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Event Notification Report for October 30, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/29/2019 - 10/30/2019

** EVENT NUMBERS **


54342543435434454358543595436054362


Agreement State Event Number: 54342
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: MEDI-PHYSICS, INCORPORATED
Region: 4
City: PHOENIX   State: AZ
County:
License #: 7-346
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: OSSY FONT 		Notification Date: 10/21/2019
Notification Time: 18:58 [ET]
Event Date: 10/21/2019
Event Time: 00:00 [MST]
Last Update Date: 10/21/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST SHIPMENT OF MO-99 GENERATORS

The following was received from the Arizona Department of Health Services (the Department) via email:

"The Department received notification on October 21, 2019, that a licensee's shipment of radioactive material, sent July 9, 2019, with an expected delivery date of July 18, 2019, has not been received by the intended Consignee/Receiver, and is currently unaccounted for. The shipment contained five (5) Mo-99 generators, totaling approximately 192 milliCuries (7.1 GBq). The Department has requested additional information and continues to investigate the event."

Arizona incident 19-025

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: 54343
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: BAY AREA GEOTECHNICAL GROUP
Region: 4
City: SAN JOSE   State: CA
County:
License #: 1625-43
Agreement: Y
Docket:
NRC Notified By: K. ARUNIKA HEWADIKARAM
HQ OPS Officer: OSSY FONT 		Notification Date: 10/22/2019
Notification Time: 15:41 [ET]
Event Date: 10/21/2019
Event Time: 02:30 [PDT]
Last Update Date: 10/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health Radiologic Health Branch (RHB) via email:

"On 10/21/19, the RSO [radiation safety officer] contacted RHB to report a stolen moisture density gauge. The gauge is a CPN Model MC1Elite, S/N 30492, containing 50 mCi of Cs-137 and 50 mCi of Am-241. It was stolen on 10/21/19 around 0230 [PDT] from the back of a truck parked at the gauge user's residence. The gauge was being used at a temporary job site near the user's residence and it was stolen by cutting the locks securing the gauge. The licensee provided video footage of the crime taking place from a video camera at the user's residence. The licensee had contacted the Salinas Police Department to notify them of the incident (Case #19-101002). A flyer has been posted with a reward for the safe return of the gauge. RHB will be following up on this investigation."

CA 5010 No.: 102119

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


!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 54344
Rep Org: OZARK MEDICAL CENTER
Licensee: OZARK MEDICAL CENTER
Region: 3
City: WEST PLAINS   State: MO
County:
License #: 24-18733-01
Agreement: N
Docket:
NRC Notified By: JOHN MCKENZIE
HQ OPS Officer: OSSY FONT 		Notification Date: 10/22/2019
Notification Time: 16:24 [ET]
Event Date: 10/22/2019
Event Time: 13:30 [CDT]
Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ADMINISTRATION OF DOSE TO WRONG INDIVIDUAL

The following is a synopsis of information received via phone:

On 10/22/19, at approximately 1330 CDT, 22.0 mCi of Tc-99m-white blood cells was administered to the wrong patient. The patient was confused and not able to correctly confirm that they were the patient receiving the dose. This patient was informed of event, but has a power of attorney who will also be notified. This patient's condition means the dose, carried by the white blood cells, will possibly end up in their bowel. Extra monitoring is being performed.

The correct patient will be rescheduled.

* * * RETRACTION ON 10/29/2019 AT 1257 EDT FROM JOHN MCKENZIE TO ANDREW WAUGH * * *

After discussion with R3 (Gattone), Ozark Medical Center is retracting this event because the delivered dose does not exceed the reportable limits described in 10 CFR 35.3045.

Notified R3DO (Riemer) and NMSS Events Notification (email).

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: 54358
Facility: DRESDEN
Region: 3     State: IL
Unit: [2] [3] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: MARK SCHIMANSKI
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 10/29/2019
Notification Time: 13:12 [ET]
Event Date: 10/29/2019
Event Time: 09:19 [CDT]
Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

INADVERTENT ACTUATION OF SIRENS

"At approximately 0945 CDT, on 10/29/2019, the Dresden Station main control room was notified of the inadvertent actuation of nine full sounding sirens affecting Dresden Station in Will County Illinois. Will County notified Exelon of the inadvertent actuation that occurred on 10/29/2019, at 0919 CDT, during the performance of regular maintenance on the siren equipment at the Laraway Communication Center, the Will County Sheriff Dispatch Center.

"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies.

"The Dresden NRC Resident has been notified."

The siren equipment has been repaired and sirens have been returned to service.


Power Reactor Event Number: 54359
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: LISA PRITCHETT
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 10/29/2019
Notification Time: 13:25 [ET]
Event Date: 10/29/2019
Event Time: 09:09 [EDT]
Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GERALD MCCOY (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS FOR DUTY - CONTRACT SUPERVISOR FAILED RANDOM TEST

A contract employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's badge has been confiscated.

The NRC Resident Inspector has been notified.


Power Reactor Event Number: 54360
Facility: BRAIDWOOD
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KATHERINE MCDONALD
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 10/29/2019
Notification Time: 13:58 [ET]
Event Date: 10/29/2019
Event Time: 09:19 [CDT]
Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

INADVERTENT ACTUATION OF SIRENS

"At approximately 0945 CDT, on 10/29/2019, the Braidwood Station main control room was notified of the inadvertent actuation of 17 full sounding sirens affecting Braidwood Station in Will County, Illinois. Will County notified Exelon of the inadvertent actuation that occurred on 10/29/2019, at 0919 CDT, during the performance of regular maintenance on the siren equipment at the Laraway Communication Center at the Will County Sheriff Dispatch Center.

"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies.

"The Braidwood NRC Resident Inspector has been notified."

The siren equipment has been repaired and restored to service.


Power Reactor Event Number: 54362
Facility: SAINT LUCIE
Region: 2     State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES PIKE
HQ OPS Officer: DONALD NORWOOD 		Notification Date: 10/30/2019
Notification Time: 01:20 [ET]
Event Date: 10/30/2019
Event Time: 00:26 [EDT]
Last Update Date: 10/30/2019
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GERALD MCCOY (R2DO)
LAURA DUDES (R2A)
HO NIEH (NRR)
JEFFERY GRANT (IRD)
CHRIS MILLER (NRR EO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled

Event Text

UNUSUAL EVENT DUE TO RELEASE OF FLAMMABLE GAS

"On 10/30/19 at 0026 EDT, an Unusual Event (HU3) was declared due to a release of flammable gas to the Unit 1 Pipe Penetration area (Reactor Auxiliary Building). The hydrogen supply valve to the area has been isolated. The area is being ventilated and follow-up air sampling will be performed.

"The NRC Resident Inspector has been notified."

Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATE FROM FRED POLLAK TO DONALD NORWOOD AT 0521 EDT ON 10/30/2019 * * *

"The Notice of Unusual Event was terminated at 0454 EDT on 10/30/19. The area has been purged and normal access restored."

The licensee notified the NRC Resident Inspector.

Notified R2DO (McCoy), NRR EO (Miller), and IRD (Grant). Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

Page Last Reviewed/Updated Wednesday, March 24, 2021