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Event Notification Report for April 30, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/29/2019 - 4/30/2019

** EVENT NUMBERS **


54011 54013 54019 54034 54035 54036

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Agreement State Event Number: 54011
Rep Org: ALABAMA RADIATION CONTROL
Licensee: AMERICAN TESTING LABS
Region: 1
City: BESSEMER   State: AL
County:
License #: 1052
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2019
Notification Time: 11:42 [ET]
Event Date: 04/12/2019
Event Time: 06:45 [CDT]
Last Update Date: 04/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILURE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following report was received from the Alabama Department of Public Health Radiation Control via facsimile:

"On 4/12/19, at 0645 CDT, a radiographer was shooting in the vault at ATL [American Testing Labs], when the source became un-retractable. [The radiographer] closed the vault door and called the RSO [Radiation Safety Officer].

"The RSO arrived 45 minutes later and checked the status of the crank and the positioning of the camera in the vault. The RSO then took apart the handle of the crank and manually pulled the source through the cable into a safe position within the camera.

"The crank was serviced and the RSO found some debris within the crank. The crank was cleaned and placed back into service. After several shots, the crank was operational.

"The RSO received 24 mR on his dosimeter and the radiographer received 0 mR."

Alabama Incident #19-09

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Agreement State Event Number: 54013
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City:   State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2019
Notification Time: 15:08 [ET]
Event Date: 04/15/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING INTRAVASCULAR BRACHYTHERAPY DEVICE IDENTIFIED

The following report was received from the Washington State Department of Health via email:

"UW [University of Washington] Radiation Safety (RS) conducts semi-annual sealed source leak test during the months of April and October. After analyzing a leak test for a Sr-90 Intravascular Brachytherapy (IVB) device it was found to be leaking. Details provided by the University of Washington radiation safety office are as follows:

"'The results of the sample's analysis were reviewed and it was discovered that a sample for one of the IVB source trains indicated contamination at 3737 cpm. A second sample of both IVB source trains was obtained. The sample for the 40 mm source train indicated 177 cpm and the sample for the 60 mm source train indicated 7998 cpm. The RS staff member discussed the contamination with the Radioactive Materials Compliance Manager (RMCM) and the Radiation Safety Officer (RSO). It was then discovered that the leak test procedure specified in the Novoste Beta-Cath User's Manual was not performed correctly. A swab of the water sample obtained during the leak test was analyzed rather than the whole 5 ml of water. The RS staff member performed another leak test of both IVB source trains, and analyzed the 5 ml water samples (The results are provided below). The IVB device was placed out of service and removed from Radiation Oncology. The RS staff member contacted the RSO at Best Vascular who requested the sources and items used for the leak testing be returned to Best Vascular for investigation.

"'Radiation Safety counted the 5 ml water samples using one of their liquid scintillation counters (LSC) [Packard Tricarb 2900TR - S/N 426395]. Using an efficiency of 100 percent for Sr-90 (Beckman Coulter's Isotope Booklet for Liquid Scintillation Counters - 2002) the activity calculated was:

"'40 mm source train: 396 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 6.6 Bq

"'60 mm source train: 17429 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 290 Bq

"'The activity level of the 60 mm source train leak test sample exceeded the limit of 185 Bq. The contamination in the leak test for the 40 mm source train is believed to be a result of cross contamination from the 60 mm source train leak test.'"

WA Event Report ID No.: WA-19-013

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Agreement State Event Number: 54019
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO   State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: MARY BURKHART
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/22/2019
Notification Time: 17:38 [ET]
Event Date: 04/19/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED I-125 SOURCE

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

"The RSO [radiation safety officer] at the University of Chicago [Hospital], called to report that the University received one lsoAid, Model IAl-125A, I-125 source for a seed localization procedure. It had an activity of 271 microCuries when implanted in the patient on Thursday, April 18, 2019. On Friday, the patient's tissue [containing the I-125 seed was excised] and sent to pathology for evaluation. During all steps, the individuals involved reported that they measured appropriate dose rates from the seed. The Pathology technician was using scissors on the patient's tissue and the seed popped out of the specimen and fell into the sink. The seed was recovered before it went down the drain. Surveys of the sink show no contamination or dose rate measurements. The radiation safety staff measured the recovered source with both a survey instrument and a gamma counter, and the source has no measureable dose rate. The patient was surveyed and it was determined that the source [was] not in the patient.

"A review of the SSDR [sealed source and device registry] sheet has determined that this source contains I-125 adsorbed on a silver rod which is further encased in the outer capsule. The outer capsule measures 3.0 mm x 0.5 mm and there are no visible signs that the source was cut. They plan to take the seed for an x-ray today to determine if the inner rod is missing and to see if there are obvious signs that the outer capsule was breached.

"UPDATE: The I-125 seed was found intact in the sink trap. The source that was initially believed to be the subject seed was from another patient and was a three-year-old prostate seed that had decayed to background."

NMED Item Number: IL190012

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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Non-Power Reactor Event Number: 54034
Facility: UNIV OF MISSOURI-COLUMBIA
RX Type: 10000 KW TANK
Comments:
Region: 0
City: COLUMBIA   State: MO
County: BOONE
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: BRUCE MEFFERT
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/29/2019
Notification Time: 12:19 [ET]
Event Date: 04/28/2019
Event Time: 06:33 [CDT]
Last Update Date: 04/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
GEOFFREY WERTZ (NRR)
ELIZABETH REED (NRR)

Event Text

CONTROL BLADE INOPERABLE

"On April 28, 2019, at 0633 CDT, with the University of Missouri-Columbia Research Reactor (MURR) operating at 10 MW in the automatic control mode, the Lead Senior Reactor Operator (LSRO) was conducting surveillance Technical Specification (TS) 4.2.a, which states, 'All control blades, including the regulating blade, shall be verified operable within a shift.' During this verification of control blade operability, shim control blades 'A,' 'B,' 'C,' and the regulating blade were verified operable. However, shim control blade 'D' would not move in the inward direction. The LSRO then immediately shut down the reactor by initiating a manual scram by placing Master Control Switch 1S1 to the 'TEST' position. The LSRO completed all immediate and applicable subsequent actions of reactor emergency procedure REP-8, 'Control Rod Drive Mechanism Failure or Stuck Rod,' and verified all shim control blades were fully inserted.

"This email is a required notification per TS 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by TS 1.1.b, has occurred. MURR was not in compliance with all of the Limiting Conditions for Operations (LCOs) as established in TS Section 3.0. The failure of the control rod drive mechanism to insert shim control blade 'D' is a deviation from TS 3.2.a, which states, 'All control blades, including the regulating blade, shall be operable during reactor operation.' In addition, shim control blade 'D' would not have inserted during the activation of any rod run-in function listed in TS 3.2.f - shim control blades 'A,' 'B,' and 'C' would have inserted. All reactor safety system scram functions were unaffected and remained operable during this event.

"Troubleshooting revealed a broken wire to the inward motor winding of shim blade 'D' control rod drive mechanism. The wire was repaired, and the shim control blade 'D's operability was tested satisfactorily. Permission from the Reactor Facility Director was obtained prior to reactor startup per TS 6.6.c(4), and the reactor returned to 10 MW operation at 1319 CDT on April 28. A detailed event report will follow within 14 days as required by TS 6.6.c(3)."

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Power Reactor Event Number: 54035
Facility: NINE MILE POINT
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JUSTIN FARELLA
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/29/2019
Notification Time: 20:01 [ET]
Event Date: 04/29/2019
Event Time: 16:33 [EDT]
Last Update Date: 04/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JON LILLIENDAHL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 82 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO POWER OSCILLATIONS AND HIGH PRESSURE COOLANT INJECTION SYSTEM INITIATION

"During power ascension on April 29, 2019, at 1630 [EDT], Nine Mile Point Unit 1 power and pressure oscillations were observed with reactor power at approximately 82 [percent]. At time 1633 [EDT], the reactor was manually scrammed when the scram criteria of greater than 4 [percent] APRM power oscillations were observed in accordance with special operating procedures. All control rods fully inserted and all plant systems responded per design following the scram.

"Following the manual scram, the High Pressure Coolant Injection (HPCI) System automatically initiated as expected. At Nine Mile Point Unit 1, a HPCI system actuation signal on low Reactor Pressure Vessel (RPV) level is normally received following a reactor scram, due to level shrink. HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System. At 1633 [50 seconds after the reactor scram], RPV level was restored above the HPCI System low level actuation setpoint and the HPCI System initiation signal was reset. Pressure control was established on the Turbine Bypass Valves, the preferred system. No Electromatic Relief Valves actuated due to this scram.

"Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. The offsite grid is stable with no grid restrictions or warnings in effect. The cause of the power oscillations is currently under investigation."

The NRC Resident Inspector was notified.

The New York State public service commission was notified.

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Power Reactor Event Number: 54036
Facility: COOK
Region: 3     State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BUD HINKLEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/29/2019
Notification Time: 22:50 [ET]
Event Date: 04/29/2019
Event Time: 20:29 [EDT]
Last Update Date: 04/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DARIUSZ SZWARC (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO A SPURIOUS ACTUATION OF AN EMERGENCY SIREN

"On 4/29/19, at approximately 2029 EDT, the Operations Shift Manager was made aware that the Berrien County Sheriff's Department (BCSD) had been notified of an Emergency Siren that had spuriously actuated. BCSD was notified by local residents. The affected siren has been disabled and it has been verified that all associated local areas still have coverage from other functional emergency sirens.

"The cause of the actuation is under investigation at this time.

"This notification is being made under 10 CFR 50.72(b)(2)(xi), Offsite Notification, as a four (4) hour report."

The licensee has notified the NRC Resident Inspector.


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019