Event Notification Report for April 27, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/26/2022 - 04/27/2022

EVENT NUMBERS
55785 55849 55850 55851 55852 55859
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55785
Facility: Turkey Point
Region: 2     State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: James Jackson
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/12/2022
Notification Time: 06:56 [ET]
Event Date: 03/12/2022
Event Time: 00:50 [EST]
Last Update Date: 04/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N N 0 Hot Standby 0 Hot Shutdown
Event Text
EN Revision Imported Date: 4/27/2022

EN Revision Text: MAIN STEAM ISOLATION VALVE FAILED TO SHUT

The following information was provided by the licensee via email:

"At 0050 EST on 3/12/22, while shutting down for entry into a scheduled refueling outage, the station discovered that a single Main Steam Isolation Valve (4A MSIV) did not fully close on demand. All other equipment operated as expected.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 04/26/22 AT 1422 EDT FROM DAVID STOIA TO BRIAN PARKS * * *

The following information was provided by the licensee via email:

"On 3/12/2022 at 0656 EDT Turkey Point Unit 4 notified the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) that a single Main Steam Isolation Valve (MSIV) did not fully close when manually demanded from the control room during shutdown of Unit 4 for a refueling outage. Following disassembly and inspection of the MSIV, Florida Power & Light Engineering identified the cause of the deficiency and determined that the valve would have fully seated under its design accident conditions.

"This notification is a retraction of EN# 55785. The NRC Resident Inspector has been notified of this retraction."

Notified R2DO (Miller).


Agreement State
Event Number: 55849
Rep Org: WA Office of Radiation Protection
Licensee: Packaging Corporation
Region: 4
City: Wallula   State: WA
County:
License #: WN-I004-1
Agreement: Y
Docket:
NRC Notified By: Jasmin Hernandez
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/19/2022
Notification Time: 19:45 [ET]
Event Date: 04/15/2022
Event Time: 08:00 [PDT]
Last Update Date: 04/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_Events_Notification, (EMAIL)
Event Text
AGREEMENT STATE REPORT - EQUIPMENT MISUSE

The following was received from the Washington Office of Radiation Protection via email:

"Incident took place on 4/15/22 at approximately 0800 PDT Wallula, WA. A fixed gauge [KayRay model 7062 bp; 50mCi Cs-137] was found unmounted and uncontrolled, nearby it's normally installed location. Source is intact and shutter mechanism has remained in the locked/closed position. No over exposure or spread of contamination. The fixed gauge is currently reinstalled at it's normal location, pending further investigation and report.

Incident Number: WA-22-010


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1DO)
Event Text
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


Agreement State
Event Number: 55851
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia   State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Brian Parks
Notification Date: 04/20/2022
Notification Time: 11:49 [ET]
Event Date: 04/18/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/20/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dentel, Glenn (R1DO)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the Pennsylvania Bureau of Radiation Protection by e-mail:

"On April 18, 2022, a patient underwent a Y-90 SIR-Sphere treatment. The prescribed dosage was 7.07 milliCuries, however only 5.27 milliCuries was able to be delivered, or 74.5 percent. The apparent cause is that the blood vessel the catheter was placed in had a complicated vasculature which inhibited the flow of the spheres. No harm is expected to the patient. The referring physician and the patient have been informed."

Event Report ID Number: PA220014

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: 55852
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Riverside Methodist Hospital
Region: 3
City: Columbus   State: OH
County:
License #: 02120250070
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Brian Parks
Notification Date: 04/20/2022
Notification Time: 14:09 [ET]
Event Date: 04/18/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/20/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Pelke, Patricia (R3DO)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the Ohio Bureau of Radiation Protection by e-mail:

"On 4/18/22, a patient was scheduled to receive 120 Gy to the right hepatic lobe of the liver [involving Y-90 TheraSpheres], however only 94.2 Gy was delivered, resulting in an underdose of 21.5 percent. The [authorized user] notified the [Radiation Safety Officer] on 4/19/22. Stasis was not reached and at this time no cause was identified."

Item Number: OH220006

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: 55859
Facility: Brunswick
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Christopher Denton
HQ OPS Officer: Brian P. Smith
Notification Date: 04/26/2022
Notification Time: 13:13 [ET]
Event Date: 03/07/2022
Event Time: 00:40 [EDT]
Last Update Date: 04/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 100 Power Operation
Event Text
INVALID ACTUATION 60-DAY TELEPHONE NOTIFICATION

The following information was provided by the licensee via fax or email:

"This 60-day telephone notification is being made in lieu of an LER submittal per 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for invalid actuations of systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 0040 Eastern Standard Time (EST) on March 7, 2022, Unit 1 received inadvertent High-Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) initiation signals. Subsequently, at approximately 0148 EST on March 7, 2022, Unit 1 received inadvertent Low-Pressure Coolant Injection (LPCI) and Core Spray initiation signals. In addition, all four Emergency Diesel Generators auto started, Group 10 (Instrument Air) Primary Containment Isolation System actuations occurred, and the Residual Heat Removal (RHR) Service Water Booster pumps tripped resulting in a brief interruption (approximately 9 minutes) to the Shutdown Cooling (SDC) heatsink. Jumpers, installed per planned refueling outage activities, prevented discharge of Emergency Core Cooling Systems into the reactor. HPCI, RCIC, and RHR Loop `A' were removed from service and under clearance. RHR SDC remained operable via RHR Loop `B' and forced circulation was maintained in the reactor.

"At the time of these events, Unit 1 was shutdown for refueling and the `A' and `C' reactor water level transmitters had been isolated in preparation for planned replacement. Leak-by of the instrument isolation valves occurred on both transmitters. Leak-by on the `C' instrument occurred at a faster rate with the `A' instrument providing the confirmatory signals resulting in Low Level 2 (LL2) and Low Level 3 (LL3) indication at approximately 0040 EST and 0148 EST, respectively. All actuations occurred as designed for LL2 and LL3 signals. During these events, reactor water level remained stable at the Reactor Vessel Head Flange and the `B' and `D' reactor water level transmitters remained off-scale-high, as expected under these conditions. Therefore, the actuations were not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system (i.e., there was no low reactor water level condition). Considering the above, these actuations were invalid."

"There was no impact on the health and safety of the public or plant personnel."

Page Last Reviewed/Updated Wednesday, April 27, 2022