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Event Notification Report for August 28, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/27/2019 - 8/28/2019

** EVENT NUMBERS **


54226 54227 54228 54230 54231 54242

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Agreement State Event Number: 54226
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HALLIBURTON ENERGY SERVICES, INC.
Region: 4
City: HOUSTON   State: TX
County:
License #: LICEN-RAM-L02113
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/19/2019
Notification Time: 09:26 [ET]
Event Date: 08/17/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - CESIUM-137 SOURCE INIVOLVED IN VEHICLE FIRE

The following information was received via E-mail:

"This report is sent for informational purposes. On August 17, 2019, the Agency [Texas Department of State Health Services] received a call from the answering service and was informed that a licensee had reported a fire during transport of a density gauge. The Agency called the licensee, Halliburton Energy Services and was informed of the event. The licensee stated one of their blending trucks had been traveling on highway 285 south near Orla, Texas when the driver saw sparks coming from the road behind their truck. The driver pulled over and when they went to the back of the truck they found a tire had blown out and was now burning.

"The driver called for help, but by the time the fire department arrived, the truck was fully involved in the fire. The truck was transporting a 100 millicurie cesium-137 source installed on a pipe. The licensee stated the dose rate at 30 centimeters from the gauge, taken after the fire was extinguished, was 2 millirem per hour, which is normal. The licensee stated the truck and trailer were taken to their facility and a leak test was taken on the gauge. The licensee stated the driver had pulled off the road and traffic was not restricted. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9703

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


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1013 EDT ON 8/19/2019 * * *

The following information was received via E-mail:

"The Agency received a call from the licensee at 0856 CDT on August 19, 2019. The licensee stated they had conducted additional surveys this morning and found dose rates were as high as five millirem per hour at one meter from the gauge. The licensee contacted their manufacturing section and one of the individuals was familiar with this type of event stated the gauge shielding was probably compromised, but believed the source was undamaged. The licensee stated the gauge would be returned to its manufacturing facility for inspection. No exposure has occurred from this event. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Young) and the NMSS Events Notification E-mail group.

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Non-Agreement State Event Number: 54227
Rep Org: USAF DEFENSE LOGISTICS AGENCY
Licensee: UNITED STATES AIR FORCE
Region: 1
City: FORT EUSTIS   State: VA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: SCOTT NEMMERS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 08/19/2019
Notification Time: 12:31 [ET]
Event Date: 07/11/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CALE YOUNG (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

NI-63 SOURCE INADVERTENTLY SENT TO DISPOSAL FACILITY

The following is a summary of a phone call with the licensee:

The U.S. Air Force Defense Logistics Agency (DLA) received report of a source which they believe has been inadvertently sent to a waste disposal facility.

The source (Ni-63, 15 mCi, S/N 30306) was housed in a desktop chemical scanner, and has been in use for some time. On 4/26/2019, the scanner was sent to the U.S. Air Force Defense Reutilization and Marketing Office (DRMO). On 5/13/2019, DRMO then sent the scanner to DLA as scrap/waste, after which it was likely sent to a disposal facility. On 7/11/19, it was determined that the source has been inadvertently disposed of. DLA is currently working to determine which waste facility received the source, so recovery can be attempted.

The source was last leak tested on 10/01/2018, with no leaks detected. No exposures were expected from the disposal of the source.

The licensee has contacted NRC RIV (Poston-Brown).

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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Agreement State Event Number: 54228
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NUCOR STEEL OF TUSCALOOSA
Region: 1
City: TUSCALOOSA   State: AL
County:
License #: 1426
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: KERBY SCALES
Notification Date: 08/19/2019
Notification Time: 12:04 [ET]
Event Date: 08/18/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE LOCKING MECHANISM

The following report was received via fax:

"On August 19, 2019, an Environmental Engineer for Nucor Steel of Tuscaloosa, Alabama notified the Office of Radiation Control [Agency] that a gauge stored in a caster mechanism had a loss of containment and damaged the locking mechanism of the gauge. The shutter mechanism is working, but the gauge cannot be locked out.

"The licensee notified the Alabama Emergency Operations Center of the event on August 18, 2019, at 1757 CDT. The licensee chose to follow-up with the Agency to ensure proper notification. The Agency told the licensee to send a synopsis of the events and a plan of action to maintain or dispose of the gauge.

"As of 1100 CDT today, the gauge is secure, but unlockable. The licensee has contacted the manufacturer for possible repair or disposable options. This incident remains open until a decision is made by the licensee for repair or disposal."

Alabama Incident: 19-20

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Agreement State Event Number: 54230
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Notification Date: 08/19/2019
Notification Time: 14:17 [ET]
Event Date: 08/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDER-DOSAGE

The following was received via fax:

"On August 16, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The treatment plan was for 2 administrations of Y-90. The first administration was delivered without incident. The second administration was to be a total dosage of 12.27 mCi delivered to the right lobe of the liver. During this second administration, it was observed that the team had backflow into the administration vile. The administration was immediately halted, and the team took readings to ascertain the amount of material delivered. It was estimated that only 28 percent of the dose was delivered to the patient. The patient was verbally informed the day of the event. The referring physician was left a voicemail on the day of the event, however further attempts will be made to contact him directly."

Event Report ID No.: PA190019

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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Agreement State Event Number: 54231
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: DALLAS   State: TX
County:
License #: L04878
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/20/2019
Notification Time: 11:19 [ET]
Event Date: 07/30/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSAGE ADMINISTERED

The following was received via email:

"On August 19, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred. The event occurred on a patient who was prescribed to receive four treatments of lutetium-177 at 200 milliCuries each. After the third treatment, the physician was supposed to change the dose of the fourth and final dose to 100 milliCuries. The radiopharmaceutical was ordered, and the dose was administered. The RSO stated that during the review of the patient's treatment, they found the pharmacy had sent a unit dose of 200 milliCuries instead of the requested 100 milliCuries. The RSO stated both the prescribing physician and the patient were notified of the error. No adverse effects are expected on the patient.

"The Agency has requested additional information on this event. Additional information will be provided as it is received in accordance with SA-300."

* * * UPDATE ON 8/20/19 AT 1133 EDT FROM ART TUCKER TO BETHANY CECERE * * *

"On August 20, 2019, the licensee contacted the Agency and stated the treatment site was the mid-gut. The treatment was conducted on July 30, 2019. The error was discovered the day of the event. Additional information will be provided as it is received in accordance with SA-300."

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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Power Reactor Event Number: 54242
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT CAMENISCH
HQ OPS Officer: ANDREW WAUGH
Notification Date: 08/27/2019
Notification Time: 02:34 [ET]
Event Date: 08/27/2019
Event Time: 01:09 [EDT]
Last Update Date: 08/27/2019
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):
STEVE ROSE (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP

"At 0109 EDT, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to a dropped rod causing a negative rate trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by the auxiliary feedwater (AFW) and steam dump systems. Unit 2 is not affected.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system.

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


Page Last Reviewed/Updated Wednesday, August 28, 2019
Wednesday, August 28, 2019