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Event Notification Report for April 14, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/13/2020 - 4/14/2020

** EVENT NUMBERS **


54635 54636 54637 54638 54640 54641 54642 54643 54663

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Agreement State Event Number: 54635
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. CATHERINE OF SIENA
Region: 4
City: DENVER   State: CO
County:
License #: GL002332
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: OSSY FONT
Notification Date: 04/03/2020
Notification Time: 11:25 [ET]
Event Date: 12/14/2017
Event Time: 00:00 [MDT]
Last Update Date: 04/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (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 summary was received from the state of Colorado via email:

The licensee had two tritium exit signs, containing 6.2 Ci each, removed and replaced with non-radioactive signs.

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: 54636
Rep Org: COLORADO DEPT OF HEALTH
Licensee: VERANDA HIGHPOINTE
Region: 4
City: DENVER   State: CO
County:
License #: GL002276
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/03/2020
Notification Time: 13:46 [ET]
Event Date: 05/10/2018
Event Time: 00:00 [MDT]
Last Update Date: 04/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (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 summary was received from the state of Colorado via email:

The licensee is unable to locate 16 tritium exit signs. Management claims the signs are not on their property. Each sign has an activity of 6 Ci.

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: 54637
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LDS CHURCH - PARKER - TARA LANE
Region: 4
City: PARKER   State: CO
County:
License #: GL001883
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/03/2020
Notification Time: 16:20 [ET]
Event Date: 06/05/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (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 summary was received from the state of Colorado via email:

The licensee is unable to locate a tritium exit sign with an activity of 11.5 Ci.

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: 54638
Rep Org: COLORADO DEPT OF HEALTH
Licensee: BONANZA CREEK ENERGY INC.
Region: 4
City: EVANS   State: CO
County:
License #: GL002371
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/03/2020
Notification Time: 16:59 [ET]
Event Date: 06/28/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (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 summary was received from the state of Colorado via email:

The licensee is unable to locate three tritium exit signs with an activity of 6 Ci each.

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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Fuel Cycle Facility Event Number: 54640
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON   State: NC
County: NEW HANOVER
License #: SNM-1097
Docket: 07001113
NRC Notified By: PHILLIP OLLIS
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/04/2020
Notification Time: 18:43 [ET]
Event Date: 04/04/2020
Event Time: 09:30 [EDT]
Last Update Date: 04/04/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
MARK MILLER (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

OFFSITE NOTIFICATION

At approximately 0930 EDT on April 4, 2020, the New Hanover County Deputy Fire Marshall was notified per state code requirements that the fire alarm system and accompanying fire pumps encompassing the fuel manufacturing operation (FMO) were placed on backup power due to a planned power outage. Additional compensatory measures were enacted. Power was restored at approximately 1800 EDT on April 4, 2020. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c).

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Agreement State Event Number: 54641
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALBERT EINSTEIN HEALTHCARE NETWORK
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0135
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: KERBY SCALES
Notification Date: 04/06/2020
Notification Time: 14:09 [ET]
Event Date: 04/03/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the State of Pennsylvania via E-mail:

"The [PA DEP Bureau of Radiation Protection] Department received notification from a licensee on April 3, 2020 of a medical event involving Y-90 TheraSphere microspheres. The licensee believes a patient undergoing a multiple lobe injection of the liver received only 62.7 percent of the prescribed dose in one of the lobes. The second lobe is believed to have received the correct dose. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided.

"The Department will perform a reactive inspection as soon as possible."

Pennsylvania Event Report ID No.: PA200007


* * * UPDATE ON 04/07/2020 AT 1353 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *

The following was received from the State of Pennsylvania via E-mail:

"The patient was prescribed TheraSphere Y-90 Microspheres at 2.47 GBq total with 2.25 Gbq prescribed to the liver because of 9.1 percent lung shunt. The licensee reports total dose 1.536 GBq, and 1.4 GBq to liver. Ultimately only 62.7 percent (75.3 Gy) of the planned dose was able to be administered to segment 6 of the liver. While attempting to administer the Y-90 dose to treat a lesion in Segment 6 of the liver there was significant resistance to flow. The AU evaluated the microcatheter system to ensure that there were no kinks along the catheter course external to the patient or visualized internally under fluoroscopy. The licensee believes the issue came from blockage at or before the 'E' site on the labeled tubing of the administration set, given that when it was disconnected from the microcatheter at that location, they were able to successfully flush the catheter. The patient then had a subsequent segment 7 segmentectomy using tubing from a box set from a different lot number without incident. No adverse effects to the patient are anticipated and the patient and referring physician were notified the day of the event."

Notified R1DO (Lilliendahl) and NMSS Events Notification via 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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Agreement State Event Number: 54642
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: NRC INSPECTION AND TESTING LLC
Region: 4
City: WILLISTON   State: ND
County:
License #: 33-59101-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/06/2020
Notification Time: 15:28 [ET]
Event Date: 04/06/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/06/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
WILLIAM GOTT (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IMPROPER CONTROL OF A SEALED SOURCE


The following information is a summary received from the state of North Dakota via telephone:

On April 5, 2020, one of the licensee's sealed sources was temporarily in the possession of a non-authorized user. One of the owners, who is not an authorized user, took possession of four of the company's radiography vehicles and a sealed source was still in one of the vehicles. The source was subsequently retrieved, verified not to have been tampered with, and is back in storage.

The source contains 88 Ci of Ir-192.

North Dakota has notified their R4 Agreement State Officer (Erickson).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 54643
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKINELMER, INC
Region: 1
City: BOSTON   State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: ANTHONY CARPENITO
HQ OPS Officer: KERBY SCALES
Notification Date: 04/06/2020
Notification Time: 15:52 [ET]
Event Date: 04/06/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/10/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
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 MATERIAL IN TRANSIT

The following is summarized from an e-mail received from the Commonwealth of Massachusetts:

The licensee reported on 4/6/20 that three UN2915 White I label packages, shipped from Germany via common carrier, each containing 21.14 Ci Sulfur-35, did not arrive on 3/29/20 as expected. Upon inquiry on 3/31/20, the common carrier informed the licensee that the packages arrived at JFK Airport, NY, and had not yet been forwarded. The common carrier informed the licensee on 4/6/20 that the three packages could not be located within its system, all flights were cancelled from JFK to Boston due to the COVID-19 situation, and affected freight would be forwarded via ground. The licensee continues to work with the common carrier to locate the packages. There is no significant public health and safety concern due to the package radiation levels being at background.

* * * UPDATE ON 4/9/2020 AT 1410 EDT FROM ANTHONY CARPENITO TO JEFFREY WHITED * * *

The following was received from the Commonwealth of Massachusetts via e-mail:

"The licensee (PerkinElmer) on 4/9/2020 reported to this Agency [the Massachusetts Radiation Control Program] that three packages previously reported as missing were found in [the common] carrier's warehouse at JFK Airport in NY. The licensee stated that the packages were reportedly intact, unopened and undamaged. The licensee stated that the packages are expected to be ground transported to licensee in Boston for arrival on 4/10/2020. The licensee stated that a comprehensive incoming package survey will be performed on packages upon arrival at licensee facility. This Agency considers this event to still be OPEN until licensee confirmation of package arrival in regulatory-acceptable condition."

Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.

* * * UPDATE ON 4/10/2020 AT 1635 EDT FROM ANTHONY CARPENITO TO OSSY FONT * * *

The following was received from the Commonwealth of Massachusetts via e-mail:

"The licensee (PerkinElmer) on 4/10/2020 reported to this Agency that three subject packages were received at the licensee's facility on the afternoon of 4/10/20. The licensee performed an incoming package survey and determined the outside of the packages were not radioactively contaminated, there was no physical damage to the packages, and the inner packaging and contents remained intact. The Agency expects this event to remain OPEN until all details, including action docket numbers, are compiled and relevant documentation is completed."

Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.

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: 54663
Facility: MILLSTONE
Region: 1     State: CT
Unit: [] [] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JASON PARIS
HQ OPS Officer: OSSY FONT
Notification Date: 04/13/2020
Notification Time: 19:33 [ET]
Event Date: 04/13/2020
Event Time: 15:50 [EDT]
Last Update Date: 04/13/2020
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):
DONNA JANDA (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 82 Power Operation 0 Hot Standby

Event Text

AUTOMATIC TRIP DUE TO LOW CONDENSER VACUUM

"At 1550 EDT on 4/13/2020, with Millstone Power Station Unit 3 operating at approximately 82 percent reactor power, an automatic reactor trip occurred following a turbine trip due to low condenser vacuum caused by the trip of multiple circulating water pumps. Due to the loss of the circulating water pumps, decay heat removal was established by the steam generator atmospheric dump valves. All other systems responded as expected to the trip.

"Auxiliary feedwater actuated automatically as expected following the trip due to low-low levels in the steam generators.

"There was no risk to the public. There was no impact to Millstone Unit 2.

"The Senior Resident Inspector has been informed.

"This event is being reported as a four hour report under 10 CFR 50.72(b)(2)(iv)(B) as a condition that resulted in actuation of the reactor protection system while the reactor was critical, and as an eight hour report under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72(b)(3)(iv)(B) for actuation of the auxiliary feedwater system."

The licensee also notified the state of Connecticut, the Connecticut Department of Energy and Environmental Protection, and the city of Waterford.


Page Last Reviewed/Updated Tuesday, April 14, 2020
Tuesday, April 14, 2020