Event Notification Report for October 26, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/25/2022 - 10/26/2022

EVENT NUMBERS
56169 56170 56177 56178
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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
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


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
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
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
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.


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
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
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
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
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
Event Text
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."


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
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
Emergency Class: Non Emergency
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)
Event Text
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.

Page Last Reviewed/Updated Wednesday, October 26, 2022