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Event Notification Report for September 06, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/5/2018 - 9/6/2018

** EVENT NUMBERS **


53571 53572 53580 53584

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Agreement State Event Number: 53571
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLORIDA HOSPITAL
Region: 1
City: ALTAMONT SPRINGS   State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: OSSY FONT
Notification Date: 08/29/2018
Notification Time: 09:30 [ET]
Event Date: 08/16/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED

The following was received from the State of Florida:

"[The State of Florida Bureau of Radiation Control] received a call from [the Medical Physicist] to report the loss of a [190 microCurie] I-125 brachytherapy seed. It is believed that the seed was removed from a patient between July 25 and 26 and placed into the biohazard waste container. The lost seed was discovered missing on Aug. 7th and all attempts to locate the seed have failed.

"There was no adverse outcome in patient care from this incident.

"No personnel or general public exposure would have been significant based upon the low exposure rate and the nature of controlled biohazard waste. The waste was incinerated. The majority of the radioactivity would have been released through the stack with minimal residual activity. No environmental impact is expected."

Corrective actions taken include reeducation of proper documentation methods and reeducation of the proper use and checkoff of the inventory log.

Florida Incident Report #: FL18-110


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

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Agreement State Event Number: 53572
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ROQUETTE AMERICA INCORPORATED
Region: 3
City: GURNEE   State: IL
County: LAKE
License #: IL-01033-01
Agreement: Y
Docket:
NRC Notified By: SANDY KESSINGER
HQ OPS Officer: BRIAN LIN
Notification Date: 08/29/2018
Notification Time: 12:28 [ET]
Event Date: 08/28/2018
Event Time: 12:40 [CDT]
Last Update Date: 08/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEVEL GAUGE STUCK SHUTTER

The following information was obtained from the State of Illinois via email:

"The RSO of Roquette America, Inc. (IL-01033-01) called [The Illinois Emergency Management Agency] and left a message that he had a stuck shutter on a Kay Ray Mode! 70628P/ 5 milliCurie gauge. The shaft of the shutter is simply worn. Local Thermo servicemen arrived and got the shutter working temporarily. The device is still in service on the mill line and able to be manually closed as needed. All employees are aware that the device shutter must be manually closed should there be a problem with other equipment in the area. There are no exposures beyond normal operations associated with this event. The manufacturer will replace the device. "

Illinois incident no. IL180035

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Power Reactor Event Number: 53580
Facility: SAN ONOFRE
Region: 4     State: CA
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: TIM CUSICK
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 09/05/2018
Notification Time: 12:53 [ET]
Event Date: 09/05/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JASON KOZAL (R4DO)
CHRIS MILLER (NRR EO)
JEFFERY GRANT (IRD)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Defueled 0 Defueled
3 N N 0 Defueled 0 Defueled

Event Text

NOTIFICATION TO A GOVERNMENT AGENCY FOR ASSISTANCE RELATIVE TO A MEDICAL EMERGENCY

"At approximately 0608 Pacific Daylight Time (PDT), the Control Room was notified of a SONGS SCE [San Onofre Nuclear Generating Station Southern California Edison] employee experiencing a non-work related medical emergency outside the protected area, inside the owner controlled area. SONGS fire brigade was dispatched. Camp Pendleton Fire ambulance was requested. At 0644 [PDT] Camp Pendleton Fire department in communication with a doctor determined the victim is deceased.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) for a situation related to the health of on-site personnel for which a notification to other government agencies is planned. California Highway Patrol and Coroner notified and expect the California Occupational Safety and Health Administration (Cal-OSHA) will be notified.

"NRC Region IV was notified (approximately 0900 PDT) as SONGS does not have a NRC resident inspector."

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Power Reactor Event Number: 53584
Facility: NINE MILE POINT
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: GREGORY BIXBY
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/06/2018
Notification Time: 17:18 [ET]
Event Date: 03/19/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
CHRISTOPHER LALLY (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

INVALID SPECIFIED SYSTEM ACTUATION

"Pursuant to 50.73(a)(1) the following information is provided as a sixty (60) day telephone notification to the NRC. This notification, reported under 50.73(a)(2)(iv), is being provided in lieu of the submittal of a written LER [Licensee Event Report] to report a condition that resulted in an invalid actuation of the high pressure coolant injection (HPCI). At Nine Mile Point Unit 1, HPCI is a flow control mode of the normal feedwater system and is not an emergency core cooling system.

"On March 19, 2018 Nine Mile Point Unit 1 (NMP1) was at 0 percent power and in cold shutdown in support of a planned maintenance outage. At approximately 0118 [EDT], a reactor water level transient initiated by the fill and vent of 12 Reactor Recirculation Pump (12 RRP) occurred. During the fill and vent, Reactor Pressure Vessel (RPV) level lowered quickly from the initial level of 68 inches and a low level alarm was received. Control Room Operators reduced Reactor Water Clean-Up (RWCU) reject flow to turn the level trend and clear the low level alarm generated off of the compensated, GEMAC, level instrumentation. RWCU reject flow was reduced by 50 percent which caused RPV level to start to rise. RPV level was raised to approximately 72 inches at which time the Reactor Operator began to raise reject flow to reestablish the normal level band. During the RPV level transient, with actual water level at 74 inches on the GEMAC, the Yarway level instrumentation, which is not density compensated and therefore invalid, reached 92 inches causing an invalid high RPV water level turbine trip signal and associated invalid HPCI initiation signal. At no point in time did actual RPV water level reach the high RPV water level turbine trip set point of 92 inches. The potential for a turbine trip signal to occur due to shutdown activities was understood and tags were hung to lockout the Feedwater Pumps to prevent the HPCI start signal. Therefore, no HPCI injection occurred.

"The Licensee has notified the NRC Resident Inspector."


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