Event Notification Report for May 18, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/17/2022 - 05/18/2022
Fuel Cycle Facility
Event Number: 55902
Facility: Nuclear Fuel Services Inc.
Region: 2 State: TN
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Heu Conversion & Scrap Recovery
Naval Reactor Fuel Cycle
Leu Scrap Recovery
NRC Notified By: Daniele Rogers
HQ OPS Officer: Ossy Font
Region: 2 State: TN
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Heu Conversion & Scrap Recovery
Naval Reactor Fuel Cycle
Leu Scrap Recovery
NRC Notified By: Daniele Rogers
HQ OPS Officer: Ossy Font
Notification Date: 05/19/2022
Notification Time: 11:45 [ET]
Event Date: 05/18/2022
Event Time: 14:50 [EDT]
Last Update Date: 05/19/2022
Notification Time: 11:45 [ET]
Event Date: 05/18/2022
Event Time: 14:50 [EDT]
Last Update Date: 05/19/2022
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
Fuels Group, - (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
Fuels Group, - (EMAIL)
CRITICALITY ACCIDENT ALARM SYSTEM SPEAKERS DISABLED
The following information was provided by the licensee via email:
"On May 18, 2022, at approximately 1450 (EDT), an electrical switch for the Criticality Accident Alarm System (CAAS) legacy speakers was noted to be out of its normal position. A functional redundant speaker system is installed in the main processing plant and laboratory. As a consequence of the switch being out of position, in the highly unlikely event that the CAAS had actuated, the alarm would not have been annunciated in areas outside of the main processing area and laboratory where there are no redundant speakers. Compliance was restored at approximately 1500 (EDT) when the switch was placed back in its normal position. The system was subsequently tested and confirmed to be operational. The most recent audibility test of the speaker system had been performed on May 13, 2022, at approximately 1100 (EDT). The licensee notified the NRC Resident Inspector on May 18, 2022, at approximately 1625 (EDT). There were no actual nuclear safety consequences. The potential consequence was that, in the event of a nuclear criticality accident, evacuation could have been delayed for those personnel outside of the main processing area where redundant speakers have not been installed."
The following information was provided by the licensee via email:
"On May 18, 2022, at approximately 1450 (EDT), an electrical switch for the Criticality Accident Alarm System (CAAS) legacy speakers was noted to be out of its normal position. A functional redundant speaker system is installed in the main processing plant and laboratory. As a consequence of the switch being out of position, in the highly unlikely event that the CAAS had actuated, the alarm would not have been annunciated in areas outside of the main processing area and laboratory where there are no redundant speakers. Compliance was restored at approximately 1500 (EDT) when the switch was placed back in its normal position. The system was subsequently tested and confirmed to be operational. The most recent audibility test of the speaker system had been performed on May 13, 2022, at approximately 1100 (EDT). The licensee notified the NRC Resident Inspector on May 18, 2022, at approximately 1625 (EDT). There were no actual nuclear safety consequences. The potential consequence was that, in the event of a nuclear criticality accident, evacuation could have been delayed for those personnel outside of the main processing area where redundant speakers have not been installed."
Agreement State
Event Number: 55903
Rep Org: North Dakota Department of Health
Licensee: American Crystal Sugar Company
Region: 4
City: Drayton State: ND
County:
License #: 33-15115-01
Agreement: Y
Docket:
NRC Notified By: Karen Deibert
HQ OPS Officer: Kerby Scales
Licensee: American Crystal Sugar Company
Region: 4
City: Drayton State: ND
County:
License #: 33-15115-01
Agreement: Y
Docket:
NRC Notified By: Karen Deibert
HQ OPS Officer: Kerby Scales
Notification Date: 05/19/2022
Notification Time: 16:13 [ET]
Event Date: 05/18/2022
Event Time: 00:00 [MDT]
Last Update Date: 05/19/2022
Notification Time: 16:13 [ET]
Event Date: 05/18/2022
Event Time: 00:00 [MDT]
Last Update Date: 05/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
AGREEMENT STATE REPORT - SHUTTER FAILURE
The following is a synopsis of an email received from the state of North Dakota:
On 5/18/2022, the licensee reported to the North Dakota Department of Environmental Quality an equipment failure of a nuclear device sealed source shutter manufactured by Berthold Technologies. The seal source is model SSC-100, containing 20 millicuries of Cs-137. The source holder is Berthold Technologies model LB 300 IRL Type I. The manufacturer was contacted by the licensee to come on site and evaluate the device.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The source is in a safe location and there was no exposure to personnel.
The following is a synopsis of an email received from the state of North Dakota:
On 5/18/2022, the licensee reported to the North Dakota Department of Environmental Quality an equipment failure of a nuclear device sealed source shutter manufactured by Berthold Technologies. The seal source is model SSC-100, containing 20 millicuries of Cs-137. The source holder is Berthold Technologies model LB 300 IRL Type I. The manufacturer was contacted by the licensee to come on site and evaluate the device.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The source is in a safe location and there was no exposure to personnel.
Agreement State
Event Number: 55904
Rep Org: PA Dept of Environmental Protection
Licensee: University of Penn. Philadelphia
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Licensee: University of Penn. Philadelphia
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 05/20/2022
Notification Time: 09:21 [ET]
Event Date: 05/18/2022
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2022
Notification Time: 09:21 [ET]
Event Date: 05/18/2022
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 5/26/2022
EN Revision Text: AGREEMENT STATE REPORT - TARGET TISSUE MISSED
The following was received from the Pennsylvania Department of Environmental Protection (the Department) via email:
"On May 19, 2022, the licensee informed the Department of an incident involving Cobalt 60 in a Leksell (R) Gamma Knife Perfexion. It is reportable as per 10 CFR 35.3045(a)(1).
"On May 18, 2022, a patient underwent treatment of four lesions in the brain. Upon review of the treatment, the physicist noticed that all four lesions were missed by approximately 0.5 centimeters and healthy brain tissue was treated. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.
"The Department will perform a reactive inspection. More information will be provided as received."
Event Report ID No: PA220018
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.
* * * UPDATE ON 05/25/2022 AT 0949 EDT FROM JOHN CHIPPO TO OSSY FONT * * *
The following updated was received from the Department via email:
"The patient had MRIs and CT Scans. Those images were fused by the neurosurgeon and radiation oncologist. Upon completion of the treatment, they discovered that although the targets were moved with the second image fusion, the shots and contours were not. This resulted in the treatment being 0.5 cm off for all 4 targets. Prescribed dose was 20 to 21 Gy, delivered dose to target tissue was 8 to 15 Gy, maximum dose to healthy tissue is estimated to range from 21.82 to 27.09 Gy. More information is expected once the licensee completes their investigation."
Notified R1DO (Eve) and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - TARGET TISSUE MISSED
The following was received from the Pennsylvania Department of Environmental Protection (the Department) via email:
"On May 19, 2022, the licensee informed the Department of an incident involving Cobalt 60 in a Leksell (R) Gamma Knife Perfexion. It is reportable as per 10 CFR 35.3045(a)(1).
"On May 18, 2022, a patient underwent treatment of four lesions in the brain. Upon review of the treatment, the physicist noticed that all four lesions were missed by approximately 0.5 centimeters and healthy brain tissue was treated. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.
"The Department will perform a reactive inspection. More information will be provided as received."
Event Report ID No: PA220018
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.
* * * UPDATE ON 05/25/2022 AT 0949 EDT FROM JOHN CHIPPO TO OSSY FONT * * *
The following updated was received from the Department via email:
"The patient had MRIs and CT Scans. Those images were fused by the neurosurgeon and radiation oncologist. Upon completion of the treatment, they discovered that although the targets were moved with the second image fusion, the shots and contours were not. This resulted in the treatment being 0.5 cm off for all 4 targets. Prescribed dose was 20 to 21 Gy, delivered dose to target tissue was 8 to 15 Gy, maximum dose to healthy tissue is estimated to range from 21.82 to 27.09 Gy. More information is expected once the licensee completes their investigation."
Notified R1DO (Eve) and NMSS Events Notification via email.