Event Notification Report for January 18, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/17/2021 - 01/18/2021
Agreement State
Event Number: 55057
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRAPHIC PACKAGING INTERNATIONAL
Region: 1
City: Macon State: GA
County:
License #: GA 179-2
Agreement: Y
Docket:
NRC Notified By: Peter Leonbruno
HQ OPS Officer: Brian Lin
Licensee: GRAPHIC PACKAGING INTERNATIONAL
Region: 1
City: Macon State: GA
County:
License #: GA 179-2
Agreement: Y
Docket:
NRC Notified By: Peter Leonbruno
HQ OPS Officer: Brian Lin
Notification Date: 01/07/2021
Notification Time: 10:01 [ET]
Event Date: 01/07/2021
Event Time: 00:00 [EST]
Last Update Date: 01/14/2021
Notification Time: 10:01 [ET]
Event Date: 01/07/2021
Event Time: 00:00 [EST]
Last Update Date: 01/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 1/15/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTERS
The following information was received from the state of Georgia via email:
"During the semi-annual check of installed gauges, shutters on three devices were found to be stuck in the 'open' position. Note that 'open' is the normal operating position. The three devices measure level within a silo at the facility. The licensee contacted the manufacturer, Berthold for assistance and will send us a written follow-up report."
GA Incident Number: 33
* * * UPDATE FROM GREGORY REESE TO DONALD NORWOOD AT 0610 EST ON 1/14/21 * * *
The following information was received via E-mail:
The licensee reported on 1/8/2021 that the shutters on all three devices were unstuck on the afternoon of 1/7/2021. The shutters are now working properly.
Notified R1DO (Lilliendahl) and NMSS Events Notifications E-mail group.
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTERS
The following information was received from the state of Georgia via email:
"During the semi-annual check of installed gauges, shutters on three devices were found to be stuck in the 'open' position. Note that 'open' is the normal operating position. The three devices measure level within a silo at the facility. The licensee contacted the manufacturer, Berthold for assistance and will send us a written follow-up report."
GA Incident Number: 33
* * * UPDATE FROM GREGORY REESE TO DONALD NORWOOD AT 0610 EST ON 1/14/21 * * *
The following information was received via E-mail:
The licensee reported on 1/8/2021 that the shutters on all three devices were unstuck on the afternoon of 1/7/2021. The shutters are now working properly.
Notified R1DO (Lilliendahl) and NMSS Events Notifications E-mail group.
Agreement State
Event Number: 55059
Rep Org: Dow Chemical Company
Licensee: Dow Chemical Company
Region: 3
City: Midland State: MI
County:
License #: 21-00265-06
Agreement: N
Docket:
NRC Notified By: Kelly Wegener-Gave
HQ OPS Officer: Thomas Herrity
Licensee: Dow Chemical Company
Region: 3
City: Midland State: MI
County:
License #: 21-00265-06
Agreement: N
Docket:
NRC Notified By: Kelly Wegener-Gave
HQ OPS Officer: Thomas Herrity
Notification Date: 01/08/2021
Notification Time: 14:15 [ET]
Event Date: 01/08/2021
Event Time: 11:20 [EST]
Last Update Date: 01/08/2021
Notification Time: 14:15 [ET]
Event Date: 01/08/2021
Event Time: 11:20 [EST]
Last Update Date: 01/08/2021
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PROCESS GAUGE SHUTTER STUCK OPEN
The following is a synopsis of the phone call and email from Dow Chemical, Midland:
While conducting a troubleshooting evaluation on the process gauge, personnel became aware that the shutter for the gauge was stuck in the open (normal operating) position. The unit is located approximately fifteen feet above the operating level. Personnel exposure is precluded by the location. The vendor has been contacted to determine a resolution plan and will be on-site next week.
Gauge Info:
Manufacturer: Vega Americas
Source Holder Model: SH-F2B
Isotope and quantity: Cesium-137, 750 mCi
Source serial number 9006CP
Source holder serial number 46168107
The following is a synopsis of the phone call and email from Dow Chemical, Midland:
While conducting a troubleshooting evaluation on the process gauge, personnel became aware that the shutter for the gauge was stuck in the open (normal operating) position. The unit is located approximately fifteen feet above the operating level. Personnel exposure is precluded by the location. The vendor has been contacted to determine a resolution plan and will be on-site next week.
Gauge Info:
Manufacturer: Vega Americas
Source Holder Model: SH-F2B
Isotope and quantity: Cesium-137, 750 mCi
Source serial number 9006CP
Source holder serial number 46168107
Agreement State
Event Number: 55060
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Regents of the University of California, Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Kathleen Harkness
HQ OPS Officer: Lloyd Desotell
Licensee: Regents of the University of California, Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Kathleen Harkness
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/11/2021
Notification Time: 14:15 [ET]
Event Date: 01/08/2021
Event Time: 00:00 [PST]
Last Update Date: 01/11/2021
Notification Time: 14:15 [ET]
Event Date: 01/08/2021
Event Time: 00:00 [PST]
Last Update Date: 01/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT UNDERGOING RADIATION TREATMENT
The following information was received from the Radiologic Health Branch, California Department of Public Health via email:
"On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7.
"Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%.
"On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. "
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.
The following information was received from the Radiologic Health Branch, California Department of Public Health via email:
"On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7.
"Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%.
"On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. "
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.
Power Reactor
Event Number: 55071
Facility: Pilgrim
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Michael McDonough
HQ OPS Officer: Howie Crouch
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Michael McDonough
HQ OPS Officer: Howie Crouch
Notification Date: 01/18/2021
Notification Time: 17:31 [ET]
Event Date: 01/18/2021
Event Time: 16:00 [EST]
Last Update Date: 01/18/2021
Notification Time: 17:31 [ET]
Event Date: 01/18/2021
Event Time: 16:00 [EST]
Last Update Date: 01/18/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
LILLIENDAHL, JON (R1)
LILLIENDAHL, JON (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
OFFSITE NOTIFICATION DUE TO LEAK FROM UNDERGROUND SEWAGE STORAGE TANK
"On January 18, 2021 at 1600 hours (EDT), Holtec Decommissioning International (HDI) made an off-site notification to the Environmental Protection Agency's Enforcement and Compliance Assurance Division in accordance with Section B of the station's National Pollutant Discharge Elimination System (NPDES) Permit No. 0003557. The event was associated with an underground sewage water system holding tank. The specific details of the occurrence are as follows:
"On January 13, 2021 at 1000 hours [EDT] site personnel identified what appeared to be water bubbling up from an unidentified cover within the security protected area of the site. The water emanating from the cap had no visible color or solid material and no odor. The water estimated at 25 gallons per hour or less was flowing to a site storm drain connected to permitted outfall number 007. Initial indication was that the water was potable water as part of the station's fire protection system. Further investigation determined that a back-up in an underground sewage holding tank inlet was the source of the leakage. By 1400 hours [EDT] when bathrooms including toilets on site were shutdown and removed from service, efforts were underway to pump the tank and remove the blockage, and the bubbling from the cover had stopped."
The licensee has notified the Massachusetts Environmental Protection Agency, the Massachusetts Emergency Management Agency and the NRC Resident Inspector.
"On January 18, 2021 at 1600 hours (EDT), Holtec Decommissioning International (HDI) made an off-site notification to the Environmental Protection Agency's Enforcement and Compliance Assurance Division in accordance with Section B of the station's National Pollutant Discharge Elimination System (NPDES) Permit No. 0003557. The event was associated with an underground sewage water system holding tank. The specific details of the occurrence are as follows:
"On January 13, 2021 at 1000 hours [EDT] site personnel identified what appeared to be water bubbling up from an unidentified cover within the security protected area of the site. The water emanating from the cap had no visible color or solid material and no odor. The water estimated at 25 gallons per hour or less was flowing to a site storm drain connected to permitted outfall number 007. Initial indication was that the water was potable water as part of the station's fire protection system. Further investigation determined that a back-up in an underground sewage holding tank inlet was the source of the leakage. By 1400 hours [EDT] when bathrooms including toilets on site were shutdown and removed from service, efforts were underway to pump the tank and remove the blockage, and the bubbling from the cover had stopped."
The licensee has notified the Massachusetts Environmental Protection Agency, the Massachusetts Emergency Management Agency and the NRC Resident Inspector.