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Event Notification Report for April 12, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/11/2019 - 4/12/2019

** EVENT NUMBERS **


53971 53972 53974 53975 53978 53979 53980 53991 53993

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Agreement State Event Number: 53971
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UMASS MEMORIAL HEALTH CARE
Region: 1
City: WORCHESTER   State: MA
County:
License #: 60-0096
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 04/03/2019
Notification Time: 12:25 [ET]
Event Date: 04/02/2019
Event Time: 10:42 [EDT]
Last Update Date: 04/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE ADMINISTRATION OF Y-90 MICROSPHERES

The following was received from the Commonwealth of Massachusetts via e-mail:

"On 4/2/19, 1430 EDT, the licensee reported a medical event involving Nordion TheraSpheres (SS&D NR-0220-D-131-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-vial Y-90 62 mCi (13 mCi and 49 mCi vials) microsphere therapy treatment delivered to the patient's liver on 4/2/19 was stuck in the catheter causing delivery of approximately 37 mCi Y-90. This was discovered immediately after treatment. The administered dose to the treatment area differed from the prescribed dose by approximately 40 percent. The licensee stated that the primary cause was an equipment malfunction. The first vial of 13 mCi was delivered fully, but only 24 mCi of the second vial containing 49 mCi was actually administered to the patient. The prescribing physician, referring physician and patient have been notified. The licensee stated that there were no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment will be required. Corrective actions will include removal of the suspect equipment (catheter) and return of said equipment to the manufacturer for evaluation. A larger diameter catheter will be used during future therapy treatments. The licensee will submit a written report within 15 days of the discovery date. Agency on-site investigation is pending. This is a next day reportable medical event per regulations.

"Investigation ongoing. Agency considers this event docket to still be OPEN."

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: 53972
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: BAPTIST HEALTH LEXINGTON
Region: 1
City: LEXINGTON   State: KY
County:
License #: 202-004-27
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: JIM DRAKE
Notification Date: 04/03/2019
Notification Time: 13:40 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- ELUATE EXCEEDED BREAKTHROUGH LIMITS ON RUBIDIUM - 82 GENERATOR

The following was received from the State of Kentucky via fax.

"On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO [Radiation Safety Officer] was notified and the hospital was instructed to discontinue use."

Kentucky Event Report ID No.: KY190003

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: 53974
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NRD, LLC
Region: 1
City: GRAND ISLAND   State: NY
County:
License #: NYS C1391
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/03/2019
Notification Time: 17:09 [ET]
Event Date: 04/01/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
ANDREA KOCK (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POSSIBLE INTERNAL OVEREXPOSURE

The following was received from the State of New York via fax:

"The Radiation Safety Officer [RSO] of NRD, LLC, called to report an incident in which three individuals may have been exposed to Americium-241. NRD, LLC has a specific radioactive material license with the NYS [New York State] Department of Health to Manufacture Radioactive Products. Below is a brief description of the information reported so far.

"On Monday [4/1/19] evening an individual (Person1) was trying to clean up a 'small rusty contamination' in the change area using a HEPA vac. The vacuum was previously used in a different area (Silver Recovery) area to clean up Americium-241 metal. He turned on the vacuum and noticed it was blowing stuff out. He turned it off and told a second individual (Person 2) to shut the doors. After doing so, Person 2 went into another room. During this time the RSO (Person 3) was notified. Person 3 'stuck his head in the room for a minute.' Person 1 and person 2 were in the area for about a minute. Person 1 was in the area for approximately 20 minutes.

"The reading on a nose swab done on Person 1 read 6600 dpm [see update below]. After his clothing was removed and he took a shower and blew his nose, a second swab was done. The reading on the those swabs were 4884 dpm (right nostril), 1729 dpm (left nostril). On day 2 a third set of swab were done with the following reading: 67 dpm (right nostril), 36 dpm (left nostril).

"The lab remains closed and there is no work being done. They are trying to set up an access control point to enter the lab.

"The RSO indicated he was in communication with REACTS [Radiation Emergency Assistance Center/Training Site]. They suggested the Person 1 and Person 2 see their medical doctors. The bioassays collected were going out today, Wednesday, April 3, 2019.

"Based on the results reported for the initial nose swab, this incident is reportable under 10 CFR 20.2202(a)(1). NYSDOH [New York State Department of Health] Incident No. 1278 has been assigned to track this event."

New York Event Report ID No.: NY-19-04

Exposure to person 1 may have resulted in an intake five times the occupational Annual Limit on Intake (ALI).

* * * UPDATE ON 4/4/19 AT 1055 EDT FROM DESMOND GORDON TO BETHANY CECERE * * *

The initial report was incorrect for the nose swab done on person 1 - it read 66,000 dpm, not 6,600 dpm.

Notified R1DO (Young), and NMSS_Events_Notification email group.

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Agreement State Event Number: 53975
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THERMO FINNIGAN LLC
Region: 4
City: AUSTIN   State: TX
County:
License #: Licen-RAM-L01186
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/04/2019
Notification Time: 09:19 [ET]
Event Date: 01/08/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

The following was received via e-mail:

"On January 8, 2019, the Agency [Texas Department of State Health Services] was contacted by the license and notified they have some conflicting data that suggest they may have up to three (3) leaking Nickel (Ni) - 63 ten milliCurie sources that may be slightly above the 0.005 microCuries reporting limit. The licensee stated they need to investigate further as a second set of leak tests showed no detectable activity on the same three sources. The three sealed sources in question have been bagged and are slotted for disposal. The licensee will provide additional information as it is received.

"On January 25, 2019, the licensee contacted the Agency and stated they had leak tested all similar sources in their possession. The licensee found a total of four sources exceeded the limit. The sources are all Ni-63 containing 10 milliCuries. The licensee stated they will dispose of all leaking sources. The licensee stated it believed the sources were manufactured in Singapore. The sources are used in gas chromatographs. The Agency conducted an on site investigation at the facility on March 11, 2019. During the investigation the licensee stated none of their customers who had been provided a device had reported a source that failed a leak test.

"On April 3, 2019, the Agency was notified by the licensee that they were going to restrict access to a room for more than 24 hours due to fixed and removable radioactive contamination levels. The contamination was found while performing surveys in the area in response to leak test results of four Ni-63 sources exceeding the limit (NMED report number 190032). The licensee will perform bioassay sampling of all individuals who had been in the room. The licensee stated they have begun decontamination of the room. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: 9648

* * * UPDATE AT 1645 EDT ON 4/15/2019 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On April 15, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee that they had found additional contamination in the facility and had closed the facility until a full survey can be completed and any areas found to be contaminated released. The licensee is working on a bioassay plan for the employees."

Notified the R4DO (Pick) and NMSS (via e-mail).

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Agreement State Event Number: 53978
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL OPERATING COMPANY
Region: 3
City: BRILLIANT   State: OH
County:
License #: 31201420000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/04/2019
Notification Time: 15:19 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE MISSING SHUTTER

The following report was received via e-mail:

"On 4/3/19, during preparation to conduct maintenance on a coal chute, workers prepared to isolate a gauge from service to prevent worker exposure to the beam. It was discovered that the gauge was missing its isolation shutter. The RSO [Radiation Safety Officer] and plant personnel conducted an extensive search and investigation of the missing shutter, but it could not be located. A six-month physical inventory of the facilities devices was conducted on 3/26/19 and 3/27/19 and there was no notation of any problems with this gauge on the inventory sheets. The gauge involved is a Texas Nuclear Model 5189 with a 20 mCi Cesium-137 source.

"The RSO and job supervisor held a discussion and decided that they could use the shutter from another Model 5189 gauge in the vicinity. The second gauge is used in a continuously operating process line and would have the shutter open for operations. The area around the second gauge will have signage and barricades installed to safely mark the area if future work activities will take place in that location. The shutter from the second gauge was placed on the first gauge and it was tagged out for maintenance of the coal chute. The second gauge remains in the open position during operation of the second process line.

"The RSO contacted ThermoFisher Scientific and discovered that because of the age of the gauge, replacement parts could not be obtained. They were provided with a list of third-party service providers to assist with proper repair or removal and disposal of the gauge. The licensee will explore options and inform ODH [Ohio Department of Health] of the actions to be taken."

Ohio Item Number: OH190005

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Agreement State Event Number: 53979
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: LA PORTE   State: TX
County:
License #: RAM-L01774
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/04/2019
Notification Time: 16:50 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

The following report was received via e-mail:

"On April 4, 2019, the Agency was notified by the licensee that one of their radiography crews was unable to retract a source on April 3, 2019, when a jig on a ladder fell on the source tube. The crew contacted the RSO [Radiation Safety Officer]. The RSO, an authorized source retriever, reported to the temporary job site in approximately 20 minutes and retrieved the source.

"No member of the general public received an exposure from this event. No additional information has been provided. The radiographers were to be interviewed on April 4, 2019. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident: 9670

* * * UPDATE ON 4/5/2019 AT 1222 EDT FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"On April 5, 2019, the licensee provided the following information. The device was a QSA 880D exposure device containing a 62 curie iridium-192 source. The highest exposure received from this event to any of the individuals involved was to the individual who retrieved the source. [The RSO] received 370 millirem whole body dose and his right hand received 350 millirem. No individual exceeded any exposure limits due to this event. The exposure device has been returned to the manufacturer for service and the guide tube has been taken out of service. Additional information will be provided as it is received in accordance with SA-300."

Notified the R4DO (Kozal) and NMSS Events Notification (via e-mail).

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Agreement State Event Number: 53980
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TECHNICAL TESTING SERVICES, INC.
Region: 4
City: SHREVEPORT   State: LA
County:
License #: LA-3773-L01A
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/04/2019
Notification Time: 17:36 [ET]
Event Date: 03/12/2019
Event Time: 10:00 [CDT]
Last Update Date: 04/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POTENTIAL EXCESSIVE EXPOSURE AND SAFETY EQUIPMENT FAILURE

The following information was received via e-mail:

"Louisiana Department of Environmental Quality (LDEQ) was notified of this event on Monday, April 1, 2019. This event occurred in a manufacturing fabrication shop in a fixed shooting bay.

"On Tuesday, March 12, 2019, the Radiation Safety Officer (RSO) and a radiography trainee were shooting welds at the Steel Forgigs, Inc. (SF) site. The RSO stated the QC/QA [Quality Control/Quality Assurance] safety checks had been performed before the 'radiography work' began. During radiography work of shooting welds and exchanging out pipe to be x-rayed, the trainee proceeded to change out the film on the pipe while the RSO went to retrieve a new piece of pipe. The safety alarm/lights were not flashing and the trainee assumed the source had been retracted into the shielded position. However, the trainee's survey meter saturated and his pocket dosimeter went off scale. The lights and alarm were still not responding. The RSO stated 'I knew the trainee did not exceed the 5 REM exposure limit due to my work experience.'

"The survey meter was functioning properly when removed from the 'high radiation' field and his pocket dosimeter appeared to function properly when re-zeroed after the off-scale reading. The trainee's personnel monitor was sent to be processed for his personal exposure. The exposure results were 2.488 REM exposure.

"The equipment involved in the incident was a QSA 880 Delta, s/n D5843, exposure device with a QSA source model A424-9, Ir-192 source, s/n 71973G with an activity of 19 Ci.

"The internal investigation documented there was no excessive exposure to the trainee. However, the late reporting of the incident, not reporting of the incident by regulatory requirement and no commitment to corrective actions to prevent these events from reoccurring in the future are still outstanding.

"LDEQ is seeking escalated enforcement actions pertaining to this licensee and NMED incident."

Louisiana Event Report ID No.: LA-190005

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Power Reactor Event Number: 53991
Facility: WATERFORD
Region: 4     State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: DAVID LITOLFF
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/11/2019
Notification Time: 10:28 [ET]
Event Date: 04/11/2019
Event Time: 02:00 [CDT]
Last Update Date: 04/11/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GREG WERNER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM ENVELOPE INOPERABLE DUE TO DOOR HANDLE DETACHING

"On April 11, 2019, at 0200 CDT the shift operating crew declared the control room envelope inoperable in accordance with Technical Specification (TS) 3.7.6.1 due to the door handle for Door 86 (H&V Airlock Access Door) being detached. Operations entered TS 3.7.6.1 action b, which requires that with one or more control room emergency air filtration trains inoperable due to inoperable control room envelope boundary in MODES 1, 2, 3, or 4, then: 1. Immediately initiate action to implement mitigating actions; 2. Within 24 hours, verify mitigating actions ensure control room envelope occupant exposures to radiological, chemical, and smoke hazards will not exceed limits; and 3. Within 90 days, restore the control room envelope boundary to OPERABLE status. Action b.1 was completed by sealing the hole in Door 86 at 0232 CDT. This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), 'event or condition that could have prevented fulfilment of a safety function of structures or systems that are needed to (D) mitigate the consequences of an accident,' due to the control room envelope being inoperable.

"The licensee notified the NRC Resident."

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Part 21 Event Number: 53993
Rep Org: AMETEK
Licensee: AMETEK SOLIDSTATE CONTROLS INC.
Region: 3
City: COLUMBUS   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ETHAN SALSBURY
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/12/2019
Notification Time: 09:31 [ET]
Event Date: 04/12/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
NICOLE COOVERT (R2DO)
STEVE ORTH (R3DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - OVERHEATING AND FAILURE OF TRANSFORMERS

The following was received via e-mail:

"COMPONENT DESCRIPTION: AMETEK part number 80-315382-90, T801 main transformer.

"PROBLEM YOU COULD SEE: Overheating and failure of transformers installed in equipment with 0.7 power factor load requirements

"CAUSE: The inverters on AMETEK job number C72143 were required to support a 0.7 power factor load. To meet this requirement, CVT capacitors were added which led to overcurrent on the capacitor current windings and overheating. The overheating led to a breakdown in insulation between windings, causing a premature failure of the transformer set and inverter relative to its 40-year qualification life.

"EFFECT ON SYSTEM PERFORMANCE: The overheating accelerates the degradation of the insulation between windings and eventually leads to shorting. This will cause an inverter failure and require the load to be transferred to bypass.

"ACTION REQUIRED: This is the only instance AMETEK has experienced for this issue. Therefore, action is only required for the equipment on AMETEK job number C72143, located at TVA Sequoyah. New transformers have been provided as replacements that require fewer capacitors, contain additional venting to improve cooling, and include larger winding material to reduce current density. The main transformers (T801) installed in the serial numbers associated with this job (C72143-0111 through 0911) should be replaced to prevent any similar occurrences.

"AMETEK SOLIDSTATE CONTROLS CORRECTIVE ACTION: AMETEK has enhanced this particular transformer design to improve cooling and reduce capacitor current. Additionally, corrective action #175 has been issued in AMETEK's system.

"If you have any questions, please contact Mr. Mark Shreve of the Client Services group at 1- 800-222-9079 or 1-614-846-7500 ext. 6332. mark.shreve@ametek.com."

Sequoyah is the only site affected by this Part 21 Report.


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019