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Event Notification Report for October 20, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/19/2021 - 10/20/2021

Power Reactor
Event Number: 55534
Facility: Palo Verde
Region: 4     State: AZ
Unit: [1] [3] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Stephanie Brabson
HQ OPS Officer: Donald Norwood
Notification Date: 10/21/2021
Notification Time: 00:02 [ET]
Event Date: 10/20/2021
Event Time: 14:46 [MST]
Last Update Date: 12/03/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
GEPFORD, HEATHER (R4)
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
3 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 1/3/2022

EN Revision Text: VALID SPECIFIED SYSTEM ACTUATIONS OF UNIT 1 AND UNIT 3 EMERGENCY DIESEL GENERATORS

"At 1446 MST on October 20, 2021, a start-up transformer de-energized, resulting in a loss of power to the Unit 1 Train B 4.16 kV Class 1E Bus and the Unit 3 Train A 4.16 kV Class 1E Bus. The Unit 1 Train B Emergency Diesel Generator (EDG) and Unit 3 Train A EDG automatically started and energized their respective 4.16 kV Class 1E Buses.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems.

"All systems operated as expected. Per the Emergency Plan, no classification was required due to the event. Units 1 and 3 both remain in Mode 1 at 100 percent power. Unit 2 is currently in a refueling outage and defueled. The 4.16 kV Class 1E Buses in Unit 2 were not affected by the de-energization of the start-up transformer since it was not aligned as normal power for Unit 2.

"The cause of the start-up transformer being de-energized is under investigation.

"The NRC Resident Inspectors have been informed."

* * * UPDATE ON 12/3/21 AT 1652 EST FROM MATT BRADFIELD TO KERBY SCALES * * *

"As a result of the Loss of Power on the Unit 1 Train B 4.16 kV Class 1E Bus, the B Auxiliary Feedwater Pump automatically started, as expected. The B Auxiliary Feedwater Pump was not needed for steam generator water level control and no auxiliary feedwater valves repositioned. The B Auxiliary Feedwater Pump did not supply feedwater to the steam generators."

The NRC Resident Inspector will be notified.

Notified R4DO (Taylor).


Agreement State
Event Number: 55537
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: University of Chicago Medical Center
Region: 3
City: Chicago   State: IL
County:
License #: Il-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Notification Date: 10/21/2021
Notification Time: 17:02 [ET]
Event Date: 10/20/2021
Event Time: 14:20 [CDT]
Last Update Date: 10/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
SZWARC, DARIUSZ (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 11/19/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE

The following report was received from the Illinois Emergency Management Agency [the Agency] via email:

"The Agency was contacted on the afternoon of 10/21/21 by the University of Chicago to advise of a reportable medical event that occurred the day before. A human research subject was reportedly administered 79.8 mCi of a prescribed 100 mCi dose of I-131 under the therapeutic portion of a study protocol. There is no root cause available at this time, although the licensee suspects an inadequate volume of saline flush. Inspectors will evaluate any other contributing factors including equipment, personnel involved and unique procedures for this study protocol. At this time, the licensee is not expecting any adverse impact to the patient and they are following up with the study sponsor to determine if additional treatment is required. The referring physician has been notified and the licensee is aware of the requirement to notify the patient. This matter is reportable under 32 Ill. Adm. Code 335.1080(a) for a dose differing from the prescribed dose by 20 percent or more. The administration was started at 1420 CDT on 10/20/21 and the matter reported to the Agency at 1219 CDT on 10/21/21. The reporting criteria has been met. In accordance with Agency policy, inspectors will perform a reactionary inspection within 10 days of the incident."

Illinois Report Number: IL210032

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: 55578
Rep Org: Colorado Dept of Health
Licensee: Pindustry
Region: 4
City: Greenwood Village   State: CO
County:
License #: GL002686
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 11/15/2021
Notification Time: 14:50 [ET]
Event Date: 10/20/2021
Event Time: 15:37 [MST]
Last Update Date: 11/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 12/15/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via E-mail:

"One exit sign, model SLX60 was reported as lost when the State requested registration for 17 exit signs shipped to Pindustry for installation."

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: 55592
Rep Org: Alabama Radiation Control
Licensee: Vital Inspection Professionals
Region: 1
City: Alabaster   State: AL
County:
License #: RML 1118
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Mike Stafford
Notification Date: 11/18/2021
Notification Time: 10:39 [ET]
Event Date: 10/20/2021
Event Time: 00:00 [CST]
Last Update Date: 11/18/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 12/17/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LOCKING MECHANISM MALFUNCTION

The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:

"On 10/28/2021, Alabama licensee Vital Inspection Professionals, Inc. (RML 1118, Alabaster, AL) reported during the Agency's inspection that camera INC- 100 s/n 4481 appeared to have a malfunctioning locking mechanism. The licensee stated the malfunction was discovered on 10/20/2021 at a temporary job site. The licensee stated that the source appeared to be in the shielded position, and that personnel did not receive over exposures as a result of the faulty mechanism (consistent with inspection results). The licensee stated that the camera was taken out of service after the faulty mechanism was discovered. The licensee had a plan of action to send the camera for repair at the time of the inspection. The camera was loaded with an Ir-192 source, 100 curies on 9/27/2021."

Alabama Event 21-34


Power Reactor
Event Number: 55660
Facility: Browns Ferry
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Mark Acker
HQ OPS Officer: Brian Lin
Notification Date: 12/16/2021
Notification Time: 14:57 [ET]
Event Date: 10/20/2021
Event Time: 07:05 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2)
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: 1/14/2022

EN Revision Text: INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

* The following information was provided by the licensee via email:

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of the Reactor Protection System (RPS). On October 20, 2021, at approximately 0705 hours Central Daylight Time (CDT), Browns Ferry, Unit 1, 1B RPS bus unexpectedly lost power. The loss of the bus resulted in a half scram, automatic Primary Containment Isolation System (PCIS) Groups 2, 3, 6, and 8 isolations, and Trains A, B, and C SBGT [Stand-By Gas Treatment] and A CREV [Control Room Emergency Ventilation system] started. All systems responded as expected. At 0720 hours CDT, the bus was placed on the alternate power supply and the half scram and PCIS isolations were reset.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The cause of the RPS bus loss was a trip of the underfrequency relay due to drift of the relay setpoint. The relay was replaced and 1B RPS bus was returned to the normal power supply on October 21, 2021, at 0510 hours CDT.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Report 1729592.

"The NRC Resident Inspector has been notified of this event."