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Event Notification Report for May 18, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/17/2023 - 05/18/2023

Agreement State
Event Number: 56514
Rep Org: Texas Dept of State Health Services
Licensee: Chi St Lukes Hlth Baylor Clg of Med
Region: 4
City: Houston   State: TX
County:
License #: L-06661
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Donald Norwood
Notification Date: 05/10/2023
Notification Time: 13:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_Events_Notification, (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via email from the Texas Dept. of State Health Services (the Agency):

"On May 9, 2023, the Agency was notified by the licensee that a medical event occurred earlier that day. The licensee stated a patient was prescribed two doses of SIR-Spheres yittrium-90 (Y-90). After the procedure, it was determined that the patient received doses differed from the prescribed doses by more than 20 percent. The patient was prescribed doses of 14.5 mCi and 21.7 mCi. The patient received 5.3 mCi (for the syringe dose of 14.2 mCi) and 12.31 mCi (for the syringe dose of 21.5 mCi). Delivered doses differed by 37.3 percent and 57.2 percent respectively. The prescribing physician and patient were notified of the error. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10017

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: 56516
Rep Org: Arizona Dept of Health Services
Licensee: Banner University Medical Center - Phoenix
Region: 4
City: Phoenix   State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bill Gott
Notification Date: 05/11/2023
Notification Time: 00:18 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [MST]
Last Update Date: 05/11/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. 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 number: 23-008

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: 56519
Facility: Beaver Valley
Region: 1     State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Kevin Morse
HQ OPS Officer: Sam Colvard
Notification Date: 05/16/2023
Notification Time: 08:09 [ET]
Event Date: 05/15/2023
Event Time: 12:08 [EDT]
Last Update Date: 05/16/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Defrancisco, Anne (R1DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
FITNESS FOR DUTY REPORT

The following information was provided by the licensee via phone:

"A licensed operator failed a test specified by the FFD testing program. The individual's site access has been terminated.

"The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 56520
Facility: Wolf Creek
Region: 4     State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: David Christiansen
HQ OPS Officer: Sam Colvard
Notification Date: 05/16/2023
Notification Time: 17:20 [ET]
Event Date: 05/16/2023
Event Time: 12:27 [CDT]
Last Update Date: 05/16/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Azua, Ray (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
EMERGENCY EXHAUST INOPERABLE

The following information was provided by the licensee via phone and email:

"At 1127 CDT on 5/16/2023, during the reperformance of test procedure 'STS PE-006, Charcoal Adsorber In-Place Leak Test' due to a failure from the previous day, both trains of emergency exhaust were rendered inoperable due to incorrect performance of the procedure. Performers incorrectly de-energized the humidity control heating coil for the unit not under test, rendering it inoperable. This issue was identified and rectified at 1138 CDT on 5/16/2023, exiting the LCO [limiting condition of operation] for both trains inoperable at that time. There was no impact to the health and safety of the public."


Power Reactor
Event Number: 56521
Facility: South Texas
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Dustin Janak
HQ OPS Officer: Brian P. Smith
Notification Date: 05/17/2023
Notification Time: 03:25 [ET]
Event Date: 05/16/2023
Event Time: 16:30 [CDT]
Last Update Date: 05/17/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
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
Event Text
FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

"On May 16, 2023, it was determined that a licensed operator violated the station's FFD policy. The employee's unescorted access at South Texas has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC resident inspector has been notified."


Power Reactor
Event Number: 56522
Facility: Diablo Canyon
Region: 4     State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Don Townsend
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 05/17/2023
Notification Time: 18:21 [ET]
Event Date: 05/17/2023
Event Time: 06:49 [PDT]
Last Update Date: 05/17/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

On May 17, 2023, at 0649 PDT, it was determined that a prohibited item had been found inside the protected area.

The NRC Resident Inspector has been notified.


Agreement State
Event Number: 56517
Rep Org: SC Dept of Health & Env Control
Licensee: Suominen Nonwovens
Region: 1
City: Bethune   State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Bill Gott
Notification Date: 05/12/2023
Notification Time: 10:07 [ET]
Event Date: 03/31/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/12/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"The licensee [Bethune Nonwovens, Inc., d/b/a Suominen Nonwovens] notified the Department in writing on April 21, 2023, that a generally licensed fixed gauging device had a failed shutter which had been repaired by the manufacturer on April 3, 2023. The licensee discovered that the event occurred on March 31, 2023, and reported that upon discovery of the stuck shutter, that the manufacturer arrived on site on the same day and placed the device out of service until repaired. The event involved a Mahlo fixed gauging device (model number: 11-200933, serial number 11-011985-AH-5783), which housed an Isotope Product Laboratories, krypton-85 sealed source (model number KAC.D3, serial number: AH-5783), with an activity of 9.62 GBq (260 mCi). The licensee reported that the cause of this equipment failure was attributed to corrosion around the shutter assembly.

"On May 2, 2023, a Department inspector was dispatched to the facility to conduct an on-site investigation. All dose measurements were consistent with the Sealed Source Device Registry certificate for the device. Based on the resulting dose rate surveys conducted by the Department and the manufacturer, interviews with licensee representatives, and the removal of the device from service at the time that the failure was discovered, it does not appear that any radiation exposure to workers, or any other individual members of the public has occurred.

"This event is considered closed."

Internal ID number: SC230009


Fuel Cycle Facility
Event Number: 56523
Facility: Global Nuclear Fuel - Americas
Region: 2     State: NC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Leu Fabrication
Lwr Commerical Fuel
NRC Notified By: Phillip Ollis
HQ OPS Officer: Sam Colvard
Notification Date: 05/18/2023
Notification Time: 14:50 [ET]
Event Date: 05/18/2023
Event Time: 09:40 [EDT]
Last Update Date: 05/18/2023
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
CONCURRENT REPORT - FIRE DOOR MALFUNCTION

The following information was provided by the licensee via email:

"At approximately 0940 EDT on May 18th, the New Hanover County Deputy Fire Marshal was notified that the fire door of the dry conversion process (DCP) elevator shaft malfunctioned and was in the open position. The DCP elevator is located on the south wall of the DCP which is a credited fire barrier. A fire watch was initiated and maintained until the elevator door was closed at approximately 1030 EDT. The elevator was restored to full operation at approximately 1330 EDT on May 18th. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The NRC region will be notified.