Event Notification Report for December 01, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/30/2021 - 12/01/2021
Hospital
Event Number: 55639
Rep Org: Greenwich Hospital
Licensee: Greenwich Hospital
Region: 1
City: Greenwich State: CT
County:
License #: 06-09522-01
Agreement: N
Docket:
NRC Notified By: Adel Mustafa
HQ OPS Officer: Bethany Cecere
Licensee: Greenwich Hospital
Region: 1
City: Greenwich State: CT
County:
License #: 06-09522-01
Agreement: N
Docket:
NRC Notified By: Adel Mustafa
HQ OPS Officer: Bethany Cecere
Notification Date: 12/09/2021
Notification Time: 15:21 [ET]
Event Date: 12/01/2021
Event Time: 14:04 [EST]
Last Update Date: 12/10/2021
Notification Time: 15:21 [ET]
Event Date: 12/01/2021
Event Time: 14:04 [EST]
Last Update Date: 12/10/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 1/10/2022
EN Revision Text: DEVIATION OF DELIVERY PROCEDURE BY COMMON CARRIER STAFF LEAVING RADIOACTIVE MATERIAL UNATTENDED
"A Medical Oncology employee discovered a radioactive source package when exiting the Medical Oncology suite around 1420 EST on Wednesday, 12/1/2021. She noticed the label 'Radiation' and proceeded to pick it up and bring it into the Radiation Oncology suite down the hallway on the same floor (2nd floor) of the building. Radiation Oncology Staff notified Chief Therapist and Physicist who promptly brought the source into the designated area, performed a survey and inspection to ensure no break in seals or radiation leakage and to document the receipt of the package. [The source was a 10 Ci Ir-192 source. On contact readings with the package were 4.2 mR/hr and one meter survey reading was 0.6 mR/hr.] Later that evening, the regional Smilow radiation oncology physicist notified the hospital radiation safety officer who started an investigation on Thursday, 12/2/2021, morning.
"[The common carrier's] tracking indicated that the package was delivered at 1404 EST on 12/1/2021, i.e., a few minutes prior to its discovery outside the Medical Oncology suite. The Medical Oncology secretary indicated that she had noticed a [common carrier] person in the hallway a few minutes prior to her finding the package outside the suite. The package was not delivered to the radiation therapy department at Greenwich Hospital as indicated by the shipper's declaration for dangerous goods and no signature/confirmation was obtained from the radiation therapy department for the delivery. Radiation exposure and potential risk to staff from this well shielded source over the incident encounter time would be negligible.
"The carrier has been notified of the incident, the fact that proper protocol was not followed in delivering the package and the fact that this is unacceptable.
"There was no measurable exposure to staff or patients. The incident is categorized as deviation from an already established and practiced radioactive material delivery procedure by [common carrier] staff. Radiation Oncology team had an in-service [training] to all concerned explaining this incident and as a reminder of procedures on delivery of radioactive material packages.
"We escalated this matter to the system [Yale New Haven Health System] (YNHHS) strategic resources who contacted the regional [common carrier] to obtain an explanation and corrective action from them."
EN Revision Text: DEVIATION OF DELIVERY PROCEDURE BY COMMON CARRIER STAFF LEAVING RADIOACTIVE MATERIAL UNATTENDED
"A Medical Oncology employee discovered a radioactive source package when exiting the Medical Oncology suite around 1420 EST on Wednesday, 12/1/2021. She noticed the label 'Radiation' and proceeded to pick it up and bring it into the Radiation Oncology suite down the hallway on the same floor (2nd floor) of the building. Radiation Oncology Staff notified Chief Therapist and Physicist who promptly brought the source into the designated area, performed a survey and inspection to ensure no break in seals or radiation leakage and to document the receipt of the package. [The source was a 10 Ci Ir-192 source. On contact readings with the package were 4.2 mR/hr and one meter survey reading was 0.6 mR/hr.] Later that evening, the regional Smilow radiation oncology physicist notified the hospital radiation safety officer who started an investigation on Thursday, 12/2/2021, morning.
"[The common carrier's] tracking indicated that the package was delivered at 1404 EST on 12/1/2021, i.e., a few minutes prior to its discovery outside the Medical Oncology suite. The Medical Oncology secretary indicated that she had noticed a [common carrier] person in the hallway a few minutes prior to her finding the package outside the suite. The package was not delivered to the radiation therapy department at Greenwich Hospital as indicated by the shipper's declaration for dangerous goods and no signature/confirmation was obtained from the radiation therapy department for the delivery. Radiation exposure and potential risk to staff from this well shielded source over the incident encounter time would be negligible.
"The carrier has been notified of the incident, the fact that proper protocol was not followed in delivering the package and the fact that this is unacceptable.
"There was no measurable exposure to staff or patients. The incident is categorized as deviation from an already established and practiced radioactive material delivery procedure by [common carrier] staff. Radiation Oncology team had an in-service [training] to all concerned explaining this incident and as a reminder of procedures on delivery of radioactive material packages.
"We escalated this matter to the system [Yale New Haven Health System] (YNHHS) strategic resources who contacted the regional [common carrier] to obtain an explanation and corrective action from them."
Power Reactor
Event Number: 55619
Facility: Quad Cities
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: Ron Snook
HQ OPS Officer: Brian Lin
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: Ron Snook
HQ OPS Officer: Brian Lin
Notification Date: 12/02/2021
Notification Time: 00:58 [ET]
Event Date: 12/01/2021
Event Time: 18:47 [CST]
Last Update Date: 12/02/2021
Notification Time: 00:58 [ET]
Event Date: 12/01/2021
Event Time: 18:47 [CST]
Last Update Date: 12/02/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Stoedter, Karla (R3)
Stoedter, Karla (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 12/30/2021
EN Revision Text: UNIT 1 HPCI INOPERABLE
"At 1847 CST on December 1, 2021, it was discovered that the HPCI [high pressure coolant injection] system was inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Unit 1 RCIC [reactor core isolation cooling] system was Operable during this time period. There was no impact on the health and safety of the public or plant personnel. The NRC Resident has been notified."
Unit 1 HPCI operability was restored at 2110 CST.
EN Revision Text: UNIT 1 HPCI INOPERABLE
"At 1847 CST on December 1, 2021, it was discovered that the HPCI [high pressure coolant injection] system was inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Unit 1 RCIC [reactor core isolation cooling] system was Operable during this time period. There was no impact on the health and safety of the public or plant personnel. The NRC Resident has been notified."
Unit 1 HPCI operability was restored at 2110 CST.
Part 21
Event Number: 55620
Rep Org: Callaway
Licensee: Ameren Ue
Region: 4
City: Fulton State: MO
County: Callaway
License #:
Agreement: N
Docket: 05000483
NRC Notified By: Todd Witt
HQ OPS Officer: Mike Stafford
Licensee: Ameren Ue
Region: 4
City: Fulton State: MO
County: Callaway
License #:
Agreement: N
Docket: 05000483
NRC Notified By: Todd Witt
HQ OPS Officer: Mike Stafford
Notification Date: 12/02/2021
Notification Time: 13:36 [ET]
Event Date: 12/01/2021
Event Time: 00:00 [CST]
Last Update Date: 12/02/2021
Notification Time: 13:36 [ET]
Event Date: 12/01/2021
Event Time: 00:00 [CST]
Last Update Date: 12/02/2021
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):
Taylor, Nick (R4)
Part 21/50.55 Reactors, - (EMAIL)
Taylor, Nick (R4)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 12/30/2021
EN Revision Text: PART 21 - 15V AND 48 V POWER SUPPLY DEFECT
"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided in 30 days.
"On November 10, 2021, Callaway Plant received written notification from Paragon Energy Solutions, LLC, pursuant to 10 CFR 21.21(b), which identified a deviation associated with the DC/DC converter in two power supplies, NLI-STM15-15M20 (15 VDC) and NLI-STM48-14M20 (48 VDC) that had been sent to Paragon for evaluation and failure analysis following failures of individual components within the power supplies at Callaway Plant. The notification identified the following failed components:
"For the NLI-STM15-15M20 [15 VDC] power supply, the failed components were the Vicor Module, P/N: V150A28C500BL, and the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511
"For the NLI-STM48-14M20 [48 VDC] power supply, the failed component was the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511
"Fourteen of these power supplies (in total) are used in three Balance of Plant Engineered Safety Feature Actuation System (BOP-ESFAS) cabinets and two Load Shed and Emergency Load Sequencer (LSELS) cabinets.
"Based upon the 10 CFR 21.21(b) transfer from Paragon Energy Solutions, Callaway Plant has determined that a Substantial Safety Hazard could be created by the failure of the power supplies. The responsible officer was notified on December 1, 2021.
"The NRC Resident Inspector at Callaway Plant has been notified."
EN Revision Text: PART 21 - 15V AND 48 V POWER SUPPLY DEFECT
"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided in 30 days.
"On November 10, 2021, Callaway Plant received written notification from Paragon Energy Solutions, LLC, pursuant to 10 CFR 21.21(b), which identified a deviation associated with the DC/DC converter in two power supplies, NLI-STM15-15M20 (15 VDC) and NLI-STM48-14M20 (48 VDC) that had been sent to Paragon for evaluation and failure analysis following failures of individual components within the power supplies at Callaway Plant. The notification identified the following failed components:
"For the NLI-STM15-15M20 [15 VDC] power supply, the failed components were the Vicor Module, P/N: V150A28C500BL, and the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511
"For the NLI-STM48-14M20 [48 VDC] power supply, the failed component was the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511
"Fourteen of these power supplies (in total) are used in three Balance of Plant Engineered Safety Feature Actuation System (BOP-ESFAS) cabinets and two Load Shed and Emergency Load Sequencer (LSELS) cabinets.
"Based upon the 10 CFR 21.21(b) transfer from Paragon Energy Solutions, Callaway Plant has determined that a Substantial Safety Hazard could be created by the failure of the power supplies. The responsible officer was notified on December 1, 2021.
"The NRC Resident Inspector at Callaway Plant has been notified."