Event Notification Report for March 06, 2020
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U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 54545 | 54547 | 54548 | 54561 | 54567 | 54569 |
| 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 |
| Non-Agreement State | Event Number: 54547 |
| Rep Org: VETERANS HEALTH ADMINISTRATION Licensee: VETERANS HEALTH ADMINISTRATION Region: 4 City: NORTH LITTLE ROCK State: AR County: License #: 03-23853-01VA Agreement: Y Docket: NRC Notified By: KIM WIEBECK HQ OPS Officer: OSSY FONT |
Notification Date: 02/27/2020 Notification Time: 10:38 [ET] Event Date: 02/27/2020 Event Time: 06:10 [CST] Last Update Date: 02/27/2020 |
| Emergency Class: NON EMERGENCY 10 CFR Section: 20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS |
Person (Organization): STEVE ORTH (R3DO) MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) |
Event Text
| NON-AGREEMENT STATE REPORT - EXTERNALLY CONTAMINATED PACKAGE The following was received from the Veterans Health Administration via E-mail: "Per 10 CFR 20.1906(d), Veterans Health Administration (VHA) National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. "The package was received Thursday, February 27, 2020, at around 0710 EST by the North Florida/South Georgia Veterans Health System [Permit No.: 0912467-02] in Gainesville, Florida. This facility holds permit number 09-12467-02 under the VHA master materials license. "The package was checked-in and surveyed upon receipt around 0710 EST. Wipe tests performed on the external surface of the entire package indicated a removable contamination level of around 560 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. Removable contamination level on the bottom surface of the package, indicated a removable contamination level of around 413 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. "The package contained three unit doses consisting of a 6 mCi dose of Tc-99m Mebrofenin (calibrated for 1330), a 25 mCi dose of Tc-99m Sestamibi (calibrated for 0930), and a 1 mCi dose of Tc-99m Sulfur Colloid (calibrated for 0800). "The dosage was shipped from Triad Isotopes, out of Jacksonville, Florida, who was also the delivery carrier. The facility Radiation Safety Officer immediately notified the delivery carrier by phone about the contaminated package around 0730 EST. "The patient dosages inside the package were not impacted and were able to be used. As corrective actions, the packaging materials were bagged in plastic and set aside in a restricted area at the facility. "VHA National Health Physics Program, who manages the master materials license, was notified of the incident around 0840 EST. "In addition, the licensee is notifying their NRC Region III project manager (Parker) of the event by inclusion in this email." The external contamination was Tc-99m and the package will be held until the isotope has decayed prior to returning it to the pharmacy. * * * UPDATE FROM THE STATE OF FLORIDA, BUREAU OF RADIATION CONTROL TO DONALD NORWOOD AT 1725 EST ON 2/28/2020 * * * The following is a synopsis of information received via E-mail: Reporting Organization: State of Florida Bureau of Radiation Control NRC Notified By: Matthew Senison Licensee: Jubilant DraxImage Radiopharmacies, Inc. City, State: Jacksonville, Florida License Number: 4587-5 Jubilant, Jacksonville received a call from the VHA in Gainesville, Florida about a delivery bag which had been delivered around 0710 EST that was contaminated on the outside. Jubilant, Jacksonville then notified their RSO who notified Jubilant's corporate RSO. Jubilant, Jacksonville personnel reviewed surveys and DOT documentation and found no removable contamination. They immediately pulled all six carts that are used in the pharmacy and wipe tested and surveyed each cart using a single channel analyzer and found only background. The driver is a third party (MDS) and had just returned. Jubilant, Jacksonville personnel surveyed and wipe tested the entire van and found it to also be at background. The Jubilant, Jacksonville RSO then called the VHA's RSO to relay that three patient doses were in the bag and no removable contamination had been found in the bag nor on the doses. VHA's RSO stated that she was notifying the NRC who would notify BRC. Since the NRC report shows the activity was Tc-99m, and neither party could find the source; at this point greater than five half-lives have passed, so there are no current plans to deploy investigators to either facility at this time. Florida Incident Number: FL20-023 (2) Notified R1DO (Ferdas), R3DO (Orth), and the NMSS Events Notification E-mail group. |
| Agreement State | Event Number: 54548 |
| 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: MARK SEIDENSTICKER HQ OPS Officer: DONALD NORWOOD |
Notification Date: 02/27/2020 Notification Time: 15:54 [ET] Event Date: 02/24/2020 Event Time: 00:00 [EST] Last Update Date: 02/27/2020 |
| Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE |
Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) |
Event Text
| MEDICAL EVENT - HDR UNDERDOSE TO PATIENT The following information was received from the state of Florida via E-mail: "[The licensee] reported to the BRC [Bureau of Radiation Control] on 25 Feb 2020, and e-mailed an incident report on 26 Feb 2020 at 1224 EST that on 24 Feb 2020 at 1315 EST an HDR [high dose rate] incident occurred to a patient receiving skin therapy. "The patient was prescribed 7.5 Gray x 5 fractions, on five different parts of the left hand. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient by 56.25 percent. No Authorized Users were exposed to the source or otherwise contaminated." Florida Incident Number: FL20-022 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. |
| !!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!! | |
| 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: 03/05/2020 |
| 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
EN Revision Imported Date : 3/6/2020 EN Revision Text: NOTIFICATION TO OTHER GOVERNMENT AGENCY "On March 4, 2020, an actual Unusual Event code was inadvertently sent to an offsite agency, Institute of Nuclear Power Operations (INPO), and to a former NRC Resident Inspector during a planned emergency response drill. "The NRC Resident Inspector has been notified." * * * RETRACTION ON 3/5/2020 AT 1554 EST FROM RONALD ROHAN TO DONALD NORWOOD * * * Based on further review of the NRC reporting guidance relative to these criteria, STP has concluded that this condition is below the reporting threshold outlined in NUREG-1022 Revision 3. NUREG-1022 states the following (page 54): 'Licensees generally do not have to report media and government interactions unless they are related to the radiological health and safety of the public or on-site personnel, or protection of the environment. "The condition originally reported in EN 54561 is not a news release or government notification and has no impact on the radiological health and safety of the public or on-site personnel, or protection of the environment. Therefore, STP is retracting EN 54561. "The NRC Resident Inspector was notified on 3/5/2020 at 1310 CST." Notified R4DO Rick Deese. |
| Power Reactor | Event Number: 54567 |
| Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: ROBERT KIRCHNER HQ OPS Officer: ANDREW WAUGH |
Notification Date: 03/05/2020 Notification Time: 16:48 [ET] Event Date: 03/05/2020 Event Time: 12:35 [EST] Last Update Date: 03/05/2020 |
| Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL |
Person (Organization): KARLA STOEDTER (R3DO) |
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | |||||||
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
Event Text
| SECONDARY CONTAINMENT MOMENTARILY INOPERABLE "On March 05, 2020, at 1235 EST, with the reactor at 100 percent core thermal power and steady state conditions, plant personnel notified the main control room that both doors in the secondary containment airlock on the reactor building fifth floor were opened simultaneously for a period of approximately three seconds (i.e., from 12:35:00 to 12:35:03 EST). The failure of this interlock, which is intended to prevent both doors from being opened simultaneously, resulted in the Technical Specification (TS) Surveillance Requirement (SR) 3 .6.4.1.3 not being met. The maximum secondary containment pressure observed during that time remained within TS limits. There were no radiological releases associated with this event. "Declaring secondary containment inoperable as a result of not meeting TS SR 3.6.4.1.3 is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material. "The licensee has notified the NRC Resident Inspector." |
| Power Reactor | Event Number: 54569 |
| Facility: SEABROOK Region: 1 State: NH Unit: [1] [] [] RX Type: [1] W-4-LP NRC Notified By: ERIC MALLETT HQ OPS Officer: ANDREW WAUGH |
Notification Date: 03/05/2020 Notification Time: 21:14 [ET] Event Date: 03/05/2020 Event Time: 21:00 [EST] Last Update Date: 03/05/2020 |
| Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization): DON JACKSON (R1DO) |
| 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
| PLANNED PLANT COMPUTER OUTAGE FOR SYSTEM UPGRADE "On March 05, 2020, at 2100 EST, the site commenced a planned upgrade of the main plant computer system (MPCS). During this upgrade, the normal computer data will not be available to the emergency response facilities, but compensatory capabilities will be in place. The scheduled duration for the MPCS upgrade is 96 hours. Since the compensatory measures will be in place in excess of 72 hours, this condition is being reported pursuant to 10 CFR 50.72(b)(3)(xiii). "The NRC Resident Inspector has been notified." |
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021