Event Notification Report for May 27, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/26/2022 - 05/27/2022
Non-Agreement State
Event Number: 55901
Rep Org: Pharmalogic Puerto Rico
Licensee: Pharmalogic Puerto Rico
Region: 1
City: San Juan State: PR
County:
License #: 52-2536101MD
Agreement: N
Docket:
NRC Notified By: Rolando Garcia
HQ OPS Officer: Thomas Herrity
Notification Date: 05/19/2022
Notification Time: 10:45 [ET]
Event Date: 05/19/2022
Event Time: 02:00 [ADT]
Last Update Date: 05/19/2022
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(1) - Unplanned Contamination
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
NON-AGREEMENT STATE REPORT - TECHNETIUM-99M SPILL
The following is a synopsis of information provided by the licensee via phone call:
At approximately 0200 on May 19, 2022, a spill of approximately 3 curies of Tc-99m occurred in the compounding room at the Pharmalogic Puerto Rico facility in San Juan, PR. The spill was contained to the compounding room (a restricted area). One worker received a skin contamination that did not require medical attention.
Fuel Cycle Facility
Event Number: 55902
Facility: Nuclear Fuel Services Inc.
RX Type: Uranium Fuel Fabrication
Comments:
Heu Conversion & Scrap Recovery
Naval Reactor Fuel Cycle
Leu Scrap Recovery
Region: 2
City: Erwin State: TN
County: Unicoi
License #: SNM-124
Docket: 07000143
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
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
Fuels Group, - (EMAIL)
Event Text
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."
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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
Event Text
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.
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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
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.
Power Reactor
Event Number: 55915
Facility: Grand Gulf
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Leroy Purdy
HQ OPS Officer: Ernest West
Notification Date: 05/26/2022
Notification Time: 10:34 [ET]
Event Date: 05/26/2022
Event Time: 06:30 [CDT]
Last Update Date: 05/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Pick, Greg (R4DO)
Power Reactor Unit Info
| Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
N |
Y |
92 |
Power Operation |
92 |
Power Operation |
Event Text
SPURIOUS SIREN ACTUATION
The following information was provided by the licensee via phone and email:
"On May 26, 2022, at 0753 CDT, the Grand Gulf Nuclear Station was notified of a spurious actuation of a single Alert Notification System siren in Tensas Parish, Louisiana. The actuation occurred during siren testing conducted at approximately 0630 CDT - no emergency conditions are present at Grand Gulf Nuclear Station.
"A press release from Entergy is not planned at this time.
"This condition is reportable under 10 CFR 50.72(b)(2)(xi) as a notification of an offsite government agency.
"The NRC Senior Resident Inspector has been notified."