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Event Notification Report for August 29, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/28/2019 - 8/29/2019

** EVENT NUMBERS **

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: 08/28/2019
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

EN Revision Imported Date : 8/29/2019

EN Revision Text: AGREEMENT STATE REPORT - CESIUM-137 SOURCE INVOLVED 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.

* * * UPDATE FROM ART TUCKER TO RICHARD SMITH AT 1743 EDT ON 8/28/2019 * * *

"On August 28, 2019, the licensee notified the Agency that the results of the leak test performed on the source involved in this event had come back reading 0 dpm. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Azua) and the NMSS Event Notification E-mail group.

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.

Power Reactor	Event Number: 54244
Facility: GRAND GULF Region: 4 State: MS Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: RONALD WALTERS HQ OPS Officer: RICHARD SMITH	Notification Date: 08/28/2019 Notification Time: 19:10 [ET] Event Date: 08/28/2019 Event Time: 13:16 [CDT] Last Update Date: 08/28/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): RAY AZUA (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

LOSS OF HIGH PRESSSURE CORE SPRAY

"On Wednesday, August 28, 2019, at 1316 CDT, Grand Gulf Nuclear Station experienced a power loss to the Control Room High Pressure Core Spray (HPCS) Instrumentation Panel due to an internal inverter failure. The power loss caused the loss of the HPCS System (a single train system). The minimum flow valve (a Primary Containment Isolation Valve) for HPCS opened due to this power loss as well. This valve was manually closed in response to this, and the outboard isolation requirement for the associated penetration [which] is closed [for the] system remained intact throughout this event.

"No other accident mitigation systems were affected by this event.

"The cause of this event is under investigation at this time.

"The NRC Resident Inspectors were notified.

"This Condition is an 8-hour reportable condition as an event or condition that could have prevented the fulfillment of a safety function, in accordance with 10 CFR 50.72(b)(3)(v)(D)."

Page Last Reviewed/Updated Wednesday, March 24, 2021