Event Notification Report for May 13, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/12/2021 - 05/13/2021
Agreement State
Event Number: 55258
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Ashley Lively of Watson Clinic LLP
Region: 1
City: Lakeland State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Kerby Scales
Licensee: Ashley Lively of Watson Clinic LLP
Region: 1
City: Lakeland State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Kerby Scales
Notification Date: 05/13/2021
Notification Time: 21:25 [ET]
Event Date: 05/13/2021
Event Time: 20:20 [EDT]
Last Update Date: 05/13/2021
Notification Time: 21:25 [ET]
Event Date: 05/13/2021
Event Time: 20:20 [EDT]
Last Update Date: 05/13/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DIMITRIADIS, ANTHONY (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
DIMITRIADIS, ANTHONY (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 6/11/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE
The following was received from the Florida Department of Health (Bureau of Radiation Control) via email:
"At around 2020 [EDT] this evening, [the licensee] reported a lost radiography source from the Nuc-Med department.
"It was confirmed as missing from the lead pig this morning by a PET-CT tech after performing a [quality control] QC check on the camera. The PET-CT tech believes that they put it in their pocket yesterday afternoon after they were finished using it, instead of putting it back in the pig. [The] licensee reports to have used four detectors in the work area, and in the PET-CT's car and residence, but the source is still missing."
Source: Na-22
Activity: 100 uCi on 01 June 2018, 45uCi today
Manufacturer: Eckert & Ziegler
Serial Number: Q5-225
Florida Event Number: FL21-063
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
EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE
The following was received from the Florida Department of Health (Bureau of Radiation Control) via email:
"At around 2020 [EDT] this evening, [the licensee] reported a lost radiography source from the Nuc-Med department.
"It was confirmed as missing from the lead pig this morning by a PET-CT tech after performing a [quality control] QC check on the camera. The PET-CT tech believes that they put it in their pocket yesterday afternoon after they were finished using it, instead of putting it back in the pig. [The] licensee reports to have used four detectors in the work area, and in the PET-CT's car and residence, but the source is still missing."
Source: Na-22
Activity: 100 uCi on 01 June 2018, 45uCi today
Manufacturer: Eckert & Ziegler
Serial Number: Q5-225
Florida Event Number: FL21-063
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
Non-Agreement State
Event Number: 55262
Rep Org: Defense Health Agency
Licensee: Defense Health Agency
Region: 1
City: San Diego State: CA
County:
License #: 45-35423-01
Agreement: N
Docket:
NRC Notified By: Col. Ricardo Reyes
HQ OPS Officer: Brian Lin
Licensee: Defense Health Agency
Region: 1
City: San Diego State: CA
County:
License #: 45-35423-01
Agreement: N
Docket:
NRC Notified By: Col. Ricardo Reyes
HQ OPS Officer: Brian Lin
Notification Date: 05/17/2021
Notification Time: 20:15 [ET]
Event Date: 05/13/2021
Event Time: 00:00 []
Last Update Date: 05/17/2021
Notification Time: 20:15 [ET]
Event Date: 05/13/2021
Event Time: 00:00 []
Last Update Date: 05/17/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
Person (Organization):
GREIVES, JONATHAN (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (FAX)
YOUNG, CALE (R4DO)
GREIVES, JONATHAN (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (FAX)
YOUNG, CALE (R4DO)
EN Revision Imported Date: 6/17/2021
EN Revision Text: MISSING IODINE-125 BRACHYTHERAPY SEEDS
"A brachytherapy treatment was performed at the hospital on 13 May 2021. From a total of 111 Iodine -125 seeds, 88 were implanted into the patient's prostate as planned. The oncology medical physicist mistakenly thought that she had placed the remaining, unused 23 in two lead containers, but did not perform a physical inventory to confirm it. She did not realized that 4 unused seeds were left in a shielded box. Each seed had approximately 0.26 mCi in each. After the procedure, Radiation Safety surveyed the treatment room. All radiation levels were background. The medical physicist returned the unused seeds to Radiation Safety indicating that 23 seeds were in two small lead pigs. The box containing the 4 seeds was put in the medical waste bag and were apparently processed as medical waste. On 14 May 2021, Radiation Safety initiated preparing the unused seeds for shipment to the vendor that provided them. At that point, Radiation Safety realized that only 19 were in the lead containers and 4 were not returned. At that point, Radiation Safety contacted Radiation Oncology. They were not able to locate them at their department. A team consisting of Radiation Safety and Radiation Oncology staff searched for them, unsuccessfully, in the [Operating Room]. The team then searched in the medical waste dumpster bins at the hospital. This search was also unsuccessful locating the missing seeds. It was determined that a dumpster container that likely had the missing seeds was picked up early in the day. The waste management company was contacted, but the company was not able to provide information about what truck or container was involved and its location. The hospital is currently waiting for more information from the waste management company."
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
EN Revision Text: MISSING IODINE-125 BRACHYTHERAPY SEEDS
"A brachytherapy treatment was performed at the hospital on 13 May 2021. From a total of 111 Iodine -125 seeds, 88 were implanted into the patient's prostate as planned. The oncology medical physicist mistakenly thought that she had placed the remaining, unused 23 in two lead containers, but did not perform a physical inventory to confirm it. She did not realized that 4 unused seeds were left in a shielded box. Each seed had approximately 0.26 mCi in each. After the procedure, Radiation Safety surveyed the treatment room. All radiation levels were background. The medical physicist returned the unused seeds to Radiation Safety indicating that 23 seeds were in two small lead pigs. The box containing the 4 seeds was put in the medical waste bag and were apparently processed as medical waste. On 14 May 2021, Radiation Safety initiated preparing the unused seeds for shipment to the vendor that provided them. At that point, Radiation Safety realized that only 19 were in the lead containers and 4 were not returned. At that point, Radiation Safety contacted Radiation Oncology. They were not able to locate them at their department. A team consisting of Radiation Safety and Radiation Oncology staff searched for them, unsuccessfully, in the [Operating Room]. The team then searched in the medical waste dumpster bins at the hospital. This search was also unsuccessful locating the missing seeds. It was determined that a dumpster container that likely had the missing seeds was picked up early in the day. The waste management company was contacted, but the company was not able to provide information about what truck or container was involved and its location. The hospital is currently waiting for more information from the waste management company."
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: 55256
Facility: South Texas
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rick Nance
HQ OPS Officer: Kerby Scales
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rick Nance
HQ OPS Officer: Kerby Scales
Notification Date: 05/13/2021
Notification Time: 20:35 [ET]
Event Date: 05/13/2021
Event Time: 10:45 [CDT]
Last Update Date: 05/13/2021
Notification Time: 20:35 [ET]
Event Date: 05/13/2021
Event Time: 10:45 [CDT]
Last Update Date: 05/13/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
GADDY, VINCENT (R4)
FFD GROUP, (EMAIL)
GADDY, VINCENT (R4)
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 | Y | 90 | Power Operation | 98 | Power Operation |
EN Revision Imported Date: 6/11/2021
EN Revision Text: FITNESS FOR DUTY REPORT
A non-licensed temporary supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
EN Revision Text: FITNESS FOR DUTY REPORT
A non-licensed temporary supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 55345
Facility: Limerick
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Richard Wagner
HQ OPS Officer: Brian P. Smith
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Richard Wagner
HQ OPS Officer: Brian P. Smith
Notification Date: 07/08/2021
Notification Time: 20:07 [ET]
Event Date: 05/13/2021
Event Time: 07:00 [EDT]
Last Update Date: 07/08/2021
Notification Time: 20:07 [ET]
Event Date: 05/13/2021
Event Time: 07:00 [EDT]
Last Update Date: 07/08/2021
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
LILLIENDAHL, JON (R1)
LILLIENDAHL, JON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Shutdown | 100 | Power Operation |
EN Revision Imported Date: 8/6/2021
EN Revision Text: INVALID ACTUATION OF CONTAINMENT ISOLATION SIGNAL
"This 60-Day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of containment isolation signal affecting more than one system. On May 13, 2021, during the restoration of the Unit 2 Refuel Floor High Radiation Isolation Logic an invalid isolation signal was received. The condition requiring an isolation signal was verified not to be present prior to restoring the logic; however, it was not recognized that a previous isolation signal was latched in and had not been reset. When the isolation logic was restored, the Primary Containment Isolation System (PCIS) isolated on the invalid signal. The systems successfully completed the isolation per the plant design and plant configuration.
"The following systems actuated due to the Unit 2 PCIS Group 6C Isolation:
- Isolation of Containment Hydrogen and Oxygen Sampling Valves,
- Start of the 2A Reactor Enclosure Recirculation System,
- Trip of the Units 1 and 2 Refuel Floor HVAC,
- Start of the A and B Trains of Standby Gas Treatment Systems."
The NRC Resident Inspector was notified.
EN Revision Text: INVALID ACTUATION OF CONTAINMENT ISOLATION SIGNAL
"This 60-Day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of containment isolation signal affecting more than one system. On May 13, 2021, during the restoration of the Unit 2 Refuel Floor High Radiation Isolation Logic an invalid isolation signal was received. The condition requiring an isolation signal was verified not to be present prior to restoring the logic; however, it was not recognized that a previous isolation signal was latched in and had not been reset. When the isolation logic was restored, the Primary Containment Isolation System (PCIS) isolated on the invalid signal. The systems successfully completed the isolation per the plant design and plant configuration.
"The following systems actuated due to the Unit 2 PCIS Group 6C Isolation:
- Isolation of Containment Hydrogen and Oxygen Sampling Valves,
- Start of the 2A Reactor Enclosure Recirculation System,
- Trip of the Units 1 and 2 Refuel Floor HVAC,
- Start of the A and B Trains of Standby Gas Treatment Systems."
The NRC Resident Inspector was notified.