Event Notification Report for June 14, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/13/2022 - 06/14/2022
Agreement State
Event Number: 55928
Rep Org: Kentucky Dept of Radiation Control
Licensee: Carmeuse Lime Stone, Black River Op
Region: 1
City: Butler State: KY
County:
License #: 201-111-57
Agreement: Y
Docket:
NRC Notified By: Curt Pendergrass
HQ OPS Officer: Kerby Scales
Licensee: Carmeuse Lime Stone, Black River Op
Region: 1
City: Butler State: KY
County:
License #: 201-111-57
Agreement: Y
Docket:
NRC Notified By: Curt Pendergrass
HQ OPS Officer: Kerby Scales
Notification Date: 06/06/2022
Notification Time: 08:48 [ET]
Event Date: 06/01/2022
Event Time: 00:00 [CDT]
Last Update Date: 06/06/2022
Notification Time: 08:48 [ET]
Event Date: 06/01/2022
Event Time: 00:00 [CDT]
Last Update Date: 06/06/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Greives, Jonathan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Greives, Jonathan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FIXED GAUGE INADVERTENTLY DISCARDED
The following report was received from the state of Kentucky via email:
"A Berthold fixed gauging device containing 16 milli-Curies of Cs-137 was out of service and scheduled for replacement when it was inappropriately removed from a belt line by a maintenance worker and thrown in a scrap metal hopper for later recycling on May 13, 2022. The licensee conducted scheduled 6 month physical inventory on June 1, 2022 and discovered a gauge was missing from the belt line where it had been installed. Carmeuse personnel conducted a search of the premises and discovered the gauge in scrap metal hopper under additional scrap metal and approximately 10 inches of gravel. The licensee reported the material contained in the hopper is placed there using equipment (e.g. forklifts, etc.). The licensee removed the device from scrap the metal bin and conducted radiation surveys. Reported exposure rates approximately were 30 mR/hr on contact. The gauge was placed in a steel cabinet for storage with reported exposure rates of less-than 1 mR/hr on exterior. All was work performed without notification to or consultation with [Radiation Health Branch] RHB. The licensee indicated the metal cabinet is located in a warehouse on premises, but made no mention of security, access control, posting, relationship to occupied spaces, etc. The licensee reported to RHB in written response that 'device was rusted and shutter was not reliable' which was itself reportable. No mention was made of lock out/tag out, position of shutter mechanism, condition of labels, presence of posting, training of worker who performed removal work, etc. A reactive inspection planned for June 8, 2022."
The following report was received from the state of Kentucky via email:
"A Berthold fixed gauging device containing 16 milli-Curies of Cs-137 was out of service and scheduled for replacement when it was inappropriately removed from a belt line by a maintenance worker and thrown in a scrap metal hopper for later recycling on May 13, 2022. The licensee conducted scheduled 6 month physical inventory on June 1, 2022 and discovered a gauge was missing from the belt line where it had been installed. Carmeuse personnel conducted a search of the premises and discovered the gauge in scrap metal hopper under additional scrap metal and approximately 10 inches of gravel. The licensee reported the material contained in the hopper is placed there using equipment (e.g. forklifts, etc.). The licensee removed the device from scrap the metal bin and conducted radiation surveys. Reported exposure rates approximately were 30 mR/hr on contact. The gauge was placed in a steel cabinet for storage with reported exposure rates of less-than 1 mR/hr on exterior. All was work performed without notification to or consultation with [Radiation Health Branch] RHB. The licensee indicated the metal cabinet is located in a warehouse on premises, but made no mention of security, access control, posting, relationship to occupied spaces, etc. The licensee reported to RHB in written response that 'device was rusted and shutter was not reliable' which was itself reportable. No mention was made of lock out/tag out, position of shutter mechanism, condition of labels, presence of posting, training of worker who performed removal work, etc. A reactive inspection planned for June 8, 2022."
Agreement State
Event Number: 55929
Rep Org: PA Bureau of Radiation Protection
Licensee: MikRon Inc.
Region: 1
City: Philadelphia State: PA
County:
License #: PA-R0331
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Kerby Scales
Licensee: MikRon Inc.
Region: 1
City: Philadelphia State: PA
County:
License #: PA-R0331
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Kerby Scales
Notification Date: 06/07/2022
Notification Time: 08:28 [ET]
Event Date: 06/05/2022
Event Time: 00:00 [EDT]
Last Update Date: 06/07/2022
Notification Time: 08:28 [ET]
Event Date: 06/05/2022
Event Time: 00:00 [EDT]
Last Update Date: 06/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Greives, Jonathan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Greives, Jonathan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SUSPICIOUS ACTIVITY RELATED TO IRRADIATOR MOVE
The following was received from the Pennsylvania Department (DEP) Bureau of Radiation Protection via email:
"On June 5, 2022, the DEP was present for the removal of an irradiator at Children's Hospital of Philadelphia, a location on University of Pennsylvania license (PA-0131). A crew member of the rigging subcontractor was seen livestreaming the operation. Campus police were immediately notified, the filming was stopped, and the crew member was removed from the site. The DEP is investigating and will update this event as soon as more information is provided."
Event Report Identification Number: PA220020
The following was received from the Pennsylvania Department (DEP) Bureau of Radiation Protection via email:
"On June 5, 2022, the DEP was present for the removal of an irradiator at Children's Hospital of Philadelphia, a location on University of Pennsylvania license (PA-0131). A crew member of the rigging subcontractor was seen livestreaming the operation. Campus police were immediately notified, the filming was stopped, and the crew member was removed from the site. The DEP is investigating and will update this event as soon as more information is provided."
Event Report Identification Number: PA220020
Power Reactor
Event Number: 55938
Facility: Columbia Generating Station
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Michael Garcia
HQ OPS Officer: Thomas Herrity
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Michael Garcia
HQ OPS Officer: Thomas Herrity
Notification Date: 06/13/2022
Notification Time: 18:21 [ET]
Event Date: 06/13/2022
Event Time: 09:23 [PDT]
Last Update Date: 06/13/2022
Notification Time: 18:21 [ET]
Event Date: 06/13/2022
Event Time: 09:23 [PDT]
Last Update Date: 06/13/2022
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):
Azua, Ray (R4DO)
Azua, Ray (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 40 | Power Operation | 40 | Power Operation |
EN Revision Imported Date: 6/14/2022
EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE
The following information was provided by the licensee via email:
"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.
"Emergency assessment capability was restored at 1008 PDT upon system restoration."
The NRC resident was notified by the licensee.
EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE
The following information was provided by the licensee via email:
"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.
"Emergency assessment capability was restored at 1008 PDT upon system restoration."
The NRC resident was notified by the licensee.
Agreement State
Event Number: 55933
Rep Org: INW Multicare
Licensee: Washington State
Region: 4
City: Spokane State: WA
County:
License #: WN-m005-1
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Ernest West
Licensee: Washington State
Region: 4
City: Spokane State: WA
County:
License #: WN-m005-1
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Ernest West
Notification Date: 06/08/2022
Notification Time: 15:35 [ET]
Event Date: 06/07/2022
Event Time: 00:00 [PDT]
Last Update Date: 06/08/2022
Notification Time: 15:35 [ET]
Event Date: 06/07/2022
Event Time: 00:00 [PDT]
Last Update Date: 06/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE
The following information was received from the Washington State Department of Health via email:
"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."
WA incident no.: WA-19-004
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 Washington State Department of Health via email:
"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."
WA incident no.: WA-19-004
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: 55942
Facility: Prairie Island
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Logan Miller
HQ OPS Officer: Brian Parks
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Logan Miller
HQ OPS Officer: Brian Parks
Notification Date: 06/14/2022
Notification Time: 15:57 [ET]
Event Date: 06/14/2022
Event Time: 08:47 [CDT]
Last Update Date: 06/14/2022
Notification Time: 15:57 [ET]
Event Date: 06/14/2022
Event Time: 08:47 [CDT]
Last Update Date: 06/14/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
FFD Group, (EMAIL)
Feliz-Adorno, Nestor (R3DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"A licensed operator supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.
"The NRC Senior Resident Inspector has been notified."
The following information was provided by the licensee via email:
"A licensed operator supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.
"The NRC Senior Resident Inspector has been notified."