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Event Notification Report for July 24, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/23/2019 - 7/24/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State	Event Number: 53672
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: CLEVELAND CLINIC FOUNDATION Region: 3 City: CLEVELAND State: OH County: License #: 02110180013 Agreement: Y Docket: NRC Notified By: MICHAEL RUBADUE HQ OPS Officer: ANDREW WAUGH	Notification Date: 10/18/2018 Notification Time: 13:08 [ET] Event Date: 10/16/2018 Event Time: 00:00 [EDT] Last Update Date: 07/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVID HILLS (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 7/24/2019

EN Revision Text: AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was obtained from the State of Ohio via email:

"On October 16, 2018, a suspected medical event occurred. A patient was prescribed a dose of 120 Gy for segment 4 of the left lobe of the liver involving Y-90 TheraSpheres. All the pre-procedural safety checks were made and appropriate imaging (cone beam CT) was performed to check the catheter position and lesion location. During the first set of infusions, there was high resistance felt on the syringe which continued for the next few infusions. It was decided to stop the treatment as there was risk of inadequate delivery of the microspheres due to possibility of stasis and concern for non-target embolization to other sites. The residual was calculated and it was noted that estimated dose delivered was 6.4 Gy to the target lesion. Post-procedure, the patient had a PET CT to check the Y-90 microspheres distribution and it did not demonstrate any non-targeted deposition.

"The administered dose was 6.4 Gy to segment 4 of the left lobe of the liver. The dose was therefore 5% of the prescribed dose, a 95% difference.

"The microspheres not delivered to the target were contained in the catheter. No contamination occurred as a result of this event.

"The referring physician has been notified as well as the patient.

"A follow-up inspection will be conducted during the week of Oct. 22, 2018."

Ohio NMED Report No.: OH180010

* * * RETRACTION ON 7/23/2019 AT 1526 EDT FROM MICHAEL RUBADUE TO ANDREW WAUGH * * *

The following retraction was obtained from the State of Ohio via email:

"A follow-up inspection was conducted on October 24, 2018 to determine the circumstances leading up to this event.

"It was determined the difference in administered dose was due to emergent patient conditions and resistance of the patient's complex hepatic arterial system; stasis. There was no evidence of catheter misplacement, non-target disposition or mechanical failure of the Y-90 microsphere delivery system. There was also no evidence of any non-compliance with NRC guidelines or Ohio Administrative Code regulations."

Notified R3DO (Norton) and NMSS Events Notification (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.

Agreement State	Event Number: 54164
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: PROFESSIONAL SERVICES INDUSTRIES, INC. Region: 3 City: DAYTON State: OH County: License #: 31261310039 Agreement: Y Docket: NRC Notified By: STEPHEN JAMES HQ OPS Officer: JEFF HERRERA	Notification Date: 07/16/2019 Notification Time: 12:48 [ET] Event Date: 07/15/2019 Event Time: 00:00 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RHEX EDWARDS (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE DUE TO TRUCK FIRE

The following report was received from the Ohio Bureau of Environmental Health and Radiation Protection via email:

"The licensee [Professional Service Industries, Inc.] experienced a vehicle fire today (7/15/19) involving a Troxler 3430P gauge, S/N 70185, containing a double-encapsulated sealed source of Cs-137 (8 mCi [0.30 GBq]) plus a double-encapsulated sealed source of Am-241 (40 mCi [1.48 GBq]).

"The vehicle driver pulled over on the shoulder of the interstate when he noticed smoke [coming] from the bed of the truck. The licensee believes that the cause of the fire may have been as a result of vandalism that ruptured the fuel tank. The licensee reported that such activities have occurred in the past. No one was injured.

"After the fire was extinguished, the device was surveyed using a calibrated NDS Model ND-500A survey meter. The measured radiation levels of the device were 20 mR/hr at the surface, and 0.9 mR/hr at 1 meter, without the transport case. The device has been leak tested pending results and Troxler has been contacted for disposal."

Item Number: OH190011

Agreement State	Event Number: 54165
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: RAYONIER ADVANCED MATERIALS Region: 1 City: JESUP State: GA County: License #: GA-381-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/16/2019 Notification Time: 13:34 [ET] Event Date: 07/16/2019 Event Time: 00:00 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER MALFUNCTIONED

The following information was obtained from the state of Georgia via email:

"The shutter on a saltcake density meter was identified as needing attention on the last inventory and Berthold was scheduled to come on the next outage to repair or replace as needed. The outage is scheduled for 7/31/19.

"Today, [the licensee] identified that a saltcake pump near the gauge needs to be replaced and the gauge is listed on the pump's lockout sheet. When IM [instrument maintenance] attempted to lock out the meter as part of the established lock out, the shutter handle broke meaning the gauge cannot be locked out. (Lock out requires all energy sources affecting the pump to be locked out. The gauge is in the line ahead of the pump and about 6 feet away so does not really affect the pump.) Radiation survey at the pump showed 65 microRem/hr radiation. (500 microRem/hr at gauge surface and 134 microRem/hr at one foot)

"Maintenance work at the pump will continue with a lock out variance to cite not being able to close the shutter and a proximity radiation work permit used. Berthold is still scheduled to come in 7/31/19 for gauge shutter repair.

"Source is Cesium-137, 20 mCi, model P-2623-100 in LB7440 holder, serial no. 2104-6-90."

Fuel Cycle Facility	Event Number: 54166
Facility: GLOBAL NUCLEAR FUEL - AMERICAS RX Type: URANIUM FUEL FABRICATION Comments: LEU CONVERSION (UF6 TO UO2) LEU FABRICATION LWR COMMERICAL FUEL Region: 2 City: WILMINGTON State: NC County: NEW HANOVER License #: SNM-1097 Docket: 07001113 NRC Notified By: PHILLIP OLLIS HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/16/2019 Notification Time: 14:42 [ET] Event Date: 07/16/2019 Event Time: 11:33 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL	Person (Organization): FRANK EHRHARDT (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT NOTIFICATION DUE TO SPRINKLER MAINTENANCE

"At 1133 EDT on July 16, 2019, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system for the Fuel Manufacturing Operation Shop Support Areas was taken offline for planned maintenance to modify sprinkler piping. Compensatory measures were enacted. The system was taken offline at approximately 0800 EDT and was returned to service at approximately 1400. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will be notifying the North Carolina Emergency Management Agency and NRC Region 2.

Power Reactor	Event Number: 54179
Facility: SAN ONOFRE Region: 4 State: CA Unit: [] [2] [3] RX Type: [1] W-3-LP,[2] CE,[3] CE NRC Notified By: RUSSELL BREEDLOVE HQ OPS Officer: ANDREW WAUGH	Notification Date: 07/23/2019 Notification Time: 19:50 [ET] Event Date: 07/23/2019 Event Time: 14:05 [PDT] Last Update Date: 07/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): NICK TAYLOR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Defueled

Event Text

OFFSITE NOTIFICATION

"On 7/23/2019 at 1405 PDT, San Onofre Nuclear Generating Station (SONGS) made a required formal notification to the Regional Water Quality Control Board for the state of California concerning a monthly oil sample of the oil removal system. The sample was analyzed to contain 42 ppm oil. This number exceeds the daily instantaneous maximum of 20 ppm.

"An additional sample was taken approximately one minute later and was analyzed to contain 8.1 ppm oil, potentially indicating a problem with the initial sample. Additional investigation is underway and a written follow-up report will be submitted to the Regional Water Quality Control Board within 5 days in accordance with the National Pollutant Discharge Elimination System permit."

The licensee will inform NRC Region IV staff.

Page Last Reviewed/Updated Wednesday, March 24, 2021