Event Notification Report for February 07, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/04/2022 - 02/07/2022
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 55652
Rep Org: U.S. Air Force
Licensee: U.S. Air Force
Region: 4
City: Albuquerque State: NM
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt Col Christina Peace
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 20:53 [ET]
Event Date: 12/15/2021
Event Time: 14:38 [MST]
Last Update Date: 02/06/2022
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL
The following is a summary from a phone call with the licensee:
At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
* * * RETRACTION ON 02/06/2022 AT 2211 EST FROM CHRISTINA PEACE TO OSSY FONT * * *
The following retraction was received from the licensee via email:
"On December 15, 2021, [the licensee reported] telephonically about a leaking radium-226 source at the TS-1 site at Kirtland AFB, which prompted a radioactive material incident report. After further examination, the suspected radium dial was identified as a `Delco-Remy Ignition Unit.' Upon re-surveying the unit, only background readings were identified. Due to the newly discovered information, the [(Radioisotope Committee Secretariat)] RICS and Kirtland AFB request to retract the incident."
Notified R4DO (Josey) and NMSS Events Notification via email.
Agreement State
Event Number: 55716
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.
"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.
"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"
Item Number: IL220002
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: 55717
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE
The following report was received from the California Department of Public Health (RHB) via email:
"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."
California Event Number: 012822
Agreement State
Event Number: 55718
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Lixi, Inc.
Region: 3
City: Carpentersville State: IL
County:
License #: IL-01339-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/31/2022
Notification Time: 14:14 [ET]
Event Date: 01/30/2022
Event Time: 16:00 [CST]
Last Update Date: 01/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3DO)
Josey, Jeffrey (R4DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN RADIOACTIVE GAUGES
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"The Agency was notified early in the morning of 1/31/22 that an Illinois licensee (Lixi, Inc., IL-01339-01) operating in Anaheim, California under reciprocity had two radioactive gauges stolen from their rental car on the afternoon of January 30, 2022 [approximately 1600 PST]. Local law enforcement have been notified and responded. The gauges were padlocked preventing the sources from being used and the keys were not stolen. The California program has been notified and is copied on this correspondence. The licensee appears to have reported the theft in a timely manner.
"The stolen devices were portable fluoroscopes containing approximately 1 Curie of Gd-153 each and were taken from the Staybridge Suites parking garage at 1050 W. Ball Rd. in Anaheim. The police report is 22-15907. The devices were model number TG41 source holders with serial numbers 3217 and 3218. They are marked with the model number 'TG41' and will display 'ON' when the source holder is rotated to expose the source. The radioactive material within the device is in the form of a powder, contained within a tungsten capsule approximately 7mm x 10mm. The source cannot be removed from the device without special tools which were not stolen. If it were somehow removed, it would appear as a stainless steel capsule and is engraved with the word 'Radioactive' and the words 'Gd153', 'C-381' and 'MDSN/LIXI'."
Item Number: IL220003
* * * UPDATE AT 1918 EST ON 01/31/22 FROM ROBERT GREGER TO THOMAS KENDZIA * * *
The following update was received from the California Department of Public Health via E-mail:
"On Sunday, January 30, 2022, [at 2247 PST], the Lixi, Inc. RSO reported to CAL OES [California Governor's Office of Emergency Services] the theft of two Gadolinium-153 sealed sources used in their Lixi pipe profilers, source S/N: 11/21 (943.15 mCi) and source S/N: 12/21 (926.46 mCi), source holders S/N 3217 and 3218). The users had been inspecting pipes at an Albertsons distribution center located in Brea, CA for two weeks. The theft was discovered on Sunday evening, where the locked and alarmed rental GMC Terrain SUV was parked in the hotel parking structure (address above). The employees stored the Lixi profilers with the Gd-153 source holders attached to the Lixi profiler detector system with the sources locked in the shielded position. There was no sign of forced entry, police speculated the thieves had an electronic bypass system of some kind since four cars were broken into. The value of each Lixi profiler is $50,000 to $75,000. Hotel security is reviewing garage camera footage and will update the PD [police department]. The sources had Caution: Radioactive Materials labeling on them. A police report was made with the Anaheim Police Department (Number 22-15907). The licensee will submit a lost/reward ad in the local paper/website and gather additional information for the follow up investigation."
CA 5010 Number: 013022
Notified R3DO (Orth), R4DO (Josey), and NMSS Events Notification, ILTAB, and CNSNS via email.
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: 55719
Rep Org: Florida Bureau of Radiation Control
Licensee: Driggers Engineering Services
Region: 1
City: Sarasota State: FL
County:
License #: 1562-3
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/31/2022
Notification Time: 16:05 [ET]
Event Date: 01/31/2022
Event Time: 00:00 [EST]
Last Update Date: 01/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE
The following is a synopsis of an email received from the State of Florida:
"[RSO] called and reported that a Nuclear Moisture Density Gauge fell out of the back of his pickup truck while traveling/transporting the gauge from the office to a work site at SR 64 and Dam Rd. The gauge was padlocked in its case and chained on each side of the case to eyelets in the back of the truck using padlocks to secure the chains. Upon arrival at the worksite (Manatee County) the truck tailgate was open and the gauge was missing. The padlocks securing the chains were broken. [RSO] retraced his travel route two times to look for the missing gauge. The gauge was NOT found. [The RSO] reported the incident to both the Manatee County's and Sarasota County's Sheriffs Departments. Sarasota County Sheriff Dept. Case number 22-8695 was issued."
Report identified the sources to be Cesium-137 (10 milliCuries) and Americium-241/Be (50 milliCuries).
Florida Incident Number: FL22-012
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: 55732
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Brian Lin
Notification Date: 02/04/2022
Notification Time: 20:30 [ET]
Event Date: 02/04/2022
Event Time: 17:00 [EST]
Last Update Date: 02/04/2022
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):
Orth, Steve (R3)
Power Reactor Unit Info
Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
2 |
A/R |
Y |
58 |
Power Operation |
0 |
Hot Standby |
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: AUTOMATIC REACTOR SCRAM
The following information was provided by the licensee via email:
"At 1700 EST, on February 4, 2022 with the unit in Mode 1 at 58 percent power, the reactor automatically scrammed due to low Reactor water level due to a transient on the Feedwater System while preparing to shutdown for a refueling outage. The scram was not complex, with systems responding normally post-scram.
"Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred while in the process of removing the South Reactor Feed Pump from service. While reducing speed on the South, the North Reactor Feed Pump increased in speed and tripped on low suction. The plant was preparing to shut down for a refueling outage when the trip occurred.
"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, in preparation of plant shutdown, Primary Containment De-Inerting was in progress. The low Reactor water level caused an isolation of Primary Containment (Groups 4/13/15). The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."
Power Reactor
Event Number: 55733
Facility: Oconee
Region: 2 State: SC
Unit: [2] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: Christopher Tam
HQ OPS Officer: Lloyd Desotell
Notification Date: 02/05/2022
Notification Time: 04:32 [ET]
Event Date: 02/05/2022
Event Time: 03:57 [EST]
Last Update Date: 02/05/2022
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Miller, Mark (R2)
Veil, Andrea (NRR)
Dudes, Laura (R2 RA)
Gott, William (IR)
Power Reactor Unit Info
Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
2 |
A/R |
Y |
100 |
Power Operation |
0 |
Hot Standby |
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: UNUSUAL EVENT DECLARED DUE TO VISUAL OBSERVATION OF SMOKE AND MULTIPLE FIRE ALARMS IN THE WEST PENETRATION ROOM
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At 0357 EST on 2/5/22, Oconee Unit 2 declared an Unusual Event due to a multiple fire alarms and visual observance of a smoke filled room in the West Penetration Room (EAL HU 4.1). Unit 2 automatically tripped and entered Mode 3. There was an indication that a release to the environment potentially occurred. Units 1 and 3 remained at 100% power.
The Licensee notified the NRC Resident Inspector, the State, and local authorities.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), and DHS Nuclear SSA (email).
* * * UPDATE ON 2/5/22 AT 0748 EST FROM CHUCK CLEMONS TO LLOYD DESOTELL * * *
The following information was provided by the licensee via email:
"At 0343 EST on February 5th, 2022, with Unit 2 in Mode 1 at 100% power, the reactor automatically tripped due to Reactor Coolant Pump (RCP) Flux/Flow Imbalance caused by the simultaneous trip of all 4 RCPs. The cause of the loss of all RCPs is under investigation. The trip was not complex. There was no inoperable equipment prior to the event that contributed to it.
"Operations responded and stabilized the plant. Decay heat is being removed by the Reactor Coolant System (RCS) in natural circulation with normal feedwater flow.
"Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The Licensee notified the State and local authorities.
Notified R2DO (Miller)
* * * UPDATE ON 2/5/22 AT 0815 EST FROM CHUCK CLEMONS TO LLOYD DESOTELL * * *
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At 0811 EST on 2/5/22, Oconee Unit 2 terminated the notification of unusual event because EAL HU 4.1 criteria were no longer met. Unit 2 remains shutdown in Mode 3.
The licensee has notified the State and local authorities and will notify the NRC Resident Inspector.
Notified R2DO (Miller), IRD MOC (Gott), NRR EO (Regan), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
Power Reactor
Event Number: 55734
Facility: Davis Besse
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Nicholas Buehler
HQ OPS Officer: Brian Lin
Notification Date: 02/05/2022
Notification Time: 18:54 [ET]
Event Date: 02/05/2022
Event Time: 15:14 [EST]
Last Update Date: 02/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(i) - Plant S/D Reqd By Ts
Person (Organization):
Orth, Steve (R3)
Regan, Chris (NRR EO)
Gott, William (IR)
Dickson, Billy (R3)
Power Reactor Unit Info
Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
1 |
N |
Y |
98 |
Power Operation |
15 |
Power Operation |
Event Text
EN Revision Imported Date: 2/7/2022
EN Revision Text: TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
The following information was provided by the licensee via email:
"At approximately 1402 EST on 2/5/2022, with the Unit in Mode 1 at approximately 98 percent power, Operations was performing a valve lineup and inadvertently isolated a portion of the Reactor Coolant System (RCS) Letdown System, resulting in the system relief valve lifting and entry into the Makeup and Purification System Malfunction Abnormal Procedure due to loss of letdown. Pressurizer level increased and Technical Specification (TS) Limiting Condition for Operation (LCO) 3.4.9 CONDITION A was entered at 1414 EST due to Pressurizer level not below the limit of 228 inches, which has a REQUIRED ACTION to restore Pressurizer level within one hour. A rapid plant down power was initiated at approximately 1430 EST to reduce Pressurizer level.
"At 1514 EST on 2/5/2022, TS LCO 3.4.9 CONDITION B was entered, which has a REQUIRED ACTION to place the Unit in MODE 3 in 6 hours and in MODE 4 in 12 hours. As the Unit was continuing to down power, this represents initiation of a Technical Specification required shutdown, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i).
"At approximately 1542 EST the down power was stopped at 15 percent power. Pressurizer level was restored to less than 228 inches at approximately 1603 EST, and TS LCO 3.4.9 was exited.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."