Event Notification Report for September 23, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/22/2021 - 09/23/2021
Agreement State
Event Number: 55491
Rep Org: Alabama Dept. of Public Health
Licensee: West Rock Mill
Region: 1
City: Demopolis State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Thomas Herrity
Licensee: West Rock Mill
Region: 1
City: Demopolis State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2021
Notification Time: 17:40 [ET]
Event Date: 09/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Notification Time: 17:40 [ET]
Event Date: 09/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
LALLY, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
LALLY, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/22/2021
EN Revision Text: AGREEMENT STATE - FIXED GAUGE SHUTTER WILL NOT FULLY CLOSE
The following was received via email:
"On 9/23/2021, the Radiation Safety Officer (RSO) for West Rock Mill Company, LLC in Demopolis, AL reported that a fixed gauge was found to have a defective shutter on 9/22/2021. The RSO reported that the gauge's shutter will not rotate fully to the 'locked off' position. The gauge is still mounted in place until a replacement device and tungsten shielding plate is received. No inadvertent exposures to personnel or members of the public were indicated or reported. The gauge is an Ohmart SHF-1B-45, s/n 4-2425, with a 100 millicurie cesium-137 source, assayed in 1994."
Alabama Event: 21-31
EN Revision Text: AGREEMENT STATE - FIXED GAUGE SHUTTER WILL NOT FULLY CLOSE
The following was received via email:
"On 9/23/2021, the Radiation Safety Officer (RSO) for West Rock Mill Company, LLC in Demopolis, AL reported that a fixed gauge was found to have a defective shutter on 9/22/2021. The RSO reported that the gauge's shutter will not rotate fully to the 'locked off' position. The gauge is still mounted in place until a replacement device and tungsten shielding plate is received. No inadvertent exposures to personnel or members of the public were indicated or reported. The gauge is an Ohmart SHF-1B-45, s/n 4-2425, with a 100 millicurie cesium-137 source, assayed in 1994."
Alabama Event: 21-31
Agreement State
Event Number: 55489
Rep Org: LOUISIANA DEQ
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington State: LA
County: St. Tammany
License #: LA-0569-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington State: LA
County: St. Tammany
License #: LA-0569-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2021
Notification Time: 13:48 [ET]
Event Date: 09/23/2021
Event Time: 16:00 [CDT]
Last Update Date: 09/24/2021
Notification Time: 13:48 [ET]
Event Date: 09/23/2021
Event Time: 16:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/22/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERES
The following information was received via email:
"Louisiana Department of Environmental Quality (LDEQ) was notified by the St. Tammany Parish Hospital Director of Radiology via the LDEQ Radiation Hotline at approximately 0915 CDT on September 24, 2021, concerning a medical event which took place at the licensee's facility between 1500 and 1600 CDT on September 22, 2021. According to the Director of Radiology, the patient received 366.2 Gray of the radiation dose of Y-90 TheraSpheres, instead of the prescribed radiation dose of 720 Gray, which is more than 20 percent below the prescribed dose.
"The facility Physicist was notified by the Director of Radiology concerning the above medical event on or about 1600 CDT on September 22, 2021. The Physicist in turn notified the hospital Radiation Safety Officer (RSO), who notified the hospital administration concerning the medical event at approximately 0955 CDT on September 23, 2021. According to the Physicist (during a conference call with LDEQ), the remaining Y-90 dose was not shunted, but remained within the TheraSphere kit. According to the Director of Radiology and the Physicist, the prescribing physician stated the patient nevertheless received an adequate therapeutic dose of Y-90."
LDEQ Event Report ID No.: LA 20210008
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.
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERES
The following information was received via email:
"Louisiana Department of Environmental Quality (LDEQ) was notified by the St. Tammany Parish Hospital Director of Radiology via the LDEQ Radiation Hotline at approximately 0915 CDT on September 24, 2021, concerning a medical event which took place at the licensee's facility between 1500 and 1600 CDT on September 22, 2021. According to the Director of Radiology, the patient received 366.2 Gray of the radiation dose of Y-90 TheraSpheres, instead of the prescribed radiation dose of 720 Gray, which is more than 20 percent below the prescribed dose.
"The facility Physicist was notified by the Director of Radiology concerning the above medical event on or about 1600 CDT on September 22, 2021. The Physicist in turn notified the hospital Radiation Safety Officer (RSO), who notified the hospital administration concerning the medical event at approximately 0955 CDT on September 23, 2021. According to the Physicist (during a conference call with LDEQ), the remaining Y-90 dose was not shunted, but remained within the TheraSphere kit. According to the Director of Radiology and the Physicist, the prescribing physician stated the patient nevertheless received an adequate therapeutic dose of Y-90."
LDEQ Event Report ID No.: LA 20210008
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: 55484
Facility: Limerick
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kris Strausser
HQ OPS Officer: Howie Crouch
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kris Strausser
HQ OPS Officer: Howie Crouch
Notification Date: 09/23/2021
Notification Time: 18:46 [ET]
Event Date: 09/23/2021
Event Time: 14:43 [EDT]
Last Update Date: 09/23/2021
Notification Time: 18:46 [ET]
Event Date: 09/23/2021
Event Time: 14:43 [EDT]
Last Update Date: 09/23/2021
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):
LALLY, CHRISTOPHER (R1)
LALLY, CHRISTOPHER (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 10/22/2021
EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE
"During planned testing of the Unit 1 HPCI [high pressure coolant injection] system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable."
HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done.
The licensee has notified the NRC Resident Inspector.
EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE
"During planned testing of the Unit 1 HPCI [high pressure coolant injection] system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable."
HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done.
The licensee has notified the NRC Resident Inspector.