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

Event Notification Report for August 09, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/8/2019 - 8/9/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54189
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: DMS HEALTH TECHNOLOGIES, INC. Region: 3 City: TINLEY PARK State: IL County: License #: IL-02372-02 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: KERBY SCALES	Notification Date: 07/31/2019 Notification Time: 15:20 [ET] Event Date: 07/29/2019 Event Time: 00:00 [CDT] Last Update Date: 07/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RHEX EDWARDS (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TRANSPORTATION ACCIDENT

The following is a synopsis of information received from the Illinois Emergency Management Agency via email:

On July 29, 2019, there was a vehicle accident while transporting medical radioactive materials near Tinley Park, IL. There was no release of material nor contaminated individuals. Details are pending from the licensee. This is a reportable incident under 32 Ill. Adm. Code 341.10(b)(5) as detailed in 49 CFR Part 171.15.

Initial reports indicate at least one diagnostic radiopharmaceutical unit dose and a Co-57 sheet source were in transit at the time of the accident. Leak tests are pending, but initial surveys and an assessment of the radiopharmaceuticals indicates no escape of licensed material outside of the ammo can in which they were being transported. Serial number and leak test results of the sheet source as well as a description of the RAM in transit are pending. Licensee staff have reportedly taken possession of the licensed material and conducted surveys to ensure public safety.

Illinois Event Report ID: IL190024

Agreement State	Event Number: 54192
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: MID-STATE ENGINEERING AND TESTING Region: 4 City: COLUMBUS State: NE County: License #: 09-07-01 Agreement: Y Docket: NRC Notified By: JULIA SCHMITT HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/01/2019 Notification Time: 14:25 [ET] Event Date: 07/02/2019 Event Time: 00:00 [CDT] Last Update Date: 08/01/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEREMY GROOM (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERY OF A MOISTURE DENSITY GAUGE

The following was received from the Nebraska Department of Health and Human Services via email:

"Mid-State Engineering and Testing (MSET) reported the loss and recovery of a moisture/density gauge (CPN International MC Series) that contained a 1.85 GBq (50 mCi) Am-Be source and a 0.37 GBq (10 mCi) Cs-137 source. The gauge was initially believed to have been lost on July 2, 2019, somewhere between Aurora and Columbus, Nebraska, on a route that included Highways 14 and 30. The driver reported that approximately 1.5 miles west of the Highway 30 and Highway 81 intersection he had to forcefully apply the truck brakes to avoid a collision. The gauge was locked inside of a transportation case and secured to the truck with a lock and chain. When the brakes were applied, the transportation case handle was pulled out of the case and the tailgate of the truck fell open. When the truck accelerated after stopping at the intersection of Highways 30 and 81, the transportation case fell out of the vehicle. MSET attempted to locate the gauge without success.

"Nebraska State Patrol, Nebraska Department of Roads, Columbus Police Department and Platte County Sheriffs Department were notified. The gauge was found by a member of the public on July 2, 2019. The member of the public contacted MSET on July 2, 2019, and the gauge was retrieved by MSET. The handle on the locked transportation case was damaged. The gauge inside did not appear to be damaged. The Nebraska Office of Radiological Health is investigating."

Nebraska State Report # 190003

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: 54193
Rep Org: COLORADO DEPT OF HEALTH Licensee: UNIVERSITY OF COLORADO HOSPITAL Region: 4 City: ANSCHUTZ State: CO County: AURORA License #: 828-01 Agreement: Y Docket: NRC Notified By: SHIYA WANG HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/01/2019 Notification Time: 18:13 [ET] Event Date: 08/01/2019 Event Time: 15:30 [MDT] Last Update Date: 08/01/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEREMY GROOM (R4DO) LANCE ENGLISH (ILTAB) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - POSSIBLE LOST RADIOACTIVE MATERIAL

The following was received from the Colorado Department of Public Health and Environment (CDPHE) via e-mail:

"The licensee reported at approximately 1530 hrs. [MDT] of August 1, 2019 to CDPHE that there was a package in the morning of August 1, 2019, with its shipping paper indicating two vials of Lu-177 (200 mCi). The licensee only has 1 vial in possession and the nuclear medicine technician who opened the package did not remember seeing two vials in the package. The package has been disposed of in the hospital dumpster before the licensee identified this. The licensee surveyed the dumpster but did not identify any source of Lu-177. The licensee contacted the vendor and is awaiting more information from the vendor regarding whether a second vial was ever shipped from the vendor to the licensee."

Colorado Event Report No: CO190015

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: 54205
Facility: WATERFORD Region: 4 State: LA Unit: [3] [] [] RX Type: [3] CE NRC Notified By: REMY DEVOE HQ OPS Officer: CATY NOLAN	Notification Date: 08/08/2019 Notification Time: 13:26 [ET] Event Date: 06/25/2019 Event Time: 17:13 [CDT] Last Update Date: 08/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION	Person (Organization): GREG WARNICK (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INVALID ENGINEERED SAFETY FEATURE ACTUATION SIGNAL DUE TO HUMAN ERROR

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Engineered Safety Feature actuation signal.

"On June 25, 2019, at Waterford 3, while performing an emergent replacement of relays on the Engineered Safety Features Actuation System Train A that affected Shield Building Ventilation Train A and HVAC Equipment Room Supply Fan AH-1 3A, unintentional contact was made between two contacts on the relay, resulting in an inadvertent initiation of other relays in the sequencer circuit. This caused the starting of Low Pressure Safety Injection Pump A, Switchgear Ventilation Fan A, and Boric Acid Makeup pumps. This was a partial actuation of Engineered Safety Features Actuation System Train A. Affected plant systems started and functioned successfully.

"This inadvertent actuation was caused by human error and was not a valid signal resulting from parameter inputs. The 1992 Statements of Consideration define an invalid signal to include human error. Therefore, this actuation is considered invalid. This event was entered into the Waterford 3 corrective action program for resolution. This event did not result in any adverse impact to the health and safety of the public.

"In accordance with 10 CFR 50.73(a)(1), a telephone notification is being made in lieu of submitting a written Licensee Event Report.

"The NRC Senior Resident Inspector has been notified."

Part 21	Event Number: 54206
Rep Org: COLUMBIA GENERATING STATION Licensee: SPECTRUM TECHNOLOGIES Region: 4 City: RICHLAND State: WA County: License #: Agreement: Y Docket: 05000397 NRC Notified By: DON GREGOIRE HQ OPS Officer: CATY NOLAN	Notification Date: 08/08/2019 Notification Time: 17:03 [ET] Event Date: 08/05/2019 Event Time: 15:19 [PDT] Last Update Date: 08/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): DAN SCHROEDER (R1DO) GERALD MCCOY (R2DO) PATRICIA PELKE (R3DO) GREG WARNICK (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - SPECTRUM TECHNOLOGIES CONTROL POWER TRANSFORMER

"Pursuant to 10 CFR 21.21(d)(3)(i), this is a non-emergency notification by Energy Northwest concerning a defect on a control power transformer (CPT) resulting in a failed starter coil while in service at Columbia Generating Station. The defect was associated with a CPT provided by Spectrum Technologies (model Micron B150-2957-1).

"On June 14, 2019, a failure analysis was completed that determined that the failure of the coil occurred because the starter coil was exposed to chronic elevated temperatures. These elevated temperatures were caused by the associated control power transformer (CPT) secondary voltage being maintained outside the coil's rated voltage range. Previously on June 10, 2019, it was determined that the CPT installed in the Spectrum Technologies motor starter assembly did not meet procurement specifications resulting in a turns ratio that produced higher voltages on the motor starter coil than its rated voltage. This led to overheating and breakdown of the coil insulation that created a short between two windings.

"On August 5, 2019, Energy Northwest completed a Part 21 evaluation in accordance with 10 CFR 21.21(a)(1) and determined that this deviation could create a substantial safety hazard as defined in 10 CFR 21.3.

"The NRC Resident Inspector has been notified."

The licensee has 14 Spectrum transformers that are continuously energized that could be affected. The one transformer that experienced the failure was out of service for maintenance at the time of discovery. Four other coils were inspected for extent of condition and no more failures were found.

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