Event Notification Report for May 06, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/05/2022 - 05/06/2022

EVENT NUMBERS
55865 55869 55870 55878
Agreement State
Event Number: 55865
Rep Org: Texas Dept of State Health Services
Licensee: Blue Cube Operations LLC
Region: 4
City: Freeport   State: TX
County:
License #: L069226
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Brian P. Smith
Notification Date: 04/28/2022
Notification Time: 17:23 [ET]
Event Date: 04/28/2022
Event Time: 12:00 [CDT]
Last Update Date: 04/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Cale (R4DO)
Event Text
AGREEMENT STATE REPORT - SHUTTER MALFUNCTION

The following report was received via e-mail from the Texas Department of State Health Services (the Agency):

"On April 28, 2022, the licensee notified the Agency that the shutter handle on one of its Ohmart Vega model SH-F2 gauges, containing a 200 milliCurie cesium-137 source, had malfunctioned. A service company was preparing the gauge for removal and had opened and closed the shutter. The shutter closed completely (verified by survey), but they could not lock the shutter handle. A repair kit will be ordered and upon receipt the service company will make the repair and complete the removal. The gauge is in an area of the plant that is no longer operational in a location that is inaccessible without scaffolding. The scaffolding being used at the time of this event will be removed until time for repair.

"There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9927


Agreement State
Event Number: 55869
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Medical Center of Oshkosh
Region: 3
City: Oshkosh   State: WI
County:
License #: 139-1025-01
Agreement: Y
Docket:
NRC Notified By: Luther S. Loehrke
HQ OPS Officer: Ossy Font
Notification Date: 04/29/2022
Notification Time: 10:07 [ET]
Event Date: 06/21/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DISCREPENCY WITH WRITTEN DIRECTIVE

The following summary was received from the Wisconsin Department of Public Health (the Department) via email:

On April 28, 2022, during an inspection, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on June 21, 2021. A patient's procedure planned for two vials and an activity of 2.81 GBq, which were administered. The written directive erroneously only accounted for one vial and a prescribed activity of 1.94 GBq; therefore, the administered activity was 138.4 percent of the activity specified on the written directive. The administered activity was within 2 percent of the planned activity.

Wisconsin Event Report ID No.: WI220010

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: 55870
Rep Org: Alabama Radiation Control
Licensee: The University of South Alabama
Region: 1
City: Mobile   State: AL
County:
License #: RML 584
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/29/2022
Notification Time: 17:58 [ET]
Event Date: 04/27/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
Event Text
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION

The following information was received from the Alabama Office of Radiation Control (the Department) via E-mail:

"The Department received a phone call and e-mail on 4/28/2022 from the licensee regarding two patients that apparently received the wrong radiopharmaceuticals on 4/27/2022. The patients' doses appeared to have been inadvertently switched.

"Patient: 1 (male)
"Ordered dose: 10.0 mCi Fluciclovine (Axumin) F-18
"Given: 10.64 mCi FDG F-18

"Patient: 2 (female)
"Ordered dose: 10.0 mCi FDG F-18
"Given: 12.62 mCi Fluciclovine (Axumin) F-18

"It appears that at least one patient received an effective dose over 500 mrem.

"Alabama Radiation Control will provide more information as the investigation continues."

Alabama Event: 22-07

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: 55878
Facility: Palo Verde
Region: 4     State: AZ
Unit: [2] [3] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Joshua McDowell
HQ OPS Officer: Brian P. Smith
Notification Date: 05/05/2022
Notification Time: 04:30 [ET]
Event Date: 05/04/2022
Event Time: 19:55 [MST]
Last Update Date: 05/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Warnick, Greg (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation
Event Text
VALID ACTUATION OF UNIT 2 AND UNIT 3 EMERGENCY DIESEL GENERATORS AND UNIT 3 AUXILIARY FEEDWATER PUMP

The following information was provided by the licensee via email:

"At 1955 on May 4, 2022, a start-up transformer de-energized, resulting in a loss of power to the Unit 2 Train A 4.16 kV Class 1E Bus and the Unit 3 Train B 4.16 kV Class 1E Bus. The Unit 2 Train A Emergency Diesel Generator (EDG) and Unit 3 Train B EDG automatically started and energized their respective 4.16 kV Class 1E Buses.

"As a result of the Loss of Power on the Unit 3 Train B 4.16 kV Class 1E Bus, the B Auxiliary Feedwater Pump automatically started, as expected. The B Auxiliary Feedwater Pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The B Auxiliary Feedwater Pump did not supply feedwater to the steam generators.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems and an auxiliary feedwater system."

Page Last Reviewed/Updated Friday, May 06, 2022