Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2020

Event Notification Report for May 07, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/6/2020 - 5/7/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54683
Rep Org: TENNESSEE DIV OF RAD HEALTH Licensee: SERVICE KING COLLISION REPAIR Region: 1 City: MT. JULIET State: TN County: License #: GL1192/GL1193 Agreement: Y Docket: NRC Notified By: ANDREW HOLCOMB HQ OPS Officer: HOWIE CROUCH	Notification Date: 04/28/2020 Notification Time: 14:49 [ET] Event Date: 02/24/2020 Event Time: 00:00 [EDT] Last Update Date: 04/28/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): DAN SCHROEDER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) LAURA PEARSON (ILTAB)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST STATIC ELIMINATORS CONTAINING POLONIUM-210

The following information was obtained from the state of Tennessee via email:

"During a recent inventory at two different locations of Service King Collision Repair Centers, two static elimination devices were found to be missing. One location in Chattanooga, TN, lost the device during the transition of closing the repair center. Updated information will be included in a follow-up report. The information for the devices is below:

Manufacturer Model Serial# Isotope Activity
NRD, LLC P-2021 A2LV457 Po-210 10 mCi
NRD, LLC P-2021 A2LU553 Po-210 10 mCi"

Tennessee Event Report ID No.: TN-20-076

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

Agreement State	Event Number: 54684
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT HOSPITAL Region: 1 City: ATLANTA State: GA County: License #: GA 292-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: HOWIE CROUCH	Notification Date: 04/29/2020 Notification Time: 16:16 [ET] Event Date: 05/28/2019 Event Time: 00:00 [EDT] Last Update Date: 04/29/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAN SCHROEDER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE OF YTTRIUM-90 THERASPHERES DIFFERED FROM PRESCRIBED DOSE BY GREATER THAN 20 PERCENT

The following information was received from the state of Georgia via email:

"On May 28, 2019, it was brought to [Piedmont Hospital's radiation safety officer (RSO)] attention that a Y-90 TheraSphere administration had not delivered the full prescribed activity to the patient as intended. Upon further discussion, it was noted that the performing physician noticed, after connection of the line between the microcatheter and the delivery vial, that multiple air bubbles had become trapped in the line. He then created a closed system manifold using a three-way stopcock and syringes to effectively bleed out air bubbles and flush back as much of the dose as possible to the patient. The closed system prevented any spillage or contamination and residual dose was retained in the syringes and stopcocks. Despite these actions taken by [the performing physician], a post-administration assay of the waste container showed that the full desired activity had not made it out of the delivery equipment and into the patient. The procedure was a segmentectomy, and the patient will be re-evaluated in one month's time to determine if an additional therapeutic administration will be needed.

"The prescribed activity to be delivered to the patient was 2.15 GBq (58 mCi). The calculated delivered activity to the patient was 1.01 GBq (27.3 mCi). Delivered activity was determined by comparing pre- and post-administration survey meter measurements of the administration equipment, as per standard TheraSphere procedure.

"Root Cause - Human error: Air was likely trapped somewhere in the system during the initial setup of the equipment. Operator technique failed to completely purge the lines of this air. Air bubbles in the line were not visible or not noticed prior to the connection of the line. Efforts to eliminate the air and deliver the full dose to the patient were then not successful."

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: 54697
Facility: BROWNS FERRY Region: 2 State: AL Unit: [] [2] [] RX Type: [1] GE-4,[2] GE-4,[3] GE-4 NRC Notified By: ALLEN BUCKNER HQ OPS Officer: BETHANY CECERE	Notification Date: 05/06/2020 Notification Time: 14:11 [ET] Event Date: 03/08/2020 Event Time: 20:21 [CDT] Last Update Date: 05/06/2020
Emergency Class: Non Emergency 10 CFR Section: 50.73(a)(1) - Invalid Specif System Actuation	Person (Organization): MARK MILLER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system. On March 8, 2020, at approximately 2021 CDT, Browns Ferry Nuclear Plant Unit 2 experienced an unexpected loss of the 2A Reactor Protection System (RPS). This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and the initiation of Standby Gas Treatment Trains A and B, and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The RPS MG Set trip was believed to have been caused by an intermittent short across a spike suppressor, which led to a loss of generator output signal to a voltage regulator. The affected components have been replaced.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Report 1593265.

"The NRC Resident Inspector has been notified of this event."

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