Event Notification Report for April 11, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/10/2022 - 04/11/2022
Agreement State
Event Number: 55842
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: Mike Stafford
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: Mike Stafford
Notification Date: 04/13/2022
Notification Time: 13:10 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/13/2022
Notification Time: 13:10 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the [authorized user] noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The [authorized user] was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause."
Item Number: IL220012
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 RECEIVED DOSE LESS THAN PRESCRIBED
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the [authorized user] noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The [authorized user] was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause."
Item Number: IL220012
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: 55838
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Isomedix Operations, Inc.
Region: 3
City: Libertyville State: IL
County:
License #: IL-01123-02
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Lloyd Desotell
Licensee: Isomedix Operations, Inc.
Region: 3
City: Libertyville State: IL
County:
License #: IL-01123-02
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/12/2022
Notification Time: 12:38 [ET]
Event Date: 04/11/2022
Event Time: 12:00 [CDT]
Last Update Date: 04/12/2022
Notification Time: 12:38 [ET]
Event Date: 04/11/2022
Event Time: 12:00 [CDT]
Last Update Date: 04/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.
"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.
"No personnel injuries or exposures and no adverse effects on the security system were reported."
Item Number: IL220011
EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.
"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.
"No personnel injuries or exposures and no adverse effects on the security system were reported."
Item Number: IL220011
Agreement State
Event Number: 55840
Rep Org: California Radiation Control Prgm
Licensee: Loma Linda University Health
Region: 4
City: Loma Linda State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Mike Stafford
Licensee: Loma Linda University Health
Region: 4
City: Loma Linda State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Mike Stafford
Notification Date: 04/12/2022
Notification Time: 19:47 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/12/2022
Notification Time: 19:47 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED
The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:
"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."
California Event Number: 041222
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 RECEIVED DOSE GREATER THAN PRESCRIBED
The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:
"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."
California Event Number: 041222
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: 55850
Rep Org: Georgia Radioactive Material Pgm
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: Leslines Leveque
HQ OPS Officer: Mike Stafford
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: Leslines Leveque
HQ OPS Officer: Mike Stafford
Notification Date: 04/20/2022
Notification Time: 09:36 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/25/2022
Notification Time: 09:36 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/25/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1DO)
EN Revision Imported Date: 4/26/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING SOURCE
The following is a synopsis of an email received from the state of Georgia:
On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier.
Georgia Incident Number: 53
* * * UPDATE ON 04/25/2022 AT 0945 EDT FROM LESLINES LEVEQUE TO THOMAS HERRITY * * *
The following is update was received from the state of Georgia via email:
On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident.
Notified R1DO (Young) and ILTAB and NMSS Events Notification 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
EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING SOURCE
The following is a synopsis of an email received from the state of Georgia:
On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier.
Georgia Incident Number: 53
* * * UPDATE ON 04/25/2022 AT 0945 EDT FROM LESLINES LEVEQUE TO THOMAS HERRITY * * *
The following is update was received from the state of Georgia via email:
On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident.
Notified R1DO (Young) and ILTAB and NMSS Events Notification 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: 55833
Rep Org: NC Div of Radiation Protection
Licensee: Kleinfelder
Region: 1
City: Charlotte State: NC
County:
License #: 060-0712-2
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Mike Stafford
Licensee: Kleinfelder
Region: 1
City: Charlotte State: NC
County:
License #: 060-0712-2
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Mike Stafford
Notification Date: 04/11/2022
Notification Time: 11:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Notification Time: 11:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE
The following was received via an email from the state of North Carolina:
"A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box.
"An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report."
North Carolina Tracking Number: 220003.
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
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE
The following was received via an email from the state of North Carolina:
"A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box.
"An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report."
North Carolina Tracking Number: 220003.
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: 55835
Rep Org: Colorado Dept of Health
Licensee: Service King #342
Region: 4
City: Thornton State: CO
County:
License #: GL002621
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Bethany Cecere
Licensee: Service King #342
Region: 4
City: Thornton State: CO
County:
License #: GL002621
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Bethany Cecere
Notification Date: 04/11/2022
Notification Time: 17:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 04/11/2022
Notification Time: 17:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following information was provided by the state of Colorado via email:
"Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found.
"Isotope: Po-210
Manufacturer: NRD, LLC.
Model: P-2021
Device: Static Eliminator
Serial number: A2LT196
Activity: .01 Ci"
CO Event Report ID No.: CO220009
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
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following information was provided by the state of Colorado via email:
"Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found.
"Isotope: Po-210
Manufacturer: NRD, LLC.
Model: P-2021
Device: Static Eliminator
Serial number: A2LT196
Activity: .01 Ci"
CO Event Report ID No.: CO220009
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: 55890
Rep Org: New Mexico Rad Control Program
Licensee: Pression NDT
Region: 4
City: Carlsbed State: NM
County:
License #: IR 539-06
Agreement: Y
Docket:
NRC Notified By: Victor Diaz
HQ OPS Officer: Ossy Font
Licensee: Pression NDT
Region: 4
City: Carlsbed State: NM
County:
License #: IR 539-06
Agreement: Y
Docket:
NRC Notified By: Victor Diaz
HQ OPS Officer: Ossy Font
Notification Date: 05/09/2022
Notification Time: 12:36 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 05/09/2022
Notification Time: 12:36 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 05/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gaddy, Vincent (R4DO) (R4DO)
Erickson, Randy (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gaddy, Vincent (R4DO) (R4DO)
Erickson, Randy (EMAIL)
AGREEMENT STATE REPORT - INDUSTRIAL RADIOGRAPHY EQUIPMENT FAILURE
The following is a summary received from the New Mexico Environmental Protection Division (the agency) via phone:
On 05/09/22, at 0934 MDT, the agency was notified of an industrial radiography event that occurred on 04/11/22. The licensee reported a mechanical equipment failure and that no exposure occurred. The agency is en route to follow-up and gather additional details on the event.
The agency also notified R4 (Erickson).
The following is a summary received from the New Mexico Environmental Protection Division (the agency) via phone:
On 05/09/22, at 0934 MDT, the agency was notified of an industrial radiography event that occurred on 04/11/22. The licensee reported a mechanical equipment failure and that no exposure occurred. The agency is en route to follow-up and gather additional details on the event.
The agency also notified R4 (Erickson).
Power Reactor
Event Number: 55926
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Yolanda Good
HQ OPS Officer: Ossy Font
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Yolanda Good
HQ OPS Officer: Ossy Font
Notification Date: 06/03/2022
Notification Time: 20:32 [ET]
Event Date: 04/11/2022
Event Time: 20:45 [MST]
Last Update Date: 06/03/2022
Notification Time: 20:32 [ET]
Event Date: 04/11/2022
Event Time: 20:45 [MST]
Last Update Date: 06/03/2022
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Roldan-Otero, Lizette (R4DO)
Roldan-Otero, Lizette (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
INVALID SYSTEM ACTUATION
The following information was provided by the licensee via email:
"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 10 CFR 50.73.
"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe invalid actuations of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 B Train Auxiliary Feedwater (AF) system and Essential Spray Pond (ESP) system that occurred while in a refueling outage.
"On April 11, 2022, at approximately 2045 Mountain Standard Time, an automatic start of the Unit 1 B Train AF and ESP systems occurred during restoration from a surveillance test. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the Engineered Safety Features Actuation Systems to simulated design basis events. The test portion was completed satisfactorily; however, during the restoration portion, the load sequencer inadvertently cycled between Mode 0 and Mode 1 three times in immediate succession.
"At the time of the system actuations, one of the actuation signals associated with this portion of the test had been reset per procedure. Another actuation signal was still in while restoration steps were ongoing, but the sequencer was not expected to cycle between Modes. The system actuations did not occur as a result of actual plant conditions or parameters and are therefore invalid.
"The Unit 1 B Train AF and ESP system actuations were complete and the systems started and functioned successfully. For the systems that did not actuate, the reasons are clearly understood as those systems were in an overridden condition due to test configuration.
"The spurious actuation was not able to be replicated and a direct cause was not identified. There were no adverse impacts to public health and safety nor to plant employees.
"The NRC Resident Inspectors have been informed."
The following information was provided by the licensee via email:
"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 10 CFR 50.73.
"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe invalid actuations of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 B Train Auxiliary Feedwater (AF) system and Essential Spray Pond (ESP) system that occurred while in a refueling outage.
"On April 11, 2022, at approximately 2045 Mountain Standard Time, an automatic start of the Unit 1 B Train AF and ESP systems occurred during restoration from a surveillance test. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the Engineered Safety Features Actuation Systems to simulated design basis events. The test portion was completed satisfactorily; however, during the restoration portion, the load sequencer inadvertently cycled between Mode 0 and Mode 1 three times in immediate succession.
"At the time of the system actuations, one of the actuation signals associated with this portion of the test had been reset per procedure. Another actuation signal was still in while restoration steps were ongoing, but the sequencer was not expected to cycle between Modes. The system actuations did not occur as a result of actual plant conditions or parameters and are therefore invalid.
"The Unit 1 B Train AF and ESP system actuations were complete and the systems started and functioned successfully. For the systems that did not actuate, the reasons are clearly understood as those systems were in an overridden condition due to test configuration.
"The spurious actuation was not able to be replicated and a direct cause was not identified. There were no adverse impacts to public health and safety nor to plant employees.
"The NRC Resident Inspectors have been informed."