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Event Notification Report for September 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/25/2019 - 9/26/2019

** EVENT NUMBERS **


54282542855429254293


Agreement State Event Number: 54282
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM   State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 09/17/2019
Notification Time: 13:09 [ET]
Event Date: 09/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information is a summary of an email received from the state of North Carolina:

On September 16, 2019, a patient at Duke University Medical Center was prescribed 43.2 mCi of Y-90 Theraspheres to the liver, but received 89.6 mCi. While the cause of the misadministration is not clear at this time, it is known that the dose received was intended for a different patient. Both the patient and the authorized user have been informed of the incident.

An inspector has been dispatched to conduct a reactive inspection for this event.

North Carolina Tracking Number: 190032


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.


Non-Agreement State Event Number: 54285
Rep Org: ACUREN INSPECTION INC
Licensee: ACUREN INSPECTION INC
Region: 3
City: DULUTH   State: MN
County:
License #: 22-27593-01
Agreement: Y
Docket:
NRC Notified By: JEREMY SCHREINER
HQ OPS Officer: THOMAS KENDZIA 		Notification Date: 09/18/2019
Notification Time: 15:40 [ET]
Event Date: 09/18/2019
Event Time: 00:00 [CDT]
Last Update Date: 09/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GREG PICK (R4DO)
LEAH SMITH (ILTAB)
JEFFERY GRANT (IRD)
PATRICIA MILLIGAN (INES)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Category 2" level of radioactive material.

Event Text

RADIOGRAPHY CAMERA LOST DURING SHIPPING

"On 9/11/2019 [Acuren Inspection in Billings Montana] shipped a camera to QSA Global for disposal, the exposure device serial number is D3869 source serial number 83052G.

"Acuren has not received the receiving report from QSA. The (RSO) contacted the common carrier on Monday September 16, 2019, the common carrier initiated a search for the missing package and have not been able to find it. The last place it was scanned in was at the common carrier's facility in Memphis TN, on 9/12/2019 at 12:41AM."

The source is a 30 Curie iridium 192 source.

The licensee notified Region IV Materials (Erickson).

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, DHS NICC, USDA Ops Center, EPA EOC, FDA EOC, FEMA NWC, DHS Nuclear SSA, FEMA NRCC SASC, DNDO-JAC.

* * * UPDATE ON 09/20/19 AT 1045 EDT FROM JEREMY SCHREINER TO OSSY FONT VIA PHONE * * *

The licensee notified the NRC that the common carrier located the package in Memphis, TN. The Shippers Declaration papers were ripped off. The common carrier states that the package will be delivered to Baton Rouge, LA today, 09/20/19.

Notified R4DO (Taylor), IR MOC (Grant), DHS SWO, DOE Ops Center, FEMA Ops Center, DHS NICC, USDA Ops Center, EPA EOC, FDA EOC, FEMA NWC, DHS Nuclear SSA, FEMA NRCC SASC, DNDO-JAC, and ILTAB, NMSS (Williams), NMSS Events, INES (via email), CNSC(Canada via email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Power Reactor Event Number: 54292
Facility: COLUMBIA GENERATING STATION
Region: 4     State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: QUAD VO
HQ OPS Officer: BRIAN P. SMITH 		Notification Date: 09/25/2019
Notification Time: 08:26 [ET]
Event Date: 09/24/2019
Event Time: 23:38 [PDT]
Last Update Date: 09/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
VINCENT GADDY (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF HIGH PRESSURE CORE SPRAY SYSTEM

"At 2338 PDT on September 24, 2019, the High Pressure Core Spray (HPCS) system was declared inoperable due to a leak on DSA-PCV-2C (2 inch Diesel Starting Air Pressure Control Valve). With one of two air headers isolated and being drained for maintenance, this leak caused the remaining starting air header for HPCS-GEN-DG3 (HPCS Diesel Generator) to lower to less than the operability limit.

"Upon declaring the HPCS system inoperable, TS 3.5.1 Action B was entered. In accordance with Action B, the Reactor Core Isolation Cooling (RCIC) system was verified to be operable. Action B provides a 14 day completion time to restore HPCS to an operable status.

"All other Emergency Core Cooling Systems (ECCS) were operable during this event. This event is being reported as an event or condition that could have prevented the fulfillment of a safety function credited for mitigating the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D). The HPCS system is a single train system at Columbia.

"The leak was isolated and starting air header pressure restored to the HPCS diesel generator at 0104 PDT on September 25, 2019, and all associated Technical Specifications were exited.

"The NRC Resident Inspector was notified."


Power Reactor Event Number: 54293
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: OSSY FONT 		Notification Date: 09/25/2019
Notification Time: 15:30 [ET]
Event Date: 09/25/2019
Event Time: 12:03 [EDT]
Last Update Date: 09/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT DALEY (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"At 1203 EDT, on September 25, 2019, during a Division 2 Emergency Equipment Service Water (EESW) pump and valve surveillance test, the Division 2 Emergency Equipment Cooling Water (EECW) Temperature Control Valve was found to be approximately 80 percent open rather than in its required full open position during fail safe testing. The Division 2 EESW system is required to support operability of the Division 2 EECW system. The Division 2 EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. An investigation is underway into the cause of the failure. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The NRC Senior Resident Inspector has been notified."

The licensee is in 72-hour shutdown action statement.

Page Last Reviewed/Updated Wednesday, March 24, 2021