Event Notification Report for September 15, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/14/2022 - 09/15/2022

EVENT NUMBERS
56096 56097 56098 56108
Agreement State
Event Number: 56096
Rep Org: LA Dept of Environmental Quality
Licensee: ExxonMobil Baton Rouge Plastics
Region: 4
City: Baton Rouge   State: LA
County:
License #: LA-2349-L01, Amendment 40
Agreement: Y
Docket:
NRC Notified By: Russell Clark
HQ OPS Officer: Bethany Cecere
Notification Date: 09/08/2022
Notification Time: 14:07 [ET]
Event Date: 09/07/2022
Event Time: 14:56 [CDT]
Last Update Date: 09/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - TWO GAUGES WITH STUCK SHUTTERS

The following information was received by email from the state of Louisiana Department of Environmental Quality (the Department/LDEQ):

"On September 7, 2022, at approximately 1456 CDT, [the] Site Environmental Coordinator and Radiation Safety Officer (RSO) for ExxonMobil Baton Rouge Plastics Plant, notified LDEQ of equipment malfunctions. The licensee reported that two level/density gauges located at the ExxonMobil Baton Rouge Plastics Plant have shutters that cannot be closed. The two gauges are Ronan Model SA1-F37, device serial numbers, BDL012X and BDL011BX, respectively, installed on the reactor vessel on May 12, 2008. The gauges are installed in a vertical configuration on low pressure separator vessel, V201B within the B-Line unit. The gauges each contain one sealed source with 500 mCi of Cs-137, source serial numbers, 2577CN and 2555CN, respectively.

"The gauges were undergoing routine annual shutter tests when the malfunctions were observed. [The] Lead Instrumentation and Electronics Technician and Assistant RSO for the licensee, notified [the RSO] concerning the stuck gauge shutters at approximately 1000 CDT on September 7, 2022. The gauge shutters remain open, as the gauges are needed to operate process control equipment. The gauges cannot be locked out in their current state. As a result, no vessel entries will be conducted.

"The licensee will continue to monitor the gauges' status of repair and will keep the Department updated on the progress of the repairs. No exposures to radiation workers or members of the public above regulatory limits occurred.

"The licensee plans to meet with the vendor representative to discuss recommendations and a path forward. After repairs are completed, shutter tests and radiation surveys will be conducted according to regulatory requirements to ensure that the gauges operate according to design. The licensee shall notify the Department when corrective actions are completed."

LA incident no.: LA20220007


Agreement State
Event Number: 56097
Rep Org: MA Dept of Public Health
Licensee: Beth Israel Deaconess Medical Ctr
Region: 1
City: Boston   State: MA
County:
License #: 60-0432
Agreement: Y
Docket:
NRC Notified By: Bruce Packard
HQ OPS Officer: Bethany Cecere
Notification Date: 09/08/2022
Notification Time: 16:42 [ET]
Event Date: 09/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 MICROSPHERES

The following was submitted by the MA Department of Public Health (Agency) by email:

"On 9/8/2022, 0930 EDT, [the] licensee reported potential medical event under license 60-0432 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 18 to 22.8 percent or more. A portion of the Y-90 0.5 GBq microsphere therapy treatment delivered to patient liver on 9/6/22 remained in the delivery system causing delivery of 0.386 GBq to 0.41 GBq Y-90 of the prescribed 0.5 GBq. The error was reported to the RSO the next morning. The licensee stated the cause, including possible clogged catheter, has not yet been determined. The prescribing physician has been notified. Notification of the referring physician and patient is pending. The licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment is expected due to this situation. Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

"The investigation is ongoing. The Agency considers this event docket to still be open.

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: 56098
Rep Org: Texas Dept of State Health Services
Licensee: Exxon Mobile Chemical
Region: 4
City: Mont Belvieu   State: TX
County:
License #: L03119
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Solomon Sahle
Notification Date: 09/08/2022
Notification Time: 19:08 [ET]
Event Date: 09/08/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following was submitted by the TX Department of State Health Services (the Agency):

"On September 8, 2022, the Agency was notified by the licensee that on this day, the shutter on a Vega SH-F2 gauge containing a 500 milliCuries (original activity) cesium - 137 source failed to close during routine testing. Open is the normal operating position of this gauge.

"The licensee will contact the manufacture to repair the shutter. No individual received additional exposure due to this event. "

TX event number I-9954


Power Reactor
Event Number: 56108
Facility: Calvert Cliffs
Region: 1     State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ervin Lyson
HQ OPS Officer: Adam Koziol
Notification Date: 09/14/2022
Notification Time: 21:43 [ET]
Event Date: 09/14/2022
Event Time: 13:48 [EDT]
Last Update Date: 09/14/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Young, Matt (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown
Event Text
SAFETY INJECTION ACTUATION SIGNAL WHILE SHUTDOWN

The following information was provided by the licensee via email:

"With Unit 2 in Mode 5 and cooling down for a scheduled maintenance outage, Operations was bypassing safety injection and safety injection bypass sensor modules per procedure. Due to a human performance issue, a safety injection actuation signal was generated. All equipment operated as expected. Operations has reset the safety injection actuation signal and restored the equipment to its required condition.

"Unit 1 was at 100 percent power and unaffected by this issue."

The NRC Resident Inspector will be notified.