Event Notification Report for July 18, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/15/2022 - 07/18/2022

!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55871
Facility: FitzPatrick
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Caleb Wallace
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/29/2022
Notification Time: 20:44 [ET]
Event Date: 04/29/2022
Event Time: 12:51 [EDT]
Last Update Date: 07/15/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Young, Matt (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 7/18/2022

EN Revision Text: HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE

The following information was provided by the licensee via email:

"At 1251 EDT on April 29, 2022, while troubleshooting the failure of the High Pressure Coolant Injection (HPCI) Exhaust Drain Pot High Level Alarm to clear, it was discovered that the High Pressure Coolant Injection exhaust line condensate drain system was not functioning as designed to support removal of condensate from the turbine exhaust. This resulted in some water accumulation in the turbine casing. Subsequently, the High Pressure Coolant Injection System was declared inoperable. As a result, this condition is being reported under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented fulfillment of the safety function at the time of discovery. "

* * * RETRACTION ON 07/15/22 AT 1943 EDT FROM EVAN THOMPSON TO LLOYD DESOTELL * * *

"A technical evaluation of this event was performed and concluded that the HPCI system would have been operable with this condition. If HPCI turbine actuated with the estimated amount of condensate accumulated in the casing and connecting piping, it would have performed its safety function; the HPCI Turbine Exhaust Rupture Disc would not have been challenged by calculated peak pressures; and calculated water hammer loads were within specified load capacities of the turbine flange, downstream piping, struts, snubber, and spring hanger. Based on this, the condition reported in EN 55871 is being retracted."

Notified R1DO (Bickett)


Agreement State
Event Number: 55982
Rep Org: Wisconsin Radiation Protection
Licensee: 3M Company
Region: 3
City: Menomonie   State: WI
County:
License #: 033-2030-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 12:19 [ET]
Event Date: 07/07/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 7/11/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Wisconsin Department of Health Services via email:

"On July 8, 2022, the State was contacted by a representative of the licensee to report a radiation event that had been identified on July 7. The licensee was performing routine checks on a fixed gauge device, and the individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. The device is believed to have been stuck open for approximately 13 hours. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized. The device is a Mahlo Model 11-200933, [serial number] SN: 11-011988. It contains an Eckert and Ziegler Pm-147 [Model] PHC.C1 source, SN:AH-4968. It has an assay date of April 15, 2016, 1000 mCi. It currently contains approximately 193 mCi. The licensee performed a dose reconstruction of any individual who would have been at the 8 foot boundary of the gauge, which indicates minimal exposure. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee."

WI incident no.: WI220014


Agreement State
Event Number: 55983
Rep Org: Colorado Dept of Health
Licensee: Facebook-Denver
Region: 4
City: Denver   State: CO
County:
License #: GL002581
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 15:39 [ET]
Event Date: 06/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received from the Colorado Department of Public Health and Environment (the department) via email:

The department was notified on June 6, 2022, that two SLX-60 Exit signs containing 7.62 Ci each of H-3 were lost in 2021. No additional information was provided.

CO incident no.: CO220021

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State
Event Number: 55984
Rep Org: Iowa Department of Public Health
Licensee: 3M
Region: 3
City: Knoxville   State: IA
County:
License #: 0042163FG
Agreement: Y
Docket:
NRC Notified By: Derek Elling
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:38 [ET]
Event Date: 07/07/2022
Event Time: 15:15 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Iowa Department of Public Health (IDPH) via email:

"At 1515 CDT, July 7, 2022, an NDC Technologies, Model 302 fixed gauge with [approximately] 80 mCi of Kr-85 had a shutter stick open when the line was turned off. The shutter was first identified as stuck open around 1600 when the Radiation Safety Officer was conducting their entrance radiation survey. Radiation safety perimeter was established. The service provider was called and arrived the morning of July 8, 2022. They were able to close the shutter but unable to conduct cause analysis. The gauge will be shipped back to vendor to safely analyze for cause. The IDPH will decide on a reactive inspection based on the cause of stuck shutter identified by the vendor.
Licensee aware of 30 day written notification requirement."

IA incident no.: IA220004


Agreement State
Event Number: 55985
Rep Org: Colorado Dept of Health
Licensee: Home Depot
Region: 4
City: Denver   State: CO
County:
License #: GL000714
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:06 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following summary was received from the Colorado Department of Public Health and Environment via email:

On June 6, 2022, the Colorado Department of Public Health and Environment reported one model 2040 exit sign containing an unknown amount of tritium lost by the licensee. The incident occurred between 2009-2010.

CO incident no.: CO220022

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State
Event Number: 55986
Rep Org: Alabama Radiation Control
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva   State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Event Text
EN Revision Imported Date: 7/11/2022

EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:

"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."

AL incident no.: 22-10

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: 55987
Rep Org: Alabama Radiation Control
Licensee: Southeast Health
Region: 1
City: Dothan   State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Event Text
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION

The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:

"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."

AL incident no.: 21-29

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: 55996
Facility: Braidwood
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rich Rowe
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/15/2022
Notification Time: 17:34 [ET]
Event Date: 07/15/2022
Event Time: 10:35 [CDT]
Last Update Date: 07/15/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Kozak, Laura (R3DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
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
Event Text
FITNESS-FOR-DUTY REPORT

The following information was provided by the licensee via email:

"At 1035 CDT on 7/15/2022, it was determined that a non-licensed supervisor tested positive in accordance with the fitness-for-duty testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 55997
Facility: Brunswick
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kevin Kingston
HQ OPS Officer: Bill Gott
Notification Date: 07/15/2022
Notification Time: 23:41 [ET]
Event Date: 07/15/2022
Event Time: 20:20 [EDT]
Last Update Date: 07/16/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 100 Power Operation
Event Text
HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE

The following information was provided by the licensee via email:

"At 2020 Eastern Daylight Time (EDT) on July 15, 2022, the HPCI System was declared inoperable. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) were operable during this time.

"HPCI availability was restored at 2023. Additional investigation is in-progress.

"There was no impact on the health and safety of the public or plant personnel.

"Unit 2 is not affected by this event.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

HPCI is considered inoperable but available at this time, resulting in a 14-day Shutdown LCO [Limiting Condition for Operation], due to the HPCI inoperability.

Page Last Reviewed/Updated Monday, July 18, 2022