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Event Notification Report for March 06, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/5/2020 - 3/6/2020

** EVENT NUMBERS **


54545 54547 54548 54561 54567 54569

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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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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.

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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.

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!!!!! 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.

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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."

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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 Friday, March 06, 2020
Friday, March 06, 2020