Event Notification Report for October 27, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/26/2021 - 10/27/2021
Agreement State
Event Number: 55532
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: Rhode Island Hospital
Region: 1
City: Providence State: RI
County:
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: Alexander Hamm
HQ OPS Officer: Brian P. Smith
Licensee: Rhode Island Hospital
Region: 1
City: Providence State: RI
County:
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: Alexander Hamm
HQ OPS Officer: Brian P. Smith
Notification Date: 10/19/2021
Notification Time: 15:57 [ET]
Event Date: 04/17/2019
Event Time: 12:00 [EDT]
Last Update Date: 10/19/2021
Notification Time: 15:57 [ET]
Event Date: 04/17/2019
Event Time: 12:00 [EDT]
Last Update Date: 10/19/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/27/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE OF I-131
The following report was received via email:
"Rhode Island Department of Health was notified on May 2, 2019 by a representative from Rhode Island Hospital of a medical event that occurred during an attempted dosing of 25 mCi of I-131. On April 17, 2019, a patient was administered a capsule of I-131, but was unable to swallow and the capsule began to break down in the patient's mouth. As this was not the prescribed use of the radiopharmaceutical, the staff of Rhode Island Hospital transferred the capsule to a cup as the capsule was breaking down. The cup was then brought to the lead-lined safe in the hospital's nuclear medicine hot lab. During the transfer some of the I-131 that had begun to leak from the capsule spilled onto the floor and contaminated it with I-131.
"The floor of the injection room that had been contaminated with I-131 underwent decontamination. Before decontamination, the maximum counts/min (cpm) per 100 cm squared was equal to approximately 151,000 cpm. After decontamination the maximum amount in any location was 11,000 cpm. Similarly, before the protective covering was laid over the contaminated parts of the floor, the maximum dose rate as read by Ludlum Model 9DP was 70 mR/hour on contact. Rhode Island Hospital's Radiation Safety Officer (RSO) attempted to clean up the spill and then laid protective material over the floor and measured that the dose rate upon contact with a Ludlum Model 9DP ion chamber did not exceed 70 microR per hour. No other persons or surfaces were deemed to be contaminated after surface wipe tests and a thyroid scan bioassay. The following day, April 18, 2019, 25 mCi of I-131 was attempted to be administered orally in liquid form which the patient failed to swallow as well. This did not result in a spill. The State is not performing any additional action at this time.
"The referring physician, patient, and patient's legal guardians were notified that the dose of I-131 was not received to the patient. No overexposure occurred. This event was discovered due to be reported during the October 2021 IMPEP review of the Rhode Island Radiation Control Agency."
Rhode Island Event Number: RI-21-0002
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 - MEDICAL EVENT - UNDERDOSE OF I-131
The following report was received via email:
"Rhode Island Department of Health was notified on May 2, 2019 by a representative from Rhode Island Hospital of a medical event that occurred during an attempted dosing of 25 mCi of I-131. On April 17, 2019, a patient was administered a capsule of I-131, but was unable to swallow and the capsule began to break down in the patient's mouth. As this was not the prescribed use of the radiopharmaceutical, the staff of Rhode Island Hospital transferred the capsule to a cup as the capsule was breaking down. The cup was then brought to the lead-lined safe in the hospital's nuclear medicine hot lab. During the transfer some of the I-131 that had begun to leak from the capsule spilled onto the floor and contaminated it with I-131.
"The floor of the injection room that had been contaminated with I-131 underwent decontamination. Before decontamination, the maximum counts/min (cpm) per 100 cm squared was equal to approximately 151,000 cpm. After decontamination the maximum amount in any location was 11,000 cpm. Similarly, before the protective covering was laid over the contaminated parts of the floor, the maximum dose rate as read by Ludlum Model 9DP was 70 mR/hour on contact. Rhode Island Hospital's Radiation Safety Officer (RSO) attempted to clean up the spill and then laid protective material over the floor and measured that the dose rate upon contact with a Ludlum Model 9DP ion chamber did not exceed 70 microR per hour. No other persons or surfaces were deemed to be contaminated after surface wipe tests and a thyroid scan bioassay. The following day, April 18, 2019, 25 mCi of I-131 was attempted to be administered orally in liquid form which the patient failed to swallow as well. This did not result in a spill. The State is not performing any additional action at this time.
"The referring physician, patient, and patient's legal guardians were notified that the dose of I-131 was not received to the patient. No overexposure occurred. This event was discovered due to be reported during the October 2021 IMPEP review of the Rhode Island Radiation Control Agency."
Rhode Island Event Number: RI-21-0002
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: 55535
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: Infiana USA, Inc.
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Licensee: Infiana USA, Inc.
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 03/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 03/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 20, 2021, the licensee informed the Department of a failure of a shutter. It is reportable per 10 CFR 31.5(b)(5).
"On March 26, 2019, the licensee identified a defective linear actuator assembly on one of its Beta Control Mk 1.0 (serial number 559 / KP983) devices. The device contains 267 mCi (9.9 GBq) of Kr-85. The defect prevented the source from returning fully to its home shielded position. After initial discovery, a service provider manually moved the device to fully align with the shutter assembly. At a later date, it was discovered the unit had drifted out of alignment again. At this time a service provider installed a plate directly on the device effectively sealing the unit, regardless of alignment with shutter assembly. No exposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210016
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 20, 2021, the licensee informed the Department of a failure of a shutter. It is reportable per 10 CFR 31.5(b)(5).
"On March 26, 2019, the licensee identified a defective linear actuator assembly on one of its Beta Control Mk 1.0 (serial number 559 / KP983) devices. The device contains 267 mCi (9.9 GBq) of Kr-85. The defect prevented the source from returning fully to its home shielded position. After initial discovery, a service provider manually moved the device to fully align with the shutter assembly. At a later date, it was discovered the unit had drifted out of alignment again. At this time a service provider installed a plate directly on the device effectively sealing the unit, regardless of alignment with shutter assembly. No exposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210016
Agreement State
Event Number: 55536
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: Infiana USA, Inc
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Licensee: Infiana USA, Inc
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 5, 2020, the licensee identified a failed return spring on one of its NDC 103 (serial number 3020641) devices. The device contains 148 mCi (5.55 GBq) of Am-241. The written report received from the service provider on Oct 5, 2020 stated that the secondary shutter device for the device in question failed to close. The primary shutter assembly remained operational at all times. The secondary shutter assembly defect was addressed and corrected by the service provider at the earliest possible time (next scheduled machine downtime event). No overexposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210017
EN Revision Text: AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 5, 2020, the licensee identified a failed return spring on one of its NDC 103 (serial number 3020641) devices. The device contains 148 mCi (5.55 GBq) of Am-241. The written report received from the service provider on Oct 5, 2020 stated that the secondary shutter device for the device in question failed to close. The primary shutter assembly remained operational at all times. The secondary shutter assembly defect was addressed and corrected by the service provider at the earliest possible time (next scheduled machine downtime event). No overexposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210017
Agreement State
Event Number: 55537
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: University of Chicago Medical Center
Region: 3
City: Chicago State: IL
County:
License #: Il-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Licensee: University of Chicago Medical Center
Region: 3
City: Chicago State: IL
County:
License #: Il-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Notification Date: 10/21/2021
Notification Time: 17:02 [ET]
Event Date: 10/20/2021
Event Time: 14:20 [CDT]
Last Update Date: 10/21/2021
Notification Time: 17:02 [ET]
Event Date: 10/20/2021
Event Time: 14:20 [CDT]
Last Update Date: 10/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
SZWARC, DARIUSZ (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
SZWARC, DARIUSZ (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE
The following report was received from the Illinois Emergency Management Agency [the Agency] via email:
"The Agency was contacted on the afternoon of 10/21/21 by the University of Chicago to advise of a reportable medical event that occurred the day before. A human research subject was reportedly administered 79.8 mCi of a prescribed 100 mCi dose of I-131 under the therapeutic portion of a study protocol. There is no root cause available at this time, although the licensee suspects an inadequate volume of saline flush. Inspectors will evaluate any other contributing factors including equipment, personnel involved and unique procedures for this study protocol. At this time, the licensee is not expecting any adverse impact to the patient and they are following up with the study sponsor to determine if additional treatment is required. The referring physician has been notified and the licensee is aware of the requirement to notify the patient. This matter is reportable under 32 Ill. Adm. Code 335.1080(a) for a dose differing from the prescribed dose by 20 percent or more. The administration was started at 1420 CDT on 10/20/21 and the matter reported to the Agency at 1219 CDT on 10/21/21. The reporting criteria has been met. In accordance with Agency policy, inspectors will perform a reactionary inspection within 10 days of the incident."
Illinois Report Number: IL210032
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
The following report was received from the Illinois Emergency Management Agency [the Agency] via email:
"The Agency was contacted on the afternoon of 10/21/21 by the University of Chicago to advise of a reportable medical event that occurred the day before. A human research subject was reportedly administered 79.8 mCi of a prescribed 100 mCi dose of I-131 under the therapeutic portion of a study protocol. There is no root cause available at this time, although the licensee suspects an inadequate volume of saline flush. Inspectors will evaluate any other contributing factors including equipment, personnel involved and unique procedures for this study protocol. At this time, the licensee is not expecting any adverse impact to the patient and they are following up with the study sponsor to determine if additional treatment is required. The referring physician has been notified and the licensee is aware of the requirement to notify the patient. This matter is reportable under 32 Ill. Adm. Code 335.1080(a) for a dose differing from the prescribed dose by 20 percent or more. The administration was started at 1420 CDT on 10/20/21 and the matter reported to the Agency at 1219 CDT on 10/21/21. The reporting criteria has been met. In accordance with Agency policy, inspectors will perform a reactionary inspection within 10 days of the incident."
Illinois Report Number: IL210032
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: 55549
Facility: Catawba
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Michael James
HQ OPS Officer: Donald Norwood
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Michael James
HQ OPS Officer: Donald Norwood
Notification Date: 10/27/2021
Notification Time: 20:39 [ET]
Event Date: 10/27/2021
Event Time: 14:29 [EDT]
Last Update Date: 10/27/2021
Notification Time: 20:39 [ET]
Event Date: 10/27/2021
Event Time: 14:29 [EDT]
Last Update Date: 10/27/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Miller, Mark (R2)
Miller, Mark (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
AUTOMATIC ACTUATION OF THE 1B EDG LOAD SEQUENCER ON BUS UNDERVOLTAGE CONDITION
"At 1429 EDT on October 27, 2021 with Unit 1 in Mode 6 at 0 percent power, the 1B Emergency Diesel Generator (EDG) Load Sequencer was actuated by a valid undervoltage condition on the 1B 4160V Essential Bus that occurred during 1B Sequencer calibration activities. Valid signals were sent to both the 1B EDG and Unit 1 Auxiliary Feedwater (CA) systems. Neither system automatically started as they were both removed from service for maintenance activities at the time.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 1B EDG and Unit 1 CA systems.
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"At 1429 EDT on October 27, 2021 with Unit 1 in Mode 6 at 0 percent power, the 1B Emergency Diesel Generator (EDG) Load Sequencer was actuated by a valid undervoltage condition on the 1B 4160V Essential Bus that occurred during 1B Sequencer calibration activities. Valid signals were sent to both the 1B EDG and Unit 1 Auxiliary Feedwater (CA) systems. Neither system automatically started as they were both removed from service for maintenance activities at the time.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 1B EDG and Unit 1 CA systems.
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."