Event Notification Report for November 21, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/20/2019 - 11/21/2019
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 54403
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ALLEN BRAND
HQ OPS Officer: BRIAN LIN
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ALLEN BRAND
HQ OPS Officer: BRIAN LIN
Notification Date: 11/21/2019
Notification Time: 21:11 [ET]
Event Date: 11/21/2019
Event Time: 12:25 [CST]
Last Update Date: 01/10/2020
Notification Time: 21:11 [ET]
Event Date: 11/21/2019
Event Time: 12:25 [CST]
Last Update Date: 01/10/2020
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):
JAMNES CAMERON (R3DO)
JAMNES CAMERON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 99 | Power Operation | 99 | Power Operation |
UNIT 1 HIGH PRESSURE CORE SPRAY INOPERABLE
"On 11/21/2019, at 1225 CST, as a result of Division 4 DC bus voltage oscillations, bus voltage lowered to less than the required improved technical specification (ITS) voltage of 127.6 VDC. This resulted in declaring High Pressure Core Spray (HPCS) system inoperable per technical specification LCO 3.8.4 and 3.8.9 actions. Division 4 DC bus voltage was restored to greater than 127.6 VDC at 1227 CST. The HPCS system remains inoperable due to Division 4 DC battery charger inoperability.
"Since HPCS is an emergency core cooling system and is a single train safety system, this condition is reportable under 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
Clinton Power Station has implemented required compensatory actions due to the Division 4 DC battery charger and HPCS remaining inoperable.
* * * RETRACTION ON 1/10/20 AT 1145 EST FROM JACOB HENRY TO KARL DIEDERICH * * *
"The purpose of this notification is to retract a previous report made on 11/21/2019 (EN 54403) under 10 CFR 50.72(b)(3)(v)(D). Subsequent to the initial notification, the event and the NRC guidance in NUREG-1022 pertaining to 10 CFR 50.72(b)(3)(v)(D) were reviewed further. The evaluation determined that the Division 4 DC bus voltage oscillations were caused by a degraded but operable charger. The Division 4 battery remained fully charged during the event and its operability was not impacted. Therefore, the HPCS system remained Operable.
"Under these circumstances, this event does not represent an inoperability of an accident mitigation system under 10 CFR 50.72(b)(3)(v)(D). Therefore, EN 54403 is retracted.
"The NRC Resident Inspector has been notified."
Notified R3DO (Hanna).
"On 11/21/2019, at 1225 CST, as a result of Division 4 DC bus voltage oscillations, bus voltage lowered to less than the required improved technical specification (ITS) voltage of 127.6 VDC. This resulted in declaring High Pressure Core Spray (HPCS) system inoperable per technical specification LCO 3.8.4 and 3.8.9 actions. Division 4 DC bus voltage was restored to greater than 127.6 VDC at 1227 CST. The HPCS system remains inoperable due to Division 4 DC battery charger inoperability.
"Since HPCS is an emergency core cooling system and is a single train safety system, this condition is reportable under 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
Clinton Power Station has implemented required compensatory actions due to the Division 4 DC battery charger and HPCS remaining inoperable.
* * * RETRACTION ON 1/10/20 AT 1145 EST FROM JACOB HENRY TO KARL DIEDERICH * * *
"The purpose of this notification is to retract a previous report made on 11/21/2019 (EN 54403) under 10 CFR 50.72(b)(3)(v)(D). Subsequent to the initial notification, the event and the NRC guidance in NUREG-1022 pertaining to 10 CFR 50.72(b)(3)(v)(D) were reviewed further. The evaluation determined that the Division 4 DC bus voltage oscillations were caused by a degraded but operable charger. The Division 4 battery remained fully charged during the event and its operability was not impacted. Therefore, the HPCS system remained Operable.
"Under these circumstances, this event does not represent an inoperability of an accident mitigation system under 10 CFR 50.72(b)(3)(v)(D). Therefore, EN 54403 is retracted.
"The NRC Resident Inspector has been notified."
Notified R3DO (Hanna).
Agreement State
Event Number: 54410
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: SCOTTSDALE MEDICAL IMAGING, LTD.
Region: 4
City: SCOTTSDALE State: AZ
County:
License #: 07-507
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JEFF HERRERA
Licensee: SCOTTSDALE MEDICAL IMAGING, LTD.
Region: 4
City: SCOTTSDALE State: AZ
County:
License #: 07-507
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/25/2019
Notification Time: 20:00 [ET]
Event Date: 11/21/2019
Event Time: 00:00 [MST]
Last Update Date: 11/26/2019
Notification Time: 20:00 [ET]
Event Date: 11/21/2019
Event Time: 00:00 [MST]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
ILTAB (EMAIL)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST I-125 SEED
The following report was received from the Arizona Department of Health Services (Department) via email:
"On November 25, 2019, the Department was notified of a lost I-125 seed. The licensee believes that the seed was most likely lost in pathology on November 21, 2019. The Department is continuing to investigate the event."
Arizona Incident: 19-028.
* * * UPDATE SENT BY BRAIN GORETZKI RECEIVED BY RICHARD SMITH ON NOVEMBER 26, 2019 AT 9:45 EST * * *
The following was received via email from the state of Arizona:
Vender for the I-125 seed was Isoaid, description of the seed was 5 cm stranded seed, Lot Number 63917-5, and activity was 0.197mCi I-125.
Notified: R4DO (Pick).
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 report was received from the Arizona Department of Health Services (Department) via email:
"On November 25, 2019, the Department was notified of a lost I-125 seed. The licensee believes that the seed was most likely lost in pathology on November 21, 2019. The Department is continuing to investigate the event."
Arizona Incident: 19-028.
* * * UPDATE SENT BY BRAIN GORETZKI RECEIVED BY RICHARD SMITH ON NOVEMBER 26, 2019 AT 9:45 EST * * *
The following was received via email from the state of Arizona:
Vender for the I-125 seed was Isoaid, description of the seed was 5 cm stranded seed, Lot Number 63917-5, and activity was 0.197mCi I-125.
Notified: R4DO (Pick).
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: 54404
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: BETHANY CECERE
Licensee: QSA GLOBAL, INC
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/22/2019
Notification Time: 10:50 [ET]
Event Date: 11/21/2019
Event Time: 15:14 [EST]
Last Update Date: 11/22/2019
Notification Time: 10:50 [ET]
Event Date: 11/21/2019
Event Time: 15:14 [EST]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DESIREE DAVIS (ILTAB)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DESIREE DAVIS (ILTAB)
AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE
The following information was received via E-mail from the Commonwealth of Massachusetts:
"The licensee (QSA Global, Inc.) made telephone notification at 0948 EST, on November 22, 2019, preceded by E-mail to the Agency (Massachusetts Radiation Control Program) day prior, that licensee was notified by carrier on November 21, 2019, that an incoming shipment from Edmonton, Canada and destined for QSA Global, Inc., Burlington, Massachusetts is missing.
"The licensee provided that the shipment missing is a Model 650L source changer, serial number 2239, Type B(U) package, Yellow II, UN2916, containing a single 11.9 curie (440 GBq) iridium-192 radiography source.
"The licensee provided that the shipper is Acuren Group Inc. and that the date of exportation was supposed to be October 22, 2019. The activity of the shipment was 584 GBq (15.8) curies of iridium on October 22, 2019.
"The licensee reported that an active search by the carrier is underway to find the missing materials and that so far the carrier performed search of expected travel location in Boston, Massachusetts without finding the package and is tracing the expected route back through Canada, the shipment origin.
"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
* * * UPDATE FROM JOSHUA DAEHLER TO DONALD NORWOOD AT 1310 EST ON 11/22/2019 * * *
The following information was received via E-mail from the Commonwealth of Massachusetts:
"At 1231 EST today (November 22, 2019), the licensee provided update to the Agency (Massachusetts Radiation Control Program) that the source was found; that this was a clerical error, and at no time was the shipment lost or missing. The source had been delivered on November 14, 2019, but put into the QSA Global, Inc.'s system under the wrong tracking number.
"The licensee also submitted that as a notification was made, it will write the 30-day report and forward it to the Agency. In addition a QSA Condition Report will be generated to address the receipt issue."
Notified R1DO (Cahill), ILTAB (Davis), and the NMSS Events Notifications E-mail group.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
The following information was received via E-mail from the Commonwealth of Massachusetts:
"The licensee (QSA Global, Inc.) made telephone notification at 0948 EST, on November 22, 2019, preceded by E-mail to the Agency (Massachusetts Radiation Control Program) day prior, that licensee was notified by carrier on November 21, 2019, that an incoming shipment from Edmonton, Canada and destined for QSA Global, Inc., Burlington, Massachusetts is missing.
"The licensee provided that the shipment missing is a Model 650L source changer, serial number 2239, Type B(U) package, Yellow II, UN2916, containing a single 11.9 curie (440 GBq) iridium-192 radiography source.
"The licensee provided that the shipper is Acuren Group Inc. and that the date of exportation was supposed to be October 22, 2019. The activity of the shipment was 584 GBq (15.8) curies of iridium on October 22, 2019.
"The licensee reported that an active search by the carrier is underway to find the missing materials and that so far the carrier performed search of expected travel location in Boston, Massachusetts without finding the package and is tracing the expected route back through Canada, the shipment origin.
"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
* * * UPDATE FROM JOSHUA DAEHLER TO DONALD NORWOOD AT 1310 EST ON 11/22/2019 * * *
The following information was received via E-mail from the Commonwealth of Massachusetts:
"At 1231 EST today (November 22, 2019), the licensee provided update to the Agency (Massachusetts Radiation Control Program) that the source was found; that this was a clerical error, and at no time was the shipment lost or missing. The source had been delivered on November 14, 2019, but put into the QSA Global, Inc.'s system under the wrong tracking number.
"The licensee also submitted that as a notification was made, it will write the 30-day report and forward it to the Agency. In addition a QSA Condition Report will be generated to address the receipt issue."
Notified R1DO (Cahill), ILTAB (Davis), and the NMSS Events Notifications E-mail group.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)