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Event Notification Report for August 07, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/6/2020 - 8/7/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54804
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: KishHealth System Region: 3 City: Dekalb State: IL County: License #: IL-02097-01 Agreement: Y Docket: NRC Notified By: Gary Forsee HQ OPS Officer: Thomas Herrity	Notification Date: 07/29/2020 Notification Time: 13:43 [ET] Event Date: 07/28/2020 Event Time: 00:00 [CDT] Last Update Date: 07/29/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): MICHAEL KUNOWSKI (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT- PATIENT UNDERDOSE

The following was received from the Illinois Emergency Management Agency (IEMA) via email:

"KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively.

"IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days."

Illinois item number: IL200013

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: 54805
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: Westrock Texas LP Region: 4 City: Silsbee State: TX County: License #: L 01095 Agreement: Y Docket: NRC Notified By: Arthur Tucker HQ OPS Officer: Andrew Waugh	Notification Date: 07/30/2020 Notification Time: 08:13 [ET] Event Date: 07/29/2020 Event Time: 00:00 [CDT] Last Update Date: 07/30/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): HEATHER GEPFORD (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following information was received via email:

"On July 29, 2020, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that during the performance of routine gauge inspections two gauges were found to have shutters that would not function. One was a Ronan model SA-1-F37 gauge containing a 150 mCi cesium-137 source with the shutter stuck in the open position. The second gauge was a Ronan model SA-1-C10 gauge containing a 100 mCi cesium-137 source with the shutter stuck in the closed position. Both source activities reported are the original activities. The gauge shutters are stuck in the normal operating position and do not create any additional exposure risk to any individual. The licensee has contacted a service company to repair the gauges. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9780

Agreement State	Event Number: 54807
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: Town of Littleton Region: 1 City: Attleboro State: MA County: License #: N/A Agreement: Y Docket: NRC Notified By: Zara Rejaee HQ OPS Officer: Bethany Cecere	Notification Date: 07/30/2020 Notification Time: 12:35 [ET] Event Date: 07/01/2020 Event Time: 00:00 [EDT] Last Update Date: 07/30/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): BRICE BICKETT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - ABANDONED RADIOACTIVE SCRAP METAL

The following information was received via email:

"On 7/1/2020, Massachusetts Radiation Control Program was informed by Schnitzer Steel Industries, Inc., that a scrap metal shipment from Town of Littleton Transfer Station in Littleton, MA set off the radiation monitor alarm. The vehicle was redirected back to Littleton Transfer Station for follow-up survey and mitigation in accordance with MA RCP DOT Special Permit 10656 MA-MA-20-01.

"On 7/6/20, the material was identified and segregated from the scrap metal load by an independent radiation consultant. The radioactive material discovered was radium-226 Aircraft gauge. Device is intact and not leaking as a wipe test was done by radiation consultant. A Ludlum Model 9DP-1 ion chamber was used for direct measurements on the instrument. The dose rate at 6 inches from the instrument was 1 mR/hr. Dose rate outside of drum is less than 300 microR/hr. The radium-226 activity was estimated to be approximately 31.6 microCuries based on the dose rate measured.

"The RAM material is being stored in safe secure storage away from people and labeled as radioactive material held for proper disposal.

"This activity meets the 30-day event report requirement for lost or abandoned radioactive material greater than 10 times the quantities specified in 10 CFR 20 Appendix C, or the Massachusetts equivalent, 105 CMR 120.297 Appendix C, which is ten times reportable quantity for radium-226 (1 microCurie).

"The Massachusetts Radiation Control Program considers this event to be open until proper disposal of this instrument is confirmed."

Event Docket No.: MA 19-4216

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

Power Reactor	Event Number: 54820
Facility: Peach Bottom Region: 1 State: PA Unit: [] [3] [] RX Type: [2] GE-4,[3] GE-4 NRC Notified By: Dan Dullum HQ OPS Officer: Andrew Waugh	Notification Date: 08/06/2020 Notification Time: 13:10 [ET] Event Date: 06/08/2020 Event Time: 04:24 [EDT] Last Update Date: 08/06/2020
Emergency Class: Non Emergency 10 CFR Section: 50.73(a)(1) - Invalid Specif System Actuation	Person (Organization): FRANK ARNER (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INVALID SPECIFIED SYSTEM ACTUATION

"This report is being made as required by 10 CFR 50.73(a)(2)(iv)(A) to describe an automatic actuation of containment isolation valves in more than one system. Because the actuation was invalid, this 60-day telephone notification is being made instead of a written LER [licensee event report], in accordance with 10 CFR 50.73(a)(1).

"On 06/08/2020, at approximately 0424 EDT, a trip of the Unit 3 'A' reactor protection system (RPS) MG-Set resulted in a partial activation of the primary containment isolation system and inboard containment isolation valves closed in multiple systems. All affected Group III containment isolation valves were verified to be closed. It was determined that the normal power supply for the Unit 3 'A' RPS had failed. Power was transferred from the normal to the alternate source and the RPS 'A' channel was reset.

"Investigation determined that the 3A RPS MG Set motor contactor coil winding had failed due to an internal short circuit. The motor contactor has been replaced.

"The containment isolation was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered to be an invalid actuation.

"The NRC Resident Inspector has been informed of this notification."

Page Last Reviewed/Updated Wednesday, March 24, 2021