Event Notification Report for January 27, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/26/2022 - 01/27/2022
Agreement State
Event Number: 55727
Rep Org: SC Dept of Health & Env Control
Licensee: McLeod Loris Seacoast Hospital
Region: 1
City: Little River State: SC
County:
License #: 732
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Brian Lin
Licensee: McLeod Loris Seacoast Hospital
Region: 1
City: Little River State: SC
County:
License #: 732
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Brian Lin
Notification Date: 02/03/2022
Notification Time: 14:33 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [EST]
Last Update Date: 02/03/2022
Notification Time: 14:33 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [EST]
Last Update Date: 02/03/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1)
NMSS_Events_Notification, (EMAIL)
Lilliendahl, Jon (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/3/2022
EN Revision Text: AGREEMENT STATE REPORT - LEAKING VIAL SOURCE
The following information was received from the state of South Carolina via email:
"The South Carolina Department of Health and Environmental Control was notified via email at 1327 EST on 02/01/22 that during a quarterly nuclear medicine audit conducted on 01/27/22, a leak test result of a Cs-137 vial source was above the regulatory limit of 0.005 microCi of removable contamination. The licensee is reporting that the Cs-137 vial source is a 203.9 microCi Isotope Product Laboratory Model RV-137-200U, serial number 788-6-7. The leak test result indicated a net removable contamination of 0.0155 microCi. The licensee is reporting that area survey results indicated no other contamination within the nuclear medicine department. The vial source has been placed inside a lead container, sealed, and stored in the nuclear medicine hot lab. Department inspectors were dispatched to the facility on 02/02/22. The vial source was found packaged as the licensee described. Dose rate readings using a Ludlum 14-C (calibrated 10/12/21) indicated readings as high as 12 milliR/hr on the surface of the container. Removable contamination wipes were also taken and no further contamination was detected. The vial source is awaiting disposal/transfer back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
EN Revision Text: AGREEMENT STATE REPORT - LEAKING VIAL SOURCE
The following information was received from the state of South Carolina via email:
"The South Carolina Department of Health and Environmental Control was notified via email at 1327 EST on 02/01/22 that during a quarterly nuclear medicine audit conducted on 01/27/22, a leak test result of a Cs-137 vial source was above the regulatory limit of 0.005 microCi of removable contamination. The licensee is reporting that the Cs-137 vial source is a 203.9 microCi Isotope Product Laboratory Model RV-137-200U, serial number 788-6-7. The leak test result indicated a net removable contamination of 0.0155 microCi. The licensee is reporting that area survey results indicated no other contamination within the nuclear medicine department. The vial source has been placed inside a lead container, sealed, and stored in the nuclear medicine hot lab. Department inspectors were dispatched to the facility on 02/02/22. The vial source was found packaged as the licensee described. Dose rate readings using a Ludlum 14-C (calibrated 10/12/21) indicated readings as high as 12 milliR/hr on the surface of the container. Removable contamination wipes were also taken and no further contamination was detected. The vial source is awaiting disposal/transfer back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55715
Facility: Cooper
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Aric Harris
HQ OPS Officer: Karen Cotton-Gross
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Aric Harris
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 01/27/2022
Notification Time: 15:07 [ET]
Event Date: 01/27/2022
Event Time: 10:38 [CST]
Last Update Date: 02/23/2022
Notification Time: 15:07 [ET]
Event Date: 01/27/2022
Event Time: 10:38 [CST]
Last Update Date: 02/23/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
Josey, Jeffrey (R4)
Josey, Jeffrey (R4)
| 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: 3/23/2022
EN Revision Text: LOSS OF METEORLOGICAL DATA ACQUISITION SYSTEM
The Licensee provided the following information via email:
"On January 27, 2022 at 1038 CST, with Cooper Nuclear Station in Mode 1, 100 percent power, the meteorological tower primary and backup data acquisition system failed, which resulted in a loss of meteorological data to the plant. Information technology personnel investigated and restored the primary system to service. Meteorological data to the plant was restored at 1105 CST on January 27, 2022. This notification Is being made due to a loss of emergency assessment capability In accordance with 10 CFR 50.72(b)(3)(xiii).
"The NRC Resident Inspector has been Informed."
* * * RETRACTION ON FEBRUARY 23, 2022 AT 1658 EST FROM LINDA DEWHIRST TO LLOYD DESOTELL * * *
The following information was provided by the licensee via fax:
"This notification is being made to retract event EN 55715 that was reported on January 27, 2022. Based on further investigation, the Emergency Plan and Emergency Plan Implementing Procedures provide acceptable alternative methods for performing emergency assessments that are in addition to the data obtained from the primary and backup meteorological tower information. It was determined that no actual or potential major loss of emergency assessment capability existed per 10 CFR 50.72(b)(3)(xiii). This is consistent with NUREG 1022, Revision 3, Supplement 1 and NEI 13-01, Revision 0. The NRC Resident Inspector has been notified of the retraction."
Notified R4DO (O'Keefe)
EN Revision Text: LOSS OF METEORLOGICAL DATA ACQUISITION SYSTEM
The Licensee provided the following information via email:
"On January 27, 2022 at 1038 CST, with Cooper Nuclear Station in Mode 1, 100 percent power, the meteorological tower primary and backup data acquisition system failed, which resulted in a loss of meteorological data to the plant. Information technology personnel investigated and restored the primary system to service. Meteorological data to the plant was restored at 1105 CST on January 27, 2022. This notification Is being made due to a loss of emergency assessment capability In accordance with 10 CFR 50.72(b)(3)(xiii).
"The NRC Resident Inspector has been Informed."
* * * RETRACTION ON FEBRUARY 23, 2022 AT 1658 EST FROM LINDA DEWHIRST TO LLOYD DESOTELL * * *
The following information was provided by the licensee via fax:
"This notification is being made to retract event EN 55715 that was reported on January 27, 2022. Based on further investigation, the Emergency Plan and Emergency Plan Implementing Procedures provide acceptable alternative methods for performing emergency assessments that are in addition to the data obtained from the primary and backup meteorological tower information. It was determined that no actual or potential major loss of emergency assessment capability existed per 10 CFR 50.72(b)(3)(xiii). This is consistent with NUREG 1022, Revision 3, Supplement 1 and NEI 13-01, Revision 0. The NRC Resident Inspector has been notified of the retraction."
Notified R4DO (O'Keefe)
Agreement State
Event Number: 55716
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/28/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.
"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.
"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"
Item Number: IL220002
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 - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.
"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.
"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"
Item Number: IL220002
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: 55717
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/28/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE
The following report was received from the California Department of Public Health (RHB) via email:
"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."
California Event Number: 012822
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE
The following report was received from the California Department of Public Health (RHB) via email:
"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."
California Event Number: 012822
Part 21
Event Number: 55807
Rep Org: Engine Systems, Inc.
Licensee: Engine Systems, Inc.
Region: 2
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Karen Cotton-Gross
Licensee: Engine Systems, Inc.
Region: 2
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 03/29/2022
Notification Time: 16:38 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [EDT]
Last Update Date: 03/29/2022
Notification Time: 16:38 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [EDT]
Last Update Date: 03/29/2022
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):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - ELECTRO-MOTIVE DIESEL (EMD) CYLINDER HEAD WITH FIREFACE THICKNESS BELOW SPECIFICATION
The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:
ESI reported that a fatigue crack was discovered in the fireface of an EMD cylinder head, P/N 40121485, D/C 18K, installed on an emergency diesel generator set. The crack initiated on the coolant side and propagated through the fireface wall of the combustion side resulting in a water leak. Fatigue failure was likely caused by a reduced fireface thickness which reduced overall rigidity of the fireface, allowing increased deformation and ultimately failure due to high tensile stress at the blend between the fireface and valve seat. A reduced fireface thickness could result in a through wall crack that would introduce jacket water into the combustion chamber. Over time if the crack propagated or went undetected engine damage may occur. Ultimately, a crack in the fireface could lead to a failure of the diesel engine which would prevent the emergency diesel generator set from performing during a safety-event.
This Part 21 applies to the Cylinder heads from D/C 18K, supplied within some power pack assemblies at Watts Bar Nuclear Power Plant.
Corrective Actions:
ESI recommends an ultrasonic thickness inspection on the fireface to confirm thickness is within specified range to plants with these power pack assemblies. ESI has also revised its dedication package to increase the number of ultrasonic thickness inspection points. An additional enhancement is the inclusion of an inspection map for guidance and clarity of the locations to be measured. The revision was implemented on March 15, 2022.
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 - ELECTRO-MOTIVE DIESEL (EMD) CYLINDER HEAD WITH FIREFACE THICKNESS BELOW SPECIFICATION
The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:
ESI reported that a fatigue crack was discovered in the fireface of an EMD cylinder head, P/N 40121485, D/C 18K, installed on an emergency diesel generator set. The crack initiated on the coolant side and propagated through the fireface wall of the combustion side resulting in a water leak. Fatigue failure was likely caused by a reduced fireface thickness which reduced overall rigidity of the fireface, allowing increased deformation and ultimately failure due to high tensile stress at the blend between the fireface and valve seat. A reduced fireface thickness could result in a through wall crack that would introduce jacket water into the combustion chamber. Over time if the crack propagated or went undetected engine damage may occur. Ultimately, a crack in the fireface could lead to a failure of the diesel engine which would prevent the emergency diesel generator set from performing during a safety-event.
This Part 21 applies to the Cylinder heads from D/C 18K, supplied within some power pack assemblies at Watts Bar Nuclear Power Plant.
Corrective Actions:
ESI recommends an ultrasonic thickness inspection on the fireface to confirm thickness is within specified range to plants with these power pack assemblies. ESI has also revised its dedication package to increase the number of ultrasonic thickness inspection points. An additional enhancement is the inclusion of an inspection map for guidance and clarity of the locations to be measured. The revision was implemented on March 15, 2022.
Technical questions concerning this notification can be directed to Dan Roberts, Quality Manager and John Kriesel, Engineering Manager at (252) 977-2720.