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Event Notification Report for April 24, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/23/2019 - 4/24/2019

** EVENT NUMBERS **


53879 53942 53952 54003 54021 54024

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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: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 4/25/2019

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).

* * * UPDATE FROM ANGIE HALL TO HOWIE CROUCH VIA EMAIL ON 4/24/19 AT 1708 EDT * * *

"The Department received a report on April 24, 2019 (dated April 4, 2019) from the Licensee regarding the Y-90 TheraSphere misadministration.

"The Department requested additional information on April 24, 2019, regarding the information provided by the Licensee. The request includes clarification from the manufacturer's report and the Licensee's corrective actions.

"The Department will update this report when the Licensee provides additional information."

Notified R4DO (Young) 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.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53942
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/17/2019
Notification Time: 14:10 [ET]
Event Date: 03/17/2019
Event Time: 07:35 [CDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SCOTT SHAEFFER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 47 Power Operation 47 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"At 0735 CDT on March 17, 2019, the High Pressure Coolant Injection (HPCI) system was isolated due to a water-side leak from the HPCI Gland Seal Condenser. Unit 3 declared the HPCI system Inoperable and entered Technical Specification LCO 3.5.1 Condition C with required actions to verify the Reactor Core Isolation Cooling system is Operable, and to restore the HPCI system to Operable status within 14 days. All other Unit 3 Emergency Core Cooling Systems (ECCS) remain Operable.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(V)(D), 'Any 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.' This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(V)(D).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified of this event."

* * * RETRACTION FROM WESLEY CONKLE TO HOWIE CROUCH ON 4/23/19 AT 1549 EDT * * *

"ENS Event Number 53942, made on March 17, 2019, is being retracted.

"NRC Notification 53942 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, 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.

"At 0735 CDT, on March 17, 2019, during the performance of a routine surveillance, a momentary pressure transient of 844 psig from the Feedwater system was introduced into the High Pressure Coolant Injection (HPCI) system discharge and suction piping that ruptured the seal on the gland seal condenser and flooded the U3 HPCI Room. Unit 3 HPCI was declared inoperable due to isolation of the waterside of the HPCl system.

"On April 11, 2019, a Past Operability Evaluation was completed which determined that the HPCI System remained operable. The evaluation of the potential pressure transient and room flooding concluded that the HPCI System could have performed its specified safety function of vessel injection throughout the time that the gland seal was ruptured. 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 149973.

"The licensee has notified the NRC Resident Inspector."

Notified R2DO (Ehrhardt).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53952
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL CORPORATION
Region: 1
City: BRADDOCK   State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/22/2019
Notification Time: 14:22 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 4/25/2019

EN Revision Text: AGREEMENT STATE REPORT - FAILED MOISTURE GAUGE SHUTTER

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

"The licensee reported that on March 21, 2019, the Berthold Technologies Model LB-7 410 moisture gauge containing 300 milliCuries of americium-241 was not able to operate as designed; the shutter locking mechanism cylinder was able to be pulled out of the gauge. The gauge was being removed from the east side of #3 Blast Furnace to the storage area at the Blast Furnace spares building. A service provider was already scheduled on site to observe removal and transport of the gauge. A contract employee working with the service provider stated that the cylinder was able to be pulled out of the gauge. The cylinder was never fully removed, but if it was, this would allow the shutter to be manually opened or closed. The cylinder locking device was depressed by the service provider employee and it is currently in that condition. The shutter can't be moved with the cylinder depressed. The gauge is currently locked in the storage area at the Blast Furnace spares building.

All work was performed using ALARA principles and at no point were employees exposed to excess levels of radiation. Survey results indicated no abnormal amounts of radiation in the area before, during, or after the removal of the device. Berthold has been contact for repair or replacement."

PA Event Report ID No: PA19001

* * * RETRACTION FROM THE JOHN CHIPPO TO CATY NOLAN ON 4/24/19 AT 1059 EDT * * *

The following was received via fax:

"A follow-up interview and review of the operation of the locking mechanism was conducted with the contract employee. It was determined that the contract employee was unfamiliar with the operation of the locking mechanism at the time of the removal and that the cylinder never was able to be pulled out of the gauge. Based on this investigation, it has been determined that there was not a failure of the locking mechanism or shutter during the removal of the gauge on March 21, 2019. Therefore, this event should be retracted from NMED."

Notified R1DO (Lilliendahl) and NMSS Events (via email).

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Agreement State Event Number: 54003
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: REPLOGLE ENTERPRISES
Region: 1
City: HENRY   State: TN
County:
License #: GL #708
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/16/2019
Notification Time: 15:27 [ET]
Event Date: 05/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 04/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (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 - LOST GENERALLY LICENSED TESTING DEVICE

The following report was received via e-mail:

"On January 11, 2018, FHL Industries, LLC, acquired Replogle Hardwood Flooring out of bankruptcy. The new owners were unaware of a generally licensed hazardous testing device from previous ownership. During a search of the facility during April 2018, FHL concluded the device was missing. FHL has no intentions of acquiring another radioactive testing device.

"Isotope and activity: Am-241, 0.03 mCi; Cm-244, 13.0 mCi
Manufacturer: Asoma Instruments
Model: 100
SN: 1537"

Tennessee Event: TN-18-089

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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Power Reactor Event Number: 54021
Facility: WATTS BAR
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JUSTIN GALLAGHER
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/23/2019
Notification Time: 09:44 [ET]
Event Date: 04/23/2019
Event Time: 02:32 [EDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
FRANK EHRHARDT (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N N 0 Defueled 0 Defueled

Event Text

TEMPORARY LOSS OF CONTROL ROOM ENVELOPE BOUNDARY

"At 0232 EDT on April 23, 2019, a Main Control Room (MCR) alarm was received for low control room positive pressure.

"At 0233 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains. Watts Bar Unit 1 entered Condition B. Watts Bar Unit 2 was not performing movement of irradiated fuel assemblies and did not meet the APPLICABILITY for CREVS per LCO 3.7.10.

"At 0233 EDT on April 23, 2019, the alarm cleared, CREVS was declared operable and LCO 3.7.10 Condition B was exited.

"The safety function of the CRE boundary is to ensure the in-leakage of unfiltered air into the CRE will not exceed the in-leakage assumed in the licensing basis analysis of Design Basis Accident (DBA) consequences to CRE occupants. From 0232 EDT to 0233 EDT, [Watts Bar Nuclear] WBN was unable to validate that CREVS could fulfill its required Safety Function.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 54024
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT TATRO
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/24/2019
Notification Time: 10:40 [ET]
Event Date: 04/23/2019
Event Time: 12:56 [CDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
CALE YOUNG (R4DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY REPORT - ALGORITHM USED FOR RANDOM TESTING EXCLUDED A POPULATION OF INDIVIDUALS

"On April 23, 2019, at 12:56 Central Time, South Texas Project Nuclear Operating Company (STPNOC) identified a programmatic failure, degradation, or discovered vulnerability of the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program."

The NRC Resident Inspector has been notified.


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