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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for April 22, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/19/2019 - 4/22/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 53992
Rep Org: BROOKE ARMY MEDICAL CENTER Licensee: BROOKE ARMY MEDICAL CENTER Region: 4 City: SAN ANTONIO State: TX County: License #: 42-01368-01 Agreement: N Docket: NRC Notified By: KEVIN MARTILLA HQ OPS Officer: CATY NOLAN	Notification Date: 04/11/2019 Notification Time: 18:19 [ET] Event Date: 03/13/2019 Event Time: 00:00 [CDT] Last Update Date: 04/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) - CNSNS (MEXICO) (EMAIL)

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

Event Text

LOST I-125 SEEDS

The following is a synopsis from a phone call:

At Brooke Army Medical Center, two I-125 seeds were lost on October 16, 2018. One source was 156 microCuries and the second source was 158 microCuries, totaling approximately 314 microCuries at the time. The sources were not realized missing until March 13, 2019, when the activity would have been approximately 28 microCuries each, totaling 56 microCuries.

Investigation is ongoing and actions to prevent recurrence are being implemented. There was no significant exposure above dose limits.

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: 53994
Rep Org: ALABAMA RADIATION CONTROL Licensee: VITAL INSPECTION PROGESSIONALS, INC. Region: 1 City: ALABASTER State: AL County: License #: 1118 Agreement: Y Docket: NRC Notified By: DAVID TURBERVILLE HQ OPS Officer: JEFFREY WHITED	Notification Date: 04/12/2019 Notification Time: 09:37 [ET] Event Date: 04/11/2019 Event Time: 12:23 [CDT] Last Update Date: 04/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANNE DeFRANCISCO (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POTENTIAL PERSONNEL OVEREXPOSURE

The following was received via e-mail:

"On April 11, 2019, at 1223 (CDT), the Radiation Safety Officer (RSO) for Vital Inspection Professionals, Inc. advised the [Alabama Department of Public Health] Office of Radiation Control (ORC) of an incident that occurred on that day in the permanent shooting room at their facility in Alabaster, AL. Vital Inspection Professionals, Inc. has an Alabama Radioactive Material License No. 1118 for conducting industrial radiography. Preliminary information indicates that the radiographer, working alone, cranked out a 67 Curie Ir-192 source for an exposure and failed to crank the source back in before setting up for the next exposure. The radiographer's personal dosimeter badge has been sent in for emergency processing. Results are pending.

"Personnel from ORC are currently at the licensee's facility performing an incident investigation to include interviewing personnel and conducting re-enactments of the event."

Alabama Incident: 19-08

* * * UPDATE AT 1118 EDT ON 4/15/19 FROM DAVID TURBERVILLE TO JOANNA BRIDGE * * *

The following was received via fax:

"This is an update to Alabama incident 19-08 that was reported the morning of April 12, 2019. As background, the Radiation Safety Officer (RSO) for Vital Inspection Professionals, Inc. (Alabama License No. 1118) advised the Office of Radiation Control (ORC) of an incident that occurred on April 11, 2019 in the permanent shooting room at their facility in Alabaster, AL. The radiographer, working alone, cranked out a 67 Curie Ir-192 source for an exposure and failed to crank the source back in before setting up for the next exposure.

"The radiographer's personal dosimeter badge was been sent for emergency processing and the results determined the badge received an exposure of 8.149 Rem. The licensee's preliminary investigation calculated extremity exposure to the left hand of 39.684 Rem and exposure to the right hand of 9.338 Rem. The radiographer is being monitored by a medical physician. Personnel from ORC performed an initial investigation of the incident on the morning of April 12, 2019. The primary cause of the incident appears to be human error. Specifically, the radiographer failed to crank in the source at the conclusion of the exposure; failed to observe the radiation actuated visible alarm; bypassed the audible alarm feature of the shooting room; and failed to observe his survey meter upon entry into the shooting room. The investigation concluded that all safety features were operating properly at the time of the incident. Additional contributing factors are being evaluated at this time. The licensee's written report is pending.

"The information in this report is current as of 1000 CDT, April 15, 2019."

Notified R1DO (Bicket), NMSS (Rivera-Capella), INES Coordinator (Milligan), and NMSS_Events_Notification email group.

Non-Agreement State	Event Number: 53995
Rep Org: TILDEN MINING CO Licensee: TILDEN MINING CO Region: 3 City: ISHPEMING State: MI County: License #: 21-26748-01 Agreement: N Docket: NRC Notified By: LAWRENCE GRAY HQ OPS Officer: JOANNA BRIDGE	Notification Date: 04/12/2019 Notification Time: 11:24 [ET] Event Date: 04/12/2019 Event Time: 08:00 [EDT] Last Update Date: 04/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): STEVE ORTH (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PROCESS GAUGE STUCK SHUTTER

The following is a synopsis of an event received via email:

On April 11, 2019, a trained technician was in the process of performing the biannual inventory/shutter check when the individual reported that Kay Ray Model #7050, Serial #1399, 250 mCi, Cs-137 gauge located on 5B DTU (Deslime Thickener U/Flow) in the Deslime basement had a frozen shutter mechanism and cannot be closed, rendering the shutter non-operable.

The gauge won't be replaced until the first time the slurry pipeline goes down for repair. If the line goes down prior to that, the gauge will be replaced at that time.

Similar events in the past have never had an exposure to any individuals. In the event of an emergency, the gauge will be removed and placed on a piece of lead and brought to storage.

Agreement State	Event Number: 53996
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT HOSPITAL Region: 1 City: ATLANTA State: GA County: License #: GA 292-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: CATY NOLAN	Notification Date: 04/12/2019 Notification Time: 13:21 [ET] Event Date: 04/03/2019 Event Time: 00:00 [EDT] Last Update Date: 04/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANNE DeFRANCISCO (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION OF Y-90 THERASPHERES

The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:

On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.

There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).

The licensee will follow-up with a formal report.

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.

Power Reactor	Event Number: 54012
Facility: DUANE ARNOLD Region: 3 State: IA Unit: [1] [] [] RX Type: [1] GE-4 NRC Notified By: STEPHEN SPIERS HQ OPS Officer: CATY NOLAN	Notification Date: 04/20/2019 Notification Time: 09:54 [ET] Event Date: 04/20/2019 Event Time: 05:07 [CDT] Last Update Date: 04/20/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(A) - ECCS INJECTION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): MICHAEL KUNOWSKI (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

100

Power Operation

Hot Shutdown

Event Text

BOTH REACTOR FEED PUMPS TRIP CAUSING MANUAL REACTOR SCRAM AND ECCS INJECTION

"At 0507 [CDT on April 20, 2019], the DAEC [Duane Arnold Energy Center] experienced a trip of both reactor feed pumps. Operators inserted a manual scram. All control rods inserted, as required. As a result of the feed pump trips and scram, HPCI and RCIC automatically injected. Also, containment isolations occurred, as expected for this event. All systems responded as designed.

"Operators are currently taking the unit to cold shutdown conditions. Vessel level is being controlled by RCIC with Condensate System available. Pressure is being controlled using Main Steam Line drains and the Main Condenser is available."

Normal electrical lineup remains. The cause of the reactor feed pumps tripping is believed to be an instrument air leak to flow control valves, causing loss of suction to both feed pumps.

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54014
Facility: LIMERICK Region: 1 State: PA Unit: [1] [] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: RICHARD WAGNER HQ OPS Officer: JEFFREY WHITED	Notification Date: 04/21/2019 Notification Time: 08:46 [ET] Event Date: 02/22/2019 Event Time: 10:30 [EST] Last Update Date: 04/21/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION	Person (Organization): BRICE BICKETT (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 ACTUATION OF A UNIT 1 CONTAINMENT ISOLATION LOGIC DUE TO A BLOWN FUSE

"This 60-Day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of Limerick Generating Station Unit 1 containment isolation logic.

"On February 22, 2019, while performing work on the 1C Main Seam Line Rad Monitor a partial containment isolation occurred due to a blown fuse. The blown fuse caused a single channel 'C' isolation signal for the Refueling Area Ventilation Exhaust High Radiation and the Reactor Enclosure Ventilation Exhaust-High Radiation logic.

"The following systems had components that actuated due to the partial isolation:
- Plant Process Radiation Monitoring System
- Nuclear Boiler System
- Control Rod Drive Hydraulic System
- Containment Atmospheric Control System
- Primary Containment Instrument Gas System

"This event resulted in partial Group VIC and partial Group VIIIB isolations. All the components that would actuate on a single 'C' isolation signal responded as designed."

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54015
Facility: LIMERICK Region: 1 State: PA Unit: [] [2] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: RICHARD WAGNER HQ OPS Officer: JEFF HERRERA	Notification Date: 04/21/2019 Notification Time: 12:43 [ET] Event Date: 04/21/2019 Event Time: 09:20 [EDT] Last Update Date: 04/21/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): BRICE BICKETT (R1DO) WILLIAM GOTT (IRD) CHRIS MILLER (NRR EO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Refueling

Event Text

LIMERICK ONSITE NON-WORK RELATED FATALITY

"Event of Public Interest performed to notify State and Local agencies for emergency vehicle response required due to an on-site non-work related illness. The individual was unresponsive and was unable to be resuscitated due to the medical issue. The individual was outside the Radiological Controlled Area (RCA) and no radioactive material or contamination was involved."

The NRC Resident Inspector was notified.

Power Reactor	Event Number: 54016
Facility: BRUNSWICK Region: 2 State: NC Unit: [1] [] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: ALAN SCHULTZ HQ OPS Officer: JEFFREY WHITED	Notification Date: 04/22/2019 Notification Time: 01:51 [ET] Event Date: 04/21/2019 Event Time: 23:07 [EDT] Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(A) - ECCS INJECTION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): FRANK EHRHARDT (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Shutdown

Event Text

AUTOMATIC REACTOR TRIP AND SPECIFIED SYSTEM ACTUATION

"At 2307 EDT on April 21, 2019, in Mode 1 at approximately 100 percent reactor power, Unit 1 automatically tripped due to a Main Turbine Trip. The Main Turbine Trip was a result of two out of three level instruments sensing a false high reactor water level. All control rods inserted as expected during the scram. Safety Relief Valves G and K lifted per design. The same level instruments that failed also tripped both Reactor Feed Pumps. As a result, reactor water level dropped below the Low Level 1 and 2 actuation setpoints. Per design, the Low Level 1 signal resulted in Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves) and Group 8 (i.e., shutdown cooling isolation valves) isolations. The Low Level 2 signals resulted in Group 3 (i.e. Reactor Water Cleanup) isolation, a secondary containment isolation signal, and an auto start of Standby Gas Treatment and Control Room Emergency Ventilation. Also, the Low Level 2 resulted in [high pressure coolant injection] HPCI and [reactor core isolation cooling system] RCIC automatically starting and injecting into the vessel.

"All systems responded as designed.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B) for RPS actuation and 10 CFR 50.72(b)(3)(iv)(A) as an event that results in valid actuations of the Primary Containment Isolation System.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

Decay heat is currently being removed via the turbine bypass valves. Condensate and feed water are maintaining water level. The reactor is still at saturation temperature and 475 psi, lowering slowly. The reactor is still in a normal electrical lineup.

There was no impact to Unit 2 as a result of this event.

* * * UPDATE ON 04/22/19 AT 0220 EDT FROM ALAN SCHULTZ TO JEFFREY WHITED * * *

The licensee updated the event report to include a 4-Hr Non-Emergency Notification in accordance with 10 CFR 50.72(b)(2)(iv)(A) for Emergency Core Cooling System, HPCI, Discharge to the Reactor Coolant System.

Notified R2DO (Dickson), NRR EO (Miller) and IR MOC (Gott).

Power Reactor	Event Number: 54017
Facility: VOGTLE Region: 2 State: GA Unit: [3] [4] [] RX Type: [3] W-AP1000,[4] W-AP1000 NRC Notified By: LINDSEY GRISSOM HQ OPS Officer: HOWIE CROUCH	Notification Date: 04/22/2019 Notification Time: 16:16 [ET] Event Date: 04/22/2019 Event Time: 11:30 [EDT] Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): FRANK EHRHARDT (R2DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Under Construction

Event Text

CONTRACT SUPERVISOR TEST POSITIVE FOR DRUGS ON A FOLLOW-UP TEST

A contract supervisor tested positive for drugs on a follow-up fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a random test administered the next day (see EN #54018).

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54018
Facility: VOGTLE Region: 2 State: GA Unit: [3] [4] [] RX Type: [3] W-AP1000,[4] W-AP1000 NRC Notified By: LINDSEY GRISSOM HQ OPS Officer: HOWIE CROUCH	Notification Date: 04/22/2019 Notification Time: 16:16 [ET] Event Date: 04/22/2019 Event Time: 11:30 [EDT] Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): FRANK EHRHARDT (R2DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Under Construction

Event Text

CONTRACT SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST

A contract supervisor tested positive for drugs on a random fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a follow-up test administered the previous day (see EN #54017).

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54020
Facility: BYRON Region: 3 State: IL Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: BRIAN LEWIN HQ OPS Officer: JEFF HERRERA	Notification Date: 04/22/2019 Notification Time: 20:41 [ET] Event Date: 04/22/2019 Event Time: 13:24 [CDT] Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): DARIUSZ SZWARC (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Hot Standby

Event Text

MANUAL INITIATION OF THE AUXILIARY FEEDWATER SYSTEM IN RESPONSE TO A LOSS OF FEEDWATER

"At 1324 CDT, on 4/22/2019, with unit 2 in Mode 3 at 0 percent power, an intentional manual initiation of the Auxiliary Feedwater System occurred in response to a loss of feedwater condition. The loss of feedwater condition occurred after the non-safety related Startup Feedwater Pump was secured due to high bearing temperatures. The A Train Auxiliary Feedwater Pump was started per procedure. The Auxiliary Feedwater System started and operated as designed following intentional manual initiation.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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