Event Notification Report for October 25, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/24/2022 - 10/25/2022
Agreement State
Event Number: 56166
Rep Org: Ohio Bureau of Radiation Protection
Licensee: University of Cincinnati MC
Region: 3
City: Cincinnati State: OH
County:
License #: 02110310001
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Lauren Bryson
Licensee: University of Cincinnati MC
Region: 3
City: Cincinnati State: OH
County:
License #: 02110310001
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Lauren Bryson
Notification Date: 10/17/2022
Notification Time: 13:27 [ET]
Event Date: 10/12/2022
Event Time: 00:00 [EDT]
Last Update Date: 10/17/2022
Notification Time: 13:27 [ET]
Event Date: 10/12/2022
Event Time: 00:00 [EDT]
Last Update Date: 10/17/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by the State of Ohio via email:
"On 10/12/2022, during routine maintenance and source exchange on an Elekta Flexitron HDR [High Dose Rate] unit the source became stuck in an unshielded position. The Elekta engineer immediately vacated the room and notified the medical physics staff and RSO [Radiation Safety Officer]. The area was secured by the RSO, and measurements taken outside of the secured area were at background. Licensee security was posted outside of the area to prevent entry until Elekta personnel could secure the source.
"Additional Elekta staff arrived and secured the source on 10/13/2022, and it was shipped back to the vendor on 10/14/2022."
Ohio Item number: OH220010
The following information was provided by the State of Ohio via email:
"On 10/12/2022, during routine maintenance and source exchange on an Elekta Flexitron HDR [High Dose Rate] unit the source became stuck in an unshielded position. The Elekta engineer immediately vacated the room and notified the medical physics staff and RSO [Radiation Safety Officer]. The area was secured by the RSO, and measurements taken outside of the secured area were at background. Licensee security was posted outside of the area to prevent entry until Elekta personnel could secure the source.
"Additional Elekta staff arrived and secured the source on 10/13/2022, and it was shipped back to the vendor on 10/14/2022."
Ohio Item number: OH220010
Agreement State
Event Number: 56167
Rep Org: Arizona Dept of Health Services
Licensee: American Metals Company
Region: 4
City: Mesa State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Karen Cotton-Gross
Licensee: American Metals Company
Region: 4
City: Mesa State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/17/2022
Notification Time: 19:35 [ET]
Event Date: 10/17/2022
Event Time: 00:00 [MST]
Last Update Date: 10/17/2022
Notification Time: 19:35 [ET]
Event Date: 10/17/2022
Event Time: 00:00 [MST]
Last Update Date: 10/17/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - GAUGE DISCOVERED IN SCRAP YARD
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"The Department received notification on October 17, 2022, from American Metals Company in Chandler, Arizona that a load of scrap metal that was sent to be melted had set off the portal monitor at CMC Steel in Mesa, Arizona. The load was brought back to their facility and they were able to identify a gauge with partial markings and a reading of approximately 0.5 mR/hr. The Department responded to the facility and was able to identify the gauge as a Ronan Engineering Co., RLL-1 gauge, with a partial serial number of 204614. The gauge contains Cesium-137 with an activity of 0.45 mCi. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident: 22-012
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"The Department received notification on October 17, 2022, from American Metals Company in Chandler, Arizona that a load of scrap metal that was sent to be melted had set off the portal monitor at CMC Steel in Mesa, Arizona. The load was brought back to their facility and they were able to identify a gauge with partial markings and a reading of approximately 0.5 mR/hr. The Department responded to the facility and was able to identify the gauge as a Ronan Engineering Co., RLL-1 gauge, with a partial serial number of 204614. The gauge contains Cesium-137 with an activity of 0.45 mCi. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident: 22-012
Power Reactor
Event Number: 56175
Facility: Vogtle
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Greg Crosby
HQ OPS Officer: Ernest West
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Greg Crosby
HQ OPS Officer: Ernest West
Notification Date: 10/23/2022
Notification Time: 11:14 [ET]
Event Date: 10/23/2022
Event Time: 04:05 [EDT]
Last Update Date: 10/23/2022
Notification Time: 11:14 [ET]
Event Date: 10/23/2022
Event Time: 04:05 [EDT]
Last Update Date: 10/23/2022
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 |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
STAGE FOUR AUTOMATIC DEPRESSURIZATION SYSTEM (ADS) INOPERABLE
The following information was provided by the licensee via email:
"At 0405 EDT on 10/23/2022, with [Vogtle] Unit 3 in Mode 6 and the reactor subcritical for greater than 28 hours, it was discovered that all three required flow paths for the stage four ADS were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The diverse actuation system was operable for manual stage four ADS during this time period.
"At 0432 EDT on 10/23/2022, two of the three required flow paths were restored to operable status, which exited the reportable condition. All required flow paths were operable at 0447 EDT.
"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 email:
"At 0405 EDT on 10/23/2022, with [Vogtle] Unit 3 in Mode 6 and the reactor subcritical for greater than 28 hours, it was discovered that all three required flow paths for the stage four ADS were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The diverse actuation system was operable for manual stage four ADS during this time period.
"At 0432 EDT on 10/23/2022, two of the three required flow paths were restored to operable status, which exited the reportable condition. All required flow paths were operable at 0447 EDT.
"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: 56176
Facility: Diablo Canyon
Region: 4 State: CA
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian Engleton
HQ OPS Officer: Adam Koziol
Region: 4 State: CA
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian Engleton
HQ OPS Officer: Adam Koziol
Notification Date: 10/23/2022
Notification Time: 19:05 [ET]
Event Date: 10/23/2022
Event Time: 08:30 [PDT]
Last Update Date: 10/23/2022
Notification Time: 19:05 [ET]
Event Date: 10/23/2022
Event Time: 08:30 [PDT]
Last Update Date: 10/23/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Groom, Jeremy (R4DO)
Groom, Jeremy (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY DEGRADATION
The following information was provided by the licensee via email:
"At 0830 PDT on 10/23/2022, during routine outage inspections on Unit 2, it was determined that the RCS Pressure Boundary did not meet ASME Section XI acceptance criteria on a 2-inch vacuum refill connection line. This event is being reported pursuant to 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."
The following information was provided by the licensee via email:
"At 0830 PDT on 10/23/2022, during routine outage inspections on Unit 2, it was determined that the RCS Pressure Boundary did not meet ASME Section XI acceptance criteria on a 2-inch vacuum refill connection line. This event is being reported pursuant to 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."
Power Reactor
Event Number: 56177
Facility: Catawba
Region: 2 State: SC
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Mike James
HQ OPS Officer: Ian Howard
Region: 2 State: SC
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Mike James
HQ OPS Officer: Ian Howard
Notification Date: 10/24/2022
Notification Time: 11:40 [ET]
Event Date: 10/24/2022
Event Time: 08:57 [EDT]
Last Update Date: 10/24/2022
Notification Time: 11:40 [ET]
Event Date: 10/24/2022
Event Time: 08:57 [EDT]
Last Update Date: 10/24/2022
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):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 7 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP AND AUXILIARY FEEDWATER SYSTEM ACTUATION
The following information was provided by the licensee via email:
"On 10/24/2022 at 0857 EDT, with Unit 2 in Mode 1 at 7 percent power, the reactor was manually tripped due to a 2B train main feedwater pump trip. The trip was not complex, with all systems responding normally post-trip. The auxiliary feedwater (AFW) system started automatically as expected. Operations responded and stabilized the plant. Decay heat is being removed by the steam generators and discharging to the condenser. Unit 1 is not affected.
"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). The automatic start of the auxiliary feedwater system is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).
"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 email:
"On 10/24/2022 at 0857 EDT, with Unit 2 in Mode 1 at 7 percent power, the reactor was manually tripped due to a 2B train main feedwater pump trip. The trip was not complex, with all systems responding normally post-trip. The auxiliary feedwater (AFW) system started automatically as expected. Operations responded and stabilized the plant. Decay heat is being removed by the steam generators and discharging to the condenser. Unit 1 is not affected.
"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). The automatic start of the auxiliary feedwater system is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Part 21
Event Number: 56178
Rep Org: Tioga Pipe Inc.
Licensee: Tioga Pipe Inc.
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Ian Howard
Licensee: Tioga Pipe Inc.
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Ian Howard
Notification Date: 10/24/2022
Notification Time: 16:21 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/25/2022
Notification Time: 16:21 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/25/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Dentel, Glenn (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Dentel, Glenn (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 10/26/2022
EN Revision Text: PART 21 - TIOGA PIPE PURCHASED AND SUPPLIED UNQUALIFIED PIPING
The following information was provided by Tioga Pipe via email:
"Tioga Pipe Inc. purchased unqualified [piping] from Maxim Tubes Company PVT. LTD. The unqualified [piping] passed all required tests and examinations in accordance with the requirements of ASME NCA-4255.5, however, the material was identified with multiple linear indications located on the inside diameter [surface] of the pipe. The indications were discovered by Duke Energy during their pre-fabrication inspection at the Catawba Nuclear Station. The indications ranged from one quarter of an inch to well over an inch in length. This material along with the material with the same heat number at McGuire Nuclear Station was returned to Tioga Pipe for further evaluation. The evaluation found these indications to be lap-like and thus, rejectable in accordance with ASME SA999 paragraph 28.12.
"All material supplied from Maxim Tubes Company PVT. LTD. has been identified by Duke, found not to be installed, and returned to Tioga Pipe. At this time, all of the defective material is in Tioga's possession and there is no risk of this defective material being installed into a nuclear facility."
* * * UPDATE ON 10/25/2022 AT 1657 EDT FROM SHANNON ECHOLS TO IAN HOWARD * * *
Mackson Nuclear, a Tioga Company, submitted the Tioga report referenced above via email.
Notified Part 21/50.55 Reactors group via email.
EN Revision Text: PART 21 - TIOGA PIPE PURCHASED AND SUPPLIED UNQUALIFIED PIPING
The following information was provided by Tioga Pipe via email:
"Tioga Pipe Inc. purchased unqualified [piping] from Maxim Tubes Company PVT. LTD. The unqualified [piping] passed all required tests and examinations in accordance with the requirements of ASME NCA-4255.5, however, the material was identified with multiple linear indications located on the inside diameter [surface] of the pipe. The indications were discovered by Duke Energy during their pre-fabrication inspection at the Catawba Nuclear Station. The indications ranged from one quarter of an inch to well over an inch in length. This material along with the material with the same heat number at McGuire Nuclear Station was returned to Tioga Pipe for further evaluation. The evaluation found these indications to be lap-like and thus, rejectable in accordance with ASME SA999 paragraph 28.12.
"All material supplied from Maxim Tubes Company PVT. LTD. has been identified by Duke, found not to be installed, and returned to Tioga Pipe. At this time, all of the defective material is in Tioga's possession and there is no risk of this defective material being installed into a nuclear facility."
* * * UPDATE ON 10/25/2022 AT 1657 EDT FROM SHANNON ECHOLS TO IAN HOWARD * * *
Mackson Nuclear, a Tioga Company, submitted the Tioga report referenced above via email.
Notified Part 21/50.55 Reactors group via email.
Agreement State
Event Number: 56169
Rep Org: Minnesota Department of Health
Licensee: Carris Health LLC
Region: 3
City: Willmar State: MN
County:
License #: 1207
Agreement: Y
Docket:
NRC Notified By: Brandon Juran
HQ OPS Officer: Lauren Bryson
Licensee: Carris Health LLC
Region: 3
City: Willmar State: MN
County:
License #: 1207
Agreement: Y
Docket:
NRC Notified By: Brandon Juran
HQ OPS Officer: Lauren Bryson
Notification Date: 10/19/2022
Notification Time: 15:09 [ET]
Event Date: 09/22/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Notification Time: 15:09 [ET]
Event Date: 09/22/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST SEED
The following information was provided by the Minnesota Department of Health (MDH) via email:
"The Minnesota Department of Health was notified on 9/27/2022 of a lost localization seed (I-125, 0.188 mCi) that went missing on 6/30/2022. The seed was not identified as missing until 9/22/2022 during an audit. The specimen, with the seed, was transported to pathology and kept with the tissue during the processing of the sample. The pathologist believed the seed was non-radioactive due to the proper paperwork not being present with the seed (the licensee uses radioactive and magnetic seeds). The tissue specimen and seed were disposed of in the biohazard waste stream."
Minnesota Event Number: MN220006
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 Minnesota Department of Health (MDH) via email:
"The Minnesota Department of Health was notified on 9/27/2022 of a lost localization seed (I-125, 0.188 mCi) that went missing on 6/30/2022. The seed was not identified as missing until 9/22/2022 during an audit. The specimen, with the seed, was transported to pathology and kept with the tissue during the processing of the sample. The pathologist believed the seed was non-radioactive due to the proper paperwork not being present with the seed (the licensee uses radioactive and magnetic seeds). The tissue specimen and seed were disposed of in the biohazard waste stream."
Minnesota Event Number: MN220006
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
Hospital
Event Number: 56170
Rep Org: West Valley Medical Center
Licensee: West Valley Medical Center
Region: 4
City: Caldwell State: ID
County:
License #: 11-27087-01
Agreement: N
Docket:
NRC Notified By: Peri Steele
HQ OPS Officer: Adam Koziol
Licensee: West Valley Medical Center
Region: 4
City: Caldwell State: ID
County:
License #: 11-27087-01
Agreement: N
Docket:
NRC Notified By: Peri Steele
HQ OPS Officer: Adam Koziol
Notification Date: 10/19/2022
Notification Time: 20:24 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [MDT]
Last Update Date: 10/19/2022
Notification Time: 20:24 [ET]
Event Date: 11/16/2018
Event Time: 00:00 [MDT]
Last Update Date: 10/19/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
POSSIBLE MEDICAL OVERDOSE
The following is a summary of a phone call with the licensee's Radiation Safety Officer:
During a NRC inspector audit on October 18, 2022, an apparent overdose was identified when records showed a patient received 21.1 millicuries of I-131 for thyroid therapy. The prescribed dose in the file appeared to read 20 microcuries of I-131 vice 20 millicuries. There were no reported adverse effects for the patient.
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 is a summary of a phone call with the licensee's Radiation Safety Officer:
During a NRC inspector audit on October 18, 2022, an apparent overdose was identified when records showed a patient received 21.1 millicuries of I-131 for thyroid therapy. The prescribed dose in the file appeared to read 20 microcuries of I-131 vice 20 millicuries. There were no reported adverse effects for the patient.
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.