Event Notification Report for April 25, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/24/2019 - 04/25/2019
Agreement State
Event Number: 54029
Rep Org: AZ DEPARTMENT OF HEALTH SERVIC
Licensee: ABRAZO SCOTTSDALE CAMPUS
Region: 4
City: PHOENIX State: AR
County:
License #: 07-246
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JOANNA BRIDGE
Licensee: ABRAZO SCOTTSDALE CAMPUS
Region: 4
City: PHOENIX State: AR
County:
License #: 07-246
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/25/2019
Notification Time: 17:42 [ET]
Event Date: 04/25/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2019
Notification Time: 17:42 [ET]
Event Date: 04/25/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANDREA KOCK (NMSS)
PATRICIA MILLIGAN (INES)
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANDREA KOCK (NMSS)
PATRICIA MILLIGAN (INES)
AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE
The following was received from the state of Arizona via e-mail:
"The [Arizona Department of Health Services] received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300.
"Arizona incident Number 19-008."
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.
* * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *
The following was received from the state of Arizona via e-mail:
"This correspondence is a follow-up to the notification sent [on 4/25/19] regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead [certified radiation technologist] in an [operating room] department of a hospital performing 6-7 fluoroscopic procedures per day."
It is believed that the actual exposure was just to the badge and not to the person.
Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).
The following was received from the state of Arizona via e-mail:
"The [Arizona Department of Health Services] received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300.
"Arizona incident Number 19-008."
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.
* * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *
The following was received from the state of Arizona via e-mail:
"This correspondence is a follow-up to the notification sent [on 4/25/19] regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead [certified radiation technologist] in an [operating room] department of a hospital performing 6-7 fluoroscopic procedures per day."
It is believed that the actual exposure was just to the badge and not to the person.
Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).
Power Reactor
Event Number: 54027
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: LOUIS ENGELKE
HQ OPS Officer: JOANNA BRIDGE
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: LOUIS ENGELKE
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/25/2019
Notification Time: 12:04 [ET]
Event Date: 04/25/2019
Event Time: 09:18 [EDT]
Last Update Date: 04/25/2019
Notification Time: 12:04 [ET]
Event Date: 04/25/2019
Event Time: 09:18 [EDT]
Last Update Date: 04/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
EUGENE GUTHRIE (R2DO)
EUGENE GUTHRIE (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 |
AUTOMATIC REACTOR TRIP DUE TO TURBINE GENERATOR TRIP
"At 0918 [EDT] on 4/25/19, with [Saint Lucie] Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a Turbine Trip. The reactor trip was uncomplicated with all systems responding normally.
"Operations is maintaining the plant stable in Mode 3. Decay heat removal is being accomplished by main feed water and the main condenser using the turbine steam bypass valves.
"Unit 2 is not affected and remains at 100% power.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B).
"The NRC Resident Inspector has been notified."
"At 0918 [EDT] on 4/25/19, with [Saint Lucie] Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a Turbine Trip. The reactor trip was uncomplicated with all systems responding normally.
"Operations is maintaining the plant stable in Mode 3. Decay heat removal is being accomplished by main feed water and the main condenser using the turbine steam bypass valves.
"Unit 2 is not affected and remains at 100% power.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B).
"The NRC Resident Inspector has been notified."
Non-Agreement State
Event Number: 54074
Rep Org: WIGHTMAN AND ASSOCIATES
Licensee: WIGHTMAN AND ASSOCIATES
Region: 3
City: EDWARDSBURG State: MI
County:
License #: 21-20020-01
Agreement: N
Docket:
NRC Notified By: BRYAN STYBURSKI
HQ OPS Officer: THOMAS KENDZIA
Licensee: WIGHTMAN AND ASSOCIATES
Region: 3
City: EDWARDSBURG State: MI
County:
License #: 21-20020-01
Agreement: N
Docket:
NRC Notified By: BRYAN STYBURSKI
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/21/2019
Notification Time: 14:05 [ET]
Event Date: 04/25/2019
Event Time: 15:30 [EDT]
Last Update Date: 05/22/2019
Notification Time: 14:05 [ET]
Event Date: 04/25/2019
Event Time: 15:30 [EDT]
Last Update Date: 05/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JAMNES CAMERON (R3DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CNSC (CANADA) (EMAIL)
JAMNES CAMERON (R3DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CNSC (CANADA) (EMAIL)
SOURCE LOST FROM TROXLER DENSITY GAUGE DURING USE
The following is a summary of a phone call with the licensee:
On April 25, 2019, the licensee was using a Troxler Model 3440 density gauge, serial number 24233, with (per Troxler literature) an 8 mCi Cs-137 and a 40 mCi Am-241/Be source, on a project. The technician using the gauge noted the gauge was giving different than expected readings and stopped using the gauge. The gauge was taken to a repair facility to be checked out. On May 21, 2019, the repair facility notified the licensee that the source was found to be missing on May 20, 2019, at approximately 1700 EDT.
The licensee has notified NRC Region 3 Inspector (Gattone), the State of Michigan, and the Berrin County Police. The licensee and Berrin County HazMat are trying to locate the source. Region 3 Inspector (Sulaiman) is headed to the site.
* * * UPDATE ON 05/22/2019 AT 1135 FROM BOB GATTONE (NRC) TO JEFFREY WHITED * * *
The NRC Region 3 Inspector (Gattone) requested that the licensee provide a certificate for the Cs-137 source that was lost. After receiving the certificate, it was determined that the current source activity is 4.5 mCi.
Notified R3DO (Cameron), ILTAB, NMSS Event Notification, CNSC, and NRC Region 3 Inspectors Gattone and Sulaiman via e-mail.
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
The following is a summary of a phone call with the licensee:
On April 25, 2019, the licensee was using a Troxler Model 3440 density gauge, serial number 24233, with (per Troxler literature) an 8 mCi Cs-137 and a 40 mCi Am-241/Be source, on a project. The technician using the gauge noted the gauge was giving different than expected readings and stopped using the gauge. The gauge was taken to a repair facility to be checked out. On May 21, 2019, the repair facility notified the licensee that the source was found to be missing on May 20, 2019, at approximately 1700 EDT.
The licensee has notified NRC Region 3 Inspector (Gattone), the State of Michigan, and the Berrin County Police. The licensee and Berrin County HazMat are trying to locate the source. Region 3 Inspector (Sulaiman) is headed to the site.
* * * UPDATE ON 05/22/2019 AT 1135 FROM BOB GATTONE (NRC) TO JEFFREY WHITED * * *
The NRC Region 3 Inspector (Gattone) requested that the licensee provide a certificate for the Cs-137 source that was lost. After receiving the certificate, it was determined that the current source activity is 4.5 mCi.
Notified R3DO (Cameron), ILTAB, NMSS Event Notification, CNSC, and NRC Region 3 Inspectors Gattone and Sulaiman via e-mail.
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