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Event Notification Report for January 27, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/24/2020 - 1/27/2020

** EVENT NUMBERS **

Power Reactor	Event Number: 54433
Facility: COMANCHE PEAK Region: 4 State: TX Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: MATT KARL HQ OPS Officer: HOWIE CROUCH	Notification Date: 12/10/2019 Notification Time: 11:04 [ET] Event Date: 12/10/2019 Event Time: 09:20 [CST] Last Update Date: 01/24/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): JEREMY GROOM (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

PLANNED LOSS OF EMERGENCY RESPONSE FACILITIES AND EQUIPMENT

"At 0920 CST on December 10, 2019, Comanche Peak began a planned modification on the Unit 1 Plant Computer System. During this modification, the ability to perform emergency assessment in the Technical Support Center (TSC) and the Emergency Operations Facility (EOF) will be impacted. Since the ability to perform emergency assessment is not expected to be restored within 72 hours, this is reportable per 10CFR50.72(b)(3)(xiii) as an event that results in a loss of emergency assessment capability.

"During this modification, the Control Room will continue to have the ability to perform emergency assessment. If an Alert, Site Area Emergency, or General Emergency is declared during this modification, communicators dedicated to performing emergency assessment will be stationed in the Control Room, TSC, and EOF. The Plant Computer System modification is scheduled to be completed on December 22, 2019, and a follow-up ENS notification will be made once the Unit 1 Plant Computer System is declared functional.

"The NRC Resident Inspector has been informed."

* * * UPDATE ON 1/24/20 AT 1034 EST FROM THOMAS BOWDEN TO RODNEY CLAGG * * *

Licensee provided an update to inform that as of 0853 CST on 1/24/20, the modification is complete and the emergency assessment capabilities of the TSC and EOF have been restored.

Notified R4DO (Silva)

Agreement State	Event Number: 54482
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: IRISNDT INC Region: 4 City: HOUSTON State: TX County: License #: L06435 Agreement: Y Docket: NRC Notified By: MATTHEW KENNINGTON HQ OPS Officer: OSSY FONT	Notification Date: 01/16/2020 Notification Time: 14:47 [ET] Event Date: 01/15/2020 Event Time: 00:00 [CST] Last Update Date: 01/16/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On January 16, 2020, the Agency was notified by a licensee of a source disconnect event. The licensee stated that on January 15, 2020, a crew using a QSA Spec-150 camera with 76 Curies of iridium-192 were unable to retract the source back into the camera. The source was recovered and returned to the shielded position. The licensee suspects that the source was not properly connected to the drive cable, allowing the source to be pushed inside the guide tube but unable to retract it. The licensee stated that the individuals that performed the recovery received 50 mR to 60 mR of exposure, and that no overexposures are suspected as a result of the event. Investigation is ongoing. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 9732

Agreement State	Event Number: 54483
Rep Org: ALABAMA RADIATION CONTROL Licensee: EAST ALABAMA MEDICAL CENTER Region: 1 City: OPELIKA State: AL County: License #: 105 Agreement: Y Docket: NRC Notified By: CASON COAN HQ OPS Officer: HOWIE CROUCH	Notification Date: 01/17/2020 Notification Time: 11:57 [ET] Event Date: 01/16/2020 Event Time: 14:45 [CST] Last Update Date: 01/17/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GLENN DENTEL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ALABAMA AGREEMENT STATE REPORT - PATIENT RECEIVED GREATER DOSE THAN PRESCRIBED

The following information was received from the state of Alabama via facsimile:

"On January 16, 2020 at approximately 1445 CST, [the radiation safety officer (RSO)] of Alabama licensee East Alabama Medical Center notified the Alabama Office of Radiation Control [the Agency] that a patient apparently received more dose than prescribed during a treatment via HDR [high dose rate] afterloader on or around Thursday, 1/9/2020. [The RSO] stated that he noted the matter yesterday (1/15/20 at around 1530); he stated that the physician associated with the patient's case confirmed [the RSO's] concerns about the patient's dose. [The RSO] reported that the patient apparently received dose in 1 fraction that was to be administered over 2-3 fractions. The Agency has no further information on this matter as of the date of submission of this memo.

"Of note, East Alabama Medical Center is authorized to possess and use an Elekta Flexitron model 136149A02 HDR medical irradiator under Alabama license 105, with a maximum of 12 Ci of Ir-192."

Alabama Event 20-01

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: 54484
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH Licensee: IRIS NDT Region: 4 City: MANDAN State: ND County: License #: 33-56806-01 Agreement: Y Docket: NRC Notified By: DAVID STRADINGER HQ OPS Officer: HOWIE CROUCH	Notification Date: 01/17/2020 Notification Time: 17:00 [ET] Event Date: 12/18/2019 Event Time: 22:15 [MST] Last Update Date: 01/17/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NORTH DAKOTA AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following information is summarized from an email received from the state of North Dakota:

At approximately 2215 MST on 12/18/2019, while setting up for a radiography shot, the radiography team experienced a source disconnect. When the team realized a disconnect occurred, they established a 2 mR/hr. boundary and contacted the radiation safety officer (RSO). The RSO arrived on site and was able to retrieve the source back into the shielded position. No overexposures were reported. The licensee removed the camera from service and returned it to their facility in Bismarck, ND.

The licensee determined that poor camera maintenance and personnel error contributed to the guide tube being only partially connected to the camera which led to the disconnect. The radiography crew was briefed on the cause of the event and the proper steps to maintain and inspect a camera prior to use.

The camera was a SPEC 150, serial number 2592 , with a 66 Ci Ir-192 source, serial number AK 2405.

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility	Event Number: 54492
Facility: LOUISIANA ENERGY SERVICES RX Type: Comments: URANIUM ENRICHMENT FACILITY GAS CENTRIFUGE FACILITY Region: 2 City: EUNICE State: NM County: LEA License #: SNM-2010 Docket: 70-3103 NRC Notified By: WYATT PADGETT HQ OPS Officer: THOMAS KENDZIA	Notification Date: 01/22/2020 Notification Time: 19:00 [ET] Event Date: 01/22/2020 Event Time: 16:23 [MST] Last Update Date: 01/27/2020
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE	Person (Organization): NICOLE COOVERT (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

REQUIRED PROCEDURAL CONTROLS WERE NOT FOLLOWED

"Urenco USA is conservatively reporting a condition in that Uranic bearing material was placed into the Small Component Decontamination Train (SCDT) without meeting all conditions of IROFS54a and IROFS54b.

"IROFS54a and IROFS54b are Mass Controls that ensure the configuration of the SCDT remains sub-critical. Bookkeeping elements of the IROFS were performed correctly and the masses of the components were determined properly. However the visual inspection of the SCDT to ensure it is empty, prior to introducing components, was not performed in accordance with procedure instructions.

"The components were removed and the visual inspection was performed which confirmed the SCDT was in fact empty.

"The facility was and remains in a safe and stable configuration."

The licensee will notify NRC Region 2 tomorrow.

* * * RETRACTION ON 1/24/20 AT 1130 EST FROM BLAKE BIXENMAN TO RODNEY CLAGG * * *

"This event was determined to not be reportable.

"Consistent with NRC FCSS ISG-12, Rev 1, 10 CFR Part 70, Appendix A - Reportable Safety Events, UUSA has
concluded that EN54492 was not reportable. All situations where IROFS have failed or degraded are reportable
under Paragraphs (a)(4) or (b)(2), exceptions include the following: The capabilities of the degraded IROFS are
still sufficient to meet the performance requirements of 10 CFR 70.61.

"On 01-17-2020, UUSA completed a discharge of material to the slab tanks in the Liquid Effluent Collection
Treatment & Storage (LECTS) Room. Upon completion of decontamination activities in the SCDT, procedurally
required actions were performed to ensure all in process uranic material was removed and verification of the
uranic material hold-up value was still valid in accordance with IROFS54a&b. IROFS54a&b tags and locks were
then installed indicating the IROFS functions had been performed.

"On 01-22-2020, a new work evolution began which included bookkeeping measurements to ensure the
calculated mass of uranium was below the allowable threshold prior to introduction to the SCDT. In summary, all
requirements of the IROFS54a&b boundary were functionally complete and the capabilities of the degraded
IROFS remained sufficient to meet the performance requirements of 10 CFR 70.61."

Notified the R2DO (Coovert) and NMSS Events Notification (email)

Page Last Reviewed/Updated Wednesday, March 24, 2021