Event Notification Report for May 14, 2020

U.S. Nuclear Regulatory Commission Operations Center Event Reports For 5/13/2020 - 5/14/2020 ** EVENT NUMBERS **

 

54694

54695

54696

54707

54708

54709

54710

54712

54714

Agreement State	Event Number: 54694
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT ATHENS REGIONAL MEDICAL CENTER Region: 1 City: ATHENS   State: GA County: License #: GA 4-1 Agreement: Y Docket: NRC Notified By: GREGORY REESE HQ OPS Officer: BETHANY CECERE	Notification Date: 05/05/2020 Notification Time: 13:16 [ET] Event Date: 05/04/2020 Event Time: 00:00 [EDT] Last Update Date: 05/05/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): GLENN DENTEL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE The following was received via email: "On 5/4/20, Piedmont Athens Regional Medical Center (GA 4-1) experienced a misadministration of BTG's TheraSphere Y-90 product. The plan of treatment was for [the treating physician] to deliver 120 Gy to the patient's left hepatic lobe with 1.62 GBq (43.78 milliCuries) of Y-90. The treating physician positioned the microcatheter in the left hepatic artery and verified positioning with a left hepatic arteriogram. With the microcatheter in this position, the treating physician began administering the microspheres. However, only a portion of the dose was delivered as the catheter quickly became occluded. Because of the patient's tortuous hepatic vasculature, the assessment is that a kink in the microcatheter prevented the majority of the dose from being delivered. "The delivered activity was calculated by comparing pre- and post-treatment survey meter measurements of the administration equipment as outlined in TheraSphere's administration procedure. The delivered activity to the patient was 0.28 GBq (7.52 milliCuries). The delivered activity is approximately 83 percent less than the prescribed activity. Post treatment surveys of all gowns, syringes, gloves, drapes, floor coverings, and trash revealed no contamination of the surgical suite. Post treatment planar imaging revealed no extrahepatic deposition of activity. The treating physician explained our inability to deliver the full dose with the patient and a plan was made for the patient to return on 6/5/20 for a second attempt at treating the left hepatic lobe." 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: 54695
Rep Org: COLORADO DEPT OF HEALTH Licensee: L&B Realty LLP Region: 4 City: COMMERCE CITY   State: CO County: License #: GL001377 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: ANDREW WAUGH	Notification Date: 05/05/2020 Notification Time: 17:34 [ET] Event Date: 07/01/2019 Event Time: 00:00 [MDT] Last Update Date: 05/05/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS The following information was received via email: The licensee is unable to locate six tritium exit signs that have an activity of 7.5 Ci each. The exit signs may have been lost during a renovation. 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: 54696
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: HOLY SPIRIT HOSPITAL Region: 1 City: MECHANICSBURG   State: PA County: License #: PA-0249 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: ANDREW WAUGH	Notification Date: 05/06/2020 Notification Time: 12:43 [ET] Event Date: 05/05/2020 Event Time: 00:00 [EDT] Last Update Date: 05/12/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): GLENN DENTEL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT The following information was received via email: "The Department [Pennsylvania Bureau of Radiation Protection] received notification from a licensee on May 5, 2020, of a medical event involving a Varian GammMedplus iX high dose rate remote afterloader (HDR) containing 8.6 Ci of iridium 192. The patient was set to receive 10 fractions (channels) of breast cancer treatment. An error was noted when treatment from the third channel was attempted. The source was retracted back into the safe position upon the error indication. Staff reset the unit and rebooted. The unit functioned normally for the fourth channel. During the fifth channel the machine experienced another fault, but the source did not automatically retract. Staff then attempted two emergency stop procedures; however, both failed. Staff were finally able to manually retract the source after approximately two to four minutes; however, it hasn't been determined if the source was completely retracted into the shielded safe on the HDR due to catheter interference. The patient was quickly disconnected from the catheter, everyone was immediately removed, and the room was secured from entry. No dose is expected outside the HDR room as it is housed within an accelerator vault. The manufacturer has been contacted. The licensee has also requested the log files from the manufacturer for dose reconstruction of those involved. The department is currently in contact with the licensee and will update this event as soon as more information is provided." PA Event Report ID No: PA200011 * * * UPDATE ON 5/7/20 AT 1208 EDT FROM JOHN CHIPPO TO ANDREW WAUGH * * * The following information was received via email: "Manufacturer service technicians removed the wire/source from the afterloader on 5/6/2020. Preliminarily, it appears the source became stuck approximately 4 to 5 inches from the shielded park position (inside the afterloader, but outside the shielded safe). Dosimetry badges have been sent for emergency read, results are expected today, and those results are expected to be minimal." The patient and all personnel involved were surveyed after the incident and readings were at background levels. Notified R1DO (Dentel) and NMSS Event Notifications (email). * * * UPDATE ON 5/12/20 AT 1158 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * * The following information was received via email: "The preliminary dosimetry report indicates three staff members involved in the event. The technologist received 4 mrem whole body dose, the authorized user received 3 mrem whole body dose and the AMP received 3 mrem whole body dose and a 15 mrem dose on their finger dosimeter. No other dose information was received at this time." Notified R1DO (Lally) and NMSS Event Notifications (email). 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: 54707
Facility: Catawba Region: 2     State: SC Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Walter Hunnicutt HQ OPS Officer: Brian P. Smith	Notification Date: 05/13/2020 Notification Time: 01:14 [ET] Event Date: 05/12/2020 Event Time: 22:20 [EDT] Last Update Date: 05/13/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(3)(ii)(A) - Degraded Condition	Person (Organization): MARK MILLER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

1

N

N

0

Refueling

0

Refueling

Event Text

REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED "During the performance of reactor vessel closure head (RVCH) inspections, at 2220 EDT on May 12, 2020, it was determined that the Unit 1 RVCH penetration nozzle number 18 did not meet ASME code case N-729-4 requirements. A surface examination (penetrant test) identified a linear indication on nozzle number 18. The indication was not through-wall as determined by ultrasonic testing. The condition of the Unit 1 reactor vessel head penetration nozzle number 18 will be resolved prior to re-installation of the Unit 1 reactor vessel head. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54708
Facility: Sequoyah Region: 2     State: TN Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Scott Thomas HQ OPS Officer: Andrew Waugh	Notification Date: 05/13/2020 Notification Time: 05:38 [ET] Event Date: 05/13/2020 Event Time: 02:08 [EDT] Last Update Date: 05/13/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(iv)(A) - Eccs Injection 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation	Person (Organization): MARK MILLER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

1

A/R

Y

100

Power Operation

0

Hot Standby

Event Text

AUTOMATIC REACTOR TRIP "At 0208 EDT on 05/13/2020, Sequoyah Unit 1 was at 100% power when an automatic reactor trip signal was received concurrent with a low steam line pressure safety injection signal. "The low steam line pressure safety injection signal was actuated from the steam pressure rate of decrease feature. Main steam isolation valves (MSIVs) automatically closed as designed and steam generator pressures stabilized following the isolation. All other safety-related equipment operated as designed, with the exception of 1-FCV-61-122 Glycol inboard containment isolation valve which failed to automatically isolate on a Phase A containment isolation signal. The corresponding outboard containment isolation valve, 1-FCV-61-110, automatically isolated as designed which isolated penetration X-114. "Safety injection was terminated at 0221 EDT 5/13/20, and Unit 1 is currently being maintained in Mode 3 at normal operating temperature and pressure with auxiliary feedwater supplying the steam generators and decay heat removal via steam generator atmospheric relief valves. "There is no indication of any primary to secondary leakage. The electrical alignment is normal with shutdown power supplied from off-site power. There is no current operational impact to Unit 2. "There is no impact on public health or safety. Post safety injection actuation investigation is in progress. "The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54709
Facility: Browns Ferry Region: 2     State: AL Unit: [] [] [3] RX Type: [1] GE-4,[2] GE-4,[3] GE-4 NRC Notified By: Wesley Conkle HQ OPS Officer: Kerby Scales	Notification Date: 05/13/2020 Notification Time: 13:10 [ET] Event Date: 03/16/2020 Event Time: 01:02 [CDT] Last Update Date: 05/13/2020
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

3

N

N

0

Refueling

0

Refueling

Event Text

INVALID SPECIFIED SYSTEM ACTUATION "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 16, 2020, at approximately 0102 CDT, Browns Ferry Nuclear Plant (BFN), Unit 3 received motor trip-out alarms and diagnosed Group 2 and 3 Primary Containment Isolation System (PCIS) Isolations, 3C Residual Heat Removal (RHR) Pump tripping and Reactor Water Cleanup (RWCU) system isolating. All affected safety systems responded as expected. BFN, Unit 3, was nearing the end of the U3R19 refueling outage at the time of the event, and was still dependent on the Shutdown Cooling (SDC) system. 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. At the time of the event, these conditions did not exist: therefore, the PCIS actuation was invalid. "The event was determined to have been caused by clearance restoration activities in an unprotected control panel. A fuse re-installation inadvertently created a fault condition between two different plant 120 VAC power sources when the fuse holder's lower spring clip contacted a different fuse. This was a result of age-related degradation of the fuse holder, its close proximity to other fuses, and the lack of insulating isolation barriers between fuses. "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 1594925. "The NRC Resident Inspector has been notified of this event."

Power Reactor	Event Number: 54710
Facility: Byron Region: 3     State: IL Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Steven Villacrez HQ OPS Officer: Jeffrey Whited	Notification Date: 05/13/2020 Notification Time: 18:01 [ET] Event Date: 05/13/2020 Event Time: 10:00 [CDT] Last Update Date: 05/13/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(3)(xiii) - Loss Comm/Asmt/Response	Person (Organization): ANN MARIE STONE (R3DO)

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

LOSS OF EMERGENCY RESPONSE FACILITY "At 1000 CDT on May 13, 2020, the Byron Station Technical Support Center (TSC) emergency ventilation system inlet isolation damper would not open as required to support system operation. This failure affected the ability of the TSC ventilation system to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. All other capabilities of the TSC were unaffected by this condition. If an emergency was declared requiring TSC activation during this period, the TSC would be staffed and activated using existing emergency planning procedures. If the TSC became uninhabitable, the Station Emergency Director would relocate the TSC staff to an alternate TSC location in accordance with applicable procedures. The TSC emergency ventilation system inlet isolation damper has been repaired and is now functional. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the discovered condition affected the functionality of an emergency response facility. "The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54712
Facility: Catawba Region: 2     State: SC Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Walter Hunnicutt HQ OPS Officer: Kerby Scales	Notification Date: 05/14/2020 Notification Time: 18:36 [ET] Event Date: 05/14/2020 Event Time: 16:30 [EDT] Last Update Date: 05/14/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(xi) - Offsite Notification	Person (Organization): MARK MILLER (R2DO) CHRIS MILLER (NRR EO) WILLIAM GOTT (IRD)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

1

N

N

0

Refueling

0

Refueling

2

N

Y

100

Power Operation

100

Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO CONTRACTOR FATALITY "At approximately 1430 [EDT] on May 14, 2020, Catawba Nuclear Station (CNS) requested offsite transport for treatment of a contractor to an offsite medical facility. Upon arrival of the coroner, the individual was declared deceased at 1630 [EDT] on May 14, 2020. "The fatality was not work-related and the individual was outside of the Radiological Controlled Area. No news release by CNS is planned. Notifications are planned to the South Carolina Division of Occupational Safety and Health. "This is a four-hour notification, non-emergency for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54714
Facility: South Texas Region: 4     State: TX Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Daniel Turkasz HQ OPS Officer: Kerby Scales	Notification Date: 05/14/2020 Notification Time: 19:28 [ET] Event Date: 05/14/2020 Event Time: 16:10 [CDT] Last Update Date: 05/14/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(xi) - Offsite Notification	Person (Organization): NEIL O'KEEFE (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

2

N

Y

100

Power Operation

100

Power Operation

Event Text

OFFSITE NOTIFICATION FOR HYDRAULIC OIL RELEASE "At 1535 CDT, on 5/14/2020, it was determined that approximately 10 gallons of hydraulic oil was spilled during dredging activities into the STP Intake Basin (adjacent to the Colorado River). Cleanup using oil booms is underway and there is no longer a visible sheen. The cause of the hydraulic oil spill is under investigation. "The Texas General Land Office was notified at 1610 CDT. "The NRC Resident Inspector has been notified."