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Event Notification Report for August 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/21/2020 - 8/24/2020

** EVENT NUMBERS **
 
54835 54836 54837 54838 54847 54848 54849

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.

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

!!!!! 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).

Agreement State Event Number: 54838
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: InviCRO, LLC
Region: 1
City: Boston   State: MA
County:
License #: 55-0692
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Kerby Scales		 Notification Date: 08/14/2020
Notification Time: 17:03 [ET]
Event Date: 08/05/2020
Event Time: 10:20 [EDT]
Last Update Date: 08/14/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RAM PACKAGES SWITCHED IN ERROR

The following email was received from the Massachusetts Radiation Control Program (the agency) via email:

"On August 5, 2020, InviCRO reported receiving in error on same day a White I package of 140 mCi Lu-177. Receipt survey recorded a package surface dose rate of 0.2 mRem/hr. The received package activity exceeded their license radioactive material possession limit of 125 mCi. Package held by licensee in secure storage until activity falls below license limit (Lu-177 half-life is 6.7 days). The intended activity as requested by the licensee was 60 mCi. Package ordered through Radiomedix in Texas who forwarded order to supplier (ITM Medical isotopes GmbH) in Germany. Package sent from Germany arrived in [common carrier] US facility and directly forwarded to customer without going through Texas. Agency contacted [common carrier] and Texas Department of State Health Services. Apparent cause was [common carrier] accidentally switching labels/paperwork on two similar Lu-177 packages. The package originally intended for InviCRO was forwarded to a customer licensed in Indiana. Indiana customer (Endocyte) notified by Radiomedix. All US parties identified above are aware of incident. Radiomedix continuing its internal investigation. Agency left detailed voicemail messages (including circumstances, package receipt date and activity) at Indiana Department of Homeland Security and Indiana Department of Health. Agency determined this to be a 30-day reportable event and considers this event currently still open."

MA Event Number: 20-4230

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.

Power Reactor Event Number: 54848
Facility: Perry
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: John Nakel
HQ OPS Officer: Andrew Waugh		 Notification Date: 08/21/2020
Notification Time: 12:42 [ET]
Event Date: 08/21/2020
Event Time: 09:53 [EDT]
Last Update Date: 08/21/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
50.72(b)(3)(v)(D) - Accident Mitigation		 Person (Organization):
RICHARD SKOKOWSKI (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

Event Text

STANDBY LIQUID CONTROL SYSTEM INOPERABLE

"At 0953 EDT on 8/21/20, it was discovered that both trains of the standby liquid control system were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). All control rods remained operable during this time period.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Both trains of the standby liquid control system were declared inoperable due to an inadvertent addition of water to the storage tank which caused the boron concentration in the tank to go low out of specification.

Power Reactor Event Number: 54849
Facility: River Bend
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Alfonso Croeze
HQ OPS Officer: Andrew Waugh		 Notification Date: 08/21/2020
Notification Time: 12:53 [ET]
Event Date: 08/21/2020
Event Time: 09:18 [CDT]
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):
NICK TAYLOR (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 67 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM

"On August 21, 2020 at 0908 CDT, River Bend Station was operating at 100% reactor power when reactor recirculation pump 'B' tripped. At 0918 CDT, a manual reactor scram was inserted at 67% reactor power after receiving indications of thermal hydraulic instability as indicated by flux oscillations on the period based detection system (PBDS) and average power range monitors (APRMs). All control rods fully inserted and there were no complications. All systems responded as designed. Currently River Bend Station Unit 1 is stable and pressure is being maintained using turbine bypass valves.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical and 10 CFR 50.72 (b)(3)(iv)(A) Specified System Actuation as result of Group 3 isolations.

"NRC Resident Inspector has been briefed on this event.

"No radiological releases have occurred due to this event from the unit."

Page Last Reviewed/Updated Wednesday, March 24, 2021