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Event Notification Report for June 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/25/2019 - 6/26/2019

** EVENT NUMBERS **


54120 54122 54123 54131

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Agreement State Event Number: 54120
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEST PENN ALLEGHENY HEALTH SYSTEM INC.
Region: 1
City: PITTSBURGH   State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: CATY NOLAN
Notification Date: 06/17/2019
Notification Time: 11:08 [ET]
Event Date: 06/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following was received by email from the Commonwealth of Pennsylvania:

"On Friday, June 14, 2019, the licensee experienced an equipment failure event during a brachytherapy treatment where the source failed to retract from the patient at the end of the treatment time. The catheter was immediately manually removed from the patient and placed in the emergency container and locked up. No harm is expected to the patient and no overexposures occurred. The HDR [High Dose Rate] unit, an Elekta Flexitron Model 136149A02, contained an iridium-192 source less than 12 Curies. The vendor, Best Vascular, was immediately notified and will be on site today, June 17, 2019, to retrieve the source and repair the device.

"The DEP [PA Department of Environmental Protection] will update this event as soon as more information is provided.

"The DEP will perform a reactive inspection. More information will be provided as received."

PA Event Report ID No: PA-190014

* * * UPDATE FROM JOHN CHIPPO TO OSSY FONT ON 6/19/19 AT 1002 (EDT) * * *

The following information was received from the DEP via fax:

"On Monday, June 17, 2019, a service engineer from Best Vascular was able to drive the sources into the catheter and retract them into the device several times without incident. The licensee now believes the CVBT [CardioVascular BrachyTherapy] catheter was not fully seated into the device, causing a small leak and a subsequent pressure differential which does not allow the source to fully retract into the device."

The cause of the event is believed to be operator error. The DEP will perform a reactive inspection.

Notified R1DO (Greives) and NMSS Events Notification 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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Non-Agreement State Event Number: 54122
Rep Org: U.S. AIR FORCE RADIOISOTOPE COMM
Licensee: U.S. AIR FORCE
Region: 3
City:   State: OH
County: Greene
License #:
Agreement: Y
Docket:
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 06/18/2019
Notification Time: 15:36 [ET]
Event Date: 02/27/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(4) - FIRE/EXPLOSION
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)

Event Text

RUPTURED AUTOCLAVE VALVE WITH IDENTIFIED THORIUM-232

The following was received via email.

"Between 2/27/19 and 2/28/19, an autoclave (13 inches long with 1.25 inches width) ruptured in room 2BR136 of Building 20620, at Wright Patterson Air Force Base (AFB) OH. Nobody was present at the time of the rupture. Scientists were working with unlicensed materials (potassium niobate and potassium hydroxide) at the time of the event. This autoclave originally came from Hanscom AFB .

"During the investigation, the installation Radiation Safety Officer found affixed to the inside of the autoclave canister non-removable thorium-232 (31,235 dpm/100 cm2) and a significantly lesser amount of removable thorium-232. Besides the material on the autoclave, no other contamination was present. Thorium contamination might be from the raw materials used in the autoclave and/or Hanscom AFB might have used thorium in the autoclave. The licensee are investigating and conducting additional gamma spectroscopic analysis of the interior of the ruptured autoclave.

"This was a historical incident that the licensee was made aware of, and is still uncertain if it is reportable. The licensee had a discussion with NRC Region IV regarding this event. After the discussion, the licensee chose to report to the NRC Operations Center in accordance with 10 CFR 40.60. To the best of the licensee's knowledge, nobody had radiation exposure or radioactive material uptake.

"The licensee will provide the follow-up written report within 30 days."

The Thorium-232 Appendix B annual limit on intake is 3E-3 microCuries.

The licensee contacted Region IV.

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Agreement State Event Number: 54123
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MISTRAS GROUP INC.
Region: 3
City: HEATH   State: OH
County:
License #: 03320460000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2019
Notification Time: 15:57 [ET]
Event Date: 06/17/2019
Event Time: 11:30 [EDT]
Last Update Date: 06/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGE TO RADIOGRAPHY GUIDE TUBE PREVENTING RETRACTION OF SOURCE

The following information was received from the Ohio Department of Health via E-mail:

"On 6/17/2019, the licensee reported an incident while shooting at a client location in Bremen, Ohio. They were setting up 2 inch welds on a table in the shooting vault. The spool piece weighed approximately 40 pounds. As the radiographer cranked out the shot at approximately 1130 EDT, he immediately heard a loud noise and tried to crank the shot in, but could not get the source (Ir-192; 63.8 Curies) back into the camera. The vault door was opened slightly to see what had happened. The spool piece had fallen off the table and crushed the guide tube. The door to the vault was shut and licensee staff prepared a plan to get the source back into the camera.

"The RSO [Radiation Safety Officer] made a 15 second trip into the vault to shield the source using (6) 1 inch long x 2 inch thick x 4 inch wide lead blocks. During this first entry into the vault to put the shielding down, the RSO received a dose of 20 mR. The RSO made a second trip into the vault to put more shielding down and access the situation. During this time he discovered that the drive cable was partially sheared off and the guide tube was crimped at that area. The RSO received an additional 10 mR during this trip. With the shielding in place the licensee measured approximately 0.5 mR/hr outside the shooting vault.

"Proper source retrieval procedures were followed and the source was retrieved and placed into the camera using source retrieval equipment and new cranks and guide tubes. The Ohio Department of Health, Bureau of Environmental Health and Radiation Protection was contacted by phone at approximately 1430 EDT on 6/17/2019, to inform of what transpired. At no time were there any members of the public exposed. During the whole retrieval process the RSO received a total dose of 55 mR."

Ohio Item Number: OH190008

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Power Reactor Event Number: 54131
Facility: WATERFORD
Region: 4     State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: JACK MORRISON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 06/25/2019
Notification Time: 11:09 [ET]
Event Date: 06/25/2019
Event Time: 04:28 [CDT]
Last Update Date: 06/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEREMY GROOM (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 BROAD RANGE GAS MONITORS BEING INOPERABLE

"On June 25, 2019, at 0428 CDT, the Waterford 3 shift operating crew declared the control room envelope inoperable in accordance with Technical Specification (TS) 3.7.6.1 due to both Broad Range Gas Monitors being inoperable. 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 placing the control room in isolate mode at time 0441 CDT. This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(A) and 10 CFR 50.72(b)(3)(v)(D), event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to (A) shutdown the reactor and maintain it in shutdown condition and (D) mitigate the consequences of an accident, due to the control room envelope being inoperable.

"The NRC Senior Resident Inspector has been notified."


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