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Event Notification Report for August 21, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/20/2020 - 8/21/2020

** EVENT NUMBERS **


54713 54830 54831 54833 54835 54836 54837 54847

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Agreement State Event Number: 54713
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: Thermo Scientific Portable Analytical Instrument, Inc
Region: 1
City: Tewksbury   State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Szymon Mudrewicz
HQ OPS Officer: Kerby Scales
Notification Date: 05/14/2020
Notification Time: 18:58 [ET]
Event Date: 05/14/2020
Event Time: 15:04 [EDT]
Last Update Date: 08/20/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 8/21/2020

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was received from the Commonwealth of Massachusetts via email:

"On 05/14/2020, the Massachusetts Radiation Control Program (hereafter, Agency) received a notification from Thermo Scientific Portable Analytical Instruments, Inc. (hereafter, Licensee ) of two Fe-55 leaking sealed sources. A total of 308 sealed sources (containing either Fe-55, Cd-109, or Am-241) were leak tested but only two exceeded reporting limits of 0.005 microCuries of removable contamination for each source. These sources were removed from customer devices for storage prior to disposal. The information of the two leaking sealed sources is as follows:

MAKE MODEL SERIAL INITIAL ACT. CURRENT ACT. DETECTED ACT.
QSA Global IEC.A1 OA959 20 milliCuries 0.65 milliCuries 0.0206 microCurie
QSA Global IEC.A1 OW788 20 milliCuries 0.72 milliCuries 0.0065 microCurie

"The sources have been stored in individual plastic bags, inside a lead container since December 2019. They were leak tested inside each bag and the work area was surveyed after the operation (no contamination of the work area was detected). The two sources will be transferred to a licensed waste broker in June. No radiological risk to workers was identified.

"The Agency considers this event to be open."

* * * UPDATE ON 8/20/20 AT1831 EDT FORM SZYMON MUDREWICZ TO MICHAEL BLOODGOOD * * *

The following was received from the Commonwealth of Massachusetts via email:

"On 08/07/2020, the Licensee provided a waste manifest that on 06/08/2020, the leaking sources were accepted by Alaron Nuclear Services for disposal. Also, the Licensee further explained that these leaking sources are open window sources similar to those involved in an event the Licensee reported in 2019 and the windows on the sources can be easily damaged due to age, removal from source housing, even from being leak tested.

"The Agency considers this event to be closed."

Notified R1DO (Greives) and NMSS Event Notification via e-mail.

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Agreement State Event Number: 54830
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: Sullivan & Associates, Inc.
Region: 1
City: Sumter   State: SC
County:
License #: 383
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Brian Lin
Notification Date: 08/12/2020
Notification Time: 07:54 [ET]
Event Date: 08/10/2020
Event Time: 17:30 [EDT]
Last Update Date: 08/12/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA DRIVE CABLE FAILURE

This was received from the South Carolina Department of Health and Environmental Control via email:

"On August 11, 2020, at 1500 (EDT), the Department (SC Department of Health and Environmental Control) was notified by the licensee that a drive cable used to crank out a source on a Spec 150 camera failed to function as designed. The radiographer was performing the initial source crank out of the source to check the 2 mR in any one hour boundary when he realized that the drive cable was not functioning properly and quickly retracted the source to the shielded position. The radiographer then contacted the Radiation Safety Officer (RSO) to provide him with the details. The RSO then cancelled the job for the night until the drive cable could be replaced. The RSO stated that there were no overexposures that occurred as a result of this incident. The RSO was informed by the Department's on-call duty officer that a 30-day written report will be required detailing the incident."

The event occurred on Shaw Air Force Base.

South Carolina Incident No: 54830

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Agreement State Event Number: 54831
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: Energy Solutions
Region: 1
City: Oak Ridge   State: TN
County:
License #: R-73016
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Brian Lin
Notification Date: 08/12/2020
Notification Time: 10:57 [ET]
Event Date: 08/11/2020
Event Time: 11:30 [EDT]
Last Update Date: 08/12/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

FIRE INVOLVING A CONTAINER POSSESSING LICENSED MATERIAL

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

"An incident took place while processing a liner with water filters and Dry Active Waste (DAW) in it during filter shredding operation in the Filter Shredding area of the Radioactive Material Solutions (RMS) Building on site. The container contained mixed fission and activation products with Co-60 as a primary contaminant. A fire was observed in the steel Final Form Container (FFC) liner through the remote observation. The size of the fire was limited to the container itself. The FFC is a steel liner where the material accumulates and is contained in preparation for sealing for disposal. The filter processing room was accessed via a hatch and a crane was used to seal the FFC. The fire suppression system was activated to cool down the FFC liner. The Oak Ridge Fire Department responded to the site. Since the fire was contained to the FFC liner, the Oak Ridge Fire Department did not enter the building. The area radiation and air effluent stack monitors did not alarm. Samples from air samplers are being analyzed for airborne material. Staff that remained in the building will undergo a bioassay to assess for potential uptake. A follow-up report will be submitted within 30 days."

TN Incident No.: TN-20-116

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Agreement State Event Number: 54833
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: Goodwill Industries
Region: 4
City: Eugene   State: OR
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Richard Went
HQ OPS Officer: Brian P. Smith
Notification Date: 08/12/2020
Notification Time: 14:48 [ET]
Event Date: 08/10/2020
Event Time: 00:00 [PDT]
Last Update Date: 08/12/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DAVID PROULX (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 - ABANDONED TRITIUM SIGN

The following information was received via a letter from Goodwill Industries to the Oregon Department of Health Radiation Protection:

"Goodwill Industries of Lane and South Coast Counties found an abandoned exit sign (Tritium) in their inventory. The exit sign was sent to SRB Technologies, INC. at 2580 Landmark Drive, Winston-Salem, NC 27103 (NC Radioactive Materials License# 034-0534-2) for proper disposal. One sign was sent. The sign had been manufactured by lsolite Safety Light Corp. Bloomberg, PA/ Model Number 2040. Serial Number 0412499. Date of Manufacture 12-84. Life rating/ Curies of 10 years 9.8ci. The device was never registered or installed at any of our sites as it was abandoned here.

"The Oregon Department of Health Radiation Protection will attempt to find the original owner based on the serial number. Since the light has been disposed of properly and reporting is now entered per SA300, Oregon is requesting that this event be marked as complete and request closure of this event."

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: 54835
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: St. Luke's University Health Network
Region: 1
City: Bethlehem   State: PA
County:
License #: PA-0073
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Bethany Cecere
Notification Date: 08/13/2020
Notification Time: 14:47 [ET]
Event Date: 08/11/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/13/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

"The [Pennsylvania] Department [of Environmental Protection (DEP)] received notification from a licensee on August 12, 2020, of a medical event involving Yttrium-90 Sir-Spheres. The licensee believes a patient received only 47% of the prescribed dose. The prescribed dose was 1.44 GBq and the delivered dose is believed to be 0.67 GBq. Preliminary cause is believed to be a clotted catheter. The licensee continues to investigate the event. The patient and referring physician were informed following the procedure. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."

PA NMED Event # PA2000016

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: 54836
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo   State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Brian P. Smith
Notification Date: 08/13/2020
Notification Time: 16:36 [ET]
Event Date: 06/25/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/13/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSC (CANADA) (FAX)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REORT - MISSING I-125 SEED

The following was received via fax from the New York State Department of Health:

"On July 7, 2020, the [New York State] Department [of Health] was notified of a missing Iodine-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 142 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. An lodine-125 localization seed was removed from a patient in a procedure that took place on June 25, 2020, and is believed to have been lost in the intraoperative frozen section room in surgery. The RSO [Radiation Safety Officer] was informed of the missing seed on June 29, 2020. The facility conducted searches and surveys of the Surgery, Pathology, Radiation Safety and Environmental Services areas. Trash and regulated medical waste were also surveyed and inspected. It is believed that the seed will be recovered from the facility's regular trash, but more likely in the facility's radioactive waste."

New York State Event Report Number: NYDOH 20-02

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 !!!!!
Agreement State Event Number: 54837
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: US Well Service LLC
Region: 4
City: Houston   State: TX
County:
License #: L 06930
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Bethany Cecere
Notification Date: 08/13/2020
Notification Time: 23:28 [ET]
Event Date: 08/13/2020
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DAVID PROULX (R4DO)
KEVIN WILLIAMS (NMSS EO)
WILLIAM GOTT (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 8/17/2020

EN Revision Text: AGREEMENT STATE REPORT - FIRE INVOLVING OIL WELL LOGGING SOURCE

"On August 13, 2020, the Agency [Texas Department of State Health Services] was contacted by the Nuclear Regulatory Agency (NRC) and notified that they had been contacted by a State of Texas licensee. The NRC still had the licensee on their bridge line and tied the Agency into the call with the licensee. The licensee's radiation safety officer (RSO) reported that one of their well service blending trucks was engaged in a fire. The well is located near Mentone, Texas. The truck has a TN model 5190 nuclear gauge containing a 200 milliCurie cesium - 137 source installed on the piping system. The gauge was purchased in December 2019. At the time of the call (2121 CDT) the fire was still burning, and a fire department was on scene. The RSO believed the fire department was aware of the source. The RSO stated all their personnel had been evacuated from the scene of the fire. There is no way to know the status of the gauge shielding or of the source. The RSO agreed to contact the Agency when the fire was put out, and after completing a survey of the gauge. Additional information will be provided as it is received in accordance with SA-300."

TX Incident #: I-9783

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * RETRACTION ON 8/14/2020 AT 2051 EDT FROM ART TUCKER TO KERBY SCALES * * *

The following retraction was received from the state of Texas via email:

"On August 14, 2020, the licensee reported that after the fire was extinguished it found that the fire did not reach the gauge or equipment around it. This included electrical wiring and rubber hoses which showed no damage from the fire. A portion of the equipment the gauge was mounted to did have some fire damage. An Agency radioactive material inspector went to the site and performed a dose rate survey on the gauge. Based on this survey, it does not appear there was any damage to the gauge shielding. There was a second gauge at the site, but it was not anywhere near the area of the fire and was not affected. It was also surveyed and did not appear to have had any damage. The dose rates taken on the gauges were similar. Based on this information this event does not meet the reporting criteria and is therefore retracted. The licensee has performed a leak test of the gauge and if the results are greater than the limit it will be reported in accordance with SA-30."

Notified R4DO (Proulx), NMSS EO (Williams), IRD MOC (Gott), and NMSS Event Notifications (email). Additionally notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

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Power Reactor Event Number: 54847
Facility: Turkey Point
Region: 2     State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Christopher Trent
HQ OPS Officer: Bethany Cecere
Notification Date: 08/21/2020
Notification Time: 03:12 [ET]
Event Date: 08/20/2020
Event Time: 23:54 [EDT]
Last Update Date: 08/21/2020
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):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 34 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO STEAM GENERATOR WATER LEVEL CONTROL

"On 08/20/20 at 2354 [EDT], with Unit 3 in Mode 1 at approximately 34% RTP [Rated Thermal Power], the reactor was manually tripped. This was due to Steam Generator Water Level control issues that resulted in the only Steam Generator [S/G] Feed Pump tripping on low suction pressure. Unit 3 reactor was tripped manually upon the loss of the last running feed pump. All other systems operated normally. Auxiliary Feedwater initiated as designed to provide S/G water level control. EOPs have been exited and General Operating Procedures (GOPs) were entered. Unit 3 is stable in Mode 3 at normal operating temperature and pressure.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)

"The NRC Resident Inspector bas been notified."

Decay heat removal is by the steam dumps to atmosphere. Unit 4 is not affected. The cause of the low suction feed pressure to the steam generator feed pump is under investigation.


Page Last Reviewed/Updated Friday, August 21, 2020
Friday, August 21, 2020