiopharmaceutical/sealed sources. The licensee is continuing to investigate the root cause and is preparing an initial fifteen day written report.

"The Department is waiting on information from the manufacturer(s) and licensee for further investigation. The Department will update this report when the licensee provides additional information."

Arkansas Event AR-2019-001

* * * UPDATE AT 1516 EST ON 3/7/19 FROM ANGIE HALL TO JEFF HERRERA * * *

The following update was received from the Arkansas Department of Health, Radioactive Materials Program via email:

"The Department [Arkansas Department of Health] received a Y-90 TheraSphere Glass Microsphere patient therapy misadministration notification on February 14, 2019 from a medical licensee. The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST]. The Department has received the required initial fifteen day report from the Licensee.

"The Y-90 TheraSphere therapy prescribed activity was for 0.54 GBq (14.6 mCi) on February 13, 2019. The Y-90 TheraSphere calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter. The catheter used was a Terumo-Progreat Microcatheter (2.0 French Catheter). This dose resulted in a 54.34 Gy exposure instead of the intended 143 Gy exposure.

"The Licensee performs Y-90 TheraSphere therapies on a regular basis. The Licensee's physician/Authorized User and colleagues state that they have never had this issue before. The Authorized User states that 54.34 Gy is still a therapeutic dose. A patient CT follow-up scan will be performed to evaluate the therapy dose effectiveness.

"The Department verified activity stuck at the connector site via exposure surveys with a Fluke ion chamber survey meter (reading 430 mR/hr) on February 15, 2019 at approximately 1415 [CST].

"The Licensee notified the Manufacturer and the Manufacturer will be performing an investigation on the tubing and on the radioactive sealed sources.

"There were no spills and/or contamination during this event.

"The Department is waiting on information from the Licensee regarding the Manufacturer's investigation. The Department will update this report when the Licensee provides additional information.

"Corrective Actions: In Process by Licensee and Manufacturer."

Notified the R4DO (Werner), 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.

To top of page
Agreement State Event Number: 53899
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: GENERAL ELECTRIC COMPANY
Region: 1
City: MEBANE   State: NC
County:
License #: 0318-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 02/28/2019
Notification Time: 11:11 [ET]
Event Date: 02/22/2019
Event Time: 00:00 [EST]
Last Update Date: 02/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF LICENSED MATERIAL

The following was received via email from the state of North Carolina:

"North Carolina Radiation Protection Branch (RMB) was notified on February 22, 2019, that a General Licensee could not account for two Microderm hand-held probes containing two sources each [25 micro Ci of Sr-90 and 100 micro Ci of Tl-204]. RMB has been in communications with the General Licensee to ascertain whether or not the devices containing the sources have been returned to the vendor or are indeed lost. At this time, this cannot be verified and the RMB anticipates more information to follow on March 4, 2019. Additional details to follow to complete this event report."

NC Event Tracking ID: 190007

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

To top of page
Agreement State Event Number: 53900
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: SCHLUMBERGER TECHNOLOGY CORP
Region: 4
City: SUGAR LAND   State: TX
County:
License #: L01833
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2019
Notification Time: 11:34 [ET]
Event Date: 02/14/2019
Event Time: 00:00 [CST]
Last Update Date: 02/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION FROM OIL FIELD EQUIPMENT

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

"On February 27, 2019, the Agency [Texas Department of State Health Services] confirmed that access to an oil field equipment wash building had been restricted since February 14, 2019, due to radioactive material contamination.

"On February 11, 2019, a load of waste from the licensee's facility had set off the radiation alarm at the landfill. The isotope was identified as antimony-124. The load was returned to the licensee's facility later that afternoon. On February 12, 2019, the licensee began surveying and investigating, starting with the dumpster and expanding to other areas. The contamination was found to be on piece/part of a fracking pump. On February 13, 2019, contamination was identified on a fracking pump trailer. On February 14, 2019, surveys identified contamination in the trench of one of the bays in the equipment wash building.

"Access to the building was restricted that day and is still restricted. The licensee's initial sampling from the trench identified antimony-124 and scandium-46. They are waiting on analyses of a second sampling of the trench sludge after water was removed/collected, and they will be sampling the traps/separators between the trench and the sanitary sewer system.

"The licensee is not licensed for, nor did it use, these tracer materials. Their equipment was being used on a well site at which another licensee had performed a tracer study while the equipment was in use. The tracer study licensee has been involved in some of the surveying and with the collection of contaminated equipment items they took possession of to be held or disposed in accordance with their license.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I-9656

To top of page
Agreement State Event Number: 53901
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. ANTHONY HOSPITAL - CENTURA HEALTH
Region: 4
City: LAKEWOOD   State: CO
County:
License #: CO152-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2019
Notification Time: 17:15 [ET]
Event Date: 02/28/2019
Event Time: 13:00 [MST]
Last Update Date: 02/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"At approximately 1438 MST on February 28, 2019 the RSO [Radiation Safety Officer] for CO 152-01, St. Anthony Hospital - Centura Health, notified the Department [Colorado Department of Public Health and Environment] of a Y-90 SIR-Sphere misadministration. The procedure occurred at approximately 1300 MST and it was determined that 65 percent of the prescribed dose was delivered to the patient. The RSO noted that during the procedure there were issues with the delivering catheter. During the procedure, the catheter was replaced.

"A department investigation will occur in the near future. A written report per section 7.21.4 is expected within 15 days."

Colorado Event Report ID No.: CO190003

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.

To top of page
Agreement State Event Number: 53902
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KAISER PERMANENTE
Region: 4
City: LOS ANGELES   State: CA
County:
License #: 0372
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/28/2019
Notification Time: 20:51 [ET]
Event Date: 02/25/2019
Event Time: 00:00 [PST]
Last Update Date: 02/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNINTENDED DOSE TO NON-TARGET TISSUE

The following was received from the state of California:

"The licensee reported an unintended dose to non-target tissue of a patient from an HDR [High Dose Rate] treatment, apparently due to mispositioning of the uterus-ovary applicator. The unintended dose occurred on the final of four fractions. The target tissue received the intended dose in each of the four fractions, but non-target tissue of the bowel received in excess of 50 rem and 150 percent of the expected dose to the non-target bowel tissue from the four fractions combined, with the excess non-target bowel dose occurring in the final fraction due to the mispositioned applicator.

"The licensee will submit a 15-day written report to the California Department of Public Health-Radiologic Health Branch (CDPH-RHB) in accordance with 10 CFR 35.3045(d), and will include the calculated dose to the non-target tissue of concern. That report will be forwarded to NRC by CDPH-RHB.

"The referring physician was informed of the unintended dose to the non-target bowel tissue."

CA 5010 Number: 022719

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.


Page Last Reviewed/Updated Friday, March 08, 2019
Friday, March 08, 2019