Event Notification Report for December 08, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/07/2021 - 12/08/2021

EVENT NUMBERS
55508 55617 55618 55626 55627
Agreement State
Event Number: 55508
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: CardioNavix
Region: 1
City:   State: GA
County:
License #: GA 1953-1
Agreement: Y
Docket:
NRC Notified By: Justine Johnson
HQ OPS Officer: Brian Lin
Notification Date: 10/05/2021
Notification Time: 08:55 [ET]
Event Date: 08/24/2021
Event Time: 00:00 [EDT]
Last Update Date: 12/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CARFANG, ERIN (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 12/8/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING SHIPMENT

The following information was received via email:

"The licensee contracted a common carrier to transport a Sr-82/Rb-82 generator to their RWM [radioactive waste management] site in Utah from the Warner Robins Facility (temporary job site). The package was picked up from the licensee's office on August 23, 2021 to be delivered in Utah on August 24, 2021. The package never arrived. The licensee contacted the common carrier, but was told they had to file a claim online. The package has not been found. The package was 84.63 mCi (3.13 GBq) with a Transport Index of 0.4. Results of a surface wipe test done before shipping were 203 dpm and surface reading was 6 mr/hr. "

GA Incident No.: 48

* * * UPDATE ON 12/7/2021 AT 1552 EST FROM JUSTINE JOHNSON TO TOM KENDZIA * * *

The following is a summary of information received from the Georgia Radioactive Materials Program (Department) via email:

On October 6, 2021 the Licensee reported the lost generator to the common carrier's Danger Goods Administration. The common carrier assigned an investigator to the case. After a month of searching, the investigator was unable to locate the package, and suspended the search efforts as of November 8, 2021. On November 15, 2021, the common carrier discovered that the generator was delivered to the appropriate recipient on August 24, 2021 under a different tracking number. The Licensee then notified the Department of this updated information.

Notified R1DO (Dentel), ILTAB (via email) and NMSS Events Notification group (via email).

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: 55617
Rep Org: Virginia Rad Materials Program
Licensee: Sentara Norfolk General Hospital
Region: 1
City: Norfolk   State: VA
County:
License #: 710-189-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Gerond George
Notification Date: 12/01/2021
Notification Time: 14:49 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [EST]
Last Update Date: 12/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 12/8/2021

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

The following was received from the Commonwealth of Virginia (the Agency) via email:

"On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."

Virginia Event Report ID No.: VA210008

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: 55618
Rep Org: Arizona Dept of Health Services
Licensee: Intel Corporation
Region: 4
City: Chandler   State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Mike Stafford
Notification Date: 12/01/2021
Notification Time: 17:10 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [MST]
Last Update Date: 12/01/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 12/8/2021

EN Revision Text: AGREEMENT STATE - LEAK TEST EXCEEDS LIMITS

The following was received from the Arizona Department of Health Services (the Department) via email:

"On November 30, 2021, the Department received notification from the licensee of a leak test (0.0129 microCi) that exceeded the regulatory limit of 0.005 microCi. The licensee is going to return it to the manufacturer for repair. The Department has requested additional information and continues to investigate the event.

"Particle Measurement System, Inc.
Air Sentry II Ion Mobility Spectrometer unit
SN# 59369
Cell SN5935
10 mCi of Ni-63"

Arizona Incident Number 21-011


Power Reactor
Event Number: 55626
Facility: Palo Verde
Region: 4     State: AZ
Unit: [3] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Joshua McDowell
HQ OPS Officer: Mike Stafford
Notification Date: 12/06/2021
Notification Time: 17:17 [ET]
Event Date: 12/06/2021
Event Time: 12:03 [MST]
Last Update Date: 12/06/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Young, Cale (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby
Event Text
EN Revision Imported Date: 12/8/2021

EN Revision Text: UNIT 3 AUTOMATIC TRIP

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"At 1203 MST on December 6, 2021, the Unit 3 reactor automatically tripped on low departure from nucleate boiling ratio. A part-strength control element assembly was being moved at the time of the trip.

"Unit 3 is stable and in Mode 3. In response to the reactor trip, all control element assemblies inserted fully into the core. Safety-related electrical power remains energized from off-site power sources and reactor coolant pumps continue to provide forced circulation through the reactor. Decay heat is being removed by the steam bypass control system and main feedwater system. Required systems operated as expected.

"No emergency classification was required per the Emergency Plan.

"The NRC Senior Resident Inspector has been informed."

Units 1 and 2 were unaffected by this transient.


Power Reactor
Event Number: 55627
Facility: Brunswick
Region: 2     State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Joel Gordon
HQ OPS Officer: Thomas Kendzia
Notification Date: 12/06/2021
Notification Time: 18:14 [ET]
Event Date: 12/06/2021
Event Time: 11:25 [EST]
Last Update Date: 12/06/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys 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
2 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 12/8/2021

EN Revision Text: VALID SAFETY SYSTEM ACTUATION
"On December 6, 2021, at 1125 hours Eastern Standard Time (EST), during planned maintenance activities, electrical power was lost to the 4160V emergency bus E-3. The power loss to emergency bus E-3 affected both Unit 1 and 2. Emergency Diesel Generator #3 received an automatic start signal but was under clearance for planned maintenance. Emergency bus E-3 was re-energized at 1315 EST hours via offsite power.

"The loss of power to E3 resulted in Unit 2 Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 3 (i.e., Reactor Water Cleanup), Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems), and Group 10 (i.e., air isolation to the drywell) isolations. The actuations of PCIVs were completed and the affected equipment responded as designed. Per design, no Unit 1 safety system group isolations or actuations occurred. Other Unit 2 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 2 and an automatic start signal to Emergency Diesel Generator #3.
There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Except for the Emergency Diesel Generator, which is out of service for planned maintenance, all equipment has been returned to its normal alignment.

* * * UPDATE FROM JJ STRNAD TO THOMAS KENDZIA AT 2028 EST ON DECEMBER 6, 2021 * * *

"The loss of power to E3 resulted in Unit 1 Primary Containment Isolation System (PCIS) Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems). Other Unit 1 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 1."

All Unit 1 equipment was returned to its normal alignment. The NRC Resident will be notified.

Notified R2DO (Miller).

Page Last Reviewed/Updated Wednesday, December 08, 2021