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Current Event Notification Report for August 17, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/16/2018 - 8/17/2018

** EVENT NUMBERS **


53539 53541 53542 53548 53551

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Agreement State Event Number: 53539
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: KETTERING MEDICAL CENTER
Region: 3
City: KETTERING   State: OH
County: MONTGOMERY
License #: 02120580021
Agreement: Y
Docket:
NRC Notified By: MICHAEL J RUBADUE
HQ OPS Officer: BRIAN LIN
Notification Date: 08/08/2018
Notification Time: 16:46 [ET]
Event Date: 08/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)
DAN COLLINS (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE

The following information was received via E-mail:

"The licensee reported to the [Ohio] Department [of Health] on 8/3/2018 that a potential medical event had occurred due to a delay in a surgical procedure. The delay was caused by the insurance company rescinding approval to remove a breast tumor until three medical opinions were obtained. The licensee implanted a 472 microCi I-125 seed [radioactive seed localization] (RSL) in the tumor on 5/29/2018 after receiving approval from the insurance company. The surgery was scheduled for 6/4/2018. The expected dose to the patient was 12.65 Rem to the tissue and 1.52 Rem EDE [Effective Dose Equivalent]. The surgery was delayed until approval from the insurance company was obtained, and was performed on 8/2/2018. The delay resulted in a tissue dose of 99.45 Rem and EDE of 11.93 Rem.

"A follow-up will be conducted with the routine inspection in September."

Ohio State Report: OH180006

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: 53541
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BIONOMICS
Region: 1
City: OAK RIDGE   State: TN
County:
License #: TN-R-73021-E25
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: OSSY FONT
Notification Date: 08/09/2018
Notification Time: 16:25 [ET]
Event Date: 08/08/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a 'Less than Cat 3' level of radioactive material.

Event Text

AGREEMENT STATE REPORT - UNCONTROLLED SOURCE FOUND

The following was received via email from the State of Tennessee

"Bionomics in Oak Ridge, Tennessee was contracted by a metal recycler in Arkansas to pick up some radioactive material that was rejected by a metals processor. Bionomics made the pickup on August 1st. Upon opening the shipment on August 8th they discovered an orphaned radium source. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows:

"Manufacturer: MINE SAFETY APPLIANCES COMPANY
Model: BILLION-AIRE ANALYZER
Model #: 706P
Serial #: 52328
Isotope: Ra-226 (150 microCi) (JULY 1966) [Calculated 147 microCi (August 2018)]

"A follow-up report will be submitted within 30 days."

* * * UPDATE FROM ANDREW HOLCOMB TO VINCE KLCO ON 8/14/18 AT 1211 EDT * * *

The following information was received from the State of Tennessee via email:

"Bionomics in Oak Ridge, TN was contracted by Tenenbaum Recycling Group (TRG) in Harrison, Arkansas, to pick up some radioactive scrap metals. Bionomics made the pick up on August 1st. Prior to leaving the site, the technician discovered a radium source within the pile of scrap metal scheduled for pick-up. On August 8th, Arkansas was notified by Bionomics and in turn notified the State of TN that a radium device had been picked up and was currently in Oak Ridge, TN at the Bionomics facility. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows:

"Manufacturer: MINE SAFETY APPLIANCES COMPANY

Model: BILLION-AIRE ANALYZER
Model #: 706P
Serial #: 52328
Isotope: Ra-226 (150 microCi)

"A follow-up report will be submitted within 30 days."

Tennessee Event Report ID NO.: TN-18-140

Notified the R1DO (Young) and NMSS Events Notifications via email.

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: 53542
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: FREEPORT   State: TX
County:
License #: LICEN-RAM-L00451
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/09/2018
Notification Time: 16:38 [ET]
Event Date: 08/08/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEVEL GAUGE STUCK SHUTTER

The following information was received via E-mail:

"On August 9, 2018, the Agency [Texas Department of State Health Services] received a notice from the radiation safety officer that a line level gauge was stuck in the open normal operating position. The gauge was found to be stuck during a blow-down operation yesterday afternoon. The gauge is a Ronan SA1-F37 with a Cesium-137 100 milliCurie source (serial number M5513). The gauge is to be serviced by the manufacturer's technician next week.

"The RSO was contacting the licensing section to request an amendment to the permit to operate the gauge in the stuck open position.

"The gauge is fixed at least 20 feet above ground level on a vessel and should not cause any effects to personnel. No exposures were reported upon discovery and the gauge does not present an exposure risk to any individual. The RSO will report the repair or disposal once the gauge is serviced/inspected. The investigation into this event is on-going. Updates to be provided in accordance with SA300."

Texas Incident #: I-9605

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Power Reactor Event Number: 53548
Facility: BEAVER VALLEY
Region: 1     State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROB KLINDWORTH
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/12/2018
Notification Time: 02:58 [ET]
Event Date: 08/12/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text



EN Revision Imported Date : 8/17/2018

EN Revision Text: TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - LOSS OF 480 VOLTAGE EMERGENCY BUS

"On 8-12-18 at 0158 EDT, Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. This resulted in a Loss of Safety Function due to the 2-2 Emergency Diesel Generator [EDG] being Inoperable coincident with the Residual Heat Release Valve (2SVS-HCV104). A Technical Specification shutdown is required per LCO 3.0.3."

The Licensee also stated they were in an unanalyzed condition due to the EDG and Residual Heat Release Valve being inoperable at the same time.

The Licensee is shutting down to Mode 5 (Cold Shutdown).

The Licensee is notifying the Resident Inspector.

The Licensee will be making a Press Release about the unplanned shutdown.


* * * UPDATE ON 08/16/2018 AT 1424 EDT FROM BLASE BARTKO TO KEN MOTT * * *

"On 8-12-18 at 0158 [EDT] Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. Per operational guidance, this was determined to be a Loss of Safety Function due to the Unit 2 Emergency Diesel Generator (EDG) being INOPERABLE coincident with the Residual Heat Release Valve (2SVS-HCV104) 10 CFR 50.72(b)(3)(v)(B) and (D). This was also reported as an Unanalyzed Condition 10 CFR 50.72(b)(3)(ii)(b).

"No Press Release was performed for this event.

"The NRC Resident Inspector was notified.

"At 0410 [EDT] a Technical Specification Shutdown was commenced 10 CFR 50.72(b)(2)(i).

"At 2011 [EDT] the 480 Volt 2P Emergency Bus was restored and energized.

"Further evaluation of the event has determined that this event was not an Unanalyzed Condition and did not result in a Loss of Safety Function. The classifications of Unanalyzed Condition and Loss of Safety Function are being retracted.

"The accuracy of the existing guidance relative to Safety Function has been entered in the Corrective Action Program and interim actions have been taken to provide accurate guidance."

Notified R1DO (Young) via email.

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Power Reactor Event Number: 53551
Facility: BYRON
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN CONROY
HQ OPS Officer: KENNETH MOTT
Notification Date: 08/16/2018
Notification Time: 12:08 [ET]
Event Date: 08/16/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KARLA STOEDTER (R3DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY TEST POSITIVE FOR LICENSED EMPLOYEE

"In accordance with 10 CFR 26.719(b)(2)(ii), this notification reports a licensed Operations employee had a confirmed positive for alcohol during a random fitness for duty test. The individual was not in the protected area and not performing licensed duties at the time of discovery. The employee's access to the plant has been suspended.

"The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Friday, August 17, 2018
Friday, August 17, 2018