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Event Notification Report for March 05, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/4/2020 - 3/5/2020

** EVENT NUMBERS **


54541 54542 54543 54544 54545 54560 54561 54562

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Agreement State Event Number: 54541
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: HONEYWELL INTERNATIONAL
Region: 1
City: DULUTH   State: GA
County:
License #: GA 832-1
Agreement: Y
Docket:
NRC Notified By: ROGER WILSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/25/2020
Notification Time: 06:28 [ET]
Event Date: 12/18/2018
Event Time: 00:00 [EST]
Last Update Date: 02/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING PROMETHIUM-147 SOURCE

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

"On December 11, 2018, [Honeywell International] tested a sealed source for leakage or contamination and received results on December 21, 2018. The result from [their] vendor [was] 0.0113 +/- 0.0002 microCuries. This result is above the limit of 0.005 microCuries.

"The capsule has been isolated and there [was] no loose contamination detected in [their] facility. [Honeywell] will contact the vendor and arrange to return the capsule after the new year."

The source capsule, Model PHC.C2, serial no. AE5051, was manufactured with 2 Ci of Pm-147. The capsule was returned to Eckert & Ziegler who received it on 3/4/2019.

The state of Georgia considers this matter closed.

NMED Incident # 190022

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Agreement State Event Number: 54542
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: RI-CORP DEVELOPMENT, INC
Region: 1
City: FRACKVILLE   State: PA
County:
License #: PA-G0466
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: BRIAN LIN
Notification Date: 02/25/2020
Notification Time: 13:49 [ET]
Event Date: 02/20/2020
Event Time: 00:00 [EST]
Last Update Date: 02/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE FAILURE

The following report was received via email from the Commonwealth of Pennsylvania:

"During an inspection on February 20, 2020, an above normal reading on a Cesium-137 level gauge source head was discovered. Radiation measurements ranged from approximately 15 to 45 millirem per hour at one foot from the back of the source holder cap. It should be noted this gauge is located 11.5 feet off the ground, in an area with no stationed personnel or foot traffic. The device is a Kayray Model 7062B level gauge (Serial No. 21462) containing 25 milliCuries of Cs-137. The licensee immediately removed the device from service, the area was secured to ensure background radiation levels, and the manufacturer was contacted to initiate either a repair or replacement of the gauge. The area will remain secured until the device is able to be put into service again."

PA incident number: PA200005

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Agreement State Event Number: 54543
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Region: 3
City: PEORIA   State: IL
County:
License #: IL-01474-01
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: BRIAN LIN
Notification Date: 02/25/2020
Notification Time: 17:27 [ET]
Event Date: 02/21/2020
Event Time: 00:00 [CST]
Last Update Date: 02/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN FLUORESCENCE ANALYZER EQUIPMENT

The following report was received from the state of Illinois via email:

"The Agency [Illinois Emergency Management Agency] was notified by the Radiation Safety Officer (RSO) of the Illinois Department of Public Health (IDPH) that an XRF [X-ray fluorescence] instrument was stolen the morning of 2/21/20 in Peoria, IL. The RSO was made aware of the theft at approximately 1030 [CST] today. The vehicle had been parked overnight in the driveway of an IDPH employee who works out of the Peoria field office (site #2 on IL license). The gauge was locked in the trunk, in addition to having a lock on the case itself. However, the vehicle had been left running while the user went back into their home to retrieve a laptop, and upon their return they realized the vehicle had been stolen. Peoria Police were notified and informed of the instrument and radiation source in the trunk. The XRF is model XLP303A, serial number 14472; and the source serial number is TR2743. The IDPH will keep the Agency updated if they receive any additional information related to the vehicle or XRF instrument. The theft appears to be incidental to the theft of a vehicle and not an intentional diversion of radioactive material. The sources contained within these devices are IAEA category 5, meaning no one could be permanently injured and the amount of radioactive material, even if dispersed, could not permanently injure anyone."

Illinois report no.: IL200006



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: 54544
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON   State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/25/2020
Notification Time: 18:03 [ET]
Event Date: 02/24/2020
Event Time: 13:15 [EST]
Last Update Date: 02/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"On 24 Feb. 2020, at 1315 EST, an underdose of radiation to a patient receiving skin therapy occurred. The patient was scheduled to receive five fractions, at 7.5 grays per fraction, on five different parts of the left hand per fraction. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient. No Authorized Users were exposed to the source or otherwise contaminated. The licensee has agreed to submit further information on 26 Feb 2020. Since the cause of this incident is machine generated, in accordance with BRC [State of Florida Bureau of Radiation Control] procedures, it is not being given an incident number, and is being forwarded to ERCX [the X-Ray Machine Section of the BRC]."

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: 54545
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CONFLUENCE PARK APARTMENTS
Region: 4
City: DENVER   State: CO
County:
License #: GL002442
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: KERBY SCALES
Notification Date: 02/26/2020
Notification Time: 14:11 [ET]
Event Date: 12/13/2017
Event Time: 00:00 [MST]
Last Update Date: 02/26/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
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 TRITIUM EXIT SIGN

The following was received from the state of Colorado by email:

"One tritium exit sign reported as never received or installed when conducting the annual reconciliation."

The initial date reported to the State was December 13, 2017.

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: 54560
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ANTON PESTKA
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/04/2020
Notification Time: 02:07 [ET]
Event Date: 03/03/2020
Event Time: 20:50 [MST]
Last Update Date: 03/04/2020
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):
RICK DEESE (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL

"At 2050 MST on March 3, 2020, Unit 2 reactor automatically tripped on Low Steam Generator (SG) Number 1 level signal from the Reactor Protection System. The low SG level occurred as the result of a trip of both Main Feedwater Pumps, which tripped during restoration of power to the Main Feedwater Pump Lube oil control panel. Auxiliary Feedwater (AFAS-1 and AFAS-2) actuated due to low SG levels in both SG post reactor trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"Following the reactor trip, all [control element assemblies] CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generators are being fed via the class 1 E powered motor driven auxiliary feedwater pump.

"The NRC Senior Resident Inspector has been informed."

Units 1 and 3 were unaffected by the trip and remain at 100 percent power.

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Power Reactor Event Number: 54561
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RONALD ROHAN
HQ OPS Officer: HARRY FREEMAN
Notification Date: 03/04/2020
Notification Time: 12:24 [ET]
Event Date: 03/04/2020
Event Time: 08:18 [EST]
Last Update Date: 03/04/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICK DEESE (R4DO)
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 100 Power Operation 100 Power Operation

Event Text

NOTIFICATION TO OTHER GOVERNMENT AGENCY

"On March 4, 2020, [an actual] Unusual Event Code was [inadvertently] sent to an offsite agency (INPO) and to a former NRC Resident Inspector during a planned Emergency Response Drill.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 54562
Facility: NINE MILE POINT
Region: 1     State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOEL SMITHERS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/04/2020
Notification Time: 15:35 [ET]
Event Date: 03/04/2020
Event Time: 12:05 [EST]
Last Update Date: 03/04/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DON JACKSON (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 88 Power Operation 0 Hot Shutdown

Event Text

MANUAL SCRAM IN THE TURBINE CONTROL SYSTEM

"At 1205 EST, on March 4, 2020, Nine Mile Point Unit 2 initiated a manual reactor scram due to lowering Electrohydraulic Control System (EHC) level in the turbine control system. The cause of the lowering level was a leak in the EHC system piping.

"All control rods inserted. There were no safety system actuations. The cause of the EHC leak is being investigated.

"The NRC Resident has been notified."

Additionally, the licensee notified the New York State Public Service Commission.


Page Last Reviewed/Updated Thursday, March 05, 2020
Thursday, March 05, 2020