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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53671 | 16 October 2018 05:00:00 | Agreement State | Agreement State Report - Equipment Failure | The following was received from the State of Nebraska: Event type: Equipment Failure as reportable under 10 CFR 30.50, item b.2. and Inoperability of Access Control System under 10 CFR 36.83, item 5. Event description: Nebraska Department of Health and Human Services, Office of Radiological Health was conducting a performance-based inspection of the Becton Dickinson and Company licensee (10-08-01) during the late afternoon (between 2:30 and 3:30 pm) on October 16, 2018. During the inspection, an inspector was able to open an outer door leading from the production floor area to the control room, which is a part of the licensee's controlled access area. The control room also contains an access door which leads to a panoramic, wet source storage irradiator licensed for millions of curies of Co-60. The access door in the control room did not fail and was functioning as intended. The outer door leading to the control room was able to be opened by the inspector only after a routine entry was made. During the initial inspection by the licensee, it was determined that the locking mechanism was loose and did not latch as intended. The licensee was able to repair the locking mechanism within 2 hours and could not open the outer door after a routine entry was made. The State inquired with the Region IV Regional State Agreement Officer (RSAO) in the early afternoon (between 1:30 and 2:30pm) of October 17, 2018 to ask if this incident was a reportable event under 10 CFR 37. The RSAO indicated and agreed that this incident was not a report event under the reporting requirements of 10 CFR 37. Later that afternoon (between 3:30 and 4:00 pm), the RSAO stated that this incident may be a reportable event under 10 CFR 30.50, item b.2. and 10 CFR 36.83, item 5. The State and Region IV staff are scheduled to discuss this further on October 18, 2018, and this incident may need to be retracted. State Event Report ID No.: NE-18-0008
The following retraction was received from the State of Nebraska via email: Please retract this event. This does not meet the reporting requirements of either 10 CFR 30.50 or 10 CFR 36.83 since this outer door is not a part of the access control system. This was reviewed and discussed by State staff and NRC Region IV staff this morning. Notified R4DO (Pick) and NMSS Events Notification (email). | ||
| ENS 53667 | 14 October 2018 05:00:00 | Agreement State | Agreement State Report - Stuck Irradiator Source Rack | The following was received from the State of Nebraska via email: This morning at approximately 1030 (CDT), the State of Nebraska was contacted by the RSO of Becton, Dickinson and Company located in Holdrege, NE (NE license # 37-03-01) concerning a 24 hour reportable event. I believe the reporting requirement could be 10 CFR 36.83(a)(1), source stuck in the unshielded position or 10 CFR 36.83(a)(4), failure of the cable or drive mechanism used to move the source rack. Event: Approximately 1930 (CDT) on the night of October 14, 2018, there was an alarm of the source positioning indicators alerting the operators of a moving source. When the source rack failed to reach the rack down position in the allotted time period, a fault was recorded at the control panel. It appeared that the rack was stuck in the up position. The RSO called in at approximately 1940 (CDT) to help investigate the situation. Soon after arriving at the facility, (the RSO) placed a call into MDS Nordion for help with the situation. During the 2 hour time period for MDS Nordion to call back, (the RSO) successfully returned source rack #2 to the shielded position and tried to lower the source rack #1 to its shielded position but was unable to lower source rack #1. They also did some preliminary investigations and assumed that one of the guide cables for source rack #1 had busted. Once MDS Nordion returned their call, it was verified that the guide cable for source rack #1 had busted. MDS Nordion had the operators raise source rack #2 and with source rack #2 in its up position, lower source rack #1. After a couple attempts, they were successful in lowering the source rack #1 to its shielded position. Once source rack #1 was in its shielded position, the operators lowered the source rack #2 to its shielded position. Both were verified by the source down positioning switch. Note: After about 3.5 hours of the sources being stuck in the up position, the rack deluge system (rack sprinkler system) was deployed as a precautionary step to cool the sources and the product close to the sources. The overall time the sources were in the up position was approximately 5 hours. This was Nordion Model JS-8900 commercial irradiator. It was reported that nobody entered the vault while the sources were in the up position and that there is no reason to believe that any addition exposure to the workers was involved in this incident. |