Event Notification Report for May 09, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/08/2022 - 05/09/2022
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
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
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
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
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.
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
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
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
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
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.
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
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
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
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Warnick, Greg (R4DO)
Warnick, Greg (R4DO)
| 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 |
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."
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."
Power Reactor
Event Number: 55888
Facility: Oconee
Region: 2 State: SC
Unit: [3] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: L.C. Hayes
HQ OPS Officer: Brian P. Smith
Region: 2 State: SC
Unit: [3] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: L.C. Hayes
HQ OPS Officer: Brian P. Smith
Notification Date: 05/07/2022
Notification Time: 04:37 [ET]
Event Date: 05/06/2022
Event Time: 23:10 [EDT]
Last Update Date: 05/07/2022
Notification Time: 04:37 [ET]
Event Date: 05/06/2022
Event Time: 23:10 [EDT]
Last Update Date: 05/07/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Hot Standby | 0 | Hot Standby |
AUTOMATIC ACTUATION OF EMERGENCY FEEDWATER
The following information was provided by the licensee via fax:
"At 2310 EDT on May 6, 2022, with Unit 3 in Mode 3, an actuation of the Emergency Feedwater (EFW) System occurred while entering a planned refueling outage. The reason for the EFW auto-start was a loss of all Main Feedwater (MFDW) Pumps which occurred when the 3A MFDW Pump tripped on steam generator (SG) overfill protection due to high level in the 3B SG. The high level in the 3B SG occurred when a Startup Feedwater Control Valve (3FDW-44) malfunctioned, resulting in excessive feedwater flow to the 3B SG. Investigation and repairs are in progress. Units 1 and 2 were not affected.
"This event is being reported as an 8-hr non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via fax:
"At 2310 EDT on May 6, 2022, with Unit 3 in Mode 3, an actuation of the Emergency Feedwater (EFW) System occurred while entering a planned refueling outage. The reason for the EFW auto-start was a loss of all Main Feedwater (MFDW) Pumps which occurred when the 3A MFDW Pump tripped on steam generator (SG) overfill protection due to high level in the 3B SG. The high level in the 3B SG occurred when a Startup Feedwater Control Valve (3FDW-44) malfunctioned, resulting in excessive feedwater flow to the 3B SG. Investigation and repairs are in progress. Units 1 and 2 were not affected.
"This event is being reported as an 8-hr non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55872
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: MISTRAS Group, Inc.
Region: 3
City: Burr Ridge State: IL
County:
License #: IL-01225-22
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Lloyd Desotell
Licensee: MISTRAS Group, Inc.
Region: 3
City: Burr Ridge State: IL
County:
License #: IL-01225-22
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Lloyd Desotell
Notification Date: 05/03/2022
Notification Time: 12:07 [ET]
Event Date: 05/02/2022
Event Time: 00:00 [CDT]
Last Update Date: 05/03/2022
Notification Time: 12:07 [ET]
Event Date: 05/02/2022
Event Time: 00:00 [CDT]
Last Update Date: 05/03/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Hills, David (R3DO)
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted at 0830 CDT on 5/3/22 to advise that a radiography crew had a 55 Ci Ir-192 source disconnect from the drive cable while working at a site in Bradley, Illinois over the evening. The crew contacted their RSO and the source was successfully retrieved and placed into a shielded position. As the work was done after hours, there are reportedly no concerns over public exposures. Three MISTRAS staff recorded maximum exposures of 65 mrem on their [direct reading dosimeters] DRDs from the operation and have overnighted dosimetry for processing."
Illinois Event Number: IL220013
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted at 0830 CDT on 5/3/22 to advise that a radiography crew had a 55 Ci Ir-192 source disconnect from the drive cable while working at a site in Bradley, Illinois over the evening. The crew contacted their RSO and the source was successfully retrieved and placed into a shielded position. As the work was done after hours, there are reportedly no concerns over public exposures. Three MISTRAS staff recorded maximum exposures of 65 mrem on their [direct reading dosimeters] DRDs from the operation and have overnighted dosimetry for processing."
Illinois Event Number: IL220013
Non-Agreement State
Event Number: 55874
Rep Org: Marathon Pipe Line LLC
Licensee: Marathon Pipe Line LLC
Region: 3
City: Indianapolis State: IN
County:
License #: GL-714799-27
Agreement: N
Docket:
NRC Notified By: Matt Grimes
HQ OPS Officer: Lloyd Desotell
Licensee: Marathon Pipe Line LLC
Region: 3
City: Indianapolis State: IN
County:
License #: GL-714799-27
Agreement: N
Docket:
NRC Notified By: Matt Grimes
HQ OPS Officer: Lloyd Desotell
Notification Date: 05/03/2022
Notification Time: 15:24 [ET]
Event Date: 05/02/2022
Event Time: 09:30 [EDT]
Last Update Date: 05/03/2022
Notification Time: 15:24 [ET]
Event Date: 05/02/2022
Event Time: 09:30 [EDT]
Last Update Date: 05/03/2022
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NON-AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the licensee via email:
" Marathon Pipe Line LLC and the Manufacturer, VEGA Americas, Inc., evaluated a [fixed gauge] device [OHMART/Vega Corporation Model SR-1A, S/N M5965. Cs-137 80 mCi ] on 05/02/22 to verify the operation of the shutter mechanism.
" During the evaluation of the device the VEGA FS Technician confirmed that the shutter mechanism would not close.
" The cause is internal mechanism failure of the shutter device.
" The shutter is in the Open position and won't close.
" The Open position is the normal operating position.
" There was and is no radiation exposure concern for Marathon Pipe Line LLC employees, contractors, visitors or the general public.
" Vega Americas, Inc. has been contacted for a path forward to order and install a replacement device as well as develop a plan and assist in the safe removal, isolation and disposal of this gauge."
The following information was provided by the licensee via email:
" Marathon Pipe Line LLC and the Manufacturer, VEGA Americas, Inc., evaluated a [fixed gauge] device [OHMART/Vega Corporation Model SR-1A, S/N M5965. Cs-137 80 mCi ] on 05/02/22 to verify the operation of the shutter mechanism.
" During the evaluation of the device the VEGA FS Technician confirmed that the shutter mechanism would not close.
" The cause is internal mechanism failure of the shutter device.
" The shutter is in the Open position and won't close.
" The Open position is the normal operating position.
" There was and is no radiation exposure concern for Marathon Pipe Line LLC employees, contractors, visitors or the general public.
" Vega Americas, Inc. has been contacted for a path forward to order and install a replacement device as well as develop a plan and assist in the safe removal, isolation and disposal of this gauge."