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Event Notification Report for December 17, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/16/2019 - 12/17/2019

** EVENT NUMBERS **


54426 54427 54428 54429 54446

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Agreement State Event Number: 54426
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNKNOWN
Region: 3
City: FRANKSVILLE   State: WI
County:
License #: UNKNOWN
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: OSSY FONT
Notification Date: 12/06/2019
Notification Time: 15:19 [ET]
Event Date: 12/06/2019
Event Time: 00:00 [CST]
Last Update Date: 12/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE FOUND AT SCRAP YARD

The following was received from the Wisconsin Department of Health Services Radiation Protection Section (the Department) via email:

"On December 6, 2019, the Department was notified by a local scrap facility that they had refused a load of material on December 4 after setting off portal monitors at their site. No reports were made at that time. On December 6, safety staff from the scrap facility assisted in characterization of the material at the originating location. The device was identified as a Seaman Nuclear Density Gauge (Model R-75, SN: 3032). These are manufactured with a maximum activity of 5 mCi Radium-226. No residual contamination was identified in any areas the gauge had been.

"The Department has dispatched inspectors to perform their own investigation and characterization of the material, and will provide updates as they become available."

* * * UPDATE ON 12/06/019 AT 1805 EST FROM KYLE WALTON TO OSSY FONT * * *

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

"Inspectors arrived at the originating location. The material is currently secured in a cargo container away from members of the public. Surveys and swipes do not indicate a leaking source or removable contamination. Surface readings of up to 13 mR/h were observed. The manufacturer has been contacted to identify the last known owner of the gauge."

Event Report ID No.: WI190016

Notified R3DO (Daley) and NMSS Events Notification via email.

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

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Agreement State Event Number: 54427
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: UNIVERSITY OF KANSAS HOSPITAL AUTHORITY
Region: 4
City: TOPEKA   State: KS
County:
License #: 18-C800
Agreement: Y
Docket:
NRC Notified By: DAVID M LAWRENZ
HQ OPS Officer: OSSY FONT
Notification Date: 12/06/2019
Notification Time: 15:33 [ET]
Event Date: 12/06/2019
Event Time: 13:28 [CST]
Last Update Date: 12/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERED BY MORE THAN 20 PERCENT

The following was received from the Kansas Department of Health and Environment via email:

"On December 6, 2019, at 1328 [CST], [the University of Kansas Hospital Authority] reported a medical event involving Y-90 Microspheres to the Kansas Radiation Control Program (RCP). The licensee stated that the patient had unusually small blood vessel feeding the tumor and prevented a larger than anticipated dose to the tumor. An initial written report was received at 1354 [CST] from the RSO [Radiation Safety Officer] stating that there were no errors or problems during the procedure administration. The dose differed by more than 20 percent, though the physician stated that the dose was therapeutic and will not plan to retreat. There was no report of contamination at the facility or of the patient.

"The Kansas RCP is preparing for an onsite investigation to review the incident. That investigation will be the basis for a final NMED report to follow."

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.

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Agreement State Event Number: 54428
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: WESTERN TECHNOLOGIES INC.
Region: 4
City: PHOENIX   State: AZ
County:
License #: 07-080
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: BRIAN LIN
Notification Date: 12/09/2019
Notification Time: 10:08 [ET]
Event Date: 12/09/2019
Event Time: 00:00 [MST]
Last Update Date: 12/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOST AND FOUND MOISTURE DENSITY GAUGE

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

"On December 9, 2019, the Department [Arizona Department of Health Services] was notified of a stolen portable gauge. Shortly after the initial notification, the licensee called back to update their notification and said the truck was impounded with the gauge secured in a metal box in the back of the truck. The gauge is an Instrotek Xplorer 3500. The Department is continuing to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona incident number 19-031

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Agreement State Event Number: 54429
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: DR. MICHAEL MEYER
Region: 4
City: OMAHA   State: NE
County:
License #: GL-0791
Agreement: Y
Docket:
NRC Notified By: DEB WILSON
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/09/2019
Notification Time: 16:45 [ET]
Event Date: 05/15/2019
Event Time: 00:00 [CST]
Last Update Date: 12/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

This is a summary of information received from the state of Nebraska via a phone call:

On November 20, 2019, the state of Nebraska identified a lost tritium exit sign during their quarterly reports. The general licensee indicated that they improperly disposed of the exit sign by donating it to a second-hand store on May 15, 2019. The exit sign has not been located at this time. The second-hand store turns over their inventory every six months, so it is believed that the exit sign has been sold or disposed of.

The tritium exit sign is a Betalux model BX-20-BK (S/N: C167432) with an activity of 17.51 Ci.

No further investigation is planned at this time and Nebraska has closed the event.

Nebraska incident number: NE190005

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

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Power Reactor Event Number: 54446
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEPHEN FRIESE
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/16/2019
Notification Time: 09:12 [ET]
Event Date: 12/16/2019
Event Time: 03:58 [EST]
Last Update Date: 12/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BRIAN BONSER (R2DO)
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 47 Power Operation 47 Power Operation

Event Text

EMERGENCY DIESEL GENERATOR AUTOSTART DUE TO LOSS OF POWER TO 1B SHUTDOWN BOARD

"At 0358 EST, on 12/16/2019, with Unit 1 in Mode 1 at 100 [percent] power and Unit 2 in Mode 1 at 47 [percent] power, a valid actuation of the Emergency Diesel Generators (EDG) occurred. The reason for the emergency diesel generator auto start was that the normal feeder breaker from the 1C 6.9KV Unit Board to the 1B-B 6.9KV Shutdown Board (SDBD) tripped due to the breaker's 51G relay actuating causing an under-voltage signal on the 1B-B 6.9KV Shutdown Board. All 4 Emergency Diesel Generators automatically started as designed when the 6.9KV Shutdown Board under-voltage signal was received.

"The 1B-B 6.9KV Shutdown Board was automatically energized from the 1B-B 6.9KV Diesel Generator. All required 6.9KV loads were sequenced back on to the 1B-B 6.9KV Shutdown Board as designed after the board was energized from its emergency diesel generator. The remainder of the electrical system is in normal alignment.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency Diesel Generators.

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

"The NRC Senior Resident has been notified."


Page Last Reviewed/Updated Tuesday, December 17, 2019
Tuesday, December 17, 2019