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Event Notification Report for May 17, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/16/2019 - 5/17/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
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: 05/17/2019
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

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."

* * * RETRACTION ON 5/17/19 AT 1620 EDT FROM MARIA ZAMBER TO BETHANY CECERE * * *

"This is a Non-Emergency Notification from Waterford 3. This is a retraction of EN 53991. This event was evaluated in accordance with the corrective action process. The original operability determination of inoperable was made based on a conservative evaluation that with the door handle for Door 86 (Heating and Ventilation Airlock Access Door) being detached, the control room envelope boundary could not perform its safety function. A more detailed engineering evaluation was subsequently performed. This shows that the condition of the door handle being detached is bounded by the most recently performed non-pressurized radiological tracer gas test, as the control room envelope differential pressure was maintained more positive with the detached door handle as compared to that observed during the test. Additionally, the control room envelope differential pressure trends showed no discernable change between the two conditions of the door handle detached or with the opening taped over (resulting in an air tight seal). This information supports the conclusion that with the door handle for Door 86 being detached, the control room envelope boundary remained operable and did not constitute a condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident; therefore, this event is not reportable per 10 CFR 50.72(b)(3)(v)(D).

"The licensee notified the NRC Resident Inspector."

Notified R4DO (Proulx).

Non-Agreement State	Event Number: 54042
Rep Org: INTERNATIONAL ISOTOPES, INC. Licensee: INTERNATIONAL ISOTOPES, INC. Region: 4 City: IDAHO FALLS State: ID County: License #: 11-27680-01MD Agreement: N Docket: NRC Notified By: JOHN MILLER HQ OPS Officer: HOWIE CROUCH	Notification Date: 05/03/2019 Notification Time: 01:02 [ET] Event Date: 05/02/2019 Event Time: 21:30 [MDT] Last Update Date: 05/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(1) - UNPLANNED CONTAMINATION AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) WILLIAM GOTT (IRD) ANDREA KOCK (NMSS) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNPLANNED CONTAMINATION EVENT DUE TO BREACHED CS-137 SOURCE

The Radiation Safety Officer (RSO) at International Isotopes, Inc. reported that at 2130 PDT on 5/2/19, while changing out the Cs-137 source on a research irradiator, they breached the source which resulted in widespread contamination and a possible uptake event. The irradiator is a JL Shepard Mark 168A and is located at the Harborview Research and Training Facility at the University of Washington in Seattle, WA. International Isotopes, Inc. is an NRC licensee working under reciprocity in the State of Washington (an agreement state).

After discovery of the breach, the immediate area was isolated, the building was ordered evacuated, and the ventilation was secured. Indications are that the seven members of the source retrieval team were externally and potentially internally contaminated.

The State of Washington was notified. The University of Washington RSO was sending response teams to the area. A local hazardous material team is on site.

The source was reported to be 2800 Ci.

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 FEMA NRCC SASC (email).

* * * UPDATE ON 05/03/2019 AT 1545 EDT FROM TRISTAN HAY TO JEFFREY WHITED * * *

The following update was received via E-mail from the Washington State Department of Health:

"University of Washington (UW) was having their research irradiator (Mark-1 SERIES / Cs-137) disposed of by International Isotopes (NRC License 11-27680-01MD). The Agreement state regulators were present to verify dose measurements and observe ALARA practices. During the source removal and transfer into the transport shielded cask, there was a breach of the sealed source and a small portion of the source was released into the working area. The working area was comprised of the irradiator unit, the shielded containment rig, the loading dock, a 100 feet radius around the loading dock, and the Harborview Research and Technology Center floors 1-3 and stair well. The source was encapsulated with International Isotopes' source housing capsule. A breach was identified during the precursor wipe survey performed prior to putting it into the source housing unit. Once contamination was identified, all personnel performed area contamination surveys and secured and taped off the work space area. All personnel who were present at some point during the transfer were notified of the potential contamination and were given special instructions to return to the Harborview Medical Center area for decontamination.

"Simultaneously the NRC, Washington Radiation Emergency Hotline, and the [National Materials Event Database] NMED were notified of the situation by International Isotopes immediately after the incident occurred. Seattle Fire and Seattle Hazmat units were dispatched to the scene to assess the situation and begin decontamination protocols. The International Isotope workers, UW RSO, FBI agent, and other present workers were decontaminated and placed in a contained area of the Harborview Medical Center Emergency Room. Bioassay samples were collected from urine and blood from the contaminated individuals."

Additionally, employees from the State of Washington who responded to the event were surveyed, with the highest level of contamination being 300 cpm on the individual's shoes.

Washington State Licensee: University of Washington
Washington Agreement State License No. C001
Event Report ID No.: WA-19-015

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via e-mail, 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 FEMA NRCC SASC (email).

* * * UPDATE ON 05/04/2019 AT 2136 EDT FROM JOHN MILLER TO JEFFREY WHITED * * *

The following update is a synopsis of information received via E-mail from International Isotopes:

In its E-mail, the licensee provided an initial incident report regarding the breached Cs-137 source incident that occurred during the removal of the source from the Research Irradiator at the Harborview Training and Research Building. The licensee provided a summary of planned work, a summary of the incident, a summary of the whole-body exposures received by International Isotopes and contractor employees, a summary of initial personnel skin contamination results, a summary of post-decontamination personnel skin contamination results, and a summary of recovery actions taken to date.

According to its assessment, the licensee indicated that the highest whole-body exposure to any one individual was 55 mrem. The majority of surveys taken at the loading dock level indicated that surfaces were contaminated in the 50,000 - 300,000 cpm range.

The summary of recovery actions taken to date are as follows:

International Isotopes hired a contractor to perform decontamination and remediation of the affected areas. The Department of Energy, Region 8, Radiological Assistance Program team surveyed the building floors. International Isotopes employees surveyed the parking lot area where emergency response operations took place reducing the size of the controlled area, marking spots with identified levels. The loading dock area was further isolated from the building by covering outdoor louvers and double door between corridor and loading dock with heavy plastic. International Isotopes remains on-site to support the contractor and the University of Washington by performing assessment surveys and development of the decontamination and recovery plan.

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Kock), and NMSS Events Notification via e-mail, 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 FEMA NRCC SASC (email).

* * * UPDATE AT 1648 EDT ON 05/16/2019 FROM JOHN MILLER TO JEFF HERRERA * * *

"This report provides an update to the May 2, 2019 incident involving the breached Cs-137 source.

"International Isotopes Inc. (INIS) performed dose estimates based on 24 hour urine samples collected from the INIS employees that were involved in the incident.

"There were seven INIS individuals involved, the INIS estimates are provided in the table below. Note that individuals 6 and 7 are not included in the LANL Report as their urine sample results were released later. These sample results have since been provided to LANL.

"Name; Time Between intake and sample (days); Concentration (pCi/L); Modeled Intake (uCi); Percent ALI; CED (mRem)

"Individual 1: 1.625; 15,700; 2.284; 1.142 Percent; 57.1
Individual 2: 1.396; 6,100; 1.235; 0.618 Percent; 30.9
Individual 3: 1.698; 1,280; 0.186; 0.093 Percent; 4.7
Individual 4: 1.665; 8,540; 1.242; 0.621 Percent; 31.1
Individual 5: 1.697; 19,800; 2.880; 1.440 Percent; 72.0

"Individual 6: 1.687; 5,540; 0.806; 0.403 Percent; 20.1
Individual 7: 1.437; 4,110; 0.624; 0.312 Percent; 15.6"

Notified R4DO (Proulx), IRD MOC (Kennedy), NMSS (Rivera Capella), and NMSS Events Notification via e-mail, 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 FEMA NRCC SASC (email).

Agreement State	Event Number: 54056
Rep Org: UTAH DIVISION OF RADIATION CONTROL Licensee: KENNECOTT UTAH COPPER CORPORATION Region: 4 City: State: UT County: SALT LAKE COUNTY License #: 1800289 Agreement: Y Docket: NRC Notified By: GWYN GALLOW HQ OPS Officer: THOMAS KENDZIA	Notification Date: 05/09/2019 Notification Time: 15:19 [ET] Event Date: 04/24/2019 Event Time: 16:30 [MDT] Last Update Date: 05/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILED CLOSED

The following was received via e-mail:

"On April 24, 2019 at about 4:30 PM [MDT], the RSO [Radiation Safety Officer] for Kennecott Copper Corporation called and notified a DWMRC [Utah Department of Environmental Quality, Division of Waste Management and Radiation Control] staff member that one of their gauges was not working properly. The licensee reported that the shutter on a fixed gauge, an Ohmart Vega, model number SH-F2, serial number 68852, containing 800 mCi of Cs-137 in a sealed source did not open when a shutter test was conducted. The licensee stated that the gauge would be left in place for now and removed and cleaned the next week, to see if that resolved the problem. The RSO reported that he would engage a licensed provider if disassembly is required to fix the problem.

"Another [DWMRC] staff member spoke to the licensee's RSO at about 5:00 PM that evening. The licensee's RSO indicated that they did not have the information regarding the gauge with them at the time but that they believed the gauge just needed to be cleaned. The licensee indicated that the gauge had not been in use for a while and that they were testing the device prior to putting the device back into operation when the issue was discovered. The gauge is located in an area difficult to access. The licensee would need to use certain equipment to safely reach and remove the gauge. The RSO had tried to contact their regular gauge service licensee and determined that the service licensee would not be available until after May 1, 2019. The RSO indicated that they would remove and clean the gauge the following week.

"Specific individuals on the licensee's radioactive materials license are authorized to install and remove gauges and the extra time would allow the RSO to ensure that the appropriate individuals were available. On April 30, 2019, the licensee's authorized personnel removed the gauge from its location at the pebble crusher. After a thorough cleaning of the exterior of the source housing, the shutter was still showing no movement.

"The RSO realized the gauge needed to be taken apart and cleaned in order to allow the shutter to work properly. The service licensee was contacted and arrangements were made for the service licensee to work with the gauge on May 2, 2019. The device was stored in a properly secured area at any time it was not under the licensee's constant surveillance until the service licensee took possession of the device. The licensee informed the DWMRC that they would provide a report regarding the outcome."

Event Report No.: UT190002

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

Non-Agreement State	Event Number: 54057
Rep Org: QUEENS MEDICAL CENTER Licensee: QUEENS MEDICAL CENTER Region: 4 City: HONOLULU State: HI County: License #: 53-16533-02 Agreement: N Docket: NRC Notified By: DALE SCHIPPERS HQ OPS Officer: THOMAS KENDZIA	Notification Date: 05/09/2019 Notification Time: 18:08 [ET] Event Date: 05/08/2019 Event Time: 13:17 [HST] Last Update Date: 05/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS	Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ADMINISTRATION OF LESS THAN PRESCRIBED DOSE

"This was a Y-90 TheraSphere administration [120 Gy to the right lobe of the liver]. The catheter was guided to the right hepatic artery and the position was verified by fluoroscopy. No issues with catheter flow while administering contrast and normal saline. The catheter was connected to the primed infusion system and the dose delivery was initiated. The IR (Interventional Radiology) physician, under the supervision of the Authorized User, was delivering the dose. The IR physician saw several small air bubbles in the delivery line and then experienced high resistance. Some of the Y-90 activity (approximately 13.2 mCi or 0.49 GBq) was delivered to the patient. Approximately 60% of the activity was in the administration set and catheter. No contamination of the IR suite or of any of the personnel occurred. All of the dose was either in the delivery system/catheter or the patient.

"No harm was done to the patient since the activity was delivered to the target organ and the dose did not exceed the prescribed dose.

"The referring physician and the patient were notified within 24 hours."

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.

Power Reactor	Event Number: 54068
Facility: WATERFORD Region: 4 State: LA Unit: [3] [] [] RX Type: [3] CE NRC Notified By: MARIA ZAMBER HQ OPS Officer: DONALD NORWOOD	Notification Date: 05/16/2019 Notification Time: 18:07 [ET] Event Date: 05/16/2019 Event Time: 13:48 [CDT] Last Update Date: 05/16/2019
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): DAVID PROULX (R4DO)

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 DUE TO TURBINE TRIP

"This is a non-emergency notification from Waterford 3.

"On May 16, 2019, at 1348 CDT, Waterford 3 experienced an automatic reactor trip due to Steam Generator number 1 high level, which was the result of a Main Turbine trip and subsequent reactor power cutback which had occurred at 1345 CDT. The cause of the Main Turbine trip is currently under investigation.

"Subsequent to the Reactor trip, Main Feedwater Isolation Valves number 1 and number 2 closed on high Steam Generator levels. Emergency Feedwater automatically actuated for Steam Generator number 2 at 1419 CDT and Steam Generator number 1 at 1425 CDT. Main Feedwater was restored to both Steam Generators by 1629 CDT.

"The plant entered the Emergency Operating Procedure for an uncomplicated reactor trip and is in the process of transitioning to the normal operating shutdown procedure. The plant is currently in Mode 3 and stable with Main Feedwater feeding and maintaining both Steam Generators.

"The NRC Senior Resident Inspector has been notified."

All control rods fully inserted. Decay heat is being removed through the main condenser. The plant is in a normal shutdown electrical lineup.

Power Reactor	Event Number: 54069
Facility: CALLAWAY Region: 4 State: MO Unit: [1] [] [] RX Type: [1] W-4-LP NRC Notified By: JEFF GULICK HQ OPS Officer: JOANNA BRIDGE	Notification Date: 05/17/2019 Notification Time: 03:35 [ET] Event Date: 05/16/2019 Event Time: 23:03 [CDT] Last Update Date: 05/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): DAVID PROULX (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

Startup

Hot Standby

Event Text

REACTOR TRIP DUE TO SOURCE RANGE HI FLUX SIGNAL

"This is an 8-hour, non-emergency notification for a valid reactor trip signal with the reactor not critical, and a valid auxiliary feedwater system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A) - Valid System Actuation.

"At 2303 [CDT] on May 16, 2019, the plant was administratively in mode 2 due to withdrawing control rods for startup following refuel. The reactor had not been declared critical. The P-6 permissive at 10E-10 Amps was met for one of two Intermediate Range detectors allowing for block of the Source Range high flux trip (1E5CPS). Prior to performing the block, the Source Range high flux trip setpoint was exceeded and a reactor trip received. All systems responded as expected. A feedwater isolation signal was received due to the reactor trip with feedwater temperature less than 564 degrees Fahrenheit. Auxiliary feedwater was started to maintain steam generator levels. The plant is being maintained stable in mode 3 with no complications. The NRC Resident Inspector was present during the startup and was notified of the reactor trip."

Page Last Reviewed/Updated Wednesday, March 24, 2021