Event Notification Report for November 09, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/08/2021 - 11/09/2021
Agreement State
Event Number: 55571
Rep Org: Texas Dept of State Health Services
Licensee: Chi St. Luke's Baylor College of Medicine Med Ctr
Region: 4
City: Houston State: TX
County:
License #: 06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Jeffrey Whited
Licensee: Chi St. Luke's Baylor College of Medicine Med Ctr
Region: 4
City: Houston State: TX
County:
License #: 06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Jeffrey Whited
Notification Date: 11/11/2021
Notification Time: 11:55 [ET]
Event Date: 11/09/2021
Event Time: 00:00 [CST]
Last Update Date: 11/11/2021
Notification Time: 11:55 [ET]
Event Date: 11/09/2021
Event Time: 00:00 [CST]
Last Update Date: 11/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4)
NMSS_Events_Notification, (EMAIL)
Gaddy, Vincent (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/10/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSAGE
The following was received from the Texas Department of State Health Services (the Agency):
"On November 10, 2021, the Agency received notification from [the Radiation Safety Officer] RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found."
Texas Incident: I-9895
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 - MEDICAL UNDERDOSAGE
The following was received from the Texas Department of State Health Services (the Agency):
"On November 10, 2021, the Agency received notification from [the Radiation Safety Officer] RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found."
Texas Incident: I-9895
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: 55567
Facility: Pilgrim
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Brendan Kane
HQ OPS Officer: Howie Crouch
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Brendan Kane
HQ OPS Officer: Howie Crouch
Notification Date: 11/09/2021
Notification Time: 13:33 [ET]
Event Date: 11/09/2021
Event Time: 10:40 [EST]
Last Update Date: 11/09/2021
Notification Time: 13:33 [ET]
Event Date: 11/09/2021
Event Time: 10:40 [EST]
Last Update Date: 11/09/2021
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):
Henrion, Mark (R1)
Henrion, Mark (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
EN Revision Imported Date: 12/9/2021
EN Revision Text: OFFSITE NOTIFICATION DUE TO VIOLATION OF DISCHARGE PERMIT
"At 1040 hours EST, November 9, 2021, the site reported a violation of the station National Pollutant Discharge Elimination System permit. The 24-hour environmental report addressed an unauthorized discharge of 7,245 gallons of non-radiological water that was pumped into a storm drain to de-water an on-site electrical vault located outside of the protected area. This discharge occurred from 0800 to 1230 hours on November 8, 2021. Sampling and analysis of the vault water is in progress to assess for the presence of pollutants.
"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The licensee notified the U.S. Environmental Protection Agency and the Commonwealth of Massachusetts Department of Environmental Protection.
EN Revision Text: OFFSITE NOTIFICATION DUE TO VIOLATION OF DISCHARGE PERMIT
"At 1040 hours EST, November 9, 2021, the site reported a violation of the station National Pollutant Discharge Elimination System permit. The 24-hour environmental report addressed an unauthorized discharge of 7,245 gallons of non-radiological water that was pumped into a storm drain to de-water an on-site electrical vault located outside of the protected area. This discharge occurred from 0800 to 1230 hours on November 8, 2021. Sampling and analysis of the vault water is in progress to assess for the presence of pollutants.
"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The licensee notified the U.S. Environmental Protection Agency and the Commonwealth of Massachusetts Department of Environmental Protection.
Part 21
Event Number: 55605
Rep Org: Engine Systems, Inc
Licensee: Engine Systems, Inc
Region: 1
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Brian P. Smith
Licensee: Engine Systems, Inc
Region: 1
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Brian P. Smith
Notification Date: 11/24/2021
Notification Time: 12:21 [ET]
Event Date: 11/09/2021
Event Time: 12:00 [EST]
Last Update Date: 11/24/2021
Notification Time: 12:21 [ET]
Event Date: 11/09/2021
Event Time: 12:00 [EST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Defrancisco, Anne (R1DO)
Miller, Mark (R2DO)
Peterson, Hironori (R3DO)
Kennedy, Silas (IR)
Regan, Christopher (NRR EO)
Defrancisco, Anne (R1DO)
Miller, Mark (R2DO)
Peterson, Hironori (R3DO)
Kennedy, Silas (IR)
Regan, Christopher (NRR EO)
EN Revision Imported Date: 12/23/2021
EN Revision Text: PART 21 REPORT - HINGE PIN RETAINER PLUG DEFECTIVE ON DIESEL CHECK VALVE
The following is a synopsis of information received via facsimile:
The hinge pin retainer plug used on an emergency diesel generator (EDG) stainless steel check valve exhibited low breakaway torque and thus minimal resistance to loosening when subjected to engine operating vibrations. The EDG check valve is used specifically for lube oil (LO) applications in the gallery fill line between the LO cooler and main engine pressure pump discharge elbow. Consequently, if the plug were to completely dislodge, followed by the associated hinge pin, the pressure boundary of the LO system would be compromised and oil would discharge through the 3/16 inch opening.
The dedication procedure for this check valve is currently undergoing revision to incorporate a rework activity that will eliminate unintended plug loosening from future shipments. The vendor expects this to be completed by December 7, 2021.
The potentially affected components were shipped to the following plants: Beaver Valley, Browns Ferry, Dresden, and Surry.
Technical questions concerning this notification can be directed to Dan Roberts, Quality Manager and John Kriesel, Engineering Manager at (252) 977-2720.
EN Revision Text: PART 21 REPORT - HINGE PIN RETAINER PLUG DEFECTIVE ON DIESEL CHECK VALVE
The following is a synopsis of information received via facsimile:
The hinge pin retainer plug used on an emergency diesel generator (EDG) stainless steel check valve exhibited low breakaway torque and thus minimal resistance to loosening when subjected to engine operating vibrations. The EDG check valve is used specifically for lube oil (LO) applications in the gallery fill line between the LO cooler and main engine pressure pump discharge elbow. Consequently, if the plug were to completely dislodge, followed by the associated hinge pin, the pressure boundary of the LO system would be compromised and oil would discharge through the 3/16 inch opening.
The dedication procedure for this check valve is currently undergoing revision to incorporate a rework activity that will eliminate unintended plug loosening from future shipments. The vendor expects this to be completed by December 7, 2021.
The potentially affected components were shipped to the following plants: Beaver Valley, Browns Ferry, Dresden, and Surry.
Technical questions concerning this notification can be directed to Dan Roberts, Quality Manager and John Kriesel, Engineering Manager at (252) 977-2720.