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Event Notification Report for April 15, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/14/2020 - 4/15/2020

** EVENT NUMBERS **


54641 54642 54643 54644 54645 54646 54647 54648 54664 54666

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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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Agreement State Event Number: 54644
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GEORGIA PACIFIC
Region: 1
City: CEDAR SPRINGS   State: GA
County:
License #: GA 269-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 12:39 [ET]
Event Date: 06/09/2017
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 - STUCK SHUTTER

The following is a summary of information provided by the State of Georgia via E-mail:

Licensee personnel were performing three year wipe tests when one gauge was found to have a stuck shutter. The gauge contained a Cesium-137 source (Device: Model D14400S, S/N SE4029, Source; 250 milliCuries; S/N SNC250066). The gauge was not in service at the time of the wipe test. The licensee is planning on selling the gauge and having it removed from the premises. The company buying the gauge is aware of the stuck shutter and will fix the shutter before removing it from the licensee's premises.

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Agreement State Event Number: 54645
Rep Org: COLORADO DEPT OF HEALTH
Licensee: GRIFFIS RESIDENTIAL
Region: 4
City: DENVER   State: CO
County:
License #: GL002507
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 13:46 [ET]
Event Date: 09/12/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (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 E-mail:

The licensee is unable to locate two tritium exit signs with an activity of 7.5 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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Agreement State Event Number: 54646
Rep Org: COLORADO DEPT OF HEALTH
Licensee: FOX ACRES COUNTRY CLUB
Region: 4
City: RED FEATHER LAKES   State: CO
County:
License #: GL000782
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 14:36 [ET]
Event Date: 05/16/2018
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (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 E-mail:

The licensee is unable to locate a tritium exit sign with an activity of 9.21 Ci. The exit sign may have been removed during renovation.

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: 54647
Rep Org: COLORADO DEPT OF HEALTH
Licensee: GARDEN COMMERCIAL PROPERTIES
Region: 4
City: COLORADO SPRINGS   State: CO
County:
License #: GL001607
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 17:55 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (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 E-mail:

The licensee is unable to locate two tritium exit signs with an activity of 11.5 Ci each. The site is a rental property. After the occupants moved out the property owner could not account for the exit 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: 54648
Rep Org: COLORADO DEPT OF HEALTH
Licensee: BETTER FOOD DEVELOPMENT
Region: 4
City: ENGLEWOOD   State: CO
County:
License #: GL002443
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 18:43 [ET]
Event Date: 12/31/2017
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (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 E-mail:

The licensee is unable to locate two tritium exit signs with an activity of 10 Ci each. The exit signs were apparently sold, and there was no response from the new owner.

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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Part 21 Event Number: 54664
Rep Org: SCHULZ ELECTRIC
Licensee: SCHULZ ELECTRIC
Region: 1
City: NEW HAVEN   State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: CHARLES ELDRIDGE
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 04/14/2020
Notification Time: 07:55 [ET]
Event Date: 03/12/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DONNA JANDA (R1DO)
MARK MILLER (R2DO)
JEFFREY JOSEY (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - MOTOR BEARING OIL RESERVOIR RECOATING

The following is a summary of information obtained from Schulz Electric via email report:

During the time period of January 2014 through November 2015, Schulz Electric performed recoating on several vertical motor endbell bearing oil reservoirs. In November 2015, one of Schulz Electric's nuclear customers identified an issue with the adherence of the coatings. In January 2016, the same customer reported another motor which had indicated coating adherence issues. The lack of adequate adherence root cause was determined to be a contamination that was introduced to the oil reservoir surface through the use of a chemical chelating agent to remove rust from the endbells after cleaning.

On March 12, 2020 the same customer contacted Schulz Electric again to identify that two more motors had been pulled from service for standard overhaul and the bearing oil reservoirs for both motors had degraded coatings as well. As such, Schulz Electric performed an extent of condition investigation and determined that there were additional customers for which Schulz Electric provided the bearing oil reservoir recoating.

The loss of adhesion and flaking exposes the bearing oil reservoir to oil and allows oil migration into the base metal. Over time the safety related motors could degrade from the foreign material (flaking) concerns.

The licensees affected are Hope Creek, North Anna, Hatch, Farley, Vogtle, Grand Gulf, and Columbia.

Point of Contact: Charles Eldredge, Quality Assurance Manager at Schulz Electric, 30 Gando Drive, New Haven, CT 06513, Office Number (203) 859-7413

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Power Reactor Event Number: 54666
Facility: QUAD CITIES
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM MURREY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/14/2020
Notification Time: 23:36 [ET]
Event Date: 04/14/2020
Event Time: 16:45 [CDT]
Last Update Date: 04/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (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 15 Power Operation 15 Power Operation

Event Text

CONTROL ROOM EMERGENCY VENTILATION SYSTEM INOPERABLE

"On April 14, 2020 at 1645 CDT, the Control Room Emergency Ventilation Air Conditioning (CREV AC) system was declared inoperable when the electrical feed breaker to the Refrigeration Compressor Unit (RCU) was found in a tripped condition. As a result, both units entered Technical Specification 3.7.5 Condition A. Investigation is in progress to determine the cause and corrective actions of the RCU feed breaker trip.

"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) because the CREV system is a single train system, and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident."


Page Last Reviewed/Updated Wednesday, April 15, 2020
Wednesday, April 15, 2020