Event Notification Report for April 22, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/21/2021 - 04/22/2021
Agreement State
Event Number: 55192
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Joanna Bridge
Licensee: University of Washington
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 01/01/1900
Event Time: 00:00 [PDT]
Last Update Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 01/01/1900
Event Time: 00:00 [PDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from the Washington State Department of Health:
"University of Washington broad scope license C001 reported a medical event. The event involves y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."
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.
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from the Washington State Department of Health:
"University of Washington broad scope license C001 reported a medical event. The event involves y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."
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: 55193
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Columbia Hospital At Medical City Dallas
Region: 4
City: Dallas State: TX
County:
License #: L 01976
Agreement: Y
Docket:
NRC Notified By: Randal Redd
HQ OPS Officer: Joanna Bridge
Licensee: Columbia Hospital At Medical City Dallas
Region: 4
City: Dallas State: TX
County:
License #: L 01976
Agreement: Y
Docket:
NRC Notified By: Randal Redd
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 04/14/2021
Event Time: 08:45 [CDT]
Last Update Date: 04/14/2021
Notification Time: 13:15 [ET]
Event Date: 04/14/2021
Event Time: 08:45 [CDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVES WRONG DOSE
The following was received via e-mail from the State of Texas:
"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.
"Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident #: 9840"
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.
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVES WRONG DOSE
The following was received via e-mail from the State of Texas:
"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.
"Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident #: 9840"
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: 55194
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Acuren Inspection INC
Region: 4
City: La Porte State: TX
County:
License #: L 01774
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Licensee: Acuren Inspection INC
Region: 4
City: La Porte State: TX
County:
License #: L 01774
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Joanna Bridge
Notification Date: 04/14/2021
Notification Time: 17:44 [ET]
Event Date: 04/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/14/2021
Notification Time: 17:44 [ET]
Event Date: 04/14/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PICK, GREG (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:
"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.
"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M
"Texas Incident no.: 9841"
EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:
"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.
"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M
"Texas Incident no.: 9841"
Power Reactor
Event Number: 55200
Facility: Browns Ferry
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Wesley Conkle
HQ OPS Officer: Donald Norwood
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Wesley Conkle
HQ OPS Officer: Donald Norwood
Notification Date: 04/20/2021
Notification Time: 15:36 [ET]
Event Date: 04/19/2021
Event Time: 18:10 [CDT]
Last Update Date: 04/20/2021
Notification Time: 15:36 [ET]
Event Date: 04/19/2021
Event Time: 18:10 [CDT]
Last Update Date: 04/20/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
MILLER, MARK (R2)
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 | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY REPORT - EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL
A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.
A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 55201
Facility: Catawba
Region: 2 State: SC
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Terry Odoms
HQ OPS Officer: Brian Lin
Region: 2 State: SC
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Terry Odoms
HQ OPS Officer: Brian Lin
Notification Date: 04/21/2021
Notification Time: 02:37 [ET]
Event Date: 04/20/2021
Event Time: 22:30 [EDT]
Last Update Date: 04/21/2021
Notification Time: 02:37 [ET]
Event Date: 04/20/2021
Event Time: 22:30 [EDT]
Last Update Date: 04/21/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
MILLER, MARK (R2)
MILLER, MARK (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY DEGRADED
"During the performance of reactor vessel closure head (RVCH) examinations, at 2230 EDT on April 20, 2021, it was determined that the Unit 2 RVCH penetration nozzle number 74 did not meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 . All other RVCH penetration examinations have been completed per 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 with no other relevant indications identified. The condition of the Unit 2 reactor vessel head penetration nozzle number 74 will be resolved prior to re-installation of the Unit 2 RVCH. This event is being reported as an eight-hour, non-emergency notification per 10CFR50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"During the performance of reactor vessel closure head (RVCH) examinations, at 2230 EDT on April 20, 2021, it was determined that the Unit 2 RVCH penetration nozzle number 74 did not meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 . All other RVCH penetration examinations have been completed per 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 with no other relevant indications identified. The condition of the Unit 2 reactor vessel head penetration nozzle number 74 will be resolved prior to re-installation of the Unit 2 RVCH. This event is being reported as an eight-hour, non-emergency notification per 10CFR50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55202
Facility: Pilgrim
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: David Noyes
HQ OPS Officer: Brian Lin
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: David Noyes
HQ OPS Officer: Brian Lin
Notification Date: 04/21/2021
Notification Time: 09:45 [ET]
Event Date: 04/21/2021
Event Time: 07:52 [EDT]
Last Update Date: 04/21/2021
Notification Time: 09:45 [ET]
Event Date: 04/21/2021
Event Time: 07:52 [EDT]
Last Update Date: 04/21/2021
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):
ARNER, FRANK (R1)
ARNER, FRANK (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 TO THE COMMONWEALTH OF MASSACHUSETTS
On April 21, 2021, at 0752 hours (EDT), an offsite notification was made to the Commonwealth of Massachusetts Department of Environmental Protection (MADEP) in accordance with Regulation 310 CMR 40.0000: Massachusetts Contingency Plan (MCP). The notification documents non-radiological contaminants found above reportable concentrations in select samples collected during site characterization efforts. The reported reportable concentrations were slightly above reporting limits in a soil sample for Per and Polyfluoroalkyl Substances (PFAS), two groundwater sampling locations for PFAS, and isolated instances of metals in groundwater including Arsenic, Vanadium, Lead, Antimony, Beryllium, Cadmium, Chromium, Nickel, and Thallium. This report is being submitted in accordance with 10CFR50.72(b)(2)(xi) based on notification being made to another government agency. Concentrations above reporting limits have been entered into the site's corrective action program. As per MCP, the site will proceed with requirements to implement the phased MCP process. This condition does not represent a threat to station personnel or to members of the general public.
On April 21, 2021, at 0752 hours (EDT), an offsite notification was made to the Commonwealth of Massachusetts Department of Environmental Protection (MADEP) in accordance with Regulation 310 CMR 40.0000: Massachusetts Contingency Plan (MCP). The notification documents non-radiological contaminants found above reportable concentrations in select samples collected during site characterization efforts. The reported reportable concentrations were slightly above reporting limits in a soil sample for Per and Polyfluoroalkyl Substances (PFAS), two groundwater sampling locations for PFAS, and isolated instances of metals in groundwater including Arsenic, Vanadium, Lead, Antimony, Beryllium, Cadmium, Chromium, Nickel, and Thallium. This report is being submitted in accordance with 10CFR50.72(b)(2)(xi) based on notification being made to another government agency. Concentrations above reporting limits have been entered into the site's corrective action program. As per MCP, the site will proceed with requirements to implement the phased MCP process. This condition does not represent a threat to station personnel or to members of the general public.
Agreement State
Event Number: 55195
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: Maine Health Medical Center
Region: 1
City: Portland State: ME
County:
License #: ME 05611
Agreement: Y
Docket:
NRC Notified By: Catherine Perham
HQ OPS Officer: Brian P. Smith
Licensee: Maine Health Medical Center
Region: 1
City: Portland State: ME
County:
License #: ME 05611
Agreement: Y
Docket:
NRC Notified By: Catherine Perham
HQ OPS Officer: Brian P. Smith
Notification Date: 04/15/2021
Notification Time: 10:15 [ET]
Event Date: 04/02/2021
Event Time: 12:00 [EDT]
Last Update Date: 04/15/2021
Notification Time: 10:15 [ET]
Event Date: 04/02/2021
Event Time: 12:00 [EDT]
Last Update Date: 04/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE EVENT
The following report was received by the Maine Radiation Control Program via email:
"[The doctor] prescribed a patient 3.60 GBq Y-90 resin microspheres (Sirtex SIR-Spheres) for treatment of hepatocellular carcinoma (HCC). Due to the patient's anatomy, [the doctor] administered the dosage through two separate arteries using Surefire catheters. The two administrations were 0.90 GBq and 2.70 GBq.
"The first dosage was administered successfully, with an estimated 0.87 GBq (97 percent) of the planned 0.90 GBq being deposited within the patient's liver. The second dosage was not administered successfully, with an estimated 1.59 GBq (58.7 percent) of the planned 2.70 GBq being deposited within the patient's liver. This occurred because the catheter became occluded during the administration of Y-90 microspheres.
"Overall, the patient did not receive the full prescribed dose, with an estimated 2.46 GBq (68.3 percent) of the prescribed 3.60 GBq being deposited within the patient's liver. The event occurred on April 2, 2021 around 1200 EDT."
Maine Event Number: ME 21-001
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.
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE EVENT
The following report was received by the Maine Radiation Control Program via email:
"[The doctor] prescribed a patient 3.60 GBq Y-90 resin microspheres (Sirtex SIR-Spheres) for treatment of hepatocellular carcinoma (HCC). Due to the patient's anatomy, [the doctor] administered the dosage through two separate arteries using Surefire catheters. The two administrations were 0.90 GBq and 2.70 GBq.
"The first dosage was administered successfully, with an estimated 0.87 GBq (97 percent) of the planned 0.90 GBq being deposited within the patient's liver. The second dosage was not administered successfully, with an estimated 1.59 GBq (58.7 percent) of the planned 2.70 GBq being deposited within the patient's liver. This occurred because the catheter became occluded during the administration of Y-90 microspheres.
"Overall, the patient did not receive the full prescribed dose, with an estimated 2.46 GBq (68.3 percent) of the prescribed 3.60 GBq being deposited within the patient's liver. The event occurred on April 2, 2021 around 1200 EDT."
Maine Event Number: ME 21-001
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.
Non-Agreement State
Event Number: 55196
Rep Org: Department of Veteran Affairs
Licensee: Department of Veteran Affairs
Region: 3
City: Oklahoma City State: OK
County:
License #: Master Materials License
Agreement: Y
Docket:
NRC Notified By: Curtis Kwasniewski
HQ OPS Officer: Jeffrey Whited
Licensee: Department of Veteran Affairs
Region: 3
City: Oklahoma City State: OK
County:
License #: Master Materials License
Agreement: Y
Docket:
NRC Notified By: Curtis Kwasniewski
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/16/2021
Notification Time: 15:21 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/16/2021
Notification Time: 15:21 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/16/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
STOEDTER, KARLA (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
STOEDTER, KARLA (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: MEDICAL EVENT - UNDERDOSAGE
The following is a summary of a call from the Department of Veteran Affairs:
During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCurries of the prescribed 8.1 milliCurrie dose, for an underdosage of 23 percent.
The patient is aware of the underdosage. The cause of the underdosage is currently under investigation.
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.
EN Revision Text: MEDICAL EVENT - UNDERDOSAGE
The following is a summary of a call from the Department of Veteran Affairs:
During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCurries of the prescribed 8.1 milliCurrie dose, for an underdosage of 23 percent.
The patient is aware of the underdosage. The cause of the underdosage is currently under investigation.
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: 55197
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: University of Virginia
Region: 1
City: Charlottesville State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Lloyd Desotell
Licensee: University of Virginia
Region: 1
City: Charlottesville State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/16/2021
Notification Time: 17:36 [ET]
Event Date: 04/15/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/16/2021
Notification Time: 17:36 [ET]
Event Date: 04/15/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
HENRION, MARK (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
HENRION, MARK (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITUM EXIT SIGN
The following report was received from the Virginia Radioactive Materials Program via email:
"On April 16, 2021, at 1605 EDT, the Virginia Radioactive Materials Program received a report from the licensee that a 6.2 Curie [tritium] exit sign (Shield Source Inc., S/N: 11-36361) was lost. The licensee was performing an inventory of [tritium] exit signs on April 15, 2021. The licensee's report indicated that the exit sign was not found at the location where it was last inventoried in 2020 by the Radiation Safety Department. The licensee contacted their Facilities Management Department, asked them about construction being performed at the location, and if the whereabouts of the sign was known. On April 16, 2021 after another search and email correspondence with Facilities Management, the licensee determined that the [tritium] exit sign was lost and was likely discarded with construction trash.
"The licensee submitted a corrective action plan in their report stipulating that Facilities Management will provide a point of contact with whom the Radiation Safety Program will work with regarding [tritium] exit signs to: (1) ensure they are not removed without proper notification, and (2) to notify the Radiation Safety Program of the installation of any new [tritium] exit signs placed within the University of Virginia."
Virginia Report ID No.: VA210002
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 TRITUM EXIT SIGN
The following report was received from the Virginia Radioactive Materials Program via email:
"On April 16, 2021, at 1605 EDT, the Virginia Radioactive Materials Program received a report from the licensee that a 6.2 Curie [tritium] exit sign (Shield Source Inc., S/N: 11-36361) was lost. The licensee was performing an inventory of [tritium] exit signs on April 15, 2021. The licensee's report indicated that the exit sign was not found at the location where it was last inventoried in 2020 by the Radiation Safety Department. The licensee contacted their Facilities Management Department, asked them about construction being performed at the location, and if the whereabouts of the sign was known. On April 16, 2021 after another search and email correspondence with Facilities Management, the licensee determined that the [tritium] exit sign was lost and was likely discarded with construction trash.
"The licensee submitted a corrective action plan in their report stipulating that Facilities Management will provide a point of contact with whom the Radiation Safety Program will work with regarding [tritium] exit signs to: (1) ensure they are not removed without proper notification, and (2) to notify the Radiation Safety Program of the installation of any new [tritium] exit signs placed within the University of Virginia."
Virginia Report ID No.: VA210002
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: 55205
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Diego Gil-Azamar
HQ OPS Officer: Solomon Sahle
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Diego Gil-Azamar
HQ OPS Officer: Solomon Sahle
Notification Date: 04/22/2021
Notification Time: 15:41 [ET]
Event Date: 04/22/2021
Event Time: 09:25 [MST]
Last Update Date: 04/22/2021
Notification Time: 15:41 [ET]
Event Date: 04/22/2021
Event Time: 09:25 [MST]
Last Update Date: 04/22/2021
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):
AZUA, RAY (R4)
AZUA, RAY (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 100 | Power Operation | 100 | Power Operation |
| 2 | N | N | 100 | Power Operation | 100 | Power Operation |
| 3 | N | N | 0 | Power Operation | 0 | Power Operation |
INADVERTANT ACTIVATION OF EMERGENCY SIRENS
At 0925 Mountain Standard Time (MST) on April 22, 2021, Palo Verde Nuclear Generating Station staff received reports that Emergency Notification sirens were activated. Current information indicates that the inadvertent activation of the sirens was caused by an offsite agency during performance of a planned silent test that occurred at approximately 0916 MST. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
All sirens remain functional, and the NRC Resident Inspectors have been notified of the issue.
Additional notifications will be made as needed.
At 0925 Mountain Standard Time (MST) on April 22, 2021, Palo Verde Nuclear Generating Station staff received reports that Emergency Notification sirens were activated. Current information indicates that the inadvertent activation of the sirens was caused by an offsite agency during performance of a planned silent test that occurred at approximately 0916 MST. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
All sirens remain functional, and the NRC Resident Inspectors have been notified of the issue.
Additional notifications will be made as needed.
Power Reactor
Event Number: 55206
Facility: Farley
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Richard Langford
HQ OPS Officer: Brian P. Smith
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Richard Langford
HQ OPS Officer: Brian P. Smith
Notification Date: 04/22/2021
Notification Time: 17:17 [ET]
Event Date: 04/22/2021
Event Time: 14:50 [CDT]
Last Update Date: 04/22/2021
Notification Time: 17:17 [ET]
Event Date: 04/22/2021
Event Time: 14:50 [CDT]
Last Update Date: 04/22/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
MARK MILLER (R2DO)
MARK MILLER (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 48 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP
"At 1450 CDT on April 22, 2021, with Unit 1 in Mode 1 at 48 percent reactor power, the reactor automatically tripped due to a turbine trip. The trip was not complex with all systems responding normally post-trip.
"Operations responded and stabilized the plant. Auxiliary feedwater pumps were manually started using operations procedures. Main steam isolation valves were closed to prevent excessive cooldown. Decay heat is being removed by the steam generators through the main steam system via atmospheric relief valves. Unit 2 is not affected.
"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).
"There was no impact on the health and safety of the public or plant personnel."
The Resident Inspector has been notified.
"At 1450 CDT on April 22, 2021, with Unit 1 in Mode 1 at 48 percent reactor power, the reactor automatically tripped due to a turbine trip. The trip was not complex with all systems responding normally post-trip.
"Operations responded and stabilized the plant. Auxiliary feedwater pumps were manually started using operations procedures. Main steam isolation valves were closed to prevent excessive cooldown. Decay heat is being removed by the steam generators through the main steam system via atmospheric relief valves. Unit 2 is not affected.
"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).
"There was no impact on the health and safety of the public or plant personnel."
The Resident Inspector has been notified.