Event Notification Report for September 26, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/25/2022 - 09/26/2022
Agreement State
Event Number: 56110
Rep Org: Kansas Dept of Health & Environment
Licensee: KC Testing And Engineering, LLC
Region: 4
City: Kansas City State: KS
County:
License #: 22-C250-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Steves
HQ OPS Officer: Karen Cotton-Gross
Licensee: KC Testing And Engineering, LLC
Region: 4
City: Kansas City State: KS
County:
License #: 22-C250-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Steves
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/16/2022
Notification Time: 16:42 [ET]
Event Date: 09/16/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2022
Notification Time: 16:42 [ET]
Event Date: 09/16/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - STOLEN GAUGE
The following information was provided by the Kansas Department of Health & Environment (KDHE) via email:
"On 9/16/2022 (morning), a technician with Kansas City Testing and Engineering, LLC, discovered his work truck had been broken into overnight near his home. The truck had been parked across the street from the technician's apartment. The rear passenger window was completely shattered and the Troxler moisture density gauge was missing along with a few hundred dollars of personal property and an estimated one thousand dollars of work equipment. The technician immediately called the RSO [Radiation Safety Officer] of Kansas City Testing and Engineering. Then, the technician filed a police report with local law enforcement. The RSO reported that he had called the Nuclear Regulatory Commission (NRC) to report the incident, but that the NRC had instructed him to report it to KDHE [beforehand]. The RSO also stated he reported the incident to Troxler. Stolen equipment was a Troxler 3440P (Serial Number 77305). According to the license, the sources are an 8 mCi Cs-137 and a 40 mCi Am-241/Be.
"At 1030 CDT on 9/16/2022, the inspector met in person with the technician at a job site. The inspector was informed that the gauge had been locked in the backseat of the truck cab and secured with a chain and a padlock through a metal anchor bracket. The metal anchor bracket had been cut. The gauge, chain, and padlock were all removed from the truck.
"This incident occurred in Missouri and the licensee also holds an NRC radioactive materials license."
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
The following information was provided by the Kansas Department of Health & Environment (KDHE) via email:
"On 9/16/2022 (morning), a technician with Kansas City Testing and Engineering, LLC, discovered his work truck had been broken into overnight near his home. The truck had been parked across the street from the technician's apartment. The rear passenger window was completely shattered and the Troxler moisture density gauge was missing along with a few hundred dollars of personal property and an estimated one thousand dollars of work equipment. The technician immediately called the RSO [Radiation Safety Officer] of Kansas City Testing and Engineering. Then, the technician filed a police report with local law enforcement. The RSO reported that he had called the Nuclear Regulatory Commission (NRC) to report the incident, but that the NRC had instructed him to report it to KDHE [beforehand]. The RSO also stated he reported the incident to Troxler. Stolen equipment was a Troxler 3440P (Serial Number 77305). According to the license, the sources are an 8 mCi Cs-137 and a 40 mCi Am-241/Be.
"At 1030 CDT on 9/16/2022, the inspector met in person with the technician at a job site. The inspector was informed that the gauge had been locked in the backseat of the truck cab and secured with a chain and a padlock through a metal anchor bracket. The metal anchor bracket had been cut. The gauge, chain, and padlock were all removed from the truck.
"This incident occurred in Missouri and the licensee also holds an NRC radioactive materials license."
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: 56111
Rep Org: Alabama Radiation Control
Licensee: Huntsville Hospital
Region: 1
City: Huntsville State: AL
County:
License #: RML 274
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Bill Gott
Licensee: Huntsville Hospital
Region: 1
City: Huntsville State: AL
County:
License #: RML 274
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Bill Gott
Notification Date: 09/16/2022
Notification Time: 16:53 [ET]
Event Date: 09/16/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2022
Notification Time: 16:53 [ET]
Event Date: 09/16/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Clark, Theresa (NMSS)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Clark, Theresa (NMSS)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION-DIAGNOSTIC
The following information was provided by Alabama Radiation Control via email:
"The licensee reported that a patient was scheduled on 9/16/2022 for a 1-day protocol. The patient was scheduled to receive 36 millicuries of Tc-99m labeled sestamibi/Cardiolite. The patient mistakenly received 36 millicuries of Tc-99m sodium pertechnetate. This matter does appear to meet Alabama's criteria for a misadministration with approximately 1731.6 mrem WB EDE [whole body effective dose equivalent], the highest organ/tissue does appears to be to the wall of the upper large intestine at 7592.4 mrem.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident No.: 22-17
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 provided by Alabama Radiation Control via email:
"The licensee reported that a patient was scheduled on 9/16/2022 for a 1-day protocol. The patient was scheduled to receive 36 millicuries of Tc-99m labeled sestamibi/Cardiolite. The patient mistakenly received 36 millicuries of Tc-99m sodium pertechnetate. This matter does appear to meet Alabama's criteria for a misadministration with approximately 1731.6 mrem WB EDE [whole body effective dose equivalent], the highest organ/tissue does appears to be to the wall of the upper large intestine at 7592.4 mrem.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident No.: 22-17
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: 56119
Facility: FitzPatrick
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Caleb Wallace
HQ OPS Officer: Bill Gott
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Caleb Wallace
HQ OPS Officer: Bill Gott
Notification Date: 09/26/2022
Notification Time: 05:41 [ET]
Event Date: 09/26/2022
Event Time: 03:06 [EDT]
Last Update Date: 09/26/2022
Notification Time: 05:41 [ET]
Event Date: 09/26/2022
Event Time: 03:06 [EDT]
Last Update Date: 09/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Arner, Frank (R1DO)
Arner, Frank (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 0 | Startup | 0 | Hot Standby |
AUTOMATIC REACTOR SCRAM
The following information was provided by the licensee via email:
"At 0001 EDT on September 26, 2022, James A. FitzPatrick (JAF) removed the generator from service as part of a planned shutdown for refueling.
"At 0306 EDT, with the mode switch in Startup/Hot Standby and inserting rods, JAF experienced a spurious Scram and closure of seven out of eight main steam isolation valves (MSIV's). The reactor protection system (RPS) actuated during the event, resulting in all control rods being fully inserted.
"The cause of the closure of MSIV's and the Scram is being investigated.
"This condition is being reported as a four-hour NRC report per 10 CFR 50.72(b)(2)(iv)(B) for RPS actuation, and as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the safety system actuation based on the multiple main steam isolation valves closing on an isolation signal.
"There was no impact to the health and safety of the public. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 0001 EDT on September 26, 2022, James A. FitzPatrick (JAF) removed the generator from service as part of a planned shutdown for refueling.
"At 0306 EDT, with the mode switch in Startup/Hot Standby and inserting rods, JAF experienced a spurious Scram and closure of seven out of eight main steam isolation valves (MSIV's). The reactor protection system (RPS) actuated during the event, resulting in all control rods being fully inserted.
"The cause of the closure of MSIV's and the Scram is being investigated.
"This condition is being reported as a four-hour NRC report per 10 CFR 50.72(b)(2)(iv)(B) for RPS actuation, and as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the safety system actuation based on the multiple main steam isolation valves closing on an isolation signal.
"There was no impact to the health and safety of the public. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56120
Facility: LaSalle
Region: 3 State: IL
Unit: [2] [] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Jeff Nugent
HQ OPS Officer: Bill Gott
Region: 3 State: IL
Unit: [2] [] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Jeff Nugent
HQ OPS Officer: Bill Gott
Notification Date: 09/26/2022
Notification Time: 06:39 [ET]
Event Date: 09/26/2022
Event Time: 02:38 [CDT]
Last Update Date: 09/26/2022
Notification Time: 06:39 [ET]
Event Date: 09/26/2022
Event Time: 02:38 [CDT]
Last Update Date: 09/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Szwarc, Dariusz (R3DO)
Miller, Chris (NRR EO)
Crouch, Howard (IR)
Szwarc, Dariusz (R3DO)
Miller, Chris (NRR EO)
Crouch, Howard (IR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 100 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO REPORTED FIRE ON ISOPHASE BUS DUCT
The following information was provided by the licensee via fax email:
"At 0238 CDT on 9/26/2022 with Unit 2 in Mode 1 at 100 percent power, the reactor manually tripped due to a reported fire on the isophase bus duct. The trip was uncomplicated with all systems responding normally post-trip with the exception of the 2A reactor protection system power supply, which tripped and power was transferred to the alternate source. The fire was reported extinguished at 0240 CDT on 9/26/2022. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"Operations responded using the emergency operating procedure LGA-001 and stabilized the plant in Mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via fax email:
"At 0238 CDT on 9/26/2022 with Unit 2 in Mode 1 at 100 percent power, the reactor manually tripped due to a reported fire on the isophase bus duct. The trip was uncomplicated with all systems responding normally post-trip with the exception of the 2A reactor protection system power supply, which tripped and power was transferred to the alternate source. The fire was reported extinguished at 0240 CDT on 9/26/2022. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"Operations responded using the emergency operating procedure LGA-001 and stabilized the plant in Mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56127
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Yolanda Good
HQ OPS Officer: Ernest West
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Yolanda Good
HQ OPS Officer: Ernest West
Notification Date: 09/26/2022
Notification Time: 21:16 [ET]
Event Date: 09/26/2022
Event Time: 11:00 [MST]
Last Update Date: 09/26/2022
Notification Time: 21:16 [ET]
Event Date: 09/26/2022
Event Time: 11:00 [MST]
Last Update Date: 09/26/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Kellar, Ray (R4DO)
FFD Group, (EMAIL)
Kellar, Ray (R4DO)
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 |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the licensee via email:
"On September 26, 2022, at approximately 1100 Mountain Standard Time, a Reactor Operator's test results were confirmed positive for use of a controlled substance following a random Fitness For Duty (FFD) screening test and it was determined that the individual violated the station's FFD Policy. The individual's unescorted access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee will conduct an investigation of the individual's work history.
The following information was provided by the licensee via email:
"On September 26, 2022, at approximately 1100 Mountain Standard Time, a Reactor Operator's test results were confirmed positive for use of a controlled substance following a random Fitness For Duty (FFD) screening test and it was determined that the individual violated the station's FFD Policy. The individual's unescorted access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee will conduct an investigation of the individual's work history.
Power Reactor
Event Number: 56128
Facility: Saint Lucie
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ronald Cappillo
HQ OPS Officer: Ernest West
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ronald Cappillo
HQ OPS Officer: Ernest West
Notification Date: 09/26/2022
Notification Time: 22:39 [ET]
Event Date: 09/26/2022
Event Time: 17:41 [EDT]
Last Update Date: 09/26/2022
Notification Time: 22:39 [ET]
Event Date: 09/26/2022
Event Time: 17:41 [EDT]
Last Update Date: 09/26/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1741 on September 26, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw detected during plant pressurization in preparation for startup following refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100% power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 1741 on September 26, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw detected during plant pressurization in preparation for startup following refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100% power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."