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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for May 06, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/3/2019 - 5/6/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54026
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: WEEKS MARINE, INC. Region: 4 City: HOUMA State: LA County: License #: LA-2770-L01, AI # 2380 Agreement: Y Docket: NRC Notified By: JOSEPH NOBLE HQ OPS Officer: ANDREW WAUGH	Notification Date: 04/25/2019 Notification Time: 11:04 [ET] Event Date: 04/24/2019 Event Time: 00:00 [CDT] Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE STUCK SHUTTER

The following was received via email from the State of Louisiana:

"On 04/24/2019, Weeks Marine, Inc. was performing their routine operations with their licensed device. During their dredging operations, work ceased and the gauge shutter would not close when not in operation. The gauge shutter would not close due to dirt and grime residue in the shutter mechanism. Weeks Marine, Inc. called a service contractor, Applied Health Physics, to evaluate the situation and determine the best course of action to correct the problem (clean and lubricate).

"The sources and device with the stuck open shutter will remain installed on the process until the repairs are made. This is not a radiation exposure hazard and does not pose a health and safety situation for the Weeks Marine, Inc. employees or the general public.

"The density/level gauge is a Berthold Model 7400D series device/source holder, loaded with an approximately 1500 mCi Cs-137 source, s/n 372-1-85. Initial activity was 3000 mCi in 1985 [manufacture] date.

"This event is being reported to the NRC Operations Center as required by Regulatory Requirement 10 CFR Part 30.50(b)(2) and LAC 33:XV 340.B."

Louisiana Event Report ID No.: LA-190006

* * * UPDATE AT 0933 EDT ON 4/26/2019 FROM JOSEPH NOBLE TO JEFF HERRERA * * *

The following update was received from the Louisiana Department of Environmental Quality via email:

"[On] 04/25/2019, at [1440 CDT] Weeks Marine reported that Applied Technical Services had completed the maintenance on this fixed density gauge and that Hopper Dredge # 456 is back in operation. This event is considered completed and closed."

Notified the R4DO (Young) and NMSS (via email).

Agreement State	Event Number: 54028
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: CAPE COD HOSPITAL Region: 1 City: HYANNIS State: MA County: License #: 44-0164 Agreement: Y Docket: NRC Notified By: JOSHUA DAEHLER HQ OPS Officer: BETHANY CECERE	Notification Date: 04/25/2019 Notification Time: 12:09 [ET] Event Date: 04/23/2019 Event Time: 16:11 [EDT] Last Update Date: 04/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE GREATER THAN PRESCRIBED DOSE

The following was sent by email from the Commonwealth of Massachusetts:

"The licensee reported on April 24, 2019 that it discovered on April 23, 2019 two High Dose-rate Remote Afterloader (HDR) medical events where tissue other than the treatment site received a dose exceeding the reporting requirements 105 CMR 120.594(A)(1)(c). One of the medical events occurred in March of 2019 and the other occurred in October of 2018.

"The licensee reported that a 5 cm offset from the target location resulted in dose to unintended tissue during each treatment.

"The licensee used a Varian Medical Systems, Inc. Model VariSource iX HDR containing iridium-192 to deliver the doses for both treatments. Each prescribed dose to each patient was 10 gray (1,000 rad) to the vaginal cavity across two fractions.

"Both events occurred as a result of an unintended area of each patient's vaginal cavity receiving a portion of the prescribed dose. The licensee reported that the cause of the events is a combination of a change in applicator size and incorrect parameters input into the device console. Some two years ago, the size of the vaginal applicator changed from 120 cm in length to 125 cm in length, but there were no issues until the two aforementioned events. From the administration documentation, the licensee determined that the technician erroneously entered 120 cm into the device console rather than 125 cm, effectively causing a 5 cm offset. As a result the lower 5 cm of each patient's vaginal cavity received more dose than intended. The exact number is yet unknown. The licensee will provide additional information in a written report.

"The licensee reported that the referring physician, who is the same for each patient, has been notified and that the referring physician intends to notify each patient.

"The Agency [Massachusetts Radiation Control Program] plans to perform a special inspection and considers this event to 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.

Agreement State	Event Number: 54029
Rep Org: AZ DEPARTMENT OF HEALTH SERVIC Licensee: ABRAZO SCOTTSDALE CAMPUS Region: 4 City: PHOENIX State: AR County: License #: 07-246 Agreement: Y Docket: NRC Notified By: BRIAN GORETZKI HQ OPS Officer: JOANNA BRIDGE	Notification Date: 04/25/2019 Notification Time: 17:42 [ET] Event Date: 04/25/2019 Event Time: 00:00 [CDT] Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ANDREA KOCK (NMSS) PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE

The following was received from the state of Arizona via e-mail:

"The [Arizona Department of Health Services] received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300.

"Arizona incident Number 19-008."

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.

* * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following was received from the state of Arizona via e-mail:

"This correspondence is a follow-up to the notification sent [on 4/25/19] regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead [certified radiation technologist] in an [operating room] department of a hospital performing 6-7 fluoroscopic procedures per day."

It is believed that the actual exposure was just to the badge and not to the person.

Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).

Agreement State	Event Number: 54030
Rep Org: WISCONSIN RADIATION PROTECTION Licensee: AHLSTROM-MUNKSJO NA SPECIALTY SOLUTIONS, LLC Region: 3 City: KAUKAUNA State: WI County: License #: 087-1129-01 Agreement: Y Docket: NRC Notified By: DAVID REINDL HQ OPS Officer: JOANNA BRIDGE	Notification Date: 04/26/2019 Notification Time: 17:22 [ET] Event Date: 04/22/2019 Event Time: 00:00 [CDT] Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DARIUSZ SZWARC (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the state of Wisconsin via e-mail:

"On April 26, 2019, Wisconsin Department of Health Services (DHS) was notified that at the licensee's Kaukauna facility, a fixed gauge mounted to a coal chute had been damaged and failed with the shutter closed. The incident occurred on April 22, 2019. Maintenance staffs were repairing a valve located above an Ohmart/Vega Corporation Model SHLG-1 fixed gauge containing 5 mCi of Cs-137. The valve failed, rotated downward, and made contact with the shutter actuator handle which severed the handle from the device. The gauge was not in operation at the time of the incident and the shutter remained in the closed position, the licensee's [Radiation Safety Officer] (RSO) stated on the initial phone call that the shutter is now inoperable.

"The maintenance staff called the RSO on the day of the incident and he instructed them to cordon off the area and perform surveys of the device. The surveys indicated that the source was not impacted and the RSO later performed confirmatory surveys that yielded similar results.

"Wisconsin DHS intends to perform a reactive inspection when the licensee's service provider replaces the gauge; the date is still to be determined."

Event Report No.: WI 190001

Non-Agreement State	Event Number: 54032
Rep Org: IRISNDT, LLC Licensee: IRISNDT, LLC Region: 3 City: HAMMOND State: IN County: License #: 13-32791-01, AMD 5 Agreement: N Docket: NRC Notified By: KYLE LEDBETTER HQ OPS Officer: BETHANY CECERE	Notification Date: 04/28/2019 Notification Time: 15:04 [ET] Event Date: 04/28/2019 Event Time: 05:45 [CDT] Last Update Date: 04/28/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): DARIUSZ SZWARC (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

SAFETY EQUIPMENT FAILURE - RADIOGRAPHY SOURCE FAILED TO RETRACT

"This report is intended to serve the requirements of written notification of an inability to retract a radionuclide source assembly to its fully shielded position, per 10 CFR 34.101(a)(2). The incident occurred at NIPSCO Michigan City Generating Station [in] Michigan City, IN at 0545 CDT, on 28 April, 2019. The event consisted of a temporary inability of the radiography crew to immediately return a radionuclide source assembly of Cobalt-60 (76 Ci) to its fully shielded position.

"The cause of the incident is presumed to be a source guide [tube] positioned with too tight of a radius, through which the sealed source could not be fully retracted. The equipment involved was manufactured by Source Production and Equipment Co., and was a model SPEC-300 projector (SN: 0080) and model G-70 source assembly (SN: C60-100).

"The actions taken to return the source assembly to the projector consisted retracting the source as far as possible, the RSO [Radiation Safety Officer] approaching from behind the projector, using the intrinsic shielding of the exposure device as shielding, straightening the guide tube with the use of 7 ft. remote-handling tongs, allowing the source to clear the bend in the source guide tube, then retracting the source, as normal, using the control cables.

"The incident occurred at approximately 0545 CDT, and upon discovering that the inability to fully retract the source, radiographer called [the] RSO at 0552 [CDT], while [the] assistant radiographer extended barricades to emergency distance. [The] RSO left his home promptly to gather the retrieval kit from IRISNDT's Hammond, IN office. RSO arrived on site at approximately 0715 [CDT]. After performing an assessment, the source retrieval took approximately fifteen (15) minutes to complete, and the source was returned to the shielded position by 0745 [CDT].

"All retrieval operations were conducted by individuals who have been trained to perform such tasks. All associated remote-handling equipment was subsequently removed from service for inspection. No involved equipment was found to be damaged or defective.

"No members of the public received any dose. The lead radiographer, received a dose of 8.8 mrem from the start of his shift until the retrieval was complete, the assistant radiographer, received a dose of 0.2 mrem from the start of his shift until the retrieval was complete, and the RSO performing the retrieval, received a total dose of 4.3 mrem.

"Radiographic personnel responded appropriately in identifying that the source had not returned to the shielded position, reposting and monitoring emergency barricades, contacting the Radiation Safety Officer, maintaining the restricted area while awaiting the RSO's arrival to site, and assisting with the retrieval as instructed, and following all procedures and O&E instructions."

Agreement State	Event Number: 54033
Rep Org: ARIZONA DEPT OF HEALTH SERVICES Licensee: WESTERN TECHNOLOGIES INC Region: 4 City: PHOENIX State: AZ County: License #: 07-049 Agreement: Y Docket: NRC Notified By: BRIAN D. GORETZKI HQ OPS Officer: JOANNA BRIDGE	Notification Date: 04/28/2019 Notification Time: 14:57 [ET] Event Date: 04/28/2019 Event Time: 00:00 [MST] Last Update Date: 04/28/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) SCOTT MOORE (NMSS) LEAH SMITH (ILTAB) - CNSNS (MEXICO) (EMAIL)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - THEFT OF CAT 2 MATERIAL

The following was received from the state of Arizona via e-mail:

"The [Arizona Department of Health Services] received notification that an individual stole [three] industrial radiography cameras and threatened to use them. It is believed that the individual is a current or former worker at the licensee. The isotope is Iridium-192 for all three cameras and the approximate activity amounts are 30 Curies, 49 Curies, and 80 Curies. As of approximately 1120 [MDT], the individual was located, the material was secured, and the [Radiation Safety Office] is waiting to bring the material back to the storage location. The Department has requested additional information and continues to investigate the event.

Arizona Incident No.: 19-009

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (email).

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

* * * UPDATE ON 4/28/19 AT 1920 EDT FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following is a summary of a telephone call:

The sources were safely recovered. They were found in the radiography cameras. It is widely believed that the suspect never removed the sources from the shielded cameras. The cameras have been returned to the storage facility.

Notified R4RDO (Young), NMSS Events Notification (email), NMSS (Moore), ILTAB (e-mail), CNSNS Mexico (email), IR MOC (Kennedy), ILTAB (Smith), NMSS INES Coordinator (email), INES National Officer (email).

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (email).

Power Reactor	Event Number: 54046
Facility: TURKEY POINT Region: 2 State: FL Unit: [3] [4] [] RX Type: [3] W-3-LP,[4] W-3-LP NRC Notified By: CHRISTOPHER TRENT HQ OPS Officer: CATY NOLAN	Notification Date: 05/03/2019 Notification Time: 16:43 [ET] Event Date: 05/03/2019 Event Time: 08:52 [EDT] Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): JAMIE HEISSERER (R2DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

100

Power Operation

100

Power Operation

Event Text

FITNESS-FOR-DUTY REPORT

A non-licensed contract supervisor had a confirmed positive during a for-cause fitness-for-duty test. The individual's authorization for site access has been terminated.

The NRC Resident has been notified.

Power Reactor	Event Number: 54047
Facility: MCGUIRE Region: 2 State: NC Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: DAVID PUNCH HQ OPS Officer: JEFFREY WHITED	Notification Date: 05/03/2019 Notification Time: 19:00 [ET] Event Date: 05/03/2019 Event Time: 15:54 [EDT] Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): JAMIE HEISSERER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON OVER TEMPERATURE DELTA TEMPERATURE

"At 1554 EDT on 5/3/19, with Unit 1 in Mode 1 at approximately 100 percent power, the reactor automatically tripped on Over Temperature Delta Temperature following a pressure transient in the Reactor Coolant System. The trip was uncomplicated with all systems responding normally post trip. Operations manually started the motor driven auxiliary feedwater pumps and has stabilized the plant. Decay heat is being removed by the condenser. Unit 2 is not affected.

"Due to Reactor Protection System actuation while critical and actuation of the motor driven auxiliary feedwater pumps, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an 8-hour non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).

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

Unit 1 is in a normal electrical lineup.

Prior to the automatic trip, the backup pressurizer heaters were in service as is normal during power ascension. The pressure transient started when the backup heaters were in the process of being removed from service.

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54049
Facility: COOPER Region: 4 State: NE Unit: [1] [] [] RX Type: [1] GE-4 NRC Notified By: RANDY KOUBA HQ OPS Officer: JEFFREY WHITED	Notification Date: 05/05/2019 Notification Time: 20:41 [ET] Event Date: 05/05/2019 Event Time: 14:05 [CDT] Last Update Date: 05/05/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL	Person (Organization): GREG WERNER (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

SECONDARY CONTAINMENT DECLARED INOPERABLE DUE TO POTENTIAL EQUIPMENT FAILURE

"At 1405 CDT, Secondary Containment differential pressure exceeded the Technical Specification limit due to a potential equipment failure. This required entry into [Limiting Condition of Operation] LCO 3.6.4.1 Condition A for Secondary Containment inoperability. An event or condition that could have prevented the fulfillment of a safety function requires an 8 hour report per 10 CFR 50.72(b)(3)(v)(C) for Control of Rad Release. Secondary Containment differential pressure was restored to greater than or equal to 0.25 inches vacuum, water gauge in accordance with plant procedures. Secondary Containment was declared operable at 1600 CDT. The issue has been entered in the Corrective Action Program and investigation of the cause is in progress.

"The NRC Senior Resident Inspector has been informed of this condition."

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