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Event Notification Report for January 28, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/27/2020 - 1/28/2020

** EVENT NUMBERS **


54483 54484 54492 54495

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Agreement State Event Number: 54483
Rep Org: ALABAMA RADIATION CONTROL
Licensee: EAST ALABAMA MEDICAL CENTER
Region: 1
City: OPELIKA   State: AL
County:
License #: 105
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/17/2020
Notification Time: 11:57 [ET]
Event Date: 01/16/2020
Event Time: 14:45 [CST]
Last Update Date: 01/17/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ALABAMA AGREEMENT STATE REPORT - PATIENT RECEIVED GREATER DOSE THAN PRESCRIBED

The following information was received from the state of Alabama via facsimile:

"On January 16, 2020 at approximately 1445 CST, [the radiation safety officer (RSO)] of Alabama licensee East Alabama Medical Center notified the Alabama Office of Radiation Control [the Agency] that a patient apparently received more dose than prescribed during a treatment via HDR [high dose rate] afterloader on or around Thursday, 1/9/2020. [The RSO] stated that he noted the matter yesterday (1/15/20 at around 1530); he stated that the physician associated with the patient's case confirmed [the RSO's] concerns about the patient's dose. [The RSO] reported that the patient apparently received dose in 1 fraction that was to be administered over 2-3 fractions. The Agency has no further information on this matter as of the date of submission of this memo.

"Of note, East Alabama Medical Center is authorized to possess and use an Elekta Flexitron model 136149A02 HDR medical irradiator under Alabama license 105, with a maximum of 12 Ci of Ir-192."

Alabama Event 20-01

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: 54484
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: IRIS NDT
Region: 4
City: MANDAN   State: ND
County:
License #: 33-56806-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/17/2020
Notification Time: 17:00 [ET]
Event Date: 12/18/2019
Event Time: 22:15 [MST]
Last Update Date: 01/17/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NORTH DAKOTA AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following information is summarized from an email received from the state of North Dakota:

At approximately 2215 MST on 12/18/2019, while setting up for a radiography shot, the radiography team experienced a source disconnect. When the team realized a disconnect occurred, they established a 2 mR/hr. boundary and contacted the radiation safety officer (RSO). The RSO arrived on site and was able to retrieve the source back into the shielded position. No overexposures were reported. The licensee removed the camera from service and returned it to their facility in Bismarck, ND.

The licensee determined that poor camera maintenance and personnel error contributed to the guide tube being only partially connected to the camera which led to the disconnect. The radiography crew was briefed on the cause of the event and the proper steps to maintain and inspect a camera prior to use.

The camera was a SPEC 150, serial number 2592 , with a 66 Ci Ir-192 source, serial number AK 2405.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 54492
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE   State: NM
County: LEA
License #: SNM-2010
Docket: 70-3103
NRC Notified By: WYATT PADGETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/22/2020
Notification Time: 19:00 [ET]
Event Date: 01/22/2020
Event Time: 16:23 [MST]
Last Update Date: 01/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
NICOLE COOVERT (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

REQUIRED PROCEDURAL CONTROLS WERE NOT FOLLOWED

"Urenco USA is conservatively reporting a condition in that Uranic bearing material was placed into the Small Component Decontamination Train (SCDT) without meeting all conditions of IROFS54a and IROFS54b.

"IROFS54a and IROFS54b are Mass Controls that ensure the configuration of the SCDT remains sub-critical. Bookkeeping elements of the IROFS were performed correctly and the masses of the components were determined properly. However the visual inspection of the SCDT to ensure it is empty, prior to introducing components, was not performed in accordance with procedure instructions.

"The components were removed and the visual inspection was performed which confirmed the SCDT was in fact empty.

"The facility was and remains in a safe and stable configuration."

The licensee will notify NRC Region 2 tomorrow.

* * * RETRACTION ON 1/24/20 AT 1130 EST FROM BLAKE BIXENMAN TO RODNEY CLAGG * * *

"This event was determined to not be reportable.

"Consistent with NRC FCSS ISG-12, Rev 1, 10 CFR Part 70, Appendix A - Reportable Safety Events, UUSA has
concluded that EN54492 was not reportable. All situations where IROFS have failed or degraded are reportable
under Paragraphs (a)(4) or (b)(2), exceptions include the following: The capabilities of the degraded IROFS are
still sufficient to meet the performance requirements of 10 CFR 70.61.

"On 01-17-2020, UUSA completed a discharge of material to the slab tanks in the Liquid Effluent Collection
Treatment & Storage (LECTS) Room. Upon completion of decontamination activities in the SCDT, procedurally
required actions were performed to ensure all in process uranic material was removed and verification of the
uranic material hold-up value was still valid in accordance with IROFS54a&b. IROFS54a&b tags and locks were
then installed indicating the IROFS functions had been performed.

"On 01-22-2020, a new work evolution began which included bookkeeping measurements to ensure the
calculated mass of uranium was below the allowable threshold prior to introduction to the SCDT. In summary, all
requirements of the IROFS54a&b boundary were functionally complete and the capabilities of the degraded
IROFS remained sufficient to meet the performance requirements of 10 CFR 70.61."

Notified the R2DO (Coovert) and NMSS Events Notification (email)

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Power Reactor Event Number: 54495
Facility: SUMMER
Region: 2     State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: JEFF MANROSS
HQ OPS Officer: KERBY SCALES
Notification Date: 01/27/2020
Notification Time: 09:29 [ET]
Event Date: 01/26/2020
Event Time: 23:54 [EST]
Last Update Date: 01/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NICOLE COOVERT (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

Event Text

INADVERTANT ACTIVATION OF AN EARLY WARNING SIREN

"At 2354 EST, on January 26, 2020, officials with the State Emergency Operations Center and Newberry County, SC were notified of an apparent inadvertent actuation of a single siren in the VC Summer Early Warning Siren System (EWSS).

"[VC Summer Nuclear Station] VCSNS received a report of siren actuation from a local resident at approximately 2340 EST. The EWSS indication at the Emergency Operations Facility showed siren #35 had actuated. A reset of the EWSS was performed. VCSNS is working to confirm actual siren activation and troubleshoot the issue. This event is still under investigation.

"This is a non-emergency notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

The Licensee notified state and local agencies.


Page Last Reviewed/Updated Tuesday, January 28, 2020
Tuesday, January 28, 2020