Event Notification Report for November 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/31/2019 - 11/1/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54337
Facility: BEAVER VALLEY Region: 1 State: PA Unit: [1] [] [] RX Type: [1] W-3-LP,[2] W-3-LP NRC Notified By: SHAWN SNOOK HQ OPS Officer: HOWIE CROUCH	Notification Date: 10/18/2019 Notification Time: 02:28 [ET] Event Date: 10/17/2019 Event Time: 19:51 [EDT] Last Update Date: 10/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(ii)(A) - DEGRADED CONDITION	Person (Organization): DON JACKSON (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Refueling

Event Text

REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED

"At 1951 [EDT] on October 17, 2019, fretting indications on the reactor coolant system pressure boundary piping (pressurizer spray line) were identified. This condition does not appear to meet original construction code, ANSI B31.1, 1967 Edition thru summer 1971 Addenda. The condition will be resolved prior to plant startup. This event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

This condition will be corrected prior to the plant entering Mode 4.

* * * RETRACTION ON 10/31/19 AT 1450 EDT FROM JIM SCHWER TO BETHANY CECERE * * *

"An engineering evaluation has determined that the subject fretting is not considered a flaw, but instead is considered wear. Appendix F of Section III of the ASME Boiler and Pressure Vessel Code was applied and it was determined that the pressurizer spray line piping maintained its required design safety functions in the as-found condition. The wear has been repaired during the current refueling outage in accordance with the original construction code (ANSI B3l.l, 1967 Edition through summer 1971 Addenda) as well as Owner's Requirements.

"The NRC Resident Inspector has been notified."

Notified R1DO (Young).

Agreement State	Event Number: 54346
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: YORK HOSPITAL Region: 1 City: YORK State: PA County: License #: PA-0010 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: DONALD NORWOOD	Notification Date: 10/24/2019 Notification Time: 11:51 [ET] Event Date: 10/23/2019 Event Time: 00:00 [EDT] Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): BRICE BICKETT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

INCORRECT BRACHYTHERAPY SEED SET USED FOR IMPLANTATION

The following information was received via E-mail:

"The licensee informed the Department [Pennsylvania Department of Radiation Protection] that a brachytherapy seed set was implanted in the wrong patient. It is reportable per 10 CFR 35.3045(a)(2)(iii)(B).

"On October 23, 2019, the licensee was performing a permanent brachytherapy during which an incorrect prostate brachytherapy seed set (lsoRay Model CS-1) was brought to the procedure room and 6 Cs-131 seeds were implanted into the prostate of a patient. The procedure was stopped immediately when the error was recognized. The correct seeds were then brought to the operating room and the procedure was completed using the correct seeds. Forty Seven (47) seeds, 85 gray, (3.135 mCi) were prescribed and 3.03 mCi given. The Authorized User notified the urologist and patient this morning (10/24/19). No harm is expected to the patient.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID No: PA190024

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-Power Reactor	Event Number: 54349
Facility: ARMED FORCES RADIOBIOLOGY RSCH INST RX Type: 1100 KW TRIGA MARK-F Comments: Region: 0 City: BETHESDA State: MD County: MONTGOMERY License #: R-84 Agreement: Y Docket: 05000170 NRC Notified By: DALE TOMLINSON HQ OPS Officer: DONALD NORWOOD	Notification Date: 10/24/2019 Notification Time: 16:30 [ET] Event Date: 10/24/2019 Event Time: 00:00 [EDT] Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): BRICE BICKETT (R1DO) CINDY MONTGOMERY (DLP) NMSS_EVENTS_NOTIFICATION (EMAIL) LEAH SMITH (ILTAB)

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

Event Text

UNACCOUNTED FOR FISSION CHAMBER

On October 24, 2019, during performance of an annual inventory, one fission chamber could not be accounted for. After a thorough search, the fission chamber was declared missing. The fission chamber was manufactured by Reuter-Stokes with a part number of: RS-P6-0805-134 and a serial number of: 14K024C5. The fission chamber contains 0.12988 grams of Uranium-235.

The last known accounting of this fission chamber was during the previous annual inventory. The licensee is continuing to search for the fission chamber.

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

Page Last Reviewed/Updated Thursday, March 25, 2021