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| Event date | Site | Region | State | Event description | Topic | |
|---|---|---|---|---|---|---|
| ENS 57382 | 14 October 2024 19:00:00 | University of Missouri-Columbia | NRC Region 3 | Missouri | The following information was provided by the licensee via phone and email: University of Missouri Research Reactor (MURR), a 10 MW reactor, is reporting an abnormal occurrence as required per Technical Specification (TS) 1.1 b and c. One of two redundant switches on the Fluxtrap irradiations reactivity safety trip device failed reactor pre-startup checks on October 14, 2024. This failure would have prevented the switch from sending a scram input to the reactor protection system. MURR TS 3.2.g.21 requires a 1/N logic of 2, meaning both switches must be operational during operation of the reactor. The faulty switch was last confirmed operating properly prior to reactor startup on October 7, 2024. MURR cannot positively state when the switch failed. This condition could have existed during operations at some point between October 7 and October 13, 2024. The second switch was verified to be operable. The faulty switch and its associated wiring were replaced, retested satisfactorily, and the reactor was returned to operation the evening of Monday, October 14, 2024 with authorization from the Facility Director. MURR will follow up with a written report to the NRC within 14 days as required by TS 6.6.c. NRC Project Manager has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: A causal investigation is in progress. Equipment age is the potential cause of the failure. | |
| ENS 57375 | 9 October 2024 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Bureau) via email: On October 10, 2024, the licensee informed the Bureau of a medical event involving a treatment with TheraSpheres. It is reportable per 10 CFR 35.3045. On October 9, 2024, a patient was receiving a (Y-90) TheraSphere treatment. Only 32.7 percent of the prescribed activity (15.975 mCi) was administered to the patient. The physician and the patient were informed on October 9, 2024, following the treatment. It is suspected that the cause was an occlusion within the catheter which prevented the proper flow of fluid and TheraSpheres into the patient. The official cause is still under investigation. The Bureau will perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID: PA240019 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. | TheraSphere Underdose Reactive Inspection |
| ENS 57207 | 3 July 2024 13:07:00 | University of Maryland | NRC Region 0 | Maryland | The following information was provided by the licensee via phone and email: On July 3, 2024, at 0907 EDT, a reactor operator (RO) was in the process of commencing a routine startup. During the startup, the RO switched on the ventilation fans for less than 1 second with the key in the console. (With the key in the console) the reactor did not meet the definition of 'reactor secured' and thus the confinement requirements of technical specification (TS) 3.4.2 were still required to be met. (Ventilation fans running in this condition violates the confinement requirements of TS 3.4.2.) The RO notified the director of radiation facilities and logged the action. Throughout the duration of the event all control rods were fully inserted. The director notified the NRC project manager. | |
| ENS 57196 | 27 June 2024 14:37:00 | North Carolina State University | NRC Region 0 | North Carolina | The following information was provided by the licensee via phone and email: On June 27, 2024, at 1037 EDT, the North Carolina State University (NCSU) PULSTAR reactor was shutdown due to channel failure of the N-16 detector. This channel is required during operations over 500 kW by TS 3.4a. The reactor was operating at 950 kW at the time of channel failure. The reactor operator promptly shutdown and secured the reactor. Due to the nature of an unscheduled shutdown, investigation as to the source of channel failure and remedy will be commenced. At this time, failure has been isolated to just the N-16 channel. As such, operations may continue with approval for restart by the director of the NCSU PULSTAR reactor at powers below 500 kW. To resume full operations, channel maintenance, required surveillances, and additional approval by the director of the NCSU PULSTAR reactor are required. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The N-16 channel provides a reference power level indication while adjustments are being made to other power level channels. | |
| ENS 57180 | 17 June 2024 05:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | The following information was provided by the licensee via email and phone: During investigation related to licensee event report (LER) number 24-001, a noncompliance with technical specification 3.10.d was discovered. During the period from July 2022 to April 2024, three filters operating at greater than 99 percent efficiency were not in service. The limiting condition of this technical specification is associated with operation of an I-131 processing suite, rather than with operation of the reactor. The University of Missouri Research Reactor's iodine suite ventilation includes a series of seven filter trains, each of which were in service during this period at an efficiency greater than 98 percent. Filter banks '2' and '3' were operating at greater than 99 percent efficiency. Filter '3-3' was also credited as greater than 99 percent efficiency, however, the bypass between the two banks of filter '3-3' consisted of dampers rather than valves. Therefore the total efficiency, when bypass was taken into account, was less than 99 percent. Processing of iodine was generally performed weekly during the referenced period. Processing of iodine was suspended in May 2024 in association with LER 24-001, and remains suspended until compliance is achieved. Several detectors were monitoring the suite and downstream effluent from the suite during the referenced period, including the off-gas (stack) radiation monitor per technical specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room (derived air concentration) monitors, and the remaining three I-131 processing hot cells radiation monitors. No in-service monitors indicated abnormal rises in iodine levels during the period in question. | |
| ENS 57125 | 10 May 2024 05:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | The following information was provided by the licensee via phone and email: During a routine source check on 5/10/2024, it was noted that three of the six iodine-131 processing hot cell radiation monitors were located incorrectly. Upon investigation, it was discovered that on 4/19/2024 the filter banks were switched between bank A and bank B. During this filter bank switch, the detectors monitoring the filter banks were also not changed. This led to processing iodine three times between 4/19/2024 and 5/10/2024 without meeting the conditions of Technical Specification 3.10.c regarding monitoring requirements. The event was corrected on 5/10/2024. Several detectors were monitoring the suite during the period from 4/19/2024 and 5/10/2024, including the off-gas (stack) radiation monitor per Technical Specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room DAC monitors, and the remaining three iodine-131 processing hot cell radiation monitors. No in-service monitors indicated abnormal rises in iodine levels. After the detectors were returned to service in the correct location, it was noted that the readings on the filter banks were very low. These readings provide supporting evidence that they were not being loaded while the detectors were incorrectly located. | |
| ENS 57113 | 7 May 2024 21:28:00 | Oregon State University | NRC Region 0 | Oregon | The following information was provided by the licensee via phone: Per the licensees Technical Specifications (TS) 6.1.3.a, "The minimum staffing when the reactor is not secured shall be: . A reactor operator or the senior reactor operator on duty in the control room. On May 7, 2024, following the reactor shutdown, there was an indication that one control rod was not fully inserted. Both the reactor operator and reactor engineer left the control room to investigate and discovered that one control rod was not fully inserted. The reactor operator leaving the control room violated the minimum control room staffing requirements of TS 6.1.3.a. On May 8, 2024, the licensee determined that the cause for the control rod not being fully inserted was a dislodged plastic buffer at the bottom of the control rod barrel. The NRC Project Manager has been notified. | |
| ENS 57100 | 26 April 2024 07:00:00 | University of Washington | NRC Region 4 | Washington | The following was received from the Washington State Department of Health via email: The University of Washington has indication that an electron capture device (ECD) containing nickel-63 (Ni-63) is leaking. The ECD (G1223A, serial number F7283) had been removed from the gas chromatograph (Hewlett Packard 5890) for disposal. Previous leak testing had been performed with the ECD installed in the GC, and no contamination had been identified that required reporting. The ECD contains Ni-63 that is plated onto an inner surface of the cell body. The current activity is approximately 11.9 millicuries. On April 26, 2024, a health physicist performed a leak test by taking a wipe sample on the detector inlet. The wipe from the detector inlet showed contamination of 44,536 dpm using a machine calculated efficiency of approximately 72 percent. The detector inlet indicates a contamination level of 44,536 dpm or approximately 742 Bq (0.02 microcurie). This value exceeds the limit of 185 Bq (0.005 microcurie). The ECD will be returned for recycling/disposal of the source." Washington Incident Report No.: WA-24-011 | |
| ENS 57081 | 17 April 2024 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email: On April 18, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 17, 2024, a patient was receiving an iodine-131 (sodium iodine solution) treatment. The patient was prescribed 100 mCi of I-131. However, the patient received only 5 mCi of I-131. At this time no other information is available. The Department will update this event as soon as more information is provided. The Department will perform a reactive inspection. More information will be provided upon receipt. PA Event Number: PA240006 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. | Underdose Reactive Inspection |
| ENS 57073 | 12 April 2024 15:30:00 | Medical University of South Carolina | NRC Region 1 | South Carolina | The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email: The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 (EDT) on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 (EDT). The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally. The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control. 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.
The following update was provided by the South Carolina Department of Health and Environmental Control via email: The licensee has submitted a 15-day written report. This event is still under investigation by the South Carolina Department of Health and Environmental Control. The internal identification number for this event is SC240001. Notified R1DO (Werkheiser), NMSS_EVENTS_NOTIFICATION via email.
The following information was provided by the licensee via email: Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee's notification and written report. The licensee attributes the root cause of the failure to administer the full dosage to the administration lines due to administration line blockage, specifically a faulty needle in the plunger of the administration kit. This event is considered closed. Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email. | Underdose |
| ENS 56927 | 17 January 2024 23:16:00 | University of New Mexico | NRC Region 0 | New Mexico | The following is a synopsis of information provided by the licensee via email and phone call: On January 17th, at 1616 MST, the Reactor Supervisor violated Technical Specification (TS) 6.1.12.a. During an NRC exam, a trainee was operating the reactor under the supervision of the reactor supervisor. The doorbell rang, and the supervisor requested that the reactor be scrammed and the console power be turned off, which was accomplished. The supervisor then stepped out of the reactor room, but the key remained in the console, thus the reactor was unsecured. TS 6.1.12.a requires one reactor operator or reactor supervisor to be in the room when the reactor is not secured. | |
| ENS 56661 | 5 August 2023 15:07:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the PA Bureau of Radiation Protection (the Department) via email: On August 4, 2023, the licensee, University of Pennsylvania, informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. The event is reportable per 10 CFR 35.3045(a)(1). On August 3, 2023, it was determined that 71.0 percent of the prescribed dose to the target tissue was delivered for the above treatment. The only information relayed to the Department so far was that there were no spills or leaks in the system. The DEP (Department of Environmental Protection) is currently in contact with the licensee and will update this event as soon as more information is provided. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. Event Report ID No: PA230021
An administration of Y-90 TheraSpheres occurred with no apparent difficulties. No leaks or spills were identified, as corroborated by post administration monitoring which identified no contamination. However, when the waste was measured it was determined that less than 80 percent (72.6 percent) of the prescribed activity was administered. It is estimated that 21.18 mCi of the 29.18 mCi prescribed dose was administered. The patient and prescribing physician have been informed. No adverse effects to the patient are present nor are any anticipated. Notified R1DO (Dimitriadis) and NMSS (Email). 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. | TheraSphere Underdose Reactive Inspection |
| ENS 56684 | 28 July 2023 04:00:00 | Ohio State University | NRC Region 3 | Ohio | The following report was received via email by the Ohio Bureau of Radiation Protection: On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive. Ohio Event Number: OH230009 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. | |
| ENS 56643 | 27 July 2023 22:00:00 | University of California-Davis | NRC Region 0 | California | The following information was provided by the licensee via email: This notification is being made per the requirements of technical specification 6.7.2 During the facility's routine 2023 fuel inspection on July 27th, 2023, it was discovered that a stainless steel clad standard TRIGA 20/20 element did not pass its visual inspection. The visual inspection of the element, made via an underwater camera with approximately 2 times optical magnification, showed inward pitting and unusual discoloration in the cladding of the fueled section of the element. The elongation and transverse bend of the element were measured and were within tolerance per the facility's technical specifications. The cause of this pitting is unknown at this time. The element has been permanently retired from service and placed in an in-tank fuel storage rack. No unusual radiation readings were observed leading up to the inspection or during the inspection. Therefore, it is very likely that the integrity of the cladding has not been compromised and no fission products have escaped as a result of the pitting. Though not required by the facility's technical specifications, (McClellan Nuclear Research Center) (MNRC) staff is proceeding with the inspection of all adjacent fuel elements and all other standard elements that have not been inspected within the last year. This inspection corresponds to approximately 85% of all in-core elements. The expected completion date of this inspection is August 2nd. Detailed results of this inspection will be provided in an incident report to the NRC no later than August 10, 2023. | |
| ENS 56602 | 20 June 2023 05:59:00 | University of New Mexico | NRC Region 0 | New Mexico | The following information is a summary provided by the licensee via phone and email: The University of New Mexico reported a violation of its non-power reactor technical specification (TS) 1.1.36(c) required alarm testing frequency. The alarm testing requirement requires that the site alarms be tested on a semi-annual basis, not to exceed 7.5 months. According to the licensee, the last successful test of the New Mexico non-power reactor alarm system occurred on October 27, 2022, which is in excess of the 7.5 month requirement. The reactor was at zero percent power when the TS violation was discovered and continues to be at zero percent power. Reactor operations are suspended until the issue is resolved. | |
| ENS 56553 | 2 June 2023 12:18:00 | North Carolina State University | NRC Region 0 | North Carolina | The following information was provided by the licensee via fax or email: An unscheduled shutdown of the reactor occurred on 6/2/23 at 0818 EDT due to an abnormal response of the Safety Power Level channel during the approach to power of 1 MW at 150 kW. The Reactor Operator observed a discrepancy in power indications by the Linear Power Level and Safety Power Level channels and took immediate actions required by procedure NRP-OP-105, Response to SCRAMS, Alarms, and Abnormal Conditions. The reactor was shut down and secured immediately. The Designated Senior Reactor Operator was immediately notified. The Safety Power Level channel is required to be operable per Technical Specification 3.3.b Table 3.3-1 while the reactor is being operated. During the startup checklist, the channel performed satisfactorily. The Safety Power Level channel is part of the reactor safety system and has two automatic shutdowns (SCRAMs) associated with it. Reactor power was correctly monitored by all other operable power monitoring channels which have redundant SCRAM capabilities. No SCRAM occurred or was needed due to the power level of the reactor. Following the reactor shutdown, the reactor staff investigated and determined that the high voltage power supply in the Safety Power channel was faulty. The power supply was replaced and a channel calibration of the Safety Power channel will be performed using procedure PS 1-05-03A:S1 to verify the channel is operable. Maintenance Log #0888 has been opened. There was no safety issue with this event. Procedures were followed during reactor operation, shutdown, and the investigation. This unscheduled shutdown is a reportable event per TS 6.7.1 based on the circumstances and as defined in the facility Technical Specification (TS 1.2.24.d) for reportable events from operation in violation of Limiting Conditions for Operation (LCO) established in TS. TS 1.2.24.d, does not allow for an exception for taking prompt remedial action. A report to the NRC is required within one working day and will be made by 1700 EDT by phone on 6/2/23, as required by TS 6.7.1. Also as required by TS 6.7.1, a written report to the NRC is due in 14 days (6/16/23). | |
| ENS 56579 | 31 May 2023 16:30:00 | Oregon State University | NRC Region 0 | Oregon | The following information was provided by the licensee via phone and email: (Oregon State University Radiation Center is) providing this information as a follow-up with the phone call to the Headquarters Operations Center made today at 1325 EDT (EN-56579). On the morning of 5/31/2023, a senior reactor operator and a trainee operator were performing a square-wave operation to raise power from 100 W to 1 MW. After firing the transient rod, the reactor immediately scrammed on both safety and percent power channels. Review of the chart recorder shows that reactor power likely reached 1.45 MW. This is potentially a violation of Technical Specification 3.1.1 which limits power to 1.1 MW during steady-state operations. Reviewing the power chart recorder, it appears that two immediately adjacent steps required for the square-wave operation were performed inadvertently out of order. The chart's sample rate is 1 Hz, so the resolution on the data is limited. Within 10 seconds, the final procedure steps for square-wave operation were performed (with the mode switch in square-wave mode). Once the transient rod air actuation button was pushed, starting the square-wave, the safety channel shortly thereafter (approximately 1 second) went from 0.02 percent to 145.91 percent of 1 MW. The reactor immediately scrammed and shut down the reactor as the safety and percent power channels exceeded their scram setpoints of 106 percent of 1 MW, which were checked on the daily startup checklist. The cause of the event was that two steps in the procedure were performed out of order, causing the regulating rod to withdraw to match demand power as the transient rod withdrew. As a result, this caused an additional 18 cents of reactivity to be inserted above the planned reactivity insertion of 80 cents. (Oregon State University Radiation Center plans) on following this up with a more thorough report within 14 days. | |
| ENS 56534 | 23 May 2023 13:45:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | The following information was provided by the University of Missouri-Columbia Research Reactor (MURR) via phone and email: During a normal reactor start up on 5/23/2023, while still approaching criticality, reactor power peaked slightly above 100 kW with a single control blade 1.4 inches below the other three control blades. This is a violation of Technical Specification (TS) 3.2.b which states that above 100 kW, the reactor shall be operated so that the maximum distance between the highest and lowest shim blade shall not exceed 1 inch. As part of a normal reactor startup, three control blades were at 23 inches and the core was approaching criticality. As the fourth control blade was being pulled to the bank height, the Lead Senior Reactor Operator stated power was approaching 100 kW, alerting the Reactor Operator to the TS of no more than a one-inch height differential between control blades. Reactor power slowly increased. The Reactor Operator stopped shimming out on Control Blade 'A' and shimmed the other three rods inward individually to stop the power rise. He continued to then pull Control Blade 'A' out while leveling power by shimming the other three rods in. The control room continued the startup. No other issues occurred during the approach to full power (10 MW). After the startup, the Lead Senior Reactor Operator raised a concern that it was possible power peaked slightly above 100 kW with Control Blade 'A' at 1.4 inches below the other three control blades. Strip charts confirmed power peaked at 103.5 kW during this time. Total duration in this unapproved control blade configuration was less than one minute. The Reactor Manager was informed of the problem, and he informed the Interim Facility Director. MURR Licensee Event Report (LER) 13-03 discusses a similar event. Calculations performed for that event show that a control blade can differ by as much as 4 inches from the bank with no adverse effects to the core. MURR reactor operations were continued. MURR will follow up with an LER to address this issue. | |
| ENS 56466 | 4 April 2023 18:00:00 | University of Utah | NRC Region 4 | Utah | The following information was provided by the Utah Division of Waste Management and Radiation Control (DWMRC) via email: The University of Utah contacted the DWMRC to report that they had found that an Isotope Products Laboratories, Cs-137 Resin Vial Source, Source Number 988-97-3 with an assayed activity of 208.9 microcuries (assay date May 1, 2004), was leaking. A routine quarterly leak test was taken of the sealed source. When counted with a PerkinElmer 2480 Wizard2 radiation detector, the wipe showed an elevated reading. The wipe results showed 4531 cpm (background 32 cpm). The technologist who performed the wipe contacted the licensee's Radiological Health Department. The technologist was told to count the wipe in the well counter (Biodex AtomLab 500). The well counter on the Cs-137 channel showed there was 0.6 microcuries with a 0.3 microcuries background on the sample for a leak test result of 0.3 microcuries. Since there was no obvious leak in the resin vial, the licensee suspected it had been contaminated with short lived radioisotopes. The source was doubly bagged and isolated in storage until the next day when it was again verified to be above background. On April 11, 2023, it was retested. The leak test was performed with both an alcohol pad and a gauze pad. The results of these samples were counted with the PerkinElmer instrument, but not the well counter. The result of the wipes was 4248 cpm and 7303 cpm respectively (PerkinElmer 2480 Wizard2 radiation detector for both tests was 32 cpm). This showed it was not a short-lived isotope and the source was leaking. The individual stated that when he performed the wipe test on April 11, 2023, he heard the plastic vial crack and the crack opened while the wipe was being taken but returned to a 'closed position' when the wipe was completed. He immediately returned the wipe to the baggies and put it in storage. Since the wipes taken verified the original assessment was correct, the licensee stated that the source would be placed with their waste and disposed in their normal waste shipments to a licensed radioactive waste disposal site. After the initial finding on April 4, 2023, radiation surveys of the area and equipment were conducted to verify that no contamination was present. No contamination was found, and the area and equipment were released for use. The licensee stated that the vial appeared to be slightly yellowed around the crack and believes the plastic may have cracked due to radiation fatigue. The licensee had ordered two of these sources in 2004. The other source was in use at one of the licensee's other medical facilities but was removed from service and will be disposed of with the leaking source as a precaution. Utah Event Report ID Number: UT 23-0004 | |
| ENS 56400 | 7 March 2023 05:00:00 | Ohio State University | NRC Region 3 | Ohio | The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email: Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable. Reference Number OH 2023-006 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. | |
| ENS 56331 | 31 January 2023 08:00:00 | University of California-Davis | NRC Region 0 | California | The following information was provided by the licensee via email: (University of California, Davis McClellan Nuclear Research Center) MNRC received its new 20 year operating license from the NRC on November 21, 2022. As part of the new license, several new conditions in the technical specification were added for consistency with other non-power reactors and to give greater assurances of public safety beyond the previous technical specifications. The license condition involved in this event is Technical Specification 3.3 specification 4 concerning the maximum allowable activity of radionuclides in MNRC's primary cooling water with half-lives greater than 24 hours. The specific requirement is that these radionuclide concentrations shall be less than the 10 CFR 20 Appendix B table 3 values for the reactor to be operated. When agreeing to this new technical specification, MNRC staff looked at the historical values for all non-tritium nuclides having half-lives greater than 24 hours. These nuclides are assayed at MNRC via high resolution gamma-ray spectroscopy. For these nuclides MNRC is able to meet the new (limiting condition of operation) LCO limit easily. Separately, MNRC staff evaluated the tritium activity that was provided to MNRC via a 3rd party laboratory. The latest result from the 3rd party laboratory appeared to confirm that MNRC would meet the new tritium limit of 0.01 uCi/ml by having a tritium concentration of approximately 1/40th of this value. On January 31, 2023, during the planning for the required surveillance of technical specification 3.3 item 4, it was discovered that the 3rd party laboratory result was incorrect and they mistakenly underreported tritium concentrations by a factor of 100. At approximately 1600 (PST) on the same day, it was verified that MNRC's primary water tritium concentration was approximately 2.5 times the new technical specification limit given in section 3.3 item 4, resulting in not being able to meet an LCO. A more thorough data review shows that historical concentrations of the tritium in MNRC's primary coolant are very constant (except for the misreported data used to evaluation MNRC's ability to meet the new technical specification 3.3 item 4). Therefore, failing to meet this LCO is a condition that has likely existed since the issuing of the new license on November 21, 2022. MNRC was not operating at the time of this discovery and has not resumed reactor operations. There has likely been no increase in the amount of tritium in MNRC's primary cooling water nor has any primary cooling water been released from the reactor tank since the new technical specification took effect. There are no safety or security concerns generated as a result of this event. The facility license holder (level 1 management), the chair of the MNRC safety committee, MNRC's NRC program manager, assistant program manager, and inspector have been notified of this event. The ultimate resolution of this issue will need to be a license amendment increasing the permissible tritium concentration in the primary cooling water as a condition for reactor operation as it is physically impossible to lower the tritium concentration in order to meet the LCO. | |
| ENS 57086 | 31 January 2023 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240010 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. | |
| ENS 57085 | 29 December 2022 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240009 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. | |
| ENS 57084 | 28 December 2022 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240008 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. | |
| ENS 56267 | 6 December 2022 17:30:00 | University of Utah | NRC Region 0 | Utah | The following information was provided by the licensee via email: On December 6th, 2022, University of Utah Training Reactor (UUTR) was in the process of performing a research sample irradiation. The sample was known to have a negative reactivity worth and was therefore placed in the reactor prior to reactor startup. Upon commencing reactor startup procedures, the reactor operator subsequently terminated the startup attempt after noting that the sample appeared to demonstrate a larger negative reactivity worth than what was initially anticipated. After investigating, we identified that there was an inconsistency/miscommunication regarding the sample materials specifications, and the actual negative sample reactivity worth was a larger negative value than that of the original estimate. Immediately afterwards, we performed an updated materials assessment of the sample, which, following reactor calculations, revealed that the sample indeed demonstrated a larger negativity reactivity worth than was originally predicted. As a result, this report is being submitted in accordance with UUTR Technical Specification (TS) 6.7.2 due to 'observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy could have caused the existence or development of an unsafe condition with regard to reactor operation.' In accordance with UUTR TS, the reactor was secured, and Utah Nuclear Engineering Program Director notified, and operations shall not resume unless authorized by the Director. The NRC Project manager was notified. | |
| ENS 56313 | 23 November 2022 20:20:00 | University of New Mexico | NRC Region 0 | New Mexico | The following information was provided by the licensee via email: (An) iodized table salt (sample) was inserted to centerline at 1222 (MST) to be irradiated at 4.0 watts. At 1227 the reactor was established as critical at 4.0 watts. The iodized table salt was irradiated until 1320. At 1320 the senior reactor operator communicated to a licensed operator that the salt would be removed. The senior reactor operator pulled the salt out with the power level at 4 watts. The reactor then entered a positive period and jumped to 6.0 watts, resulting in an unintentional high-level scram. The senior reactor operator called the chief supervisor and alerted him immediately of the event who then advised to create a report of the event. The chief supervisor then advised that in the future, better communication is necessary to account for the reactivity differences between an inserted sample and the inserted fuel rods. This event will be added to 'Lessons Learned' for future trainees. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee notified the NRR Project Manager (Helvenston). All reactor systems responded as designed. | |
| ENS 56296 | 22 September 2022 18:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | The following information was provided by the licensee via email: In accordance with (University of Missouri Research Reactor) MURR Technical Specification 6.6 paragraph 'c', MURR is reporting an abnormal occurrence. The NRC informed MURR's Reactor Manager today that an (Senior Reactor Operator) SRO's license could not be renewed due to MURR submitting the request within 30 days of the expiration date and the license expiring prior to the NRC being able to act on the application. This meant the license expired on September 22, 2022. The Reactor Manager informed the interim Reactor Facility Director of this issue. MURR validated the current SRO in the control room has a valid license and determined the reactor was in a safe condition, operating at 10 (Megawatts) MW. A review of the records shows that all other reactor operator and senior reactor operator licenses are current. MURR reviewed all operating logs dating back to September 22, 2022 and has determined that there were three days during which this now unlicensed SRO was in the control room supervising evolutions that require an SRO to be present per Tech Spec 6.1. f. (Initial startup and approach to power, and relocation of any experiment with a reactivity worth greater than 0.0074 units). MURR will not let the individual with an expired license stand any control room positions until he obtains a license. MURR will follow up with a letter detailing an investigation into this issue and any other corrective actions from that investigation. The Reactor Manager notified the NRC Project Manager and Branch Chief for Non-Power Reactors. | |
| ENS 56122 | 21 September 2022 05:00:00 | University of Missouri-Columbia | NRC Region 3 | Tennessee California Missouri | The following information was provided by the licensee via phone: A shipment of Lutetium-177 was reported lost on September 21, 2022, en route from the University of Missouri to the University of California, San Francisco. The sample was 105 mCi when shipped on September 8 and would be no more than 20 mCi when reported lost on September 21, 2022. The last known location of the package was at the common carrier's facility in Memphis, Tennessee. 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 | Moisture Density Gauge |
| ENS 55914 | 24 May 2022 17:15:00 | University of Utah | NRC Region 0 | Utah | The following information was provided by the University Of Utah Training Reactor (UUTR) via email: This is a written report to NRC regarding minor damage to a fuel element identified during routine fuel inspection operations, filed per UUTR Technical Specification para 6.7.2, 'Special Reports' noting degradation in a reactor fuel element cladding. On Tuesday, May 24 2022, at 1115 (MDT), during a routine UUTR bi-annual fuel inspection, one stainless steel U-235 TRIGA fuel element removed from core position D-14, element number 4138E, was noted to have low-level surface pitting and severe discoloration at several locations along the element length. When this fuel element was moved toward the inspection apparatus, at one of the pitted locations on the surface of the fuel element, a small stream of clear bubbles began to evolve. This was captured on high resolution video; the bubbles were presumed to be fission gas. Reinspection of this same fuel element one hour later with high resolution video showed no evolution of gas bubbles, and the element remained intact. Radiation levels throughout the facility remained constant and consistent with background levels. Response to this Event: After initial observation of the pitting and bubble evolution, the fuel element number 4138E was placed in a fuel element storage rack; local radiation levels remained at measured background levels at all times from multiple instruments. On the facility continuous air monitor, no noted deviations from background levels were observed over the entire period of concern. Radiation readings throughout the duration of this observation remained at background levels, and no significant issues or safety concerns were noted; the reactor and facility remain secure, and fuel inspection operations will continue over the next week. Follow-up Actions: UUTR reactor personnel will permanently remove fuel element number 4138E from service, and continue to monitor for any instance of elevated radiation levels from the reactor pool. All levels remain stable at background levels. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The Non-Power Reactor Project Manager will be notified and the Utah State Radiation Safety Officer was notified. The estimated time for restart is one week. | |
| ENS 55889 | 4 May 2022 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (Department) via fax: On May 6, 2022, the University of Pennsylvania informed the Department of an underdose incident on May 4, 2022, involving yttrium-90 (Y90) SIR-Spheres. A patient underwent a Y90 SIR-Sphere treatment and the catheter placement changed during a SIR-Spheres administration and the Authorized User intentionally stopped the administration as continuing could have resulted in harm to the patient. The administered activity was 67 percent of the prescribed activity (15.1 mCi vs 22.51 mCi). The Department will perform a reactive inspection and is currently in contact with the University of Pennsylvania. The event will be updated this as soon as more information is provided. It is reportable as per 10 CFR 35.3045(a)(1)(i). Pennsylvania Report Number: PA220017 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. | Underdose Reactive Inspection |
| ENS 55851 | 18 April 2022 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following was received from the Pennsylvania Bureau of Radiation Protection by e-mail: On April 18, 2022, a patient underwent a Y-90 SIR-Sphere treatment. The prescribed dosage was 7.07 milliCuries, however only 5.27 milliCuries was able to be delivered, or 74.5 percent. The apparent cause is that the blood vessel the catheter was placed in had a complicated vasculature which inhibited the flow of the spheres. No harm is expected to the patient. The referring physician and the patient have been informed. Event Report ID Number: PA220014 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. | Underdose |
| ENS 55747 | 17 February 2022 18:46:00 | North Carolina State University | NRC Region 0 | North Carolina | The following is a summary of information provided by the licensee via telephone: On February 17, 2022 at 1346 EST, while the reactor was operating at 95 percent power, the North Carolina State University test reactor was manually shutdown due to an incorrect power meter reading. The power meter was reading 20 percent power. The incorrect power meter reading violated technical specification 3.4. The facility director was notified of the event. The reactor is shutdown and secured. The NRC Project Manager was notified. | |
| ENS 55739 | 15 February 2022 13:00:00 | Ohio State University | NRC Region 0 | Ohio | The following information was provided by the licensee via fax or email: While performing the pre-start checkout on 2022-02-15 (at approximately 0800 EST), the SRO (Senior Reactor Operator) performing the checkout discovered that the building exhaust fan was not operating. This fan is required to be operating during reactor operations, and it is typically left running all the time. Troubleshooting determined that the cause of the fan loss was power loss from a conduit being cut the previous day when a small area of the cement floor in the janitor closet was being removed for replacement of the janitor closet sink. The concrete work was performed between 1200 and 1453 EST, which was when the contractor signed in and out. The reactor was shut down at 1551 EST, so the reactor was operated for at least an hour without the fan operating. There were no safety implications for the reactor, the staff, or the public. | |
| ENS 56077 | 17 December 2021 07:00:00 | Oregon State University | NRC Region 4 | Oregon | The following information was provided by Oregon Health Authority, Public Health Division, Radiation Protection Services via email: On December 17, 2021, while conducting a semi-annual inventory of radioactive material in possession, a Broad Scope A - Academic licensee found that a gas chromatograph (GC) containing one electron capture device (ECD) missing. The previous inventory was performed in May 2021 and most recent leak test performed in March 2021. (note: after March the lab was shut down during September 2021 for asbestos abatement and ECD marked as `in storage') Upon checking with the device custodian, the GC/ECD device was picked up in July 2021 by the campus surplus property group by request from the custodian for disposal. The device custodian verbally told the surplus property personnel taking the device that it contained radioactive material which they verbally acknowledged, stating they would contact Radiation Safety to remove it. However, this was not done. The licensee performed extensive searches of the lab where the device was housed, surplus property warehouse and campus metals scrap yard with negative results. It is possible the device/source was shipped to a local scrap metals dealer but after contacting the dealer this could not be confirmed. Cause and corrective actions: Primarily, the department in possession of the GC/ECD failed to notify the Radiation Safety Office of the intent to dispose of the device prior to contacting the Surplus Property Office as required by the licensee's Radiation Safety Manual. Secondarily, the Surplus Property Office personnel do not have the training to identify a device that potentially contains radioactive material and minimal, if any, radiation safety training. This resulted in loss of possession of a radioactive source with human error as the cause. Corrective actions include (1) an information bulletin was sent to departments that possess radioactive materials confirming radioactive material control procedures and responsibility for material unless explicitly cleared by Radiation Safety, (2) expanded safety instruction and meeting with surplus personnel to discuss GC/ECD's and other radiation hazards that may come to surplus, and (3) additional placarding of GC/ECD's, X-ray machines, (Liquid Scintillation Counters) LSC's, and sealed sources. Concerns: For many years, the licensee has relied on their rules contained in their Radiation Safety Manual regarding possession/security of radioactive material that are initially reviewed/acknowledged by the departments involved. The subsequent semi-annual inventories also include an acknowledgement of these rules by the department audited. Offering a device containing radioactive material for removal without first contacting the Radiation Safety Office is a violation of these rules. Surplus property personnel receive minimal, if any, radiation safety instruction and none regarding possession/security of radioactive material since the signage and sources are normally removed from the device(s) by the Radiation Safety Office prior to disposal. In addition, surplus property personnel were informed verbally of the radioactive material that was inside the device but failed to contact the Radiation Safety Office. These concerns have been adequately addressed by the licensee's corrective actions. Source: Nickel-63 Activity: 8.7 mCi (nominal 10 mCi on 4-5-01) Manufacturer: Shimadzu Model: VS2000 Serial number: C10893200343 Leak test date: March 24, 2021 Oregon Report Identification Number: 21-0061 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 | Moisture Density Gauge |
| ENS 55613 | 24 November 2021 05:00:00 | University of Virginia | NRC Region 1 | Virginia | The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email: On November 24, 2021, the agency was notified by the (radiation safety officer) at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR (high dose rate brachytherapy) had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit. This report will be updated when the licensee submits their final investigation report. Virginia Event Report ID No.: VA-21-0007 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. | Brachytherapy |
| ENS 55583 | 15 November 2021 06:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | University Of Missouri Research Reactor (MURR) Technical Specification (TS) 6.6.c(1) requires notification to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, has occurred. MURR was not in compliance with one (1) of the TS Limiting Conditions of Operations. TS 3.2.g states, 'The reactor safety system and the number (N) of associated instrument channels necessary to provide the following scrams shall be operable whenever the reactor is in operation.' Specifically, the reactor safety scram function that occurs when the differential pressure across the reactor pool reflector (PT-917) instrument channel decreases below 2.52 psi minimum in Mode 1 operation was not operable as required by TS 3.2.g.10. On 11/15/21 while the reactor was shut down, Control Room operators shut down the pool coolant system and noticed that the `Reflector Hi-Low Diff Pressure Scram' annunciator alarm did not initiate as pool coolant flow rate decreased to zero. The Control Room operators contacted reactor management, and an investigation was initiated to prove whether or not the safety scram function from the PT-917 instrument channel actuated correctly. Further testing revealed the safety scram signal from the PT-917 instrument channel did not occur due to a failed alarm-meter unit. The alarm-meter unit was replaced with an exact spare, the PT-917 instrument channel was calibrated, and the reactor safety scram functions of the PT-917 instrument channel were retested satisfactorily. In accordance with TS 6.6.c(4), the Reactor Facility Director was briefed and gave permission to restart the reactor prior to the reactor returning to operation later on 11/15/21. Currently, MURR is operating at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3). The NRC Project manager was notified. | |
| ENS 55568 | 8 November 2021 06:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | This is a required notification per University Of Missouri Research Reactor (MURR) Technical Specification (TS) 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. MURR was not in compliance with one Limiting Conditions of Operations (LCO). TS 3.2.f states, 'The reactor shall not be operated unless the following rod run-in functions are operable.' Specifically, the rod run-in function that occurs when water level in the anti-siphon system is greater than or equal to 6 inches above the anti-siphon isolation valves was not operable as required by TS 3.2.f.6. On 11/8/21 while the reactor was shut down for maintenance and conducting surveillance testing on the anti-siphon system high level rod run-in instrument channel, the surveillance testing provided measurement that indicated the rod run-in actuation may not have occurred until water level was slightly greater than 6 inches above the anti-siphon isolation valves. Previously on 4/22/2021, the anti-siphon system high level rod run-in instrument channel activated the rod run-in well below the top of the anti-siphon isolation valves. Troubleshooting revealed the stainless-steel cable that connects the channel's level controller to its suspended displacer (float) had developed loops in it, effectively shortening the cable. The cable with loops made the rod run-in actuation occur at a higher water level than when the cable has no loops in it. The loops in the cable were removed. The instrument channel was retested and documented to be back in compliance with TS 3.2.f.6. On 11/9/21, MURR engineers analyzed the data collected from the 11/8/21 measurement and concluded that prior to removing the loops from the level controller cable, the rod run-in was actuating at a level of approximately 7.3 inches above the anti-siphon isolation valves, which is greater than the maximum of 6 inches above the valves required by TS 3.2.f.6. In accordance with TS 6.6.c(4) before it was known if MURR deviated from TS 3.2.f.6, the Acting Reactor Facility Director was briefed and gave permission to restart the reactor prior to the reactor returning to operation later on 11/8/21. Currently, MURR is operating at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3). | |
| ENS 55516 | 11 October 2021 05:00:00 | University of Missouri-Columbia | NRC Region 0 | Missouri | (This notification is required) per University Of Missouri Research Reactor (MURR) Technical Specification (TS) 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.g. which states, 'The reactor safety system and the number (N) of associated instrument channels necessary to provide the following scrams shall be operable whenever the reactor is in operation..' TS 3.2.g.6 requires four (4) Primary Coolant Low Pressure reactor safety system instrument channels provide a reactor scram when the primary coolant pressure corresponding to the pressurizer during normal flow drops below 75 psia. Surveillance testing on 10/11/2021 revealed that one (1) of the four (4) channels was not operable. On 10/11/21 while the reactor was shutdown for maintenance and conducting surveillance testing on the reactor core outlet pressure channels, the surveillance testing revealed that the reactor core outlet pressure channel associated with pressure transmitter 944B did not provide a reactor scram at an appropriate TS low pressure setpoint. On 10/11/21, the Primary Coolant Low Pressure reactor safety instrument channel 944B scram setpoint was calculated to be 74.43 psia which is slightly below the required 75 psia minimum. Previously on 4/12/2021, the Primary Coolant Low Pressure reactor safety instrument channel 944B scram setpoint was calculated to be 76.94 psia which is within the TS-required setpoint range. So, sometime between 4/12/2021 and 10/11/2021, the reactor possibly operated while one (1) of the four (4) instrument channels deviated from TS 3.2.g.6. Troubleshooting revealed the component in instrument channel 944B that caused the setpoint deviation. That component was replaced with an exact spare, and the instrument channel was retested and documented to be back in compliance with TS 3.2.g.6. In accordance with TS 6.6.c(4), permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on 10/11/21. Currently, MURR is operating at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3). | |
| ENS 55525 | 5 October 2021 05:00:00 | University of Iowa | NRC Region 3 | Iowa | The following was received from the Iowa Department of Public Health (IDPH) via email: On October 5, 2021, the University of Iowa's radiation safety officer (RSO) contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21. At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr. Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can. When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2. On October 6, the RSO surveyed all of the waste containers and bags that were in the (University of Iowa Health Care) (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight. Iowa Event Number: IA210004 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 | Moisture Density Gauge |
| ENS 55482 | 9 September 2021 18:00:00 | University of Utah | NRC Region 4 | Utah | The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email: On August 27, 2021, local heavy rain infiltrated the Merrill Engineering Building, causing flooding on the first and third floors. The first floor also included some radioactive materials labs. While stripping the labs on September 9, 2021, in preparation for repair, the contractor violated policy and failed to notify the lab owners before moving material from the lab. Included in the material removed from the lab was a safe containing 13 exempt calibration sources and one 0.006 milliCurie U-235 ceramic source. The safe was moved to an onsite trailer that was under control of the contractor and not the University. When the lab owner returned to the lab later in the day they immediately reported the sources missing. Investigation by licensee personnel lead them to where the sources were being stored. The sources were out of the licensee's exclusive control for 1 to 3 hours. The sources were re-secured and placed under the licensee's exclusive control closing the incident. The report was not determined to be reportable until the Division was able to conduct its on site investigation on September 20, 2021. Utah Event Report ID Number: UT 210005 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 | Moisture Density Gauge |
| ENS 55855 | 21 July 2021 05:00:00 | Kansas State University | NRC Region 4 | Kansas | The following was received from the state of Kansas via email: On 4/21/22 during the course of an inspection of the facility, the State of Kansas discovered that an incident involving one of their portable gauges occurred on 7/21/2021. This incident was never reported to Kansas and was discovered through the inspection process. Licensee Kansas State University (# 38-C011-01) had a Campbell Pacific Nuclear model 503 portable gauge (serial number 50505) damaged while being used in a field at the Hutchinson, Kansas field research station. The gauge contained 50 mCi of AmBe. The gauge was run over when the student who was using the gauge under the oversight of the local RSO (Radiation Safety Officer) (unknown at this time if the local RSO was present at the site) backed a vehicle over it. At this time Kansas has not been able to determine if the student left the gauge unattended for a brief time or if the student did not properly secure the gauge into the vehicle and it fell out. The gauge was inspected immediately after the incident, and it was found that, though the gauge shielding appeared to be intact, the shipping case was damaged. Immediately following the incident, the student contacted their Primary Investigator (PI), who is a university instructor overseeing the student's project, to inform him of the incident, but it was reported that the PI asked if it was urgent and the student said no. The gauge was discovered damaged by the PI a week later on 7/28/2021. Upon discovery, the PI reported that he ordered a new shipping case and ordered leak tests. The leak tests were performed on 7/29/2021 and did not show damage to the source. The damage to the gauge housing was on the opposite side of the machine from the source and did not interfere with the source's insertion or retraction. Because of this, the licensee stated that they decided it was not reportable to Kansas. An investigation is underway to determine what steps were taken by the licensee, including possible repairs to the unit. Follow-up information will be provided as it is obtained. | |
| ENS 55337 | 2 July 2021 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following was received via an email from the state of Pennsylvania: The Department (PA Bureau of Radiation Protection) received notification from a licensee on July 2, 2021 of a medical event involving a Y-90 TheraSphere. The licensee noted 71 percent of the prescribed dose of 30.8 millicuries was administered to the patient. A mechanical blockage occurred in the delivery system preventing spheres from exiting the administration vial. All material was contained in the delivery system, lines, and patient. Area monitoring confirmed that no leak occurred and no contamination of the work area. Nuclear Medicine imaging of the waste confirmed activity concentrated within the vial. The physician and patient have been notified. No adverse effects to the patient are anticipated. 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: PA210006 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. | TheraSphere |
| ENS 55266 | 19 May 2021 16:00:00 | University of Missouri-Rolla | NRC Region 0 | Missouri | The (Missouri University of Science and Technology Reactor) MSTR is required by Technical Specification 4.6.2(1) to perform an experimental verification of calculated airborne effluent release values every five years and when a change in licensed power occurs. An experimental verification was performed on October 24, 2019. However, in a follow-up assessment of the verification report and data, the results and analysis were determined to be non-credible. As the most recent experimental verification was completed on October 27, 2014, the MSTR does not meet the requirement of TS 4.6.2(1). This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day (reported as EN-55266). Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. An experimental verification of gaseous effluent release will be performed as soon as practical following restoring the MSTR to an operable status, which is expected to occur no later than July 31, 2021. The licensee will notify the NRC PM (W. Kennedy). | |
| ENS 55248 | 10 May 2021 05:00:00 | Ohio State University | NRC Region 3 | Ohio | The following report was received from the state of Ohio via email: A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified. Ohio Event Number: OH210003 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. | TheraSphere |
| ENS 55197 | 15 April 2021 04:00:00 | University of Virginia | NRC Region 1 | Virginia | The following report was received from the Virginia Radioactive Materials Program via email: On April 16, 2021, at 1605 EDT, the Virginia Radioactive Materials Program received a report from the licensee that a 6.2 Curie (tritium) exit sign (Shield Source Inc., S/N: 11-36361) was lost. The licensee was performing an inventory of (tritium) exit signs on April 15, 2021. The licensee's report indicated that the exit sign was not found at the location where it was last inventoried in 2020 by the Radiation Safety Department. The licensee contacted their Facilities Management Department, asked them about construction being performed at the location, and if the whereabouts of the sign was known. On April 16, 2021 after another search and email correspondence with Facilities Management, the licensee determined that the (tritium) exit sign was lost and was likely discarded with construction trash. The licensee submitted a corrective action plan in their report stipulating that Facilities Management will provide a point of contact with whom the Radiation Safety Program will work with regarding (tritium) exit signs to: (1) ensure they are not removed without proper notification, and (2) to notify the Radiation Safety Program of the installation of any new (tritium) exit signs placed within the University of Virginia. Virginia Report ID No.: VA210002 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 | Tritium Exit Sign Moisture Density Gauge |
| ENS 55359 | 28 February 2021 20:00:00 | Purdue University | NRC Region 0 | Indiana | On February 28, 2021, (at approximately 1500 EST), following recalibration of the reactor power in accordance with PUR-1 Technical Specifications, the reactor operator operated the reactor at 8.5 kW (85% of nominal power) and noticed that the rate of temperature change of the coolant was greater than expected. Noting that this presents the possibility of the power being in excess of expectations, PUR-1 was shut down and has remained shut down to date. PUR-1 staff immediately notified the Committee on Reactor Operations (CORO) and developed a plan to perform an in-depth investigation. Since then, multiple independent assessments on the reactor power have been performed, which include: Hand calculations, Monte Carlo N-Particle code (MCNP) simulations, analysis on activity measurements of irradiated materials, a thermal-hydraulic analysis using a Computational Fluid Dynamic (CFD) model of PUR-1, and a more physical assessment using resistance heaters as heat sources to determine the coolant temperature change rate as a function of power and pool temperature, which has just been completed. These five independent evaluation methods performed to determine the core power during the experiment on February 28, 2021, suggest that the reactor may have been operated for about 4 hours at a power in the range between 118.3 percent to 129.2 percent of our 12 kW maximum allowable power (per TS 2.2). While the reactor was not operated outside the bounds of the Safety Analysis Report (SAR), this represents a potential need for reporting under TS 6.7.b.1.c.vi, 'An observed inadequacy in the implementation of procedural controls...'. Staff are currently evaluating several potential corrective actions including adjustment of the current power calibration constant, which relates the activity of the gold foil to the core power, by the most conservative factor suggested by these five analyses. There was no impact to the safety of the public or PUR-1 staff and the Safety Limit was not exceeded at any point. A formal report will be subsequently issued. | |
| ENS 55123 | 3 February 2021 06:00:00 | University of Iowa | NRC Region 3 | Illinois Iowa | The following was received from Iowa Department of Public Health via email: On February 3, 2021, the University of Iowa received a package from (the common carrier) that was labeled as one of the standing orders of 1 millicurie P-32 dCTP for the Pathology Lab at UIHC ((University of Iowa Health Care)). The outer label was correct and the packing slip inside was correct, however the contents of the package was actually a prescription of Enbrel intended for an individual in Illinois. Further, the contents had obviously been repacked. It arrived in a large (common carrier) box, much bigger than required for the P-32 order or the Enbrel. Also, the top of the original package that held the P-32 had been torn off and affixed to the replacement box in an adhesive pouch. The licensee contacted both (the common carrier) and the pharmaceutical company that shipped the Enbrel. (The common carrier) returned to retrieve the Enbrel but haven't heard anything about the location of the original P-32 order. Perkin Elmer sent a replacement shipment of P-32 to the licensee. On February 10, 2021, (the common carrier) sent an email to the licensee notifying them that the original shipment of P-32 has not been located and they were closing the case. On March 4, 2021, the Iowa Department of Public Health contacted the University of Iowa Radiation Safety Officer (RSO) and was informed by the RSO that the original shipment of P-32 is still missing. The activity of the P-32 as of March 4, 2021 is approximately 244 microcuries. Item Number: IA210001 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 | Moisture Density Gauge |
| ENS 54964 | 20 October 2020 04:00:00 | University of Pennsylvania | NRC Region 1 | Pennsylvania | The following information was received from the Commonwealth of Pennsylvania via email: On October 20, 2020 the licensee discovered a lost gadolinium-153 source. This source, Eckert and Ziegler Model NES8412, is an attenuation correction source in a SPECT camera. These sources are sold in pairs, and the serial numbers for the pair are R3-129 and R3-130. Only one is missing and it is unknown which it is currently. The licensee believes the sources were present in mid-June when the source holders were removed from the gamma camera in preparation for scrapping. The licensee is investigating to confirm that is true. The sources were nominally 250 mCi (+20%/-10%) each on March 1, 2019. The activity on June 15, 2020 was calculated to be 64 mCi, and on the date of discovery 44 mCi. The licensee has notified its facility and safety staff and is actively searching for the source. The DEP (Department of Environmental Protection) has been in contact with the licensee and will update this event as soon as more information is provided. PA incident no.: PA200022 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 | Moisture Density Gauge |
| ENS 54958 | 19 October 2020 04:00:00 | Purdue University | NRC Region 0 | Indiana | During the course of operations, a potential error in the power calibration of the PUR-1, License Number R-87, was discovered. This calibration error would result in a special report requirement as specified in ((Technical Specification)) TS 6.7.b.1.c.vi, which is that an observed inadequacy in the implementation of a procedural control such that this inadequacy could have caused the development of an unsafe condition with regards to reactor operations. By extension the miscalibration caused a true reactor power higher than the measured reactor power. As such, this likely resulted in the operation in violation of the limiting condition for operation as established in TS Section 3 Table I and operation with an actual safety system setting for a required system less conservative than the limiting safety system settings specified in the Technical Specifications. These reporting requirements are Part i. and ii. of TS 6.7.b.1.c. The calibration error implicates a violation of the maximum licensed power level of 12 kW. The Safety Limit was not exceeded at any point. | |
| ENS 54627 | 31 March 2020 23:55:00 | Washington State University | NRC Region 0 | Washington Idaho | The following is a summary of information received from the Washington State University Reactor Facility via phone conversation: At 1655 PDT on March 31, 2020, the licensee declared a Notification of Unusual Event due to seismic activity felt from an earthquake originating in southern Idaho. Operators felt the seismic activity and entered their emergency planning procedures to inspect for any damages to the reactor facility. There were no injured personnel and the reactor was shutdown at the time of the earthquake. Initial assessments revealed no damages or effects to the reactor or to the facility. Additional walk downs are in progress. The licensee notified the NRR Project Manager (Hardesty). | Earthquake |