Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2020

Event Notification Report for August 26, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/25/2020 - 8/26/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54840
Rep Org: OHIO DEPARTMENT OF HEALTH Licensee: RIVERSIDE METHODIST HOSPITAL Region: 3 City: Columbus State: OH County: License #: OH-02120250070 Agreement: Y Docket: NRC Notified By: Michael Rubadue HQ OPS Officer: Michael Bloodgood	Notification Date: 08/18/2020 Notification Time: 13:13 [ET] Event Date: 08/18/2020 Event Time: 00:00 [EDT] Last Update Date: 08/18/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): RICHARD SKOKOWSKI (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following report was received from the Ohio Department of Health via email.

"On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient."

Ohio Event No.: OH200004

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: 54841
Rep Org: COLORADO DEPT OF HEALTH Licensee: COS School District #11, Holmes Middle School Region: 4 City: Colorado Springs State: CO County: License #: GL002325 Agreement: Y Docket: NRC Notified By: Kathryn Mote HQ OPS Officer: Michael Bloodgood	Notification Date: 08/18/2020 Notification Time: 16:47 [ET] Event Date: 08/18/2020 Event Time: 00:00 [MDT] Last Update Date: 08/18/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): NICK TAYLOR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE - LOST TRITIUM EXIT SIGNS

The following information was received from the Colorado Department of Health via email.

The licensee is unable to locate sixteen tritium exit signs that have an activity of 11.5 Ci each. The signs may have been removed by a contractor.

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: 54842
Rep Org: ALABAMA RADIATION CONTROL Licensee: PPG Industries Region: 1 City: Huntsville State: AL County: License #: Agreement: Y Docket: NRC Notified By: Cason Coan HQ OPS Officer: Michael Bloodgood	Notification Date: 08/18/2020 Notification Time: 17:36 [ET] Event Date: 08/14/2020 Event Time: 00:00 [CDT] Last Update Date: 08/18/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): JONATHAN GREIVES (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 SOURCE

The following information was received from the Alabama Department of Public Health via email.

"On August 14, 2020, the Agency [Alabama Department of Public Health] received e-mail communication from PPG Industries, a general license device registrant in Huntsville, Alabama. The registrant reported that apparently a registered device containing 10 milliCuries of polonium-210 (at assay) was unable to be located for inventory. The registrant reported that the area of use was searched for 3 weeks; the device remains unaccounted for. The device has been reported to the manufacturer (NRD Systems) as lost."

Alabama Event No.: 20-19

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

Power Reactor	Event Number: 54855
Facility: Grand Gulf Region: 4 State: MS Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: Jason Overcash HQ OPS Officer: Thomas Kendzia	Notification Date: 08/25/2020 Notification Time: 02:26 [ET] Event Date: 08/24/2020 Event Time: 23:05 [CDT] Last Update Date: 08/25/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS Actuation - Critical	Person (Organization): RAY KELLAR (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

Power Operation

Hot Shutdown

Event Text

REACTOR SCRAM AFTER LOSS OF FEEDWATER - GRAND GULF

"On August 24, 2020 at 2305 CT at Grand Gulf Nuclear Station (GGNS) an Automatic Reactor Scram occurred after a trip of the Reactor Feed Pump B and subsequent lowering of reactor water level to 11.4 inches Narrow Range. The scram occurred with Reactor Power at 14% and the main generator offline.

"All control rods fully inserted and there were no complications. All systems responded as designed.

"Main Steam Isolation Valves were manually closed to control reactor cooldown, Currently GGNS reactor pressure is being maintained at 450-600psig. Reactor water level is being maintained with condensate through startup level control.

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

"The NRC Resident has been notified."

Decay heat is being removed via the main condenser.

Notified R4DO.

Non-Agreement State	Event Number: 54856
Rep Org: DIAMOND TECHNICAL SERVICES Licensee: DIAMOND TECHNICAL SERVICES Region: 1 City: Alma State: WV County: License #: 37-31259-01 Agreement: N Docket: NRC Notified By: Gregory Prebish HQ OPS Officer: Brian Lin	Notification Date: 08/25/2020 Notification Time: 14:26 [ET] Event Date: 07/29/2020 Event Time: 12:40 [EDT] Last Update Date: 08/25/2020
Emergency Class: Non Emergency 10 CFR Section: 30.50(b)(2) - Safety Equipment Failure	Person (Organization): MATT YOUNG (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NON-AGREEMENT STATE REPORT: FAILURE OF SOURCE CONNECTION

The following summary was received from the licensee via email:

On 1240 EDT on 7/29/2020, a Radiographer for Diamond Technical Services discovered that the source for a radiography projector disconnected from the drive cable. The radiation barriers were expanded, additional shielding was laid down, and site personnel were notified to clear the immediate area. No personnel were exposed at the time of the discovery. The source projector is a Sentinel 880D, S/N: 12726 with an Iridium-192 source with an activity of 52.5 Curies. The Operations Manager and Radiation Safety Officer traveled to Alma, WV from their offices in Blairsville, PA with emergency equipment and radiation safety supplies. At 1715 EDT, the source was retrieved and secured in its shielded position. There were no indications of excessive exposures. The preliminary cause of the source disconnection was determined to be fatigue failure. The components will be shipped to QSA for manufacturer evaluation and inspection.

Page Last Reviewed/Updated Wednesday, March 24, 2021