Event Notification Report for October 20, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/19/2022 - 10/20/2022

EVENT NUMBERS
56156 56160 56168
Agreement State
Event Number: 56156
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: Brian Lin
Notification Date: 10/10/2022
Notification Time: 14:18 [ET]
Event Date: 09/28/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 10/19/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION

The following summary was received from the Minnesota Department of Health via email:

A patient undergoing Lu-177 therapy was administered 110 mCi vice the prescribed 200 mCi. An investigation is in progress by the Minnesota Department of Health.

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.

Minnesota Event ID: MN220005

* * * UPDATE FROM TYLER KRUSE TO DONALD NORWOOD AT 0907 EDT ON 10/17/2022 * * *
The following information was received via email:
"The event date for this event was 09/28/2022. This event was discovered while investigating the event that occurred on 09/27/2022." [That event is recorded as EN56137.]
Notified R3DO (Kunowski) and NMSS Events Notification email group.


Agreement State
Event Number: 56160
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Siemens Medical Solutions
Region: 3
City: Hoffman Estates   State: IL
County:
License #: IL-01130-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Kerby Scales
Notification Date: 10/13/2022
Notification Time: 16:10 [ET]
Event Date: 10/12/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following was received from the Illinois Emergency Management Agency (IEMA or the Agency) via email:

"On 10/12/2022, the Radiation Safety Officer [RSO] at Siemens Medical Solutions USA, Inc. (IL-01130-02), notified the Agency regarding a leaking Co-57 sealed source received on 10/12/2022 from the manufacturer, Eckert & Ziegler. The 15 mCi point source was opened and handled in a restricted area behind a small L-block. Upon removal from the packaging (noted as intact), the source was placed in a tungsten holder and was promptly leak tested by the RSO. Leak test results indicated contamination levels of 23,000 dpm [disintegrations per minute] on the source capsule and 140,000 dpm on the inside of the baggie in which the source was shipped in. Subsequent area and personal surveys were performed with no contamination noted. The source, baggie and a few tools used in the initial handling of the source were doubled bagged and remain secured at Siemens pending return to the manufacturer. The leaking source was reported to IEMA within 5 days as required in accordance with 32 Illinois Administrative Code 340.1260 and was then reported to the NRC as required. The investigation is ongoing."

Illinois Item Number: IL220039


Power Reactor
Event Number: 56168
Facility: Browns Ferry
Region: 2     State: AL
Unit: [3] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Alex Neumann
HQ OPS Officer: Adam Koziol
Notification Date: 10/18/2022
Notification Time: 22:08 [ET]
Event Date: 10/18/2022
Event Time: 14:40 [CDT]
Last Update Date: 10/18/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
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
3 N Y 100 Power Operation 100 Power Operation
Event Text
STANDBY LIQUID CONTROL INOPERABLE

The following information was provided by the licensee via email:

"On 10/18/2022 at 1440 CDT, Browns Ferry Unit 3 declared both trains of standby liquid control (SLC) inoperable due to acceptance criteria failure of 3-SI-3.1.7.6, 'Standby Liquid Control System ATWS Equivalency Calculation for Newly Established Pump Flow Rate.' The purpose of this surveillance is to ensure the anticipated transient without scram (ATWS) calculation criteria is met after each pump flow test.

"Chemistry performed the surveillance following pump flow testing and the requirement for equivalency calculation failed low with a result of less than 1.0. CR 1810303 documents this condition in the corrective action program.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(A), 10 CFR 50.72(b)(3)(v)(C), and 10 CFR 50.72(b)(3)(v)(D). This condition is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(v)(A),10 CFR 50.73(a)(2)(v)(C), and 10 CFR 50.73(a)(2)(v)(D)."

The NRC Resident Inspector has been notified of this event.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer's report guidance:

The plant entered an 8 hour limiting condition for operation based on the above. The condition was resolved at 2053 CDT when the system was restored to normal operation.

Page Last Reviewed/Updated Thursday, October 20, 2022