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Event Notification Report for April 23, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/22/2020 - 4/23/2020

** EVENT NUMBERS **
 
54665 54667 54668 54669 54675 54677 54678

Agreement State Event Number: 54665
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LA QUINTA INN
Region: 4
City: LOUISVILLE   State: CO
County:
License #: GL000263
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: DONALD NORWOOD		 Notification Date: 04/14/2020
Notification Time: 17:29 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
JEFFREY JOSEY (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 information was received via E-mail:

21 tritium exit signs, each containing 9.21 Ci, are unaccounted for. There has been no response for annual general license registrations since 2015.

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

Agreement State Event Number: 54667
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON   State: TX
County:
License #: l-00457
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: THOMAS KENDZIA		 Notification Date: 04/15/2020
Notification Time: 09:20 [ET]
Event Date: 04/09/2020
Event Time: 00:00 [CDT]
Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE NOT DELIVERED TO THE CORRECT LOCATION DURING BRACHYTHERAPY TREATMENT

The following was received from the state of Texas via email and by telephone:

"On April 10, 2020, the licensee reported to the Agency [Texas Department of State Health Services] that it had an event on April 9, 2020, involving a Novoste device in which the source train had not advanced to the designated treatment site during two attempts to deliver intravascular brachytherapy to a patient. It was unclear if the source train had actually entered the patient and the Agency requested confirmation and more information. On April 14, 2020, the licensee reported back to the Agency confirming that the source train had stopped moving after it had entered the patient. During the first attempt, the source train of 16 Strontium-90 sources in the Novoste device failed to go to the expected treatment position and instead got stuck in the beta-rail catheter proximally to the treatment area for 6 minutes 54 seconds. The device was checked and a second attempt was made during which the source got stuck in the beta-rail catheter proximally to the desired treatment area for 3 minutes 41 seconds. The source train was stuck at different positions in the catheter for the two attempts and each time the physicians worked with the catheter to try and get the source train to move to the treatment site. Doses calculated for each of the locations: first location = 26.2 Gy at 2 mm; second location = 14.2 Gy at 2 mm. The licensee was able to fully retract the source into the device each time. The vendor is expected onsite next week to check the device and investigate the cause. The licensee has suspended this particular treatment program indefinitely pending identification of cause.

"Device Information:
Novoste device SN: 89670
Source train SN: ZA925
Active source train length: 40 mm
Number of Sr-90 sources: 16
Total activity: 2 GBq calibrated on 8/16/2002

"Treatment Information:
Vessel description: RCA
Vessel diameter: 4 mm
Lesion length: 30 mm
Radiation dose: 23 Gy
Dwell time: 5 minutes and 57 seconds

"Dose to staff was negligible since the source train was inside the patient. Effects to the patient, if any, as a result of this event were not reported with this initial information. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9760


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.

Agreement State Event Number: 54668
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE HOSPITAL
Region: 1
City: LOUISVILLE   State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: BRIAN P. SMITH		 Notification Date: 04/15/2020
Notification Time: 10:12 [ET]
Event Date: 04/14/2020
Event Time: 13:15 [EDT]
Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EVENT OF Y-90 SIRTEX

The following is a summary of an email received from the Kentucky Department of Radiation:

At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box.

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.

Agreement State Event Number: 54669
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: PIXELLE ANDROSCOGGIN LLC FORMERLY VERSO ANDROSCOGGIN MILL
Region: 1
City: JAY   State: ME
County:
License #: ME 07405
Agreement: Y
Docket:
NRC Notified By: CATHERINE PERHAM
HQ OPS Officer: DONALD NORWOOD		 Notification Date: 04/15/2020
Notification Time: 14:50 [ET]
Event Date: 04/15/2020
Event Time: 12:56 [EDT]
Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EXPLOSION OF BUILDING CONTAINING NUCLEAR GAUGES

The following information was received via e-mail:

"The State of Maine Radiation Control Program became aware of a breaking news item, reporting that the Pixelle Androscoggin paper mill in Jay, Maine had suffered an explosion. https://www.wabi.tv/content/news/Explosion-reported-at-Jay-mill-details-limited-569661451.html

"The precise location of the explosion is unknown at this time but it may be the boiler or power plant. Later report from MEMA - Maine Emergency Management Agency - says that it was 'the Digester of Pulp Mill A or maybe B.' The Maine Radiation Control Program will confirm the information as it comes in. There were no fatalities or injuries reported.

"'A' Pulp Mill contains six gauges, 'B' Pulp Mill contains three gauges, and the Power Plant/Boiler contains five gauges. There could be from three to six gauges involved in the explosion, depending on which building exploded.

"The Maine Radiation Control Program has not been notified by the mill. This report is the first written notification to NMED."

Maine Event Report ID No.: ME 20-003

Power Reactor Event Number: 54675
Facility: BRUNSWICK
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOEL GORDON
HQ OPS Officer: HOWIE CROUCH		 Notification Date: 04/22/2020
Notification Time: 10:43 [ET]
Event Date: 03/05/2020
Event Time: 10:25 [EDT]
Last Update Date: 04/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION		 Person (Organization):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 100 Power Operation

Event Text

60-DAY TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION

"This 60-day optional telephone notification is being made in lieu of an LER [licensee event report] submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 1025 Eastern Standard Time (EST) on March 5, 2020, with Unit 1 shutdown in Mode 5 for refueling, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring and Post Accident Sampling isolation valves) occurred. The invalid actuation occurred when power was lost as a result of the Inboard Isolation Logic Fuse being removed per a planned clearance hang to support maintenance.

"The PCIVs functioned successfully and the actuation was complete. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"This event did not result in any adverse impact to the health and safety of the public."

The licensee has notified the NRC Resident Inspector.

Power Reactor Event Number: 54677
Facility: HATCH
Region: 2     State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JEREMY TAYLOR
HQ OPS Officer: OSSY FONT		 Notification Date: 04/22/2020
Notification Time: 14:52 [ET]
Event Date: 04/22/2020
Event Time: 10:15 [EDT]
Last Update Date: 04/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION		 Person (Organization):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 0.4 Startup 0.4 Startup

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM (HPCI) INOPERABLE

"At 1015 [EDT], on 04/22/2020, while Unit 2 was at approximately 0.4 percent power in MODE 2, reactor pressure was increased to 150 psig while HPCI was INOPERABLE due to not having been placed in standby. HPCI does not have a redundant system; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). ADS [Automatic Depressurization System] and low pressure ECCS [Emergency Core Cooling System] systems were OPERABLE during this time. HPCI was returned to OPERABLE status at 1109 hrs. on 04/22/2020.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

Power Reactor Event Number: 54678
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: OSSY FONT		 Notification Date: 04/22/2020
Notification Time: 18:46 [ET]
Event Date: 04/22/2020
Event Time: 10:54 [MST]
Last Update Date: 04/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY		 Person (Organization):
JAMES DRAKE (R4DO)
FFD GROUP (EMAIL)
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 N 0 Defueled 0 Defueled
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY (FFD) POLICY VIOLATION

A licensed operator had a confirmed positive for alcohol during a random fitness-for-duty test. The individual's unescorted access has been terminated.

Page Last Reviewed/Updated Thursday, March 25, 2021