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Event Notification Report for August 19, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/16/2019 - 8/19/2019

** EVENT NUMBERS **
 
54204 54207 54208 54209 54210 54224

Non-Agreement State Event Number: 54204
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTESVILLE   State: VA
County:
License #: 45-30957-01
Agreement: Y
Docket:
NRC Notified By: KATHARINE ARZATE
HQ OPS Officer: CATY NOLAN		 Notification Date: 08/08/2019
Notification Time: 12:38 [ET]
Event Date: 08/07/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/08/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(a) - PROTECTIVE ACTION PREVENTED
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X		 Person (Organization):
DAN SCHROEDER (R1DO)
PATRICIA PELKE (R3DO)
GREG WARNICK (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

IRIDIUM-192 SOURCE LOST DURING SHIPMENT

A 0.78 Curie (today's activity) Ir-192 source was lost during shipment from the Mayo Clinic in Rochester, MN to Alpha-Omega Services in Vinton, LA. The last known location was Memphis, TN with the common carrier. Its original shipment date was February 8, 2019.

The licensee contacted the common carrier upon suspicion of loss on June 4, 2019. On August 7, 2019, the source had not been located and was deemed lost.

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

Non-Agreement State Event Number: 54207
Rep Org: NVI
Licensee: NVI
Region: 4
City: GRADE   State: LA
County:
License #: 17-29410-01
Agreement: Y
Docket:
NRC Notified By: KEITH GRIFFIN
HQ OPS Officer: OSSY FONT		 Notification Date: 08/09/2019
Notification Time: 10:09 [ET]
Event Date: 08/09/2019
Event Time: 07:25 [CDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X		 Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Category 3" level of radioactive material.

Event Text

LOST RADIOGRAPHY CAMERA IN INTERNATIONAL WATERS

The following is a summary of a phone call from the licensee:

NVI (Non-Destructive and Visual Inspections) notified the NRC that a radiography camera with a less than 22 Ci Ir-192 source was lost when it fell into approximately 200 feet of international waters from an oil platform in South Pass Section 60-A. The camera (SPEC 150 Model 0605; Source SPEC G-60 S/N AC0160) was locked in the shielded position during setup when the radiographer slipped. The licensee does not plan to retrieve the device.

Additionally, the licensee notified NRC R-IV and the Bureau of Safety and Environmental Enforcement.

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)

Agreement State Event Number: 54208
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTH AMERICAN STAINLESS
Region: 1
City: GHENT   State: KY
County:
License #: 201-499-57
Agreement: Y
Docket:
NRC Notified By: AJ BHATTACHARYYA
HQ OPS Officer: OSSY FONT		 Notification Date: 08/09/2019
Notification Time: 11:14 [ET]
Event Date: 08/07/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN IN DAMAGED LEVEL DENSITY GAUGE

The following was received from KY Department for Public Health & Safety, Radiation Health Branch (KY RHB) via fax:

"KY RHB was notified by telephone on 8/8/19 by a representative from a specifically licensed facility, North American Stainless, that on 8/7/19 an event occurred when molten steel escaped a mold due to an overflow in a cooling trough, and covered access to the top portion of a Berthold Model LB300ML level gauge (Serial No. 9413), containing a 1 mCi Co-60 rod sealed source (Serial No 1820-11-5). This resulted in the shutter on-off mechanism becoming disabled. After the steel and mold had cooled, it was freed on 8/8/19 and segregated into a secure storage area.

"Initial readings taken with a Ludlum 2241-3 survey instrument measured with a Ludlum 44-7 probe were less than 2 mR/hr outside the gauge storage area. No overexposures were reported.

"On 8/8/19, Radiametric Technologies, a service provider located in Lorain, Ohio, requested reciprocal approval and was granted reciprocity on 8/9/19 in order to assess and remediate the situation, to be conducted on 8/13/19.

"North American Stainless is reviewing the incident to avoid future repeat incidents involving mold flow issues, and a complete report will be provided once the remediation is complete."

Event Report ID No KY190007

Agreement State Event Number: 54209
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: OHIO STATE UNIVERSITY
Region: 3
City: COLUMBUS   State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: MICHAEL J RABADUE
HQ OPS Officer: JEFF HERRERA		 Notification Date: 08/08/2019
Notification Time: 11:11 [ET]
Event Date: 08/06/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING ECKERT & ZIEGLER CS-137 VIAL SOURCE

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

"The licensee discovered a leaking Eckert & Ziegler Cs-137 vial source. The leak test result, performed on August 6, 2019, identified 0.016 microCuries of removable activity. Notification to the Ohio Department of Health was made on August 8, 2019. The licensee will dispose of the source through a licensed waste broker.

"Device model number: RV-137-250U
Serial number: 171069"

Ohio item number: OH190014

Agreement State Event Number: 54210
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: THEDACARE REGIONAL MEDICAL CENTER - APPLETON
Region: 3
City: APPLETON   State: WI
County:
License #: 087-1014-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: CATY NOLAN		 Notification Date: 08/09/2019
Notification Time: 14:54 [ET]
Event Date: 08/09/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE TO PATIENT

The following was received from the Wisconsin Radiation Protection Section via email:

"On 8/9/19, the Department [State of Wisconsin Department of Health Services] was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit."

The patient will be notified.

Wisconsin Event Report ID: WI190009

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: 54224
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: SEAN MCCORMACK
HQ OPS Officer: KERBY SCALES		 Notification Date: 08/16/2019
Notification Time: 15:05 [ET]
Event Date: 08/16/2019
Event Time: 08:21 [MST]
Last Update Date: 08/16/2019
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):
RAY KELLAR (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

"At 0821 MST, on August 16, 2019, a main turbine trip occurred followed by a loss of power to all reactor coolant pumps. The Palo Verde Nuclear Generating Station (PVNGS) Unit 2 control room then received reactor protection system alarms for low departure from nucleate boiling ratio and an automatic reactor trip occurred. Following the reactor trip, auxiliary feedwater was manually started to maintain steam generator levels. A Main Steam Isolation Signal was manually initiated as directed by the Emergency Operating Procedures. Unit 2 is currently stable in Mode 3. Prior to the reactor trip, Unit 2 was operating normally at 100 percent power.

"No major equipment was inoperable prior to the event that contributed to the event or challenged operator response. All control element assemblies fully inserted into the core and no emergency classification was required per the PVNGS Emergency Plan. The cause of the reactor trip is under investigation.

"The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The NRC Resident Inspector has been informed of the Unit 2 reactor trip."

Decay heat is being removed via the atmospheric steam dump valves.

Units 1 and 3 were unaffected by this event.

Page Last Reviewed/Updated Wednesday, March 24, 2021