Event Notification Report for December 31, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/30/2019 - 12/31/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54425
Facility: COOPER Region: 4 State: NE Unit: [1] [] [] RX Type: [1] GE-4 NRC Notified By: RANDY KOUBA HQ OPS Officer: KERBY SCALES	Notification Date: 12/05/2019 Notification Time: 16:03 [ET] Event Date: 12/05/2019 Event Time: 08:10 [CST] Last Update Date: 12/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): NICK TAYLOR (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

EN Revision Imported Date : 12/31/2019

EN Revision Text: FIRE DOOR DISCOVERED UNLATCHED

The following was received via email from Cooper Nuclear Station:

"At 0810 [CST], on 12/5/19, Operations personnel discovered BLDG-DOOR-R209, FIRE DOOR BETWEEN CRITICAL SWITCHGEAR ROOMS F & G, was unlatched. The door was immediately latched upon discovery. Based on door logs, the door separating the two critical switchgear rooms was inadvertently left unlatched for approximately 5 minutes. This door is a Steam Exclusion Boundary (SEB) door. It is required to be closed and latched when the Auxiliary Steam Boiler is in service due to Auxiliary Steam piping passing through Critical Switchgear Room 'G'. If a steam line break was to occur with the door unlatched, steam could render both Critical Switchgear busses inoperable.

"This is being reported under 10 CFR 50.72(b)(3)(ii)(B), Unanalyzed Condition, and 10 CFR 50.72(b)(3)(v), 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 (B) remove residual heat and to (D) mitigate consequences of an accident.

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

The door closes automatically and appeared to have been left unlatched by the last person passing through. The door was tested and latches as required.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 12/30/2019 AT 1129 EST FROM DAVE VANDERKAMP TO ANDREW WAUGH * * *

CNS is retracting the 8-hour notification made for event notification 54425 which occurred on December 5, 2019 at 0810 CST. Subsequent engineering evaluation demonstrates the essential equipment located in critical switchgear room 'F' would have remained within the design limits in the event of a postulated auxiliary steam line break in critical switchgear room 'G' with door R209 open. As a result, the safety function would have been maintained and there was no unanalyzed condition that would significantly degrade plant safety.

The licensee notified the NRC Resident Inspector. Notified R4DO (Warnick).

Agreement State	Event Number: 54454
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: BUFFALO PHARMACIES, INC. Region: 1 City: EAST AMHERST State: NY County: License #: G14958 Agreement: Y Docket: NRC Notified By: DANIEL SAMPSON HQ OPS Officer: BRIAN LIN	Notification Date: 12/20/2019 Notification Time: 12:20 [ET] Event Date: 10/21/2019 Event Time: 00:00 [EST] Last Update Date: 12/20/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - TWO LOST Po-210 IONIZERS

The following was received from the New York State Department of Health (NYSDOH) via fax:

"On October 22, 2019, the Department [New York State Department of Health] was notified by e-mail of two lost static elimination devices, NRD, LLC Model P-2042 1000 'Nuclespot Ionizer', S/N A2LL994 and A2LC660. The devices has a maximum activity of 5 millicuries of Polonium-210 at the time of manufacture. Based on the information provided to the Department, the activity of the device on October 21, 2019 (date of discovery) would be approximately 0.8 and 0.14 millicuries, respectfully.

"The licensee [Buffalo Pharmacies] indicated that the devices had not been used in quite some time and that the facility at which the devices were used had recently closed. Between the lack of use and the closing of the facility, the devices has been deemed lost."

EVENT REPORT ID NO.: NYDOH-19-10

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: 54455
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: UF HEALTH SHANDS CANCER HOSPITAL Region: 1 City: GAINESVILLE State: FL County: License #: 0031-3 Agreement: Y Docket: NRC Notified By: DAVID PIESKI HQ OPS Officer: BRIAN LIN	Notification Date: 12/23/2019 Notification Time: 13:49 [ET] Event Date: 12/20/2019 Event Time: 00:00 [EST] Last Update Date: 12/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following is a synopsis of an email from the state of Florida:

On December 20th, 2019, a patient was prescribed and administered a yttrium-90 treatment. The patient received 25 percent of the prescribed dose as reported by the Radiation Safety Officer (RSO) to the Florida Bureau of Radiation Control on December 23. Further details, including actual prescription amounts, are awaiting a submitted report by the hospital's Interventional Radiology Department.

FL Incident Number: FL19-154

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.

Agreement State	Event Number: 54456
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: INTERNATIONAL PAPER COMPANY Region: 4 City: ORANGE State: TX County: License #: L06932 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: BETHANY CECERE	Notification Date: 12/23/2019 Notification Time: 14:19 [ET] Event Date: 12/20/2019 Event Time: 00:00 [CST] Last Update Date: 12/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - THREE GAUGE SHUTTERS INOPERABLE

The following was received via email from the state of Texas:

"On December 23, 2019, the licensee notified the Agency [Texas Department of State Health Services] that late, after hours, on December 20, 2019, it had discovered during routine gauge inspections that the shutters on three (3) of their Berthold Model LB 7440 gauges were inoperable. The shutters are in the open position which is the normal operating position for the gauges. Two of the gauges contain 100 milliCuries of cesium-137 each and the third contains 10 milliCuries of cesium-137. Due to their location, there is no increased risk of exposure to any persons. The licensee is in the process of scheduling repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

TX Incident # 9729

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