Event Notification Report for August 28, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/27/2019 - 08/28/2019
EVENT NUMBERS
5424854249542435424454245
Agreement State
Event Number: 54248
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CARLE FOUNDATION HOSPITAL
Region: 3
City: URBANA State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: OSSY FONT
Licensee: CARLE FOUNDATION HOSPITAL
Region: 3
City: URBANA State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: OSSY FONT
Notification Date: 08/30/2019
Notification Time: 11:08 [ET]
Event Date: 08/28/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2019
Notification Time: 11:08 [ET]
Event Date: 08/28/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOST I-125 SEED
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"Carle Foundation Hospital (Urbana, IL) reported a lost I-125 seed that occurred during a seed localization procedure in the mammography suite. The seed was 166 microCi (6.142 MBq). Three seeds were delivered for the procedure. One was used, and one was returned to the vendor. The third seed could not be found the next morning when staff performed the final inventory. It is believed the seed was thrown in the trash immediately after the procedure and went to a landfill the following morning. The investigation is ongoing and a final report to IEMA is pending."
Item Number: IL 190027
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 was received from the Illinois Emergency Management Agency (IEMA) via email:
"Carle Foundation Hospital (Urbana, IL) reported a lost I-125 seed that occurred during a seed localization procedure in the mammography suite. The seed was 166 microCi (6.142 MBq). Three seeds were delivered for the procedure. One was used, and one was returned to the vendor. The third seed could not be found the next morning when staff performed the final inventory. It is believed the seed was thrown in the trash immediately after the procedure and went to a landfill the following morning. The investigation is ongoing and a final report to IEMA is pending."
Item Number: IL 190027
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: 54249
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: PALL HAUPPAUGE
Region: 1
City: HAUPPAUGE State: NY
County:
License #: C1935
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: DONALD NORWOOD
Licensee: PALL HAUPPAUGE
Region: 1
City: HAUPPAUGE State: NY
County:
License #: C1935
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/30/2019
Notification Time: 14:42 [ET]
Event Date: 08/28/2019
Event Time: 18:00 [EDT]
Last Update Date: 08/30/2019
Notification Time: 14:42 [ET]
Event Date: 08/28/2019
Event Time: 18:00 [EDT]
Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PANORAMIC IRRADIATOR SOURCE FAILED TO RETRACT
The following information was received via facsimile:
"The New York State Department of Health (NYSDOH) was notified by the radiation safety officer (RSO) of Pall Hauppauge that they had an incident where the source did not retract completely, leaving the source partially exposed for a period of time.
"According to the RSO, on August 28, 2019 at about 1800 EDT, the source at Vault 4 had gotten stuck three inches above the down (safe) position. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action. The RSO indicated he was able to free the source by lifting it 'just an inch or two' then letting it back down.
"This is the same vault that had previous stuck source incidents (NY-19-05 and NY-19-06) [EN53984 and EN54025] this year. At that time Nordion removed the vault, re-conditioned it, and returned it to Pall.
"The RSO contacted Nordion and they are expected to be on-site the week of September 2nd. The vault will not be used until the issue is resolved. The RSO indicated he locked out all operators' key access to the vault until Nordion is on-site.
"The root cause for the source getting stuck has not yet been determined.
"DOH will continue to monitor this incident.
"Paul Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."
NY Event Report ID No.: NY-19-08
The following information was received via facsimile:
"The New York State Department of Health (NYSDOH) was notified by the radiation safety officer (RSO) of Pall Hauppauge that they had an incident where the source did not retract completely, leaving the source partially exposed for a period of time.
"According to the RSO, on August 28, 2019 at about 1800 EDT, the source at Vault 4 had gotten stuck three inches above the down (safe) position. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action. The RSO indicated he was able to free the source by lifting it 'just an inch or two' then letting it back down.
"This is the same vault that had previous stuck source incidents (NY-19-05 and NY-19-06) [EN53984 and EN54025] this year. At that time Nordion removed the vault, re-conditioned it, and returned it to Pall.
"The RSO contacted Nordion and they are expected to be on-site the week of September 2nd. The vault will not be used until the issue is resolved. The RSO indicated he locked out all operators' key access to the vault until Nordion is on-site.
"The root cause for the source getting stuck has not yet been determined.
"DOH will continue to monitor this incident.
"Paul Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."
NY Event Report ID No.: NY-19-08
Agreement State
Event Number: 54243
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee:
Region: 4
City: HERMISTON State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: RICHARD SMITH
Licensee:
Region: 4
City: HERMISTON State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/28/2019
Notification Time: 16:35 [ET]
Event Date: 08/28/2019
Event Time: 11:02 [PDT]
Last Update Date: 08/28/2019
Notification Time: 16:35 [ET]
Event Date: 08/28/2019
Event Time: 11:02 [PDT]
Last Update Date: 08/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE FOUND IN SCRAP YARD
The following is a summary of information received from the State of Oregon via phone call:
On August 28, 2019, at 1102 PDT, the Oregon Department of Health and Radiation Protection received a report from the R.S. Davis Scrap Yard, that a moisture density gauge was found in a 55 gallon drum that was crimped at the top so the gauge will not fall out. The gauge is a CPN MC-3 Porta Probe with a 10 mCi Cs-137 source and a 50 mCi Am/Be 241 source. The scrap yard employed a contractor to take radiation readings and perform a swipe test of the gauge. The gauge housing appears to be damaged but the source housing seems intact. The contractor was unable to inspect the bottom of the gauge inside the drum.
The following was measured:
A reading of 13 mR/hr on contact at the side
A reading of 200 mR/hr on contact at the bottom
A reading of 3 mR/hr one foot from the side
Swipe Test results were less than background
The State of Oregon Radiation Inspector believes the gauge is damaged because normal radiation readings for a similar gauge at one meter would be 0.4 mR/hr.
The State of Oregon will be conducting an investigation of this event. The gauge is currently under the control of the scrap yard.
Oregon Event Reference Number: 19-0037.
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 information received from the State of Oregon via phone call:
On August 28, 2019, at 1102 PDT, the Oregon Department of Health and Radiation Protection received a report from the R.S. Davis Scrap Yard, that a moisture density gauge was found in a 55 gallon drum that was crimped at the top so the gauge will not fall out. The gauge is a CPN MC-3 Porta Probe with a 10 mCi Cs-137 source and a 50 mCi Am/Be 241 source. The scrap yard employed a contractor to take radiation readings and perform a swipe test of the gauge. The gauge housing appears to be damaged but the source housing seems intact. The contractor was unable to inspect the bottom of the gauge inside the drum.
The following was measured:
A reading of 13 mR/hr on contact at the side
A reading of 200 mR/hr on contact at the bottom
A reading of 3 mR/hr one foot from the side
Swipe Test results were less than background
The State of Oregon Radiation Inspector believes the gauge is damaged because normal radiation readings for a similar gauge at one meter would be 0.4 mR/hr.
The State of Oregon will be conducting an investigation of this event. The gauge is currently under the control of the scrap yard.
Oregon Event Reference Number: 19-0037.
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: 54244
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: RONALD WALTERS
HQ OPS Officer: RICHARD SMITH
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: RONALD WALTERS
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/28/2019
Notification Time: 19:10 [ET]
Event Date: 08/28/2019
Event Time: 13:16 [CDT]
Last Update Date: 08/28/2019
Notification Time: 19:10 [ET]
Event Date: 08/28/2019
Event Time: 13:16 [CDT]
Last Update Date: 08/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY AZUA (R4DO)
RAY AZUA (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 |
LOSS OF HIGH PRESSSURE CORE SPRAY
"On Wednesday, August 28, 2019, at 1316 CDT, Grand Gulf Nuclear Station experienced a power loss to the Control Room High Pressure Core Spray (HPCS) Instrumentation Panel due to an internal inverter failure. The power loss caused the loss of the HPCS System (a single train system). The minimum flow valve (a Primary Containment Isolation Valve) for HPCS opened due to this power loss as well. This valve was manually closed in response to this, and the outboard isolation requirement for the associated penetration [which] is closed [for the] system remained intact throughout this event.
"No other accident mitigation systems were affected by this event.
"The cause of this event is under investigation at this time.
"The NRC Resident Inspectors were notified.
"This Condition is an 8-hour reportable condition as an event or condition that could have prevented the fulfillment of a safety function, in accordance with 10 CFR 50.72(b)(3)(v)(D)."
"On Wednesday, August 28, 2019, at 1316 CDT, Grand Gulf Nuclear Station experienced a power loss to the Control Room High Pressure Core Spray (HPCS) Instrumentation Panel due to an internal inverter failure. The power loss caused the loss of the HPCS System (a single train system). The minimum flow valve (a Primary Containment Isolation Valve) for HPCS opened due to this power loss as well. This valve was manually closed in response to this, and the outboard isolation requirement for the associated penetration [which] is closed [for the] system remained intact throughout this event.
"No other accident mitigation systems were affected by this event.
"The cause of this event is under investigation at this time.
"The NRC Resident Inspectors were notified.
"This Condition is an 8-hour reportable condition as an event or condition that could have prevented the fulfillment of a safety function, in accordance with 10 CFR 50.72(b)(3)(v)(D)."
Agreement State
Event Number: 54245
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: HOLLYFRONTIER TULSA REFINING
Region: 4
City: TULSA State: OK
County: TULSA
License #: GLD0027
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BRIAN LIN
Licensee: HOLLYFRONTIER TULSA REFINING
Region: 4
City: TULSA State: OK
County: TULSA
License #: GLD0027
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BRIAN LIN
Notification Date: 08/29/2019
Notification Time: 17:18 [ET]
Event Date: 08/28/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/29/2019
Notification Time: 17:18 [ET]
Event Date: 08/28/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SHUTTER FAILURE
The following was received from the Oklahoma Department of Environmental Quality via email:
"The State of Oklahoma reported that a generally-licensed Ronan Model SA-F37 fixed gauge (S/N M2265) containing 1.5 Ci of Cs-137 experienced a shutter failure during routine maintenance. The source holder is being removed from service and will be stored pending disposal."
The following was received from the Oklahoma Department of Environmental Quality via email:
"The State of Oklahoma reported that a generally-licensed Ronan Model SA-F37 fixed gauge (S/N M2265) containing 1.5 Ci of Cs-137 experienced a shutter failure during routine maintenance. The source holder is being removed from service and will be stored pending disposal."