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Event Notification Report for February 18, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/17/2020 - 2/18/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54513
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: BIG RIVERS ELECTRIC CORPORATION, DB WILSON STATION Region: 1 City: CENTERTOWN State: KY County: License #: Agreement: Y Docket: NRC Notified By: AJ BHATTACHARYYA HQ OPS Officer: BRIAN LIN	Notification Date: 02/07/2020 Notification Time: 09:23 [ET] Event Date: 02/06/2020 Event Time: 07:15 [EST] Last Update Date: 02/07/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JONATHAN GREIVES (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED PROCESS GAUGE SHUTTER MALFUNCTION

The following was received from the Commonwealth of Kentucky via email:

"The KY RHB [Kentucky Radiation Health Branch] was notified via email on 2/6/2020 (1559 EST) by a representative from specifically licensed facility, Big Rivers Electric Corp., that at 0715 on Thursday, 2/6/2020, one fixed gauging device (Kay Ray Model 7062BP, Serial Number 20086), containing 100 milliCuries Cs-137 (source serial No. 17400V; assay date 10/30/1985) had developed a potential problem while the shutter arm was moving freely. Survey results showed that the shutter remained in the shut position. The gauge is mounted on a pipe, and manned entry is not of concern, and the plant personnel have been notified that there is no access allowed to the affected pipe. All operational and maintenance activities will be delayed until the device has been removed for repair by a service provider. The licensee will be contacting a licensed service provider to remediate this situation. This is being reported under 10 CFR 30.50(b)(2)."

Kentucky Event Report ID No.: KY200001

Agreement State	Event Number: 54514
Rep Org: MINNESOTA DEPARTMENT OF HEALTH Licensee: MAYO CLINIC - ROCHESTER Region: 3 City: ROCHESTER State: MN County: License #: 1047 Agreement: Y Docket: NRC Notified By: TYLER KRUSE HQ OPS Officer: ANDREW WAUGH	Notification Date: 02/07/2020 Notification Time: 11:52 [ET] Event Date: 02/02/2020 Event Time: 00:00 [CST] Last Update Date: 02/07/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANN MARIE STONE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the state of Minnesota via email:

"Lu-177 administration was performed on February 4, 2020. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started. This resulted in an unintended dose to the kidneys. The Radiation Safety Officer (RSO) and staff were notified on February 5, 2020. They determined it was a medical event on February 7, 2020 at 0930 CST. The event was reported to the Minnesota Department of Health (MDH) at 1000 CST on February 7, 2020. The intended dose to the kidney was 490 Rem. The delivered dose to the kidney was 740 Rem (this was their 'best case scenario' calculation). This would fall under 4731.4525 Subpart 1 Item C.: 'a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 Rem and exceeds 50 percent of the dose expected from the administration defined in the written directive.'"

This event is still under investigation with MDH.

Minnesota Event Report ID: MN200002

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: 54515
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: ALPHA-OMEGA SERVICES, INC Region: 1 City: MEMPHIS State: TN County: License #: 10025-L01 Agreement: Y Docket: NRC Notified By: JAMES PLATE HQ OPS Officer: THOMAS KENDZIA	Notification Date: 02/07/2020 Notification Time: 14:32 [ET] Event Date: 02/07/2020 Event Time: 10:12 [EST] Last Update Date: 02/07/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JONATHAN GREIVES (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST OR MISSING SOURCE

The following is a synopses of the Louisiana Department of Environmental Quality email notification to the NRC:

On February 7, 2020 at 1012 EST, the Alpha-Omega Services, Inc., Radiation Safety Officer, contacted the Louisiana Department of Environmental Quality by email to report that a High Dose Rate Ir-192 source cannot be located. The source was in transit to Golden, Colorado and was last located at the Common Carrier hub in Memphis, Tennessee. The source serial number is 02-01-2012-001-012220-11606-02. The current activity of the Ir-192 source is 9.987 Ci.

Event Report ID No.: LA20200002

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Agreement State	Event Number: 54516
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: STERIS, INC. Region: 3 City: LIBERTYVILLE State: IL County: License #: 01123-02 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: THOMAS KENDZIA	Notification Date: 02/07/2020 Notification Time: 15:21 [ET] Event Date: 02/22/2019 Event Time: 00:00 [CST] Last Update Date: 02/07/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANN MARIE STONE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - REPORTABLE EQUIPMENT FAILURE

The following information was received via E-mail:

"A reportable equipment failure occurred on February 22, 2019 at a panoramic irradiator licensee in Libertyville, IL. The equipment failure was not reported to Illinois Emergency Management Agency (IEMA), but identified during a February 6, 2020 routine inspection. The affected equipment has since been repaired and no impacts to health or security were identified.

"IEMA inspectors conducted a routine inspection at Isomedix Operations d/b/a Steris, Libertyville location, on February 6, 2020. During a review of licensee files, it was determined that on the evening of February 22, 2019, required safety equipment became disabled as a result of the cell flooding. This is reportable, at a minimum, under 32 Ill. Adm. Code 340.1220c2. Inspection findings indicate that on or about 1817 CST February 22, 2019, a coupler on a 2 inch sprinkler line in the maze of the cell broke during processing. The cell consequently flooded and began to flood the warehouse. An emergency console stop was executed at approximately 1821 CST and both racks submerged. At 1824 CST, the pool high water alarm was tripped. Inspector review of the console event log indicates within the next 80 minutes the smoke detector, exhaust fans, collision bar, inside roof plug, low air pressure, high temperature, main panel communications and loss of 110 VAC and 24VDC faults were logged.

"It was also noted that at 2024 CST on February 22, 2019, the source racks were moved back up. At 2024 CST, the deionizer radiation monitor alarmed. A number of alarms and faults continued until approximately 1121 CST on 2/23/19. Reportedly, up to four inches of water covered the pool and the entirety of the warehouse. The fire department was needed to shut off the main feeding the sprinklers. Inspection findings indicate, at a minimum, high and low water monitors as well as the deionizer radiation monitor were disabled due to the wiring being flooded and shorted in the trough. The wiring for multiple components were replaced and plumbers contracted to repair the sprinkler system the following day. The licensee has moved to a manually initiated dry fire suppression system. Dosimetry was evaluated and no unusual exposures noted. Interviews of staff involved indicate security systems were not impacted. Leak tests were performed on February 22, 2019. This incident remains under investigation.

"There is no evidence of intentional disruption of safety or security systems."

Event Report ID No.: IL200005

Power Reactor	Event Number: 54528
Facility: DUANE ARNOLD Region: 3 State: IA Unit: [1] [] [] RX Type: [1] GE-4 NRC Notified By: MARK GILBERT HQ OPS Officer: BRIAN LIN	Notification Date: 02/17/2020 Notification Time: 14:51 [ET] Event Date: 02/17/2020 Event Time: 08:50 [CST] Last Update Date: 02/17/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xii) - OFFSITE MEDICAL	Person (Organization): ROBERT ORLIKOWSKI (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

TRANSPORT OF POTENTIALLY CONTAMINATED PERSON TO A MEDICAL FACILITY

"At 0850 CST, on 2/17/2020, the Control Room was notified of a personnel medical event. The individual was transported to a local hospital via ambulance. At the time of transport, the individual was considered to be potentially contaminated because complete surveys could not be performed prior to transfer. Upon arrival at the hospital, the individual and clothing were surveyed by an accompanying Site Radiation Protection Technician and no contamination was found.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(xii).

"The NRC Resident Inspector has been notified."

The individual was not performing any work related activities at the time of event.

Power Reactor	Event Number: 54529
Facility: SOUTH TEXAS Region: 4 State: TX Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: DAVID WURTZ HQ OPS Officer: BRIAN LIN	Notification Date: 02/17/2020 Notification Time: 19:23 [ET] Event Date: 02/17/2020 Event Time: 17:17 [CST] Last Update Date: 02/17/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	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

100

Power Operation

100

Power Operation

Event Text

NOTIFICATION TO OTHER GOVERNMENT AGENCY

"At 1647 CST on 2/17/2020, it was determined that approximately two quarts of hydraulic oil were spilled into the Colorado River during preparation for dredging activities. Cleanup using an oil dispersant and oil booms is underway. The cause of the hydraulic oil spill is under investigation.

"The Texas General Land Office was notified at 1717 CST. Additional reports were made to the Texas Commission of Environmental Quality, the Environmental Protection Agency National Response Center, and the Matagorda County Local Emergency Planning Committee.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, March 25, 2021