Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2020

Event Notification Report for February 14, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/13/2020 - 2/14/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54511
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: THE METHODIST HOSPITAL Region: 4 City: HOUSTON State: TX County: License #: L00457 Agreement: Y Docket: NRC Notified By: CHRIS MOORE HQ OPS Officer: HOWIE CROUCH	Notification Date: 02/05/2020 Notification Time: 09:31 [ET] Event Date: 02/04/2020 Event Time: 00:00 [CST] Last Update Date: 02/05/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NICK TAYLOR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE FAILED TO RETRACT

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

"The Methodist Hospital reported a source retraction failure during an intravascular Brachytherapy treatment performed on 2/4/2020. The intravascular brachytherapy system (Best Vascular Model A-1000 Serial #89670) contained a 1.3 GBq (35.2 mCi) Sr-90 source (AEA Model SICW.2 Serial #ZA925). The patient was treated as prescribed and the source was completely out of the patient. As it was retracting into the device, it didn't go into home position. The device was immediately placed in the emergency equipment box (shielding box) per manufacturer's instructions for response to this type of occurrence. There was no underexposure or overexposure to the patient. The manufacturer has been contacted to investigate and conduct repairs. Additional information in accordance with SA-300 will be provided."

Texas Incident No.: 9739

Agreement State	Event Number: 54512
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: QUAKER OATS COMPANY Region: 3 City: BRIDGEVIEW State: IL County: License #: GL No. 9223623 Agreement: Y Docket: NRC Notified By: CHALES VINSON HQ OPS Officer: BETHANY CECERE	Notification Date: 02/05/2020 Notification Time: 21:55 [ET] Event Date: 02/05/2020 Event Time: 00:00 [CST] Last Update Date: 02/05/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANN MARIE STONE (R3DO) ILTAB (EMAIL) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST GAUGING SOURCE

The following was sent by the Illinois Emergency Management Agency (IEMA) via email:

"The Corporate H & S Mgr. [Health & Safety Manager] at PepsiCo/Quaker Oats reported the loss of an ATl-100S/500 microCurie [Sr-90] general licensed gauging source (SN 30056). They were doing leak tests this morning and found that the whole packaging unit had been removed presumably by Dudek Scrap during a remodel some time ago. They are checking on dates and will contact the scrap dealer to try and find it. IEMA inspectors plan to investigate on 2/6/20 to confirm details at the user's site and also will visit the scrap yard to see if the source is recoverable. At the moment this is considered an accidental loss due to poor oversight and is not related to any criminal theft or diversion."

Item Number: IL200004

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

Power Reactor	Event Number: 54524
Facility: DIABLO CANYON Region: 4 State: CA Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: JOHN WHETSLER HQ OPS Officer: KERBY SCALES	Notification Date: 02/13/2020 Notification Time: 17:17 [ET] Event Date: 02/13/2020 Event Time: 10:25 [PST] Last Update Date: 02/13/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION	Person (Organization): RAY AZUA (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"On February 13, 2020, at 1025 hours [PST], during the performance of the quarterly control rod exercise surveillance test, Shutdown Bank 'B' Group 1 became misaligned greater than 12 steps from its group demand position. In accordance with Technical Specification 3.1.4, 'Rod Group Alignment Limits,' Action D, a Unit 2 shutdown to Mode 3 was commenced at 1233 hours. Investigation into the cause of the rod bank misalignment is in progress.

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

"The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54525
Facility: SUSQUEHANNA Region: 1 State: PA Unit: [] [2] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: TOM RYDZEWSKI HQ OPS Officer: BRIAN P. SMITH	Notification Date: 02/14/2020 Notification Time: 03:36 [ET] Event Date: 02/14/2020 Event Time: 00:25 [EST] Last Update Date: 02/14/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): BRICE BICKETT (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

Power Operation

Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO RISING CONDENSER BACKPRESSURE

"At 0025 EST on February 14, 2020, Susquehanna Steam Electric Station Unit 2 reactor was manually scrammed due to rising Main Condenser Backpressure caused by a loss of the Unit 2 Offgas Recombiner.

"Unit 2 reactor was being operated at maximum facility output, approximately 98% RTP, when at 0012 EST, Unit 2 Recombiner 0C145 Panel Trouble and 2C198 HWC Panel Trouble alarms were received along with rising Main Condenser Backpressure. Initial Main Condenser Backpressure was 2.6 in HgA and was rising at approximately 0.3 HgA/min. A Recirc Lim 2 was inserted to lower reactor power and condenser backpressure continued to rise following the reduction in reactor power. A manual scram was inserted at 0025 EST by placing the Mode Switch to Shutdown when condenser backpressure rose to 6 in HgA. All control rods inserted. Reactor water level lowered to -30 inches causing Level 3 (+13 inches) isolation and partial (Division 2) Level 2 (-38 inches) isolation. No ECCS actuations occurred and RCIC initiated. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water. No steam relief valves opened. The Reactor Recirculation Pumps remained in service.

"The reactor is currently stable in Mode 3. Investigation into the cause of the loss of Unit 2 recombiner is underway.

"The NRC Senior resident inspector was notified. A voluntary notification to PEMA and press release will occur."

Page Last Reviewed/Updated Wednesday, March 24, 2021