Event Notification Report for February 03, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/02/2022 - 02/03/2022
Agreement State
Event Number: 55714
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania, Philadelphia, PA
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Licensee: University of Pennsylvania, Philadelphia, PA
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Notification Date: 01/27/2022
Notification Time: 11:09 [ET]
Event Date: 01/25/2022
Event Time: 00:00 [EST]
Last Update Date: 01/27/2022
Notification Time: 11:09 [ET]
Event Date: 01/25/2022
Event Time: 00:00 [EST]
Last Update Date: 01/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1)
NMSS_Events_Notification, (EMAIL)
Gray, Mel (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/4/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received via E-mail:
"On January 26, 2022 the licensee informed the Department (Department of Environmental Protection) of a medical event. It is reportable as per 10 CFR 35.3045(a)(1)(i).
"The Department received notification from a licensee on January 26, 2022 of a medical event involving Yttium-90 TheraSpheres. The entire procedure occurred without incident and the routine contamination survey identified no contamination. However, when the waste was measured following the procedure, the percent of prescribed activity administered was 70.6 percent (administered = 27.72 mCi, prescribed activity = 39.24 mCi). No harm is expected to the patient.
"No further information is available at this time. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No.: PA220002
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
The following information was received via E-mail:
"On January 26, 2022 the licensee informed the Department (Department of Environmental Protection) of a medical event. It is reportable as per 10 CFR 35.3045(a)(1)(i).
"The Department received notification from a licensee on January 26, 2022 of a medical event involving Yttium-90 TheraSpheres. The entire procedure occurred without incident and the routine contamination survey identified no contamination. However, when the waste was measured following the procedure, the percent of prescribed activity administered was 70.6 percent (administered = 27.72 mCi, prescribed activity = 39.24 mCi). No harm is expected to the patient.
"No further information is available at this time. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No.: PA220002
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: 55720
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: Bethany Cecere
Region: 4 State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Don Townsend
HQ OPS Officer: Bethany Cecere
Notification Date: 02/01/2022
Notification Time: 11:42 [ET]
Event Date: 01/31/2022
Event Time: 13:50 [PST]
Last Update Date: 02/01/2022
Notification Time: 11:42 [ET]
Event Date: 01/31/2022
Event Time: 13:50 [PST]
Last Update Date: 02/01/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Josey, Jeffrey (R4)
FFD Group, (EMAIL)
Josey, Jeffrey (R4)
FFD Group, (EMAIL)
| 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: 2/3/2022
EN Revision Text: FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via fax or email:
"At 1350 PST on 01/31/2022, Pacific Gas and Electric determined that a non-licensed employee supervisor violated Diablo Canyon FFD policy and had a confirmed positive on a direct observed test. The employee's access to the plant has been terminated and permanent denial has been entered into PADS.
"The NRC Senior Resident Inspector has been notified."
EN Revision Text: FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via fax or email:
"At 1350 PST on 01/31/2022, Pacific Gas and Electric determined that a non-licensed employee supervisor violated Diablo Canyon FFD policy and had a confirmed positive on a direct observed test. The employee's access to the plant has been terminated and permanent denial has been entered into PADS.
"The NRC Senior Resident Inspector has been notified."
Power Reactor
Event Number: 55721
Facility: Dresden
Region: 3 State: IL
Unit: [2] [3] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Jeff Simpson
HQ OPS Officer: Karen Cotton-Gross
Region: 3 State: IL
Unit: [2] [3] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Jeff Simpson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/01/2022
Notification Time: 15:23 [ET]
Event Date: 02/01/2022
Event Time: 10:25 [CST]
Last Update Date: 02/01/2022
Notification Time: 15:23 [ET]
Event Date: 02/01/2022
Event Time: 10:25 [CST]
Last Update Date: 02/01/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Orth, Steve (R3)
Orth, Steve (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 2/3/2022
EN Revision Text: INADVERTENT SIREN ACTUATIONS
The following information was provided by the licensee via fax or email:
"At approximately 1025 CST, the Dresden Main Control was notified of Grundy County warning sirens issues during the intended monthly test. The Grundy County scheduled monthly siren test had issues with siren activation from the County's primary controller. The buttons to activate were being pressed but the intended sirens were not initiating. The Grundy County operator continued to attempt activation unknowingly activating the sirens in the northeast quadrant between 1000-1015 CST.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-Hour Reporting requirement.
"The Dresden NRC Resident has been notified."
EN Revision Text: INADVERTENT SIREN ACTUATIONS
The following information was provided by the licensee via fax or email:
"At approximately 1025 CST, the Dresden Main Control was notified of Grundy County warning sirens issues during the intended monthly test. The Grundy County scheduled monthly siren test had issues with siren activation from the County's primary controller. The buttons to activate were being pressed but the intended sirens were not initiating. The Grundy County operator continued to attempt activation unknowingly activating the sirens in the northeast quadrant between 1000-1015 CST.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-Hour Reporting requirement.
"The Dresden NRC Resident has been notified."
Power Reactor
Event Number: 55722
Facility: Braidwood
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rich Roe
HQ OPS Officer: Karen Cotton-Gross
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rich Roe
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/01/2022
Notification Time: 15:20 [ET]
Event Date: 02/01/2022
Event Time: 10:25 [CST]
Last Update Date: 02/01/2022
Notification Time: 15:20 [ET]
Event Date: 02/01/2022
Event Time: 10:25 [CST]
Last Update Date: 02/01/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Orth, Steve (R3)
Orth, Steve (R3)
| 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 |
EN Revision Imported Date: 2/3/2022
EN Revision Text: INADVERTENT SIREN ACTUATION
The following information was provided by the licensee via fax or email:
"At approximately 1025 CST on 2/1/22, the Braidwood Station Main Control Room was notified of a public notification of multiple inadvertent siren actuation affecting Braidwood Station in Will County, Illinois while testing sirens.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News release or notification of other Government Agencies.
"Braidwood NRC Resident has been notified. "
EN Revision Text: INADVERTENT SIREN ACTUATION
The following information was provided by the licensee via fax or email:
"At approximately 1025 CST on 2/1/22, the Braidwood Station Main Control Room was notified of a public notification of multiple inadvertent siren actuation affecting Braidwood Station in Will County, Illinois while testing sirens.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News release or notification of other Government Agencies.
"Braidwood NRC Resident has been notified. "
Power Reactor
Event Number: 55723
Facility: LaSalle
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Nick Najdanovich
HQ OPS Officer: Karen Cotton-Gross
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: Nick Najdanovich
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/01/2022
Notification Time: 16:24 [ET]
Event Date: 02/01/2022
Event Time: 13:28 [CST]
Last Update Date: 02/01/2022
Notification Time: 16:24 [ET]
Event Date: 02/01/2022
Event Time: 13:28 [CST]
Last Update Date: 02/01/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Orth, Steve (R3)
Orth, Steve (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 92 | Power Operation | 92 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 2/3/2022
EN Revision Text: INADVERTENT SIREN ACTUATION
The following information was provided by the licensee via fax or email:
"At approximately 1328 CST on 2/1/2022, LaSalle Generating Station was made aware of the following event that resulted in additional county emergency sirens sounding. The Grundy County monthly siren test had issues with siren activation from the County's primary controller. The buttons to activate were being pressed, but the intended sirens were not initiating. The Grundy County operator continued to attempt activation unknowingly activating the sirens in the Northeast quadrant several times between 1000-1015 CST.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-Hour Reporting requirement.
"The LaSalle NRC Resident has been notified."
EN Revision Text: INADVERTENT SIREN ACTUATION
The following information was provided by the licensee via fax or email:
"At approximately 1328 CST on 2/1/2022, LaSalle Generating Station was made aware of the following event that resulted in additional county emergency sirens sounding. The Grundy County monthly siren test had issues with siren activation from the County's primary controller. The buttons to activate were being pressed, but the intended sirens were not initiating. The Grundy County operator continued to attempt activation unknowingly activating the sirens in the Northeast quadrant several times between 1000-1015 CST.
"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-Hour Reporting requirement.
"The LaSalle NRC Resident has been notified."
Agreement State
Event Number: 55716
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Notification Time: 17:00 [ET]
Event Date: 01/27/2022
Event Time: 00:00 [CST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/4/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.
"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.
"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"
Item Number: IL220002
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 - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
"At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon.
"Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident.
"The licensee is continuing their investigation into root cause. [Agency will review the investigation results.]"
Item Number: IL220002
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: 55717
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Licensee: Mistras Group, Inc.
Region: 4
City: Benicia State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Notification Time: 19:08 [ET]
Event Date: 01/27/2022
Event Time: 21:00 [PST]
Last Update Date: 01/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
Josey, Jeffrey (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/4/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE
The following report was received from the California Department of Public Health (RHB) via email:
"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."
California Event Number: 012822
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA EQUIPMENT FAILURE
The following report was received from the California Department of Public Health (RHB) via email:
"On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO [radiation safety officer]. The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further."
California Event Number: 012822