Event Notification Report for October 11, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/07/2022 - 10/11/2022

Hospital
Event Number: 56133
Rep Org: Hartford Healthcare
Licensee: St. Vincent Medical Center
Region: 1
City: Bridgeport   State: CT
County:
License #: 06-00843-03
Agreement: N
Docket:
NRC Notified By: Mohammed Aljallad
HQ OPS Officer: Mike Stafford
Notification Date: 09/30/2022
Notification Time: 14:19 [ET]
Event Date: 09/29/2022
Event Time: 14:00 [EDT]
Last Update Date: 09/30/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Event Text
MEDICAL EVENT - PATIENT UNDERDOSE

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

On September 29, 2022, a patient was administered an I-131 treatment to the thyroid. The patient did not receive the additional administration of Thyrogen, a hormone meant to enhance the uptake of I-131 to the thyroid. This resulted in dose delivered to other areas of the body and an underdose to the thyroid of preliminarily greater than 20 percent. Additional preliminary calculations showed that the bladder received approximately 17 Rem and the patient received a whole body dose of 39 Rem.

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: 56134
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Illinois Institute of Technology
Region: 3
City: Chicago   State: IL
County:
License #: IL-01739-01
Agreement: Y
Docket:
NRC Notified By: Gary Foresee
HQ OPS Officer: Brian Lin
Notification Date: 09/30/2022
Notification Time: 16:51 [ET]
Event Date: 09/27/2022
Event Time: 12:00 [CDT]
Last Update Date: 09/30/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Event Text
AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received from the state of Illinois (the Agency) via email:

"At approximately 1200 CDT on September 27, 2022, the Radiation Safety Officer for Illinois Institute of Technology (RML IL-01739-01), contacted the Agency to advise of a missing Cf-252 source, which has decayed to approximately 25 nanocuries. Reportedly, approximately 30 minutes earlier, radiation protection staff noticed the door to the source storage room was unlocked and the padlock found beneath a desk. An inventory of the room led to the discovery the Cf-252 source was missing. It is unclear if this involved intentional theft. The licensee states they will continue to search for the source until Monday and will then report the theft to public safety. Agency staff requested that appropriate context for the hazard be communicated to law enforcement as well, if reported. The Agency is awaiting additional information on source model/serial number."

Illinois incident no.: IL220036

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: 56137
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester   State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Adam Koziol
Notification Date: 10/03/2022
Notification Time: 11:56 [ET]
Event Date: 09/27/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the state of Minnesota via email:

"A patient was prescribed 200 mCi of Lu-177 and received 140 mCi. Details about the cause of the underdose will follow in the 15 day report."

Minnesota event number: MN220004

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.


Hospital
Event Number: 56139
Rep Org: Henry Ford Hospital
Licensee: Henry Ford Hospital
Region: 3
City: Detroit   State: MI
County:
License #: 21-04-109-16
Agreement: N
Docket:
NRC Notified By: Alan Jackson
HQ OPS Officer: Kerby Scales
Notification Date: 10/04/2022
Notification Time: 14:57 [ET]
Event Date: 10/03/2022
Event Time: 12:10 [EDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
MEDICAL EVENT - INCORRECT WRITTEN DIRECTIVE

The following information was provided by the licensee via phone:

On 10/3/22, a medical event occurred when a written directive was incorrect. The nuclear medicine staff recognized the written directive was incorrect and delivered the correct dose to the proper location. The patient was not harmed.

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.


Non-Agreement State
Event Number: 56141
Rep Org: SCI Engineering, INC
Licensee: SCI Engineering, INC
Region: 3
City: Walton Spring   State: MO
County: St. Charles
License #: 24-20039-01
Agreement: N
Docket:
NRC Notified By: Dave Nolan
HQ OPS Officer: Thomas Herrity
Notification Date: 10/04/2022
Notification Time: 16:08 [ET]
Event Date: 06/12/2022
Event Time: 10:30 [CDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
NUCLEAR DENSITY GAUGE DAMAGED BY VEHICLE

The following information was provided by the licensee via phone call:

At 1030 CDT on June 12, 2022, a Humboldt gauge Model 5001, containing 10 mCi of Cs-137 and 40 mCi of Am 241, was damaged by a construction vehicle. The sources were in the safe position at the time of the event. The unit's case was damaged, but the sources were not damaged. The gauge area was quarantined. A repair company was contacted. The repair company surveyed the area, and the survey indicated that there was no leakage or contamination. The repair company took possession of the gauge.


Agreement State
Event Number: 56142
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: JFK Medical Center
Region: 1
City: Edison   State: NJ
County:
License #: 441325
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Kerby Scales
Notification Date: 10/04/2022
Notification Time: 15:56 [ET]
Event Date: 10/03/2022
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - INADVERTENT PAUSE IN TREATMENT

The following was received from the state of New Jersey via email:

"While treating a patient with a gamma-knife icon unit, there was an apparent activation of the emergency stop. No one admits to touching the emergency stop button, but the sources retracted, the unit doors remained open, and the table functions were frozen. One of the authorized medical physicists (AMP) entered the room and manually retracted the table from the unit, as per emergency procedures. The licensee reported that this is the protocol when the emergency (red) console button is pushed. The AMP and one of the authorized users (AU) helped the patient off the table. The couch lever was pushed back into place and the unit was reset so the doors would close.

"The AMP observed the treatment time at the back of the unit. The AMP repeated the sector position check of the unit without incident. The licensee contacted the device manufacturer, Elekta, about the incident. They reported that Elekta informed them it was acceptable to proceed and complete the patient treatment. They then resumed and completed the patient's treatment without further incident. The events were documented in the patient's record.

"The manufacturer sent a service technician to the licensee the next day (i.e., today, October 4, 2022) to inspect the unit, make any needed repairs and check the log files. After review of the logs, the AMP and Elekta believe patient movement triggered the incident. The dose to the AMP and AU was estimated to be 0.134 mrem. This was not a medical event, since the planned treatment was completed."


Power Reactor
Event Number: 56147
Facility: Vogtle
Region: 2     State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Chad Everitt
HQ OPS Officer: Ernest West
Notification Date: 10/06/2022
Notification Time: 10:06 [ET]
Event Date: 10/06/2022
Event Time: 02:44 [EDT]
Last Update Date: 10/06/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Defueled 0 Defueled
Event Text
AUTOMATIC ACTUATION OF REACTOR PROTECTION SYSTEM (RPS)

The following information was provided by the licensee via email:

"At 0244 EDT on 10/06/2022, with Unit 3 Defueled at 0 percent power, an actuation of the RPS occurred during restoration of Division B Class 1E DC and uninterruptible power supply system. The reason for the RPS actuation was due to the opening of the Division B passive residual heat removal (PRHR) heat exchanger outlet flow control valve. The reactor trip breakers were in an open state at the time of the event when the RPS signal was received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the RPS.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."


Fuel Cycle Facility
Event Number: 56149
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: Tom Holly
HQ OPS Officer: Adam Koziol
Notification Date: 10/06/2022
Notification Time: 13:06 [ET]
Event Date: 10/05/2022
Event Time: 15:00 [EDT]
Last Update Date: 10/14/2022
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (b)(2) - Loss Or Degraded Safety Items
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fuels Group, - (EMAIL)
Event Text
EN Revision Imported Date: 10/14/2022

EN Revision Text: DEGRADATION OF SAFETY ITEMS

The following information was provided by the licensee via e-mail:

"NFS [Nuclear Fuel Services, Inc.] evaluated a degraded Item Relied On For Safety (IROFS) in accordance with the documented Integrated Safety Analysis. During this review, the event was determined to be NON-REPORTABLE as additional controls were available and performance criteria maintained. However, during the detailed review of past performance, when the IROFS that was available in this scenario failed, the redundant IROFS would have been degraded.

"There were no actual radiological or other nuclear safety consequences to the public, workers, or the environment.

"The Senior Resident Inspector and Region II staff were notified."

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

The plant was shutdown pending repair or implementation of compensating measures.


Power Reactor
Event Number: 56152
Facility: Cooper
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Scott Johnson
HQ OPS Officer: Ernest West
Notification Date: 10/07/2022
Notification Time: 05:41 [ET]
Event Date: 10/07/2022
Event Time: 00:50 [CDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xii) - Offsite Medical
Person (Organization):
Dixon, John (R4DO)
Crouch, Howard (IR)
Miller, Chris (NRR EO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
EN Revision Imported Date: 11/4/2022

EN Revision Text: POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED TO HOSPITAL

The following information was provided by the licensee via fax:

"On 10/7/2022 at 0050 CDT, a potentially contaminated individual was transported off-site via ambulance to a local hospital. Due to the nature of the medical condition, an initial on-site survey for radioactive contamination was not performed prior to transport. Prior to arrival at the hospital, it was confirmed the individual and [the individual's] clothing were not radiologically contaminated. Follow-up surveys performed by radiation technicians identified no radiological contamination of the ambulance and response personnel. This event is being reported per 50.72(b)(3)(xii) - 'Any event requiring the transport of a radioactively contaminated person to an offsite medical facility for treatment.' The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 56153
Facility: Braidwood
Region: 3     State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Vincent Roddy
HQ OPS Officer: Ian Howard
Notification Date: 10/07/2022
Notification Time: 08:35 [ET]
Event Date: 10/07/2022
Event Time: 01:19 [CDT]
Last Update Date: 10/07/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
CONTROL ROD DRIVE MECHANISM (CRDM) PENETRATION DEGRADED

The following information was provided by the licensee via fax:

"Control Rod Drive Mechanism (CRDM) penetration 69 degraded.

"At 0119 [CDT] on October 7, 2022, it was determined that the CRDM penetration 69 was degraded because examination identified unacceptable indications in accordance with ASME Code Case N-729-6. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, November 04, 2022