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

Event Notification Report for November 04, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/1/2019 - 11/4/2019

** EVENT NUMBERS **

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

Agreement State	Event Number: 54352
Rep Org: ALABAMA RADIATION CONTROL Licensee: ALABAMA RIVER CELLULOSE Region: 1 City: PERDUE HILL State: AL County: License #: 634 Agreement: Y Docket: NRC Notified By: CASON COAN HQ OPS Officer: JEFF HERRERA	Notification Date: 10/25/2019 Notification Time: 10:19 [ET] Event Date: 10/24/2019 Event Time: 00:00 [CDT] Last Update Date: 10/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): BRICE BICKETT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILED SHUTTER ON A PROCESS GAUGE

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

"Representative reported that personnel found a gauge to have a failed shutter. Representative reported that the shutter is failed in the closed position. Representative reported that [the] gauge was discovered in the reported condition during some maintenance operations. Representative stated that the gauge was discovered in its reported condition on 10/24/2019. Representative reported this to [the] Agency [Alabama Department of Public Health] on 10/25/2019 at 0813 [CDT].

"Gauge contains source s/n 8829GK, a 500 mCi Cs-137 source. Gauge is reported as an Ohmart model SH-2. No known device issues that could have caused a failed shutter.

"Licensee is in the process of ordering parts for repair. Representative stated that ABB will repair the gauge."

Alabama Incident number 19-29.

Non-Agreement State	Event Number: 54354
Rep Org: SCHMUCKER, PAUL, NOHR, & ASSOCIATES Licensee: SCHMUCKER, PAUL, NOHR, & ASSOCIATES Region: 4 City: MITCHELL State: SD County: License #: 40-27560-01 Agreement: N Docket: NRC Notified By: JACOB SONNE HQ OPS Officer: HOWIE CROUCH	Notification Date: 10/26/2019 Notification Time: 11:29 [ET] Event Date: 10/26/2019 Event Time: 00:00 [MDT] Last Update Date: 10/27/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

While in use on a job site with the source extended, a Troxler Model 3430 moisture density gauge was damaged by a skid loader. The source was able to be retracted into the shielded area of the gauge but the shield cannot be closed due to damage to the bottom shield plate.

The licensee has established a 15 foot radius boundary per their emergency procedure and will be obtaining a survey meter to verify radiation levels at the boundary.

The licensee will be getting local assistance to secure the source for transportation back to their storage facility.

A Troxler Model 3430 normally contains a 44 mCi Am-241/Be source and a 9 mCi Cs-137 source.

Power Reactor	Event Number: 54364
Facility: NINE MILE POINT Region: 1 State: NY Unit: [] [2] [] RX Type: [1] GE-2,[2] GE-5 NRC Notified By: CARL JONES HQ OPS Officer: DONALD NORWOOD	Notification Date: 11/01/2019 Notification Time: 10:03 [ET] Event Date: 11/01/2019 Event Time: 03:16 [EDT] Last Update Date: 11/01/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): MATT YOUNG (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

HIGH PRESSURE CORE SPRAY (HPCS) SYSTEM INOPERABLE

"On November 1, 2019 at 0316 EDT, Nine Mile Point Unit 2 (NMP2) received Control Room annunciation for HPCS SYSTEM INOPERABLE and inoperable status light indication for TRIP UNITS OUT OF FILE/POWER FAIL. Initial investigation has identified a potential failed 24 vdc power supply which supplies power to the HPCS trip units for system initiation and control. The HPCS system has been declared inoperable per TS 3.5.1 resulting in an unplanned 14 day LCO.

"All other plant systems functioned as required.

"NMP2 is currently at 100 percent power in Mode 1.

"This condition is reportable under 10 CFR 50.72(b)(3)(v)(D) as, 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (D) Mitigate the consequences of an accident.'"

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54366
Facility: BEAVER VALLEY Region: 1 State: PA Unit: [1] [] [] RX Type: [1] W-3-LP,[2] W-3-LP NRC Notified By: SHAWN KEENER HQ OPS Officer: DAN LIVERMORE	Notification Date: 11/02/2019 Notification Time: 23:03 [ET] Event Date: 11/02/2019 Event Time: 15:15 [EDT] Last Update Date: 11/02/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION	Person (Organization): MATT YOUNG (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Hot Standby

Event Text

REFUELING WATER STORAGE TANK DECLARED INOPERABLE DUE TO LOW LEVEL

"At 1515 on November 2, 2019, the Refueling Water Storage Tank (RWST) was declared inoperable due to a Low Head Safety Injection relief valve discharging to the Safeguards Sump during routine surveillance testing. The leakage from the Low Head Safety Injection system in conjunction with a postulated Design Basis Accident (DBA) Loss of Coolant Accident (LOCA) with transfer to Safety Injection Recirculation may result in dose exceeding the Dose Analysis of the Exclusion Area Boundary (EAB) and the Control Room, which is common to both Unit 1 and Unit 2. This condition may not be bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The Low Head Safety Injection relief valve has been isolated to prevent further leakage, and makeup to the RWST completed. At 1602 on November 2, 2019 the RWST was declared Operable. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(B), (C), (D) as an Unanalyzed Condition and a condition that could have prevented the Fulfillment of a Safety Function."

The licensee notified the NRC resident inspector.

Power Reactor	Event Number: 54367
Facility: COMANCHE PEAK Region: 4 State: TX Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: MATT KARL HQ OPS Officer: CATY NOLAN	Notification Date: 11/03/2019 Notification Time: 09:23 [ET] Event Date: 11/03/2019 Event Time: 08:00 [CST] Last Update Date: 11/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): JOHN DIXON (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

PLANNED LOSS OF EMERGENCY RESPONSE FACILITIES AND EQUIPMENT

"At 0800 CST on November 3, 2019, Comanche Peak began a planned modification on the Unit 2 Plant Computer System. During this modification, the ability to perform emergency assessment in the Technical Support Center (TSC) and the Emergency Operations Facility (EOF) will be impacted. Since the ability to perform emergency assessment is not expected to be restored within 72 hours, this is reportable per 10 CFR 50.72(b)(3)(xiii) as an event that results in a loss of emergency assessment capability.

"During this modification, the Control Room will continue to have the ability to perform emergency assessment. If an Alert, Site Area Emergency, or General Emergency is declared during this modification, communicators dedicated to performing emergency assessment will be stationed in the Control Room, TSC, and EOF. The Plant Computer System modification is scheduled to be completed on November 24, 2019 and a follow-up ENS notification will be made once the Unit 2 Plant Computer System is declared functional.

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Thursday, March 25, 2021