Event Notification Report for June 23, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
06/22/2021 - 06/23/2021

EVENT NUMBERS
55307 55308 55309 55310 55320 55321
Agreement State
Event Number: 55307
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Cardinal Health 414, LLC
Region: 4
City: Denver   State: CO
County:
License #: CO 1219-01
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/15/2021
Notification Time: 15:51 [ET]
Event Date: 05/23/2021
Event Time: 10:28 [MDT]
Last Update Date: 06/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: AGREEMENT STATE REPORT - PACKAGE LOST IN TRANSIT

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

"A package of radium-223 (Xofigo) was lost in transit. The package was shipped on 5/22/21 containing 112.4 microCi radium-223. The final destination of the package was Saint Paul, MN; however, the last scan of the package by [the common carrier] was on 5/23/21 in Memphis, TN. Cardinal Health notified the Colorado radioactive materials unit on 6/11/21 that a package was missing and provided additional information (including isotope, activity, assay date, and tracking number) on 6/15/21. The activity of the package as of 6/11/21 (initial report date to Colorado) was approximately 33.5 microCi."

Event Report ID No.: CO210016

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: 55308
Rep Org: G2 Consulting
Licensee: G2 Consulting
Region: 3
City: Troy   State: MI
County:
License #: 21-26593-01
Agreement: N
Docket:
NRC Notified By: Bruce Wibeding
HQ OPS Officer: Thomas Herrity
Notification Date: 06/15/2021
Notification Time: 15:57 [ET]
Event Date: 06/15/2021
Event Time: 15:30 [EDT]
Last Update Date: 06/15/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
Person (Organization):
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: NON-AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE

The following was received from the licensee via email:

"On Monday afternoon June 14, 2021, [the licensee] went to perform a leak test on Troxler gauge 70894 (Model No. 3430; Cs-137 8 milliCurie; Am-241/Be 40 milliCurie), which was due for a leak test the same date 6/14/21. [The licensee] looked in [their] system to see which employee had the gauge. It was not checked out by anyone that day so [the licensee] went through the storage room in Ann Arbor and then Troy to find the gauge and perform the test. The gauge was not present in either location. [The licensee] began making phone calls to employees to see if an employee had the gauge and it was just not checked out properly in [their] system.

"[The licensee] reviewed [their] system and determined the gauge was last used by a former employee on January 5, 2021. [The licensee] was able to reach that person and he indicated he returned the gauge to the locked storage room in [the] Ann Arbor office on January 6, 2021. The gauge was not shown as having been used by any employee since that date within [the] system. [The licensee does] not know when the gauge went missing or how the gauge was removed from the office. [The licensee] also cannot confirm if the former employee actually returned the gauge on January 6, 2021. Calibration and leak tests were performed in December 2020 by ATSNUC, Inc. [The licensee] contacted all of the service facilities that [they] use to see if it might be in for service but [the licensee has] been unable to locate the gauge. [The licensee is] also checking with all service centers listed on the APNGA website to see if by chance some other party has sent in/returned this gauge to one of those facilities. It was determined today, 6/15/21, at approximately 1534 EDT (less than 24 hours after the initial discovery) that [the licensee] could not locate the gauge."

The licensee notified the NRC Region III Office.

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: 55309
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Hurst Boiler Company
Region: 1
City: Coolridge   State: GA
County:
License #: GA 918-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Thomas Kendzia
Notification Date: 06/16/2021
Notification Time: 10:14 [ET]
Event Date: 06/07/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
LILLIENDAHL, JON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST DURING SHIPPING

The following was received from the Georgia Radioactive Materials Program (Agency) via email:

"Hurst Boiler Welding Company used [a common carrier] to ship a source changer back to QSA Global. It was shipped on May 19, 2021, and officially declared lost on 6/14/21. Hurst Boiler reported the loss to [the Agency] on 6/16/21. The licensee intended to ship a source changer back to QSA global via [a common carrier] on 5/19/2021. After approximately 14 days without a confirmation of receipt. The licensee contacted [the common carrier] on 6/14/21, who confirmed the source had been lost. The Radiation Safety Officer (RSO) then contacted [the Agency] on 6/16/21. When speaking with the RSO by phone, he stated the source changer contains an Ir-192 source (Serial # 9887G Model SC-800). The source activity when shipped (5/19/21) was 8.3 Ci and as of 6/16/21 it has decayed to 6.3 Ci. The most current leak test was performed on 8/31/21. The RSO was advised to provide a written report and submit all supporting documents as soon as possible."

Georgia Incident #41

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State
Event Number: 55310
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: University of Chicago Hospital
Region: 3
City: Chicago   State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/16/2021
Notification Time: 13:10 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours.

"IEMA inspectors will perform a reactive inspection on June 17, 2021. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated once additional details become available on 6/17/21."

Item Number: IL210019

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: 55320
Facility: Braidwood
Region: 3     State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Marzano
HQ OPS Officer: Thomas Herrity
Notification Date: 06/21/2021
Notification Time: 03:06 [ET]
Event Date: 06/21/2021
Event Time: 00:51 [CDT]
Last Update Date: 06/21/2021
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):
HILLS, DAVID (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R N 100 Power Operation 0 Hot Standby
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: REACTOR TRIP ON GENERATOR LOCKOUT RELAY TRIP

"At 0051 CDT Braidwood Unit 1 experienced an automatic reactor trip due to a generator lockout relay trip and subsequent turbine trip and reactor trip.

"The cause of the generator lockout relay trip is unknown at this time and is under investigation. Numerous lightning strikes were present in the area during the time of the generator lockout relay trip.

"Both trains of auxiliary feedwater started automatically following the reactor trip to maintain steam generator water levels.

"All systems responded as expected with the exception of failure of source range nuclear instruments to automatically re-energize following the reactor trip. Both source range nuclear instruments were manually energized in accordance with station procedures. The main steam dump valves are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by Offsite Power with the 1B Diesel Generator in standby. 1A Diesel Generator is out of service for planned maintenance. All other safety systems are available. There is no impact to Unit 2.

"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4 hr. notification, and per 10 CFR 50.72(b)(3)(iv)(A) for an automatic actuation of the Auxiliary Feedwater system, 8 hr. notification.

"The NRC Resident Inspector and Illinois Emergency Management Agency have been informed."


Power Reactor
Event Number: 55321
Facility: Davis Besse
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Andrew Miller
HQ OPS Officer: Joanna Bridge
Notification Date: 06/22/2021
Notification Time: 16:55 [ET]
Event Date: 06/22/2021
Event Time: 12:08 [EDT]
Last Update Date: 06/22/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
STONE, ANN MARIE (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 6/23/2021

EN Revision Text: HIGH-ENERGY LINE BREAK DOOR UNABLE TO BE LATCHED

"At 1208 [EDT] on 6/22/2021, the high-energy line break door separating Auxiliary Feedwater Train Rooms 1 and 2 was not able to be latched following normal usage. The door was able to be closed, protecting Train 1 equipment from a break in Room 2. However, it is assumed a break in Room 1 would push the unlatched door open and allow high-energy fluids to enter Room 2. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The door was able to be latched at 1215 [EDT] on 6/22/2021 following repairs to the door latch interlocking mechanism. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). No other equipment was inoperable during this event.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, June 23, 2021