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Event Notification Report for March 30, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/27/2020 - 3/30/2020

** EVENT NUMBERS **


54589 54590 54591 54592 54593 54595 54614 54621

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Agreement State Event Number: 54589
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COLORADO DEPARTMENT OF CORRECTIONS - FREMONT FACILITY
Region: 4
City: CANON CITY   State: CO
County:
License #: GL001258
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/19/2020
Notification Time: 16:44 [ET]
Event Date: 05/19/2018
Event Time: 00:00 [MDT]
Last Update Date: 03/19/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

COLORADO AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

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

In April 2018, the Colorado Department of Corrections - Fremont Facility identified that a tritium exit sign was missing. On 5/9/19, Fremont determined that the sign was lost. The exit sign contained 11.47 Ci of tritium.

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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Agreement State Event Number: 54590
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COLORADO DEPARTMENT OF CORRECTIONS - TERRITORIAL FACILITY
Region: 4
City: CANON CITY   State: CO
County:
License #: GL000778
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/19/2020
Notification Time: 16:56 [ET]
Event Date: 05/19/2019
Event Time: 00:00 [MDT]
Last Update Date: 03/19/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

COLORADO AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

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

In April 2018, the Colorado Department of Corrections - Territorial Facility identified that 19 tritium exit signs were missing. On 5/9/19, Territorial determined that the signs were lost. The exit signs contained 219 Ci of tritium in total.

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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Agreement State Event Number: 54591
Rep Org: COLORADO DEPT OF HEALTH
Licensee: KARCHER NORTH AMERICA
Region: 4
City: ENGLEWOOD   State: CO
County:
License #: GL001195
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/20/2020
Notification Time: 10:00 [ET]
Event Date: 11/26/2018
Event Time: 00:00 [MDT]
Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

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

On November 11, 2018, Karcher North America reported that one static eliminator was lost. The device contained 0.01 Ci of radioactive material. The radioactive material was not identified. Research identified that alpha emitters, such as poloniun-210, were normally used in static eliminators.

* * * UPDATE ON 03/20/2020 AT 1259 EDT FROM KATHRYN MOTE TO OSSY FONT * * *

The following update was received from the state of Colorado via email:

The State notified the NRC that the lost radioactive material was polonium-210.

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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Agreement State Event Number: 54592
Rep Org: COLORADO DEPT OF HEALTH
Licensee: INVERNESS HOTEL AND CONFERENCE CTR
Region: 4
City: ENGLEWOOD   State: CO
County:
License #: GL001275
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: OSSY FONT
Notification Date: 03/20/2020
Notification Time: 13:57 [ET]
Event Date: 12/29/2017
Event Time: 00:00 [MDT]
Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (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 is a summary of information received from the state of Colorado via email:

A 5.75 Ci tritium exit sign was confirmed lost through annual registration.

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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Agreement State Event Number: 54593
Rep Org: COLORADO DEPT OF HEALTH
Licensee: HOTEL MONACO
Region: 4
City: DENVER   State: CO
County:
License #: GL001905
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: OSSY FONT
Notification Date: 03/20/2020
Notification Time: 16:09 [ET]
Event Date: 06/10/2019
Event Time: 00:00 [MDT]
Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following is a summary of information received from the state of Colorado via email:

The State is reporting 71 lost tritium exit signs, each containing 7.09 Ci. They were confirmed lost through annual registration. The signs were likely lost during renovations.

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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Agreement State Event Number: 54595
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY   State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: OSSY FONT
Notification Date: 03/20/2020
Notification Time: 18:30 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNPLANNED DOSE TO AN ORGAN

The following was received from the state of Wisconsin's Radiation Protection Section [the Department] via email:

"On March 20, 2020, the [Wisconsin Radiation Protection Section] Department was notified by the licensee of a medical event which occurred the same day. The licensee was performing the first fraction of a vaginal cylinder treatment using a Varian VariSource iX high dose rate remote afterloader unit. Licensee staff had difficulty removing the cylinder post-treatment, and they determined that the cylinder had perforated the patient's tissue at some point following pre-treatment imaging. The licensee estimates the cylinder moved 3-4 cm from its original position. Dose reconstruction is ongoing, but is expected to exceed the 0.5 Sv threshold to the bowel. This is all the information available at this time. The Department will determine follow-up actions and provide additional information when available."

* * * UPDATE ON 3/25/20 AT 1612 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *

"The Department performed an investigation on March 25, 2020 to review this incident. For this fraction, the patient was prescribed a 6 Gy dose to the surface of the vaginal cylinder. Using CT imaging the licensee confirmed the proper placement of the cylinder prior to treatment. The licensee performed all pre-treatment checks, connected the patient to the HDR unit, and initiated treatment. Everything appeared to be as expected. However, following treatment it was very difficult for the authorized user to remove the cylinder; there appeared to be a vacuum suction seal. The licensee determined that the cylinder had been pulled an additional 3.5 cm into the patient, perforating the vaginal wall and protruding into the bowel space. The licensee believes that the bowel conformed to the shape of the cylinder during part or all of treatment, causing a much larger volume of the bowel to receive an elevated radiation dose as compared to the treatment plan. Based on the prescribed dose, the maximum unintended dose to the bowel is 6 Gy. The patient and referring physician were immediately informed of the event. The authorized user does not expect the patient to experience any radiological consequences from this event."

Wisconsin Event Report ID No.: WI200010

Notified R3DO (Hanna) and NMSS Events Notification Email.

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: 54614
Facility: MCGUIRE
Region: 2     State: NC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM DAIN
HQ OPS Officer: OSSY FONT
Notification Date: 03/26/2020
Notification Time: 10:45 [ET]
Event Date: 03/26/2020
Event Time: 03:00 [EDT]
Last Update Date: 03/29/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text



EN Revision Imported Date : 3/30/2020

EN Revision Text: DEGRADED CONDITION

"On March 26, 2020, while McGuire Unit 2 was shut down for a scheduled refueling outage, the reactor vessel head penetrations were being examined in accordance with the in-service Inspection Program. Ultrasonic examinations identified a relevant indication in the Control Rod Drive Mechanism nozzle number 35 that did not meet the acceptance criteria under ASME, Section XI IWB-3600, 'Analytic Evaluation of Flaws.' Actions to address the relevant indication will be taken in accordance with the applicable codes, standards, and regulations.

"This event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"The relevant indication has no impact on the health and safety of the public or station employees.

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 3/29/2020 AT 1700 EDT FROM TOM BERNARD TO BRIAN P. SMITH * * *

"McGuire is retracting the eight hour non-emergency notification made on March 26, 2020, at 10:45 ET (EN#54614). A subsequent evaluation determined that the suspect indication identified during ultrasonic examination of Control Rod Drive Mechanism nozzle number 35 is not service induced nor representative of primary water stress corrosion cracking (PWSCC). The indication has been classified as "non-relevant" and is not reportable as a degraded condition.

"The senior NRC Resident Inspection has been notified."

Notified R2DO (Miller).

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Power Reactor Event Number: 54621
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: LORRAINE WEAVER
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 03/27/2020
Notification Time: 15:18 [ET]
Event Date: 03/19/2020
Event Time: 00:00 [MST]
Last Update Date: 03/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RAY KELLAR (R4DO)
- PART 21/50.55 REACTORS (EMAIL)
CHRISTOPHER CAHILL (R1DO)
MARK MILLER (R2DO)
JOHN HANNA (R3DO)
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
3 N Y 100 Power Operation 100 Power Operation

Event Text

PART 21 NOTIFICATION - TRANSDUCER DEFECT

The following is a summary of information obtained from Palo Verde via email:

During pre-installation testing, five Masoneilan Model transducers were identified as unable to be calibrated prior to installation. These transducers were received by the vendor as safety-related components and are used to provide remote control operation of the Atmospheric Dump Valves (ADVs). The ADVs provide a safety grade method for cooling the unit to Shutdown Cooling System entry conditions, should Palo Verde's preferred heat sink via the Steam Bypass Control System to the condenser and/or atmosphere not be available.

The transducer receives a 4-20 mA signal and translates it to a 3-15 psi output to the ADV positioner. This is accomplished by varying the supply air from 23-30 psi down to the appropriate 3-15 psi signal. Palo Verde provided an Interim 10 CFR 21 Report for the five Masoneilan Model 8005N transducers, Part 21 log number 2019-36-00, ML 19323C971, which was submitted by Arizona Public Service (APS) Company on November 15, 2019.

An evaluation of the transducers was completed on March 19, 2020. The evaluation concluded that the inability of the transducers to be calibrated represented a defect.

The licensees affected are undetermined at this time. Palo Verde has been in communication with the vendor. The vendor has currently not provided an extent of condition.

Point of Contact: Lorraine Weaver (602) 448-5915


Page Last Reviewed/Updated Monday, March 30, 2020
Monday, March 30, 2020