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Event Notification Report for March 12, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/11/2019 - 3/12/2019

** EVENT NUMBERS **


53904 53905 53907 53910 53924 53928

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Agreement State Event Number: 53904
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY (HOSPITAL)
Region: 1
City: LEXINGTON   State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: CATY NOLAN
Notification Date: 03/01/2019
Notification Time: 13:53 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [CST]
Last Update Date: 03/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF THERASPHERE Y-90 TREATMENT

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

"The University of Kentucky RSO [Radiation Safety Officer] reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy.

"The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days."

Kentucky Event Report ID No.: Ky190002.

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: 53905
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HOLCIM (US), INC.
Region: 1
City: WHITEHALL   State: PA
County:
License #: PA-1336
Agreement: Y
Docket:
NRC Notified By: JOHN S. CHIPPO
HQ OPS Officer: OSSY FONT
Notification Date: 03/01/2019
Notification Time: 13:56 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [EST]
Last Update Date: 03/01/2019
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 - MISSING ANALYZER SOURCE

The following was received via fax from the Pennsylvania Department of Environmental Protection:

"On March 1, 2019, a manufacturer's technician from Sabia Inc. (PA-R0124) notified the Department [Pennsylvania Department of Environmental Protection] of a missing 0.9 microgram (0.5 mCi) Californium-252 source from a Sabia XL5000 analyzer at the Holcim (US), Inc. Whitehall Cement Plant (PA-1336). The manufacturer was performing replenishment of two of seven sources [on February 28, 2019]. It was discovered that the analyzer only contained six sources. The analyzer was removed and disassembled, destroying the unit, in efforts to locate the missing source but it was not located. The manufacturer technician surveyed the unit and the area multiple times and did not find the source. The remaining sources have been packaged in a drum for safe storage until shipping can be arranged.

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

Pennsylvania Event Report ID No: PA190006

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: 53907
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: JANX
Region: 1
City: GRAYSBURG   State: NC
County:
License #: 1117-2
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/02/2019
Notification Time: 21:02 [ET]
Event Date: 03/02/2019
Event Time: 00:00 [EST]
Last Update Date: 03/02/2019
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 "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE LEFT UNSECURED

The following report was received from the North Carolina Division of Health Service Regulation, Radioactive Materials Branch via email:

"Licensee reports that an Industrial Radiography [IR] exposure device was unaccounted for during the 15 hours following work site activities on March 1st. The IR device was left unsecured the entire time until discovered the morning of March 2nd by the radiography crew that left it. The device [Spec 150; S/N: 1251] and source [72 Ci Ir-192; Model: G-60; S/N: AA0805] are secured and in possession of the corporate RSO [Radiation Safety Officer] at the time of this report. North Carolina Radioactive Materials Branch has initiated an investigation and will update this report for completion."

NC Event Tracking ID: 190008

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53910
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: FISHER WIRELINE SERVICES
Region: 4
City: HOMINY   State: OK
County:
License #: OK-27453-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: CATY NOLAN
Notification Date: 03/04/2019
Notification Time: 14:01 [ET]
Event Date: 10/17/2018
Event Time: 00:00 [CST]
Last Update Date: 03/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HQ CAT TEAM (EMAIL)
ILTAB (EMAIL)

Event Text

AGREEMENT STATE REPORT - SUSPECTED CYBER ATTACK

The following report was received via email:

"[Oklahoma Dept. of Environmental Quality] was informed this morning that Fisher Wireline Services (OK-27453-02) has been the victim of an email hack which resulted in email sent to the licensee being diverted to an unauthorized account. This included emails from NSTS [National Source Tracking System] to the licensee regarding their annual source reconciliation. It appears that the licensee's email has been compromised since Oct. 17, 2018."

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Power Reactor Event Number: 53924
Facility: BEAVER VALLEY
Region: 1     State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/11/2019
Notification Time: 10:00 [ET]
Event Date: 03/11/2019
Event Time: 08:51 [EDT]
Last Update Date: 03/11/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRED BOWER (R1DO)
ERDS (EMAIL)
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

PLANNED COMMUNICATION SYSTEM MAINTENANCE

"On 03/11/2019 planned maintenance activities will be performed on the Beaver Valley Power Station (BVPS) Unit 2 Digital Radiation Monitoring System's (DRMS) Communications System.

"The work includes upgrades to the DRMS hardware, software and computer peripherals. Components to be upgraded under this planned maintenance include: Redundant Servers, Operator Console, Health Physics Office Console/Workstation, Printers and Portable Mass Storage/Backup and Computer peripherals necessary to interface with the computer system. This planned upgrade on the Unit 2 DRMS Communications System will result in the loss of Unit 2 radiological monitoring capability in the Control Room and on the Plant Computer System (PCS). Neither the Emergency Response Facilities nor the Emergency Response Data System (ERDS) will receive radiological data. No actual radiation monitors are affected. The scheduled work duration is approximately three weeks.

"When the DRMS is out of service for the upgrade, compensatory actions will be in place. Radiation monitors will be continuously monitored for any increases in radiation levels. The Unit 2 Shift Manager will be notified of any increase in radiation monitor readings, including exceeding Emergency Action Levels (EAL).

"This is an eight-hour, non-emergency notification for a Loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the upgrade to the DRMS Communications System will result in the loss of the Unit 2 radiological monitoring capability in the Control Room and to the Unit 2 Plant Computer System that affects the functionality of an Emergency Response Facility.

"There is no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The licensee is currently in a Technical Specification Action Statement, Limiting Condition for Operation for spent fuel pool radiation monitor and leakage rate monitor.

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Part 21 Event Number: 53928
Rep Org: WEIR VALVES & CONTROLS
Licensee: WEIR VALVES & CONTROLS
Region: 1
City: IPSWICH   State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ALLEN FISHER
HQ OPS Officer: CATY NOLAN
Notification Date: 03/11/2019
Notification Time: 15:38 [ET]
Event Date: 01/18/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/11/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BINOY DESAI (R2DO)
DARIUSZ SZWARC (R3DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - IMPROPER ANTI-ROTATION KEY DIMENSION ON GLOVE VALVE

"This notification is being submitted pursuant to the guidelines of 10 CFR Part 21 to report that a 24" Class 150 Globe valve for RHRSW HX Isolation MOV, E1150F068A at Detroit Edison - Fermi 2, failed to fully open due to the failure of the anti-rotation key.

"The site notified WVC [Weir Valves and Controls] USA on January 18th of this issue involving a new bonnet that was installed which included a key bushing/key assembly. The new bonnet used was from an originally supplied valve assembly on WVC USA order 0010001147-10 with a quantity of one, Detroit Edison Company PO 4700732583. The key is welded on top and bottom in the key bushing keyway to hold the key in place. After a month in service, during operation, the welds failed which caused the key to drop out or be driven out from the key bushing by friction/vibration. Upon review of the design it was found that the key and key slot were not dimensioned properly for a tight fit allowing a larger than recommended gap between key and keyway. This gap allowed the operational torque loads to put the welds in bending which caused the welds to fail. Loss of the key renders the valve inoperable to open or close.

"The site has currently restored the key bushing/key assembly with new keys with proper fit and welds to ensure the key is retained.

"[WVC USA] has performed an extent condition review and has concluded that one other operating site, Georgia Power - SNC, Hatch Unit 1 1WVC USA order 0010000081-10 (55544A), Southern Nuclear Operating Co PO SNG10025571 has a similar key/key bushing assembly. There was a quantity of six valve assemblies shipped for this purchase order. The site has been contacted to evaluate the fit of the key bushing/key assembly.

"Engineering has determined that improper design clearance was the cause of failure. [WVC USA is] performing corrective actions to ensure future re-occurrences cannot occur in design engineering."

Affected sites include: Fermi Unit 2 and Hatch Unit 1.

For additional information, contact:

Allen Fisher
Director of Engineering
allen.fisher@mail.weir
978-825-845


Page Last Reviewed/Updated Tuesday, March 12, 2019
Tuesday, March 12, 2019