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Event Notification Report for December 06, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/5/2019 - 12/6/2019

** EVENT NUMBERS **


54368 54421 54422 54423 54424 54425

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Agreement State Event Number: 54368
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: MISTRAS
Region: 4
City: Pascagoula   State: MS
County: Jackson
License #: 12-16559-02
Agreement: Y
Docket:
NRC Notified By: JASON MOHA
HQ OPS Officer: DAN LIVERMORE
Notification Date: 11/03/2019
Notification Time: 11:38 [ET]
Event Date: 11/02/2019
Event Time: 10:40 [CST]
Last Update Date: 12/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
JOHN DIXON (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 12/6/2019

EN Revision Text: POTENTIAL OVEREXPOSURE OF RADIOGRAPHER

The following was received from the Mississippi Division of Radiological Health via phone:

A radiographer was exposed to a 100 Curie Ir-192 source for 8 minutes while changing film during a radiography shot. The radiographer was not wearing dosimetry and did not have a hand held radiation meter. While changing film, the radiographer realized the source had not been retracted and left the area. This was not an equipment malfunction, and the source was retracted when it was realized that the radiographer had been exposed. The radiographer reported the event to the Mistras Radiation Safety Officer (RSO). Estimated dose is 20 Rem to the hands and 19.6 to 19.7 Rem whole body. The radiographer was sent to a local hospital for bloodwork.

* * * UPDATE FROM ROBERT SIMS TO HOWIE CROUCH VIA EMAIL AT 1706 EST ON 11/8/19 * * *

"[A state of Mississippi Health Physicist investigator] interviewed the RSO on 11/7/2019 and investigated the incident. After reviewing and questioning the incident details, [the investigator] found the following evidence that may determine this may not have been an overexposure. The assistant radiographer retracted the source, but did not perform the bump test to fully retract the source into the locked position. This caused the assistant radiographer to believe the source was still in the collimator. When returning to change the film, he saw the red button on the camera instead of green which would indicate the source was in the locked position. The assistant was not using dosimetry, rate alarm or survey instrumentation. He appears to have panicked, came down the ladder, and couldn't get the crank to move in. The lead radiographer then grabbed the crank and cranked out and back in immediately to fully retract the source into the camera. [The investigator] reviewed compliant leak tests of camera and wipes along with maintenance and service reports before and after the incident and the RSO could not replicate any problems that would prevent them from retracting the source. There was no malfunction with the camera or the cranks. It appears that the source was in the end of the camera but not in the fully shielded position, which could allow some radiation out of the tube that the source enters. However, we do not know how much because the assistant was not wearing any dosimetry. The other assistant's dosimetry [assistant radiographer 2] only picked up 1 milliRem of dose but he was approximately 25 ft. away with steel shielding from the tank they were working on in between him and the source. [The investigator is] waiting on the emergency reading of the doses recorded on the OSL badges used by the crew and follow up doctor's visit. [The investigator] interviewed [the assistant radiographer on] 11/8/2019 at 1549 CST. [The assistant radiographer] reports that he had more blood drawn today and will provide results next week. He said he feels great and has had no sickness such as nausea, pain or redness and swelling in the hands. Will update again next week after receiving lab results."

* * * UPDATE FROM ROBERT SIMS TO THOMAS KENDZIA VIA EMAIL AT 1409 EST ON 11/19/19 * * *

"[A state of Mississippi Health Physicist investigator] interviewed the assistant radiographer [who was not wearing dosimetry] on 11/12/2019. [The assistant radiographer] reported that lab was drawn on 11/3/2019 and 11/8/2019. Both labs results returned within normal limits and [the assistant radiographer] has no physical symptoms of radiation sickness. [The assistant radiographer] remains at regular work duties recommended in his physician reports that he provided to [the investigator]. [The RSO] was interviewed on 11/11/2019 and provided the Landauer dosimetry report for the three RT crew members. The crew received new dosimeters on 11/1/2019 and they were sent for an emergency read the day after the incident.

"[The] lead radiographer received 109 milliRem, [assistant radiographer 2 who was wearing dosimetry] received 269 milliRem and [the assistant radiographer] received 150 milliRem although he was not wearing his dosimeter during this incident. [The assistant radiographer] is also on UT and other duties until the end of the year until his new annual dose limit year starts January 1, 2020. This is upon the recommendation of [the investigator] because although it has been determined that [the assistant radiographer] did not receive an over exposure equaling or exceeding the 15 to 25 RAD to cause radiation sickness, it does not rule out if he did or did not exceed his 5 rem TEDE. The licensee's personnel believe that the source was in the end of the camera, but not in the fully locked position because the red button was showing on the QSA 880 camera when [the assistant radiographer] returned from changing the digital film plate. Due to his elevation up on the tank and the tank shielding we cannot use any of the other crew members dosimetry to make any determinations. However based on the medical reports and physical evidence it appears that [the assistant radiographer] has no physical symptoms from radiation sickness. [The assistant radiographer] will have his last lab test on 11/22/2019, if it is normal, [the assistant radiographer] states that the physician intends to release him completely from all medical care related to this incident."

Notified the R4DO (O'Keefe) and NMSS Events Notification via email.

* * * UPDATE AT 1333 ON 12/5/2019 FROM ROBERT SIMS TO JEFF HERRERA * * *

"As the investigation continued [a state of Mississippi Health Investigator] reviewed additional information received throughout the day on 11/18/2019, but sufficient time did not exist to thoroughly review the latest findings to include them on the 11/19/2019 update.
The current additional findings are as follows: [the state of Mississippi Health Physicist Investigator] Re interviewed all personnel again, and requested all lab results and Physician findings from [the assistant radiographer].

"[The assistant radiographer] willingly provided all CBC and cytogenetic lab test results that were taken on 11/3/2019, 11/8/2019, and 11/22/2019. [The assistant radiographer] stated that the physician reported the lab results to be within normal limits and the physician released [the assistant radiographer] from medical care on 11/22/2019 that had resulted from this incident.

"[The state of Mississippi Health Physicist Investigator] also found during the second interview of personnel that the films that were with [the assistant radiographer] and located on the pipe during the 8 minutes that it took [the assistant radiographer] to change out the film were processed later and were acceptable images. [The state of Mississippi Health Physicist Investigator] attached the images in the file as evidence to support that [the assistant radiographer] was not overexposed. If the films had been exposed with an open source out for 8 minutes they would be blacked out from overexposure. The original exposure time to produce the radiograph with the film combination, distance and thickness of steel for this job was 1 minute. Even with digital radiography, an image receptor plate can be overexposed beyond acceptable exposure limits, and cannot be window leveled to make it an acceptable image, but this was not the case. The radiographer and RSO reported that an attempt to crank out and retract the source was made by each assistant and the radiographer when trying to retract the source after [the assistant radiographer] returned down the ladder. This would explain why the images produced were acceptable radiographs. There had been enough exposure to properly expose the film but not overexpose it. This appears to support the possibility that the source was not out the entire 8 minutes while [the assistant radiographer] was changing the film and moving the source tube on the jig. At this point [the assistant radiographer] was also down the ladder 25 feet away with the other radiographers who were wearing the required dosimetry behind the shielding of the tank. Three (3) violations were issued and corrective actions have been submitted to the Mississippi Division of Radiological Health All records are included in the 2019 Incident file at the Mississippi State Department of Health Division of Radiological Health. [The state of Mississippi Health Physicist Investigator] considers this investigation and incident closed. If you require any further information, documentation or have questions, please contact [The state of Mississippi Health Physicist Investigator].

"Mississippi Incident No.: MS-190005, NMED #190535"

Notified the R4DO (Taylor) and NMSS (via email).

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Non-Power Reactor Event Number: 54421
Facility: KANSAS STATE UNIVERSITY
RX Type: 250 KW TRIGA MARK II
Comments:
Region: 0
City: MANHATTAN   State: KS
County: RILEY
License #: R-88
Agreement: Y
Docket: 05000188
NRC Notified By: ALAN CEBULA
HQ OPS Officer: BRIAN LIN
Notification Date: 12/05/2019
Notification Time: 10:41 [ET]
Event Date: 12/04/2019
Event Time: 18:00 [CST]
Last Update Date: 12/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
ELIZABETH REED (ENC)
PATRICK BOYLE (PM)
LINH TRAN (BPM)

Event Text

ANNUAL SURVEILLANCE NOT COMPLETED

The following was received via email from Kansas State University Nuclear Reactor Facility:

"Per Technical Specification 4.7.3, fuel elements comprising approximately 1/3 of the core shall be visually inspected annually for corrosion and mechanical damage such that the entire core shall be inspected at a 3-year intervals. Due to an inspection tracking sheet sorting error, four fuel elements were not marked to be inspected and are currently outside of the required surveillance frequency. Failure to perform a surveillance within the required time interval shall result in the component being inoperable.

"The reactor is and will remain shutdown until review by the Reactor Safeguards Committee of corrective actions in accordance with the Technical Specifications.

"A written report will be submitted within ten days summarizing the reportable occurrence."

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Fuel Cycle Facility Event Number: 54422
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: KERBY SCALES
Notification Date: 12/05/2019
Notification Time: 13:20 [ET]
Event Date: 12/04/2019
Event Time: 14:30 [EST]
Last Update Date: 12/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
ALAN BLAMEY (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

FIRE SPRINKLER LINE OUT OF SERVICE

The following was received via email from Global Nuclear Fuels - Americas, LLC:

"At 1430 EST, on December 4, 2019, the New Hanover County Deputy Fire Marshall was notified that a section of fire sprinkler line supporting the Fuel Manufacturing Operation (FMO) was unable to perform its intended function. The sprinkler line supported a small section of office area. No areas supporting fuel manufacturing were affected. The fire sprinkler pipeline was returned to operation at approximately 1920 EST on December 4, 2019. The New Hanover County Deputy Fire Marshall was informed of system restoration. 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 notify the NRC Resident Inspector and the Region.

Notified R2DO (Blamey) and NMSS (email).

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Power Reactor Event Number: 54423
Facility: TURKEY POINT
Region: 2     State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: RYAN FRANK
HQ OPS Officer: OSSY FONT
Notification Date: 12/05/2019
Notification Time: 13:30 [ET]
Event Date: 12/05/2019
Event Time: 12:20 [EST]
Last Update Date: 12/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ALAN BLAMEY (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO DECEASED MANATEE IN OWNER CONTROLLED AREA

"This 4-hour non-emergency notification to the NRC is being made on a notification to another government agency per 10 CFR 50.72(b)(2)(xi).

"On 12/5/2019, at 0719 EST, a deceased manatee was identified in the Owner Controlled Area. The Federal Fish and Wildlife Service and the Florida Fish and Wildlife Conservation Commission (FWCC) were notified on 12/5/2019, at 1220 EST.

"Miami-Dade County was notified on 12/5/2019, at 1245 EST. A courtesy call to the Florida Department of Environmental Protection was made on 12/5/2019, at 1300 EST.

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 54424
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Region: 3
City: CHANHASSEN   State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GERARD HANSON
HQ OPS Officer: OSSY FONT
Notification Date: 12/05/2019
Notification Time: 14:45 [ET]
Event Date: 11/06/2019
Event Time: 00:00 [CST]
Last Update Date: 12/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
ERIN CARFANG (R1DO)
ALAN BLAMEY (R2DO)
ROBERT DALEY (R3DO)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PART 21 REPORT - POTENTIAL DEVIATION OF PRESSURE TRANSMITTERS DUE TO TEMPERATURE RISE

The following information was received from Emerson Rosemount Nuclear Instruments, Inc. via fax:

"Rosemount Nuclear Instruments, Inc. (RNII) is providing an interim evaluation report on the treatment of temperature rise due to electronics self-heating in qualified life thermal aging calculations on Model 1153 and 1154 [inclusive of 1153 Series B, 1153 Series D, 1154, and 1154 Series H] pressure transmitters. The evaluation is being conducted to determine if modifications to the currently specified qualified life are warranted.

"Qualification programs for 1153 and 1154 pressure transmitters were structured to comply with the requirements of IEEE standard 323-1974 which requires aging to establish a qualified life prior to design basis event testing. Thermal aging is considered a significant aging mechanism; therefore, accelerated thermal aging was conducted on type test specimens as described in RNII qualification reports D8300040 and D8700096. These reports document the thermal aging basis for all 1153 and 1154 models identified in section 1.0. In both type test programs, temperature rise due to electronics self-heating was present during thermal aging and was consistent with expected in service normal operating conditions.

"These evaluations are expected to be complete by February 28, 2020.

"If there are any questions, or you require additional information related to this issue, please contact Nathan Schukei (952) 949-5213 or Paul Schmeling (952) 949-5359."

There are currently no known affected customers.

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Power Reactor Event Number: 54425
Facility: COOPER
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: RANDY KOUBA
HQ OPS Officer: KERBY SCALES
Notification Date: 12/05/2019
Notification Time: 16:03 [ET]
Event Date: 12/05/2019
Event Time: 08:10 [CST]
Last Update Date: 12/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
NICK TAYLOR (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

FIRE DOOR DISCOVERED UNLATCHED

The following was received via email from Cooper Nuclear Station:

"At 0810 [CST], on 12/5/19, Operations personnel discovered BLDG-DOOR-R209, FIRE DOOR BETWEEN CRITICAL SWITCHGEAR ROOMS F & G, was unlatched. The door was immediately latched upon discovery. Based on door logs, the door separating the two critical switchgear rooms was inadvertently left unlatched for approximately 5 minutes. This door is a Steam Exclusion Boundary (SEB) door. It is required to be closed and latched when the Auxiliary Steam Boiler is in service due to Auxiliary Steam piping passing through Critical Switchgear Room 'G'. If a steam line break was to occur with the door unlatched, steam could render both Critical Switchgear busses inoperable.

"This is being reported under 10 CFR 50.72(b)(3)(ii)(B), Unanalyzed Condition, and 10 CFR 50.72(b)(3)(v), Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (B) remove residual heat and to (D) mitigate consequences of an accident.

"There was no impact on the health and safety of the public or plant personnel."

The door closes automatically and appeared to have been left unlatched by the last person passing through. The door was tested and latches as required.

The licensee notified the NRC Resident Inspector.


Page Last Reviewed/Updated Friday, December 06, 2019
Friday, December 06, 2019