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Event Notification Report for May 11, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/8/2020 - 5/11/2020

** EVENT NUMBERS **


54684 54685 54686 54689 54693 54699 54700 54701

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Agreement State Event Number: 54684
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: REPUBLIC SERVICES NORTH FLORIDA RECYCLING CENTER
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/30/2020
Notification Time: 15:37 [ET]
Event Date: 04/20/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - USED BEVERAGE CAN (UBC) BALED ALUMINUM RETURNED TO FLORIDA

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

"The state of Kentucky Radiation Health [Branch] faxed a report of rejection of an UBC [used beverage can) bale from Logan Aluminum of KY, originating from Republic Services of Jacksonville, FL. The radiation measurement was 1200 cps (also reported as 0.7 mR/hr.) midway of the enclosed trailer. Background measured 121 cps.

"DOT-SP 10656 KY-FL-20-001 was issued. Per [an employee] of Republic Services, this load was comprised of household curbside waste, and 'people put whatever they want in there.' Only one bale was higher than background. The rest of load successfully resubmitted.

"Update: This bale was returned to Florida for investigation, whereupon [the Radiation Safety Officer at Republic Services] reached out to the [Headquarters Operations Officer at the Nuclear Regulatory Commission], who transferred him to the BRC [Florida Bureau of Radiation Control]."

Florida BRC will be conducting a follow-up investigation.

Florida Incident Number: FL20-051

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Agreement State Event Number: 54685
Rep Org: NV DIV OF RAD HEALTH
Licensee: RENOWN REGIONAL MEDICAL CENTER
Region: 4
City: RENO   State: NV
County:
License #: 16-12-0016-01
Agreement: Y
Docket:
NRC Notified By: COREY CREVLING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/30/2020
Notification Time: 18:51 [ET]
Event Date: 04/29/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE DURING BRACHYTHERAPY TREATMENT

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

"The patient was undergoing radiation treatment using Ir-192 and the high dose rate remote afterloader (Varian VS 2000) in three fractions. There were no problems with fractions one and two. During the third fraction, the vaginal cylinder device was inserted into the patient by the doctor. Unknown to the doctor, the device penetrated through the body wall weakened by previous surgery (according to the doctor, [this is] not unknown following robotic hysterectomies). This penetration allowed the source to move about 4 cm past the treatment area. As a result, the treatment area only received 25 percent volume coverage instead of the planned 95 percent volume coverage."

The device was a Varian Remote Afterloader, Model VS 2000, which contained 407 GBq of Ir-192.

NMED Report No: NV200007

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: 54686
Rep Org: NV DIV OF RAD HEALTH
Licensee: COMPREHENSIVE CANCER CENTERS OF NEVADA
Region: 4
City: LAS VEGAS   State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: COREY CREVELING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/30/2020
Notification Time: 19:50 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE DUE TO AN ERROR IN THE TREATMENT PLAN

The following information is summarized from the report received from the state of Nevada via email:
A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled.

During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose.

At the time of the report, there were no acute ill-effects on the patient.

NMED Report No.: NV200006

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: 54689
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RMA GROUP
Region: 4
City: CARSON   State: CA
County:
License #: 8055-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/01/2020
Notification Time: 12:22 [ET]
Event Date: 04/28/2020
Event Time: 00:00 [PDT]
Last Update Date: 05/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

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

"On 4/30/2020, at approximately 1127 [PDT], the RSO [radiation safety officer] of RMA Group, RML Number 8055-19, contacted RHB [California Radiologic Health Branch] Brea concerning a moisture/density gauge, Troxler, model 3440, serial number 25671 (Cs-137, 0.3 GBq, Am-241, 1.50 GBq) that had been stolen from in front of a private apartment complex while the RMA employee was offloading his vehicle. The Troxler radioactive gauge was left on the sidewalk during offloading of the vehicle. [The RMA employee] forgot about the gauge he had left on the sidewalk as he then drove off to have his vehicle washed. When he returned from the carwash at approximately 1730 to 1800 on 4/28/2020, he realized that he had left the radioactive gauge in front of the apartment complex and that it was no longer there. The [RSA employee] finally reported the theft to the RMA RSO on 4/29/2020 at 1215, prior to reporting the theft to Los Angeles Police Department at the West Los Angeles office on 4/29/2020 at 1245. A copy of the theft report and the [employee's] statement has been sent to RHB Brea as part of this report. [The RMA RSO] will utilize local papers to attempt to retrieve the stolen gauge as well as notifying local servicing vendors of radioactive gauges to be alert of the serial number of the stolen gauge in case it turns up for any of their services.

"The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10 CFR 20.220(a)(1)(i) since the radioactive gauge has been stolen with the source handle locked and the Type A transport container locked."

California Report Number 5010-043020


* * * UPDATE FROM DONALD OESTERLE TO DONALD NORWOOD AT 1516 EDT ON 5/4/2020 * * *

The gauge has been recovered intact. A formal closing report will be submitted later.

Notified R4DO (Drake), and via E-mail: NMSS Events Notifications E-mail group, ILTAB, and CNSNA (Mexico).

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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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 54693
Facility: LASALLE
Region: 3     State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOE MESSINA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/04/2020
Notification Time: 23:40 [ET]
Event Date: 05/04/2020
Event Time: 16:40 [CDT]
Last Update Date: 05/08/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
ANN MARIE STONE (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

DIESEL GENERATOR COOLING WATER SYSTEM DECLARED INOPERABLE

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to mitigate the Consequences of an Accident. A through wall leak was found on piping connected to the Division 3 Diesel Generator (DG) Cooling Water Strainer. This condition has been evaluated and the Division 3 DG Cooling Water System has been declared inoperable. The Division 3 DG Cooling Water System is a support system for the Division 3 Emergency DG and the High Pressure Core Spray System (HPCS).

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON MAY 8, 2020 AT 1709 EDT FROM JOE MESSINA TO BRIAN LIN * * *

"This update retracts Event Notification #54693, which reported a condition that could have potentially prevented fulfillment of a safety function needed to mitigate the consequences of an accident.

"An evaluation of the flaw on the piping connected to the Unit 2 Division 3 Diesel Generator (DG) Cooling Water strainer concluded that the system would have remained operable. The High Pressure Core Spray system, supported by the operable DG Cooling Water system, remained operable and capable of performing its safety function.

"The NRC Resident Inspector has been notified."

Notified R3DO (Stone).

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Fuel Cycle Facility Event Number: 54699
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: Brian Lin
Notification Date: 05/08/2020
Notification Time: 14:23 [ET]
Event Date: 05/07/2020
Event Time: 16:25 [EDT]
Last Update Date: 05/08/2020
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

CONCURRENT REPORT FOR A COMMUNICATION LINE OUT OF SERVICE

The following was received via email from Global Nuclear Fuel - America:

"On May 7, 2020, Global Nuclear Fuel America initiated maintenance activities on fire alarm systems that affect the Waste Treatment facility and the Process Lagoons. Compensatory measures were enacted. Upon system restoration, it was determined that a communication line between the initiating devices of fire alarm systems and the Emergency Control Center (ECC) was not functioning. Per State code requirements, fire alarm systems must report back to a continuously monitored station. Compensatory measures remained in place.

"At approximately 1625 (EDT) on May 7, 2020, the New Hanover County Deputy Fire Marshall was notified per State code requirements that communications between the initiating devices of fire alarm systems and the ECC were not functioning. 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)."

The licensee will notify NRC Region 2.

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Fuel Cycle Facility Event Number: 54700
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: Brian P. Smith
Notification Date: 05/10/2020
Notification Time: 09:47 [ET]
Event Date: 05/09/2020
Event Time: 12:15 [EDT]
Last Update Date: 05/10/2020
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 FOR FIRE IMPAIRMENT

"On May 8th, GNF-A [Global Nuclear Fuels - America] underwent an unplanned local power outage due to failed equipment at a substation. The facility shutdown safely. While critical systems are on generators, the fire alarm systems are on batteries which will be depleted before power can be restored. Compensatory measures were enacted.

"At approximately 1215 (EDT) on May 9th, 2020, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire alarm systems would not function. 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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Power Reactor Event Number: 54701
Facility: Palo Verde
Region: 4     State: AZ
Unit: [] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Jason Hill
HQ OPS Officer: Brian Lin
Notification Date: 05/11/2020
Notification Time: 13:07 [ET]
Event Date: 03/14/2020
Event Time: 12:44 [MST]
Last Update Date: 05/11/2020
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
NEIL O'KEEFE (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

INVALID ACTUATION OF SPRAY POND PUMP SYSTEM - 60 DAY REPORTS

"The following event descriptions are based on information currently available. If through subsequent reviews of these events additional information is identified that is pertinent to the events or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(2)(iv)(A) and 50.73(a)(1) to describe invalid actuations of both trains of the Palo Verde Nuclear Generating Station (PVNGS) Unit 3 essential spray pond (SP) system, which serves as an emergency service water system that does not normally run and serves as an ultimate heat sink as described in 10 CFR 50.73(a)(2)(iv)(B)(9).

"This notification covers two similar, but separate invalid actuations occurring in Unit 3 on March 14, 2020 at 12:44 [MST] and again on April 25, 2020 at 12:10 [MST]. On each day, an invalid actuation of the Unit 3 train "B" Fuel Building Essential Ventilation Actuation Signal (FBEVAS) occurred during performance of the Balance of Plant Engineered Safety Features Actuation System weekly auto test. The auto/manual pushbutton was depressed to initiate the test and the sequencer immediately tripped FBEVAS train "B" with subsequent cross trip of FBEVAS train "A". These actuations resulted in complete and successful actuations of both trains of essential spray pond pumps.

"The events were entered into the PVNGS corrective action program and a station evaluation is in progress. There was no adverse impact to public health and safety nor to plant employees.

"The NRC resident inspectors have been informed."


Page Last Reviewed/Updated Friday, June 19, 2020
Friday, June 19, 2020