Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57198 | 28 June 2024 13:19:00 | The following information was provided by the licensee via email: At approximately 2310 EDT on June 27th, the New Hanover County deputy fire marshal was notified that the site fire alarm system was impacted by multiple power surges from lightning. Specifically, the electric fire pump, while operational, could not communicate with the fire system. A fire watch was initiated and repairs to the system began. The electric fire pump communication was restored at approximately 0745 EDT on June 28th. The deputy fire marshal was notified of communication restoration. Because the New Hanover County deputy fire marshal was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c). The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee plans to notify the NRC Region 2 office and the state of North Carolina concerning this event report. |
| ENS 57195 | 27 June 2024 14:03:00 | The following information was provided by the licensee email: On June 27, 2024, at 0804 (EDT), D.C. Cook Unit 2 had an automatic start of the turbine driven auxiliary feedwater pump (TDAFP) following a controlled down power and manual reactor trip at approximately 17 percent power. The automatic start of the TDAFP was due to a steam generator water level 'low low' signal following the reactor trip. The down power and trip were performed in accordance with normal shutdown procedures to comply with the required action C.1 of technical specification 3.4.13, 'reactor coolant system operational leakage.' Reference event notification number EN57194. An automatic start of the TDAFP is an eight hour report per 10CFR 50.72(b)(3)(iv)(A). Unit 2 is being supplied by offsite power. All control rods fully inserted. Steam generators are being fed by both motor driven auxiliary feedwater pumps. Decay heat is being removed via the steam dump system to the main condenser. Preliminary evaluation indicates plant systems functioned normally following the reactor trip. D.C. Cook Unit 2 remains in Mode 3 to repair the previously reported reactor coolant system leakage through valve 2-QRV-251, 'CVCS (chemical and volume control system) charging pumps discharge flow control' valve packing. The NRC Resident Inspector has been notified. |
| ENS 57128 | 15 May 2024 05:50:00 | The following information was provided by the licensee via email: On May 15, 2024 at 0427 EDT, DC Cooks Unit 2 reactor was manually tripped due to difficulty maintaining steam generator water levels. DC Cook Unit 2 had removed the main turbine from service at approximately 0354 EDT during a planned down-power to repair a steam leak on the high pressure turbine right outer steam/stop control valve upstream drip pot. Stable steam generator water levels were unable to be maintained. As a result, DC Cook Unit 2 was manually tripped with reactor power stabilizing at approximately 20 percent. This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System actuation as a four hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight hour report. The reactor trip was not complicated and all plant systems functioned normally. The DC Cook NRC Resident Inspector was notified. |
| ENS 57121 | 10 May 2024 08:15:00 | The following synopsis of the event was provided by the licensee via phone: On the afternoon of May 9, 2024, during a leak test, the licensee identified a damaged shutter on a gauge (Serial Number - SH-F180) with a cesium (Cs-137) source of 100 millicuries at their facility. The licensee determined that no exposures or injuries occurred as a result of the damaged shutter since the gauge is located twenty feet off the ground in a primarily inaccessible location. No surveys are known to have been performed at this time. The shutter was determined to be unworkable, and is scheduled to be replaced at a later date.
The license number was originally reported as 373525501 but it should actually be 16-35383-01. Unit is 10 feet above the floor not 20 feet. Survey readings have been taken: 25.65 mR/hr at the surface; 1.73 mR/hr at 1 foot; 0.32 mR/hr at 3 feet; 0.05 mR/hr at 4 feet. Based on the survey readings, it is believed that the shutter is closed. The mine is now looking to repair the shutter control unit, not replace the gauge. Notified R1DO (Young) and NMSS Events via email. |
| ENS 57089 | 23 April 2024 08:48:00 | The following report is a summary of the event provided via phone from the licensees radiation safety officer: At 0030 AKDT on April 23, 2024, a radiography crew utilizing a QSA Global 880D exposure device with a 50.9 Ci Ir-192 sealed source experienced an issue where the slide lock of the device actuated prior to the source being in the fully shielded position. The licensees radiation safety personnel were notified. The source was properly secured in the device at 0440 AKDT by trained personnel using a U tool to reengage the slide lock. There were no overexposures during this incident. |
| ENS 57019 | 10 March 2024 12:05:00 | The following information was provided by the licensee via email: On 3/9/2024 at 2126 CST, train C essential cooling water was declared inoperable due to a through-wall leak on the discharge vent line. This would also cascade and cause train C essential chilled water to be inoperable. On 3/10/2024 at 0353 CDT, train B essential chilled water was declared inoperable due to chilled water outlet temperature greater than 52 degrees F following startup of essential chiller 12B. Chilled water outlet temperature was adjusted to less than 52 degrees F at 0440 CDT, and train B essential chilled water was declared operable. This condition resulted in the inoperability of two of the three safety trains required for the accident mitigating functions including: high head safety injection, low head safety injection, containment spray, electrical auxiliary building HVAC, control room envelope HVAC, and essential chilled water. This is an 8 hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident. The licensee notified the NRC Resident Inspector. |
| ENS 56982 | 20 February 2024 16:10:00 | The following report was received via phone call and email from the Texas Department of State Health Services (the Department): On February 20, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a Troxler 3440 moisture/density gauge was damaged at a temporary job site. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium -137 source. The gauge operator was setting the gauge up for use when they noticed that a large number of construction equipment was moving into the area. The operator decided to move their truck out of the way and while they were doing so the gauge was struck by a piece of equipment. The RSO stated the gauge case was damaged, but the sources were not damaged. The cesium source was still in the fully shielded position when the event occurred. The RSO stated the gauge was transported back to their facility and a leak test was conducted on the sources. The RSO stated they have contacted a service company and as soon as they get the leak test results back, they will dispose of the gauge. No individual received any significant exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10089 Texas NMED Number: TX240007 |
| ENS 56930 | 22 January 2024 18:11:00 | The following is a summary of information received via email from the Washington Office of Radiation Protection: On the afternoon of Friday, January 19th, a Pluvicto (radiopharmaceutical) dose was not administered properly. A typical administered dose may have up to 2 to 4 mCi of residual activity after a 200 mCi administration. However, for this administration there was 43 mCi of residual activity and only 149 mCi of calculated administered activity for a 200 mCi prescribed dose. Pluvicto is a six fraction, six administration regimen with about six weeks between each administration, and this was the patient's fourth fractional dose. Treated as a single administration treatment, this constitutes a medical event as the dose administered activity of 149 mCi is more than 20% less than the 200 mCi prescribed dose. The final report will be sent in 15 days. Washington Event Number: WA-24-003 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 information is a synopsis of information provided by the Washington State Radioactive Materials Section: A lutetium 177 (drug name: Pluvicto) dose was prescribed to be 200 mCi. The calculated dose administered to the patient was about 149 mCi, based upon the measured residual. The underdosing occurred due to a method of folding and crimping the intravenous tube with a hemostat and gauze instead of utilizing the kit provided clamp. The hospital supply chain of the intravenous kit was recently changed and the needed clamp was thought to be missing. To prevent future crimping of the intravenous tube, the use of hemostat and gauze will no longer be used. This dose was the fourth dose of six prescribed to the patient, with six weeks between each administration. There is no expected change in the patient's treatment or prognosis based on the underdosing of the fourth fraction of six and no additional actions are required. Final report will be sent in 15 days. Washington Event Number: WA-24-003 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. Notified R4DO (Agrawal) and NMSS (email). |
| ENS 56929 | 19 January 2024 12:53:00 | The following report in part was received via email from the Maine Radiological Control Program (MRCP): The licensee service manager contacted MRCP by phone on December 22, 2023, to report that a source could not be accounted for during a monthly source inventory. The service manager reported that the missing source had been observed in the service area of the licensee's facility in Windsor, ME, approximately two weeks before the inventory identified it as missing. The missing source had been removed from a customer's machine and replaced with a new source. The missing source is an 8 mCi Ni-63 source with serial number 09-6700 from Isotope Products Laboratories, Valencia, CA. The source was still in its sealed form inside the detector housing which is assembled with tamper-proof screws. Once the source was determined unaccounted for in the monthly inventory, a team of licensee employees searched the entire facility, spending in excess of 20 man-hours trying to locate it. The licensee's best assumption is that the missing source may have been accidentally disposed of during a recent shop cleaning. MRCP conducted a site inspection on January 2, 2024, to gather information regarding the incident. A licensee service technician was able to trace the waste stream which is routinely deposited in a dumpster and is then transported to the Waterville, ME, transfer station. As of January 19, 2024, the missing Ni-63 source remains lost. Maine Event Report Number: ME 2023-002 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 |
| ENS 56905 | 21 December 2023 12:29:00 | The following summary was provided by the licensee via phone and email: On December 21, 2023, VC Summer determined that the original equipment manufacturer of its Emergency Diesel Generator (EDG) did not provide adequate documentation for an exception to ASME Code, Section III, Class 3 for the on-skid EDG fuel oil system. Specifically, the on-skid fuel oil threaded piping design used a code-allowed exception without providing adequate evaluation documentation supporting threaded Schedule 40 piping. On November 2, 2022, the 'A' EDG fuel oil piping failed during routine testing, requiring it to be declared inoperable until repairs were implemented. The NRC Senior Resident Inspector has been notified. Corrective actions: VC Summer has compensatory measures in place and is scheduled to implement a modification during the first quarter of 2024. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: In addition to VC Summer, it was discussed via phone that Farley has a similar design for its on-skid EDG fuel oil system and potentially might be affected by this Part 21 report. No other sites have been discussed at this time. The EDG manufacturer is: Fairbanks-Morse Corp. EDG Model: Colt-Pielstick 12-Cylinder PC-2.2 VC Summer POC for additional information: Justin Bouknight, Licensing Engineer, (803) 941-9828, justin.bouknight@dominionenergy.com. |
| ENS 56902 | 20 December 2023 13:05:00 | The following report was received via phone and email by the Texas Department of State Health Services (the Department): On December 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that on December 19, 2023, they were unable to retract a 52 curie iridium-192 source into a QSA 880D exposure device. The RSO stated its radiographers were performing radiography on a pipe. The pipe fell and struck the guide tube, crimping it far enough to prevent them from retracting the source. The radiographers isolated the area and contacted the RSO. A retrieval team arrived at the location and was able to retract the source. The RSO stated no individual exceeded any exposure limits. Additional information will be provided as it is receive it accordance with SA-300. Texas Incident Number: 10074 Texas NMED Number: TX230058 |
| ENS 56903 | 20 December 2023 16:12:00 | The following report was received via email from the Tennessee Division of Radiological Health: During a scheduled 3-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was in a normal operating position. A vendor field technician has been contacted about the gauge which is an Ohmart/Vega gauge, model SHLG-1, with an isotope of cesium-137, 300 millicuries. Corrective actions as well as additional information will be updated with a NMED report within 30 days. Tennessee Event Report Number: TN-23-089 |
| ENS 56904 | 20 December 2023 16:49:00 | The following information was provided by the licensee email: Pursuant to 10CFR70 Appendix A (c) Framatome is making this concurrent report: On December 17, 2023 a routine DOS (di-octyl sebacate) test of one of Framatome's final filter banks had an efficiency of 99.78% which was below the 99.95% efficiency credited by Framatome's radioactive air emissions license. In compliance with Framatome's radioactive air emissions license (RAEL-038), Framatome made the required written notification to the Washington Department of Health (WDOH). The loss of efficiency did not cause emissions to be above allowable limits. |
| ENS 56900 | 19 December 2023 18:40:00 | The following summary of events was received via phone call and email from the New Mexico Environment Department, Radiation Control Bureau (the Bureau): The licensee reported a lost source to the Bureau on December 7th, 2023. The source was described as a mixed gamma button source S/N 64820-570, 25.4 mm diameter, 1/8 inch thickness, containing multiple isotopes of low activity. The isotope with the highest present day activity was Am-241 with an activity of 0.253 microcuries. All of the other isotopes had a negligible activity by the Bureau's reporting criteria. The source was shipped by the licensee and considered lost on December 7th after receiving an email from the common carrier that they were not able to locate the shipment. There is no evidence that any individual was potentially overexposed as a result of the lost source. New Mexico Incident #: N/A 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 |
| ENS 56984 | 21 February 2023 15:53:00 | The following report was received via email from the Alabama Department of Public Health, Office of Radiation Control (the Office): The Office was notified of the medical event during a licensee inspection between February 6 to February 8, 2024. The licensee reported that during a patient's 3rd treatment on 12/4/2023, dwell positions in part of the high dose rate (HDR) applicator (2 ovoids) were successfully completed. Dwell positions in another part of the applicator (the tandem) were interrupted due to an obstruction. After repeated checks and attempts, dwell positions in the tandem could not be completed. The patient received 100 cGy of the intended 600 cGy for the third treatment on 12/4/2023. The licensee examined the applicator, and determined that there appeared to be microfractures in the area of the tandem. The licensee has replaced this applicator, and developed precautionary safety procedures to avoid this matter in the future. The licensee noted that the matter appears to be related to the autoclaving process for applicators. The licensee also revised the patient's treatment course, and the patient was successfully treated during 4th and 5th fractions. The licensee used an Elekta Flexitron serial number: FT00306, with an Alpha-Omega model 136147 source, serial number: D85F-2336, 11.86 Ci of Ir-192 on 11/17/2023." Alabama Incident Number: Pending 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 56733 | 11 September 2023 13:48:00 | The following report was received via telephone and email by the Illinois Emergency Management Agency (the Agency): At approximately 1900 (CDT) on 9/10/23, a fire/explosion was reported at the Archer Daniels Midland facility located at 4666 East Farie Parkway in Decatur, IL. Information available at this time indicates a flammable hexane environment may have contributed to the incident. The Agency contacted the facility at approximately 2100 (CDT) on 9/10/23 to determine the status of the 23 radioactive gauges located within the building. The gauges contain a quantity of radioactive material that if impacted by the fire could present non-life threatening but elevated exposure rates to first responders. At 0945 (CDT) on 9/11/23, the Agency made contact with the Radiation Safety Officer at the facility. He stated the gauges are in an adjacent part of the facility (shared wall) which remains to be determined if impacted. It was noted that the area containing the gauges has an elevated hexane concentration. The Agency is actively coordinating with the facility's radiation safety staff and the Macon County Emergency Management Agency to provide information to first responders and coordinate a site visit to determine the status of the devices. If additional information regarding integrity of the devices is not available by midday, the Agency will coordinate a site visit. Reportedly, site access is still limited and information is still forthcoming to emergency managers. The 23 Texas Nuclear Model 5205 gauges range in activity from 50 to 100 mCi of Cs-137. Information available indicates 4 gauges contain 100 mCi of Cs-137 and 19 gauges contain 50 mCi of Cs-137. 8 additional gauges containing up to 500 mCi of Cs-137 are located in other onsite buildings, but are not anticipated to have been impacted. It is unclear if the Texas Nuclear Model 5205 gauges or their containers have been impacted by the fire/explosion at this time. On scene assessment is not immediately possible and may not be within the 24-hour reporting timeframe. The matter is being reported at this time and will be retracted if the gauges are found to be undamaged. Illinois Incident Number: IL230024
The following is a summary of an update received via email from the Illinois Emergency Management Agency: The licensee's hazmat response staff was able to enter the building late yesterday (9/11/23) and indicated none of the 23 radioactive gauges appear impacted by the fire. The Illinois Emergency Management Agency (IEMA) nuclear safety staff still plan to perform confirmatory surveys and wipes once the building can be safely accessed. IEMA staff are working with the licensee and county Emergency Management Agency officials to coordinate that site visit. Based on the information available, IEMA staff do not have any radiation exposure or accountability concerns at this time. This incident will be kept open until Agency staff have conducted a site visit and confirmed the integrity of the 23 devices. Notified the Region 3 duty officer and NMSS events.
Agency staff conducted a reactionary inspection with Macon County Emergency Management Agency officials on 9/28/23. The gauges were assessed and determined to not have been damaged by fire or percussion. Therefore, this event is requested to be retracted. Notified R3DO (Orlikowski), NMSS Events (email). |
| ENS 56732 | 10 September 2023 15:31:00 | The following report was received via telephone and email by the Texas Department of State Health Services (the Department): On September 10, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that while testing a MDS Nordion Model Eldorado 8 teletherapy unit, the 1,000-curie cobalt 60 source became stuck in the unshielded position. The RSO stated that room has been isolated and the dose rates taken outside the room do not create an exposure risk to any individuals. The RSO stated that a request for service has been sent to a service contractor. Access to the room has been posted to prevent inadvertent entry into the room. The licensee will update the Department as soon as the plans for corrective actions have been completed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10049 Texas NMED Number: TX230040
On September 12, 2023, the Department was notified by the licensee that the source had been returned to the fully shielded position by a service provider. The licensee stated the individual retracting the source received less than 10 millirem during the process. The service provider is trying to determine the cause for the failure. Additional information will be provided as it is received IAW SA-300." Notified R4DO (Warnick) and NMSS_Events via email. |
| ENS 56718 | 6 September 2023 15:53:00 | The following information was provided by the licensee via telephone: On September 6, 2023, Adventist Health Castle received an expected package of TC-99M from Cardinal Health. During a wipe test that was conducted at 0737 HST, it was determined that the package had removable surface contamination levels of 17836 disintegrations per minute (dpm) per 300 centimeters squared (cm^2). The radiation safety officer (RSO)'s determination was that this exceeded a limit that he stated was 2400 dpm per 100 cm^2. The RSO notified the Headquarters Operations Officer and the carrier for follow-up. The package was stored in a secure location for the contamination level to decay. Adventist Health Castle plans to return the package to the originator following its decay to a suitable level. |
| ENS 56722 | 6 September 2023 19:22:00 | The following information was provided by the licensee via email: A supplemental contract supervisor had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated. |
| ENS 56714 | 5 September 2023 17:05:00 | The following information was provided by the licensee via email: A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated. |
| ENS 56712 | 5 September 2023 13:48:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) email: The Agency was notified after hours on September 1, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of three radiopharmaceutical packages missing in transit. This is in addition to the four previously reported missing shipments (See EN56682, EN56697, and EN56701). All three were shipped on August 24, 2023, and marked as 'missing' by the common carrier on September 1, 2023. The last known location was the (common carrier) Indianapolis transfer hub on August 24, 2023. Indiana contacted the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) and reported at least two of these packages were located in an Indiana landfill and were recovered by their responders. (One of the two packages recovered from the landfill is for a previous event, See EN56701). This investigation is ongoing. The radiopharmaceutical packages were offered for shipment on August 24, 2023, for delivery to three customers (Nuclear Medicine Associates in Redding, CA; Cardinal Health in Southfield, MI; and RLS USA INC - New Orleans in Harahan, LA). The Nuclear Medicine Associates package contained three 14.3 mCi vials of I-123; the Cardinal Health package contained one 4.1 mCi vial of In-111 and the RLS package contained one 4.1 mCi vial of In-111. Activities are those at time of shipment. Information available at this time indicates the Nuclear Medicine Associates package and at least one other package containing In-111 (see EN56701) were located at a landfill by State of Indiana officials. NMED report number: IL230023 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 |
| ENS 56716 | 5 September 2023 19:51:00 | The following is a summary from a report received via email from the Washington State Department of Health: A Troxler 3440 portable gauge (two sealed sources containing 9 mCi of Cs-137 and 44mCi of Am/Be-241) was run over by a bulldozer at a construction site. The full report with corrective actions has yet to be issued. No significant releases of radioactivity occurred. Washington Incident Number: WA-23-015 |
| ENS 56681 | 16 August 2023 15:16:00 | The following information was received via email from the New Jersey Department (NJDEP) Bureau of Environmental Radiation: On 6/28/2023, NJDEP Bureau of Environmental Radiation (BER) was notified by its NRC Regional State Agreements Officer of an allegation made by a concerned citizen regarding a powder being sold by an online marketplace. The company address is in New Jersey. The citizen believed the powder contained Thorium-232 (Th-232). BER subsequently followed up with a site investigation and confirmed that Th-232 was present. The individual on-site stated that the powder had been mixed into paint, which was used to paint the walls in his basement and bathroom. The investigation is ongoing. On 7/8/2023, BER staff visited the seller's residence to perform an interview and contamination survey. The survey confirmed the presence of alpha and beta contamination in the residence. A sample of the powder was also collected and sent for gamma spectrometry analysis by a certified laboratory. Results of the analysis were received on 8/14/2023, and indicated concentrations of Th-232 as 14,800 pCi/g. On 8/15/2023, an estimate on the total activity present was made, and it was determined that this was a reportable event. New Jersey Event Report Number: Not yet assigned |
| ENS 56682 | 17 August 2023 12:15:00 | The following information was received via email and telephone by the Illinois Emergency Management Agency (the Agency): The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below: Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received. Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.
The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed. Illinois Event Number: IL230018 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 |
| ENS 56684 | 17 August 2023 15:25:00 | 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 56641 | 26 July 2023 09:10:00 | The following information is a synopsis provided by the licensee via email: River Bend Station completed an internal Part 21 evaluation concerning a motor driven relay that failed pre-installation testing due to a buildup of corrosion between the rotor and relay core. The relay was planned for use in the Remote Shutdown System. The NRC Resident has been notified. A written notification will be provided within 30 days. Affected known plants include only River Bend at the time of the notification. |
| ENS 56624 | 16 July 2023 11:16:00 | The following report was received by the Texas Department of State Health Services (the Department) via email: On July 16, 2023, the Department was notified of an industrial radiography source that was discovered to be not connected on July 15, 2023. The licensee reported that the camera was a QSA Delta 880 with serial number D11651 which contained a 31.5 curie Ir-192 source with serial number 72211M. The radiography crew had completed their first exposure and tried to crank the source back in, but it would not lock. After several more tries, they reported the incident to their site radiation safety officer (RSO). The RSO instructed them to expand the barrier and maintain constant surveillance. When the RSO arrived, he checked the dosimetry of the two radiographers and found they were both around 1 mR. He tried cranking the source back in and found that it would not lock. He also found that the survey meter readings were not changing so he concluded the source was not connected. Using 6 foot tongs, he was able to manipulate the guide tube and get the source to drop out. He then covered the source with about 150 pounds of lead such that the exposure rate was down to 30 mR/hr. He then connected the source to the drive cable and cranked it back into the locked position. The RSO received about 14 mR to both hands and whole body. Another worker who assisted with the lead received about 10 mR to the whole body. Badges have been sent in for processing. Further information will be provided per SA-300. Texas Incident Number: 10040 Texas NMED Number: TX230031 |
| ENS 56679 | 15 August 2023 13:20:00 | The following information is a synopsis provided by the licensee via facsimile: Cooper Nuclear Station completed an internal Part 21 evaluation concerning a batch of relays procured under the same purchase order from General Electric Hitachi. Following the failure of a relay, an independent laboratory identified a mechanical problem with the hinged armature, resulting in the relay potentially failing to return to its de-energized state. The relays are not currently installed in a safety related application. The NRC Resident has been notified. A written notification will be provided within 30 days. Affected known plants include only Cooper at the time of the notification. |
| ENS 56581 | 19 June 2023 18:32:00 | The following report was received by the California Department of Public Health (the Department) via email: On June 19, 2023, the licensee notified the Department that at 0100 (PDT) one nuclear gauge (Troxler 3430, SN 19706) containing 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen from a locked vehicle that was parked in an apartment complex. The gauge was stored in its case that was chained and locked to the pick up truck bed. The gauge was not visible as the bed of the truck was fitted with a locking cover. The cover had been broken open and the locks securing the gauge were cut. Sacramento Police were notified and an electronic report was filed. The Department will investigate. California Event Number: 061923 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 |
| ENS 56713 | 5 September 2023 14:23:00 | The following report was received via email from the Georgia Radioactive Material Program (the Department): On Thursday, August 31, 2023, the radiation safety officer (RSO) reported two missing solution standard sources of Am-241, 1.0 microcurie each (37 kBq each) to the Department. These two sources were lost during transportation to Nuclear Fuel Services located in Erwin, Tennessee on June 2, 2023. The customer, Nuclear Fuel Services, notified the licensee that they did not receive the shipment package. The RSO contacted the common carrier to trace its whereabouts. On June 26, 2023, the common carrier's records show that the shipment was signed for by an individual at Nuclear Fuel Services. However, Nuclear Fuel Services confirmed that they did not receive this shipment. There is a communication discrepancy between the common carrier and Nuclear Fuel Services. Currently, the licensee is waiting for a detailed response from the customer regarding this shipment. Georgia Incident Report Number: 69 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 |
| ENS 56550 | 1 June 2023 20:16:00 | The following information was provided by the licensee via email: On June 1, 2023, during inclement weather, a Phase 2 CAAS (Criticality Accident Alarm System) detector fault was received. Troubleshooting efforts indicated two CAAS nodes are impacted and SBM1005 (Process Services Corridor) was evacuated. The affected detectors are located in the north end of the SBM1005 Process Services Corridor. Compensatory measures are implemented in the affected area to support maintenance troubleshooting efforts. UUSA is reporting this event per 10 CFR 70.50(b)(2). |
| ENS 56537 | 24 May 2023 11:37:00 | The following report was received via email by the Colorado Department of Health: On May 19, 2023, the RSO (Radiation Safety Officer) at Memorial Hospital, University of Colorado Health, reported a missing 1.2 mCi germanium-68 sealed source. The source was determined to be an internal quality control source of a PET/CT (Positron Emission Tomography/Computed Tomography) camera. The source was identified as missing during a routine 6-month inventory performed on April 21, 2023. The PET/CT camera was purchased by Siemens Medical Solutions USA, Inc. in December 2022. Siemens subcontracted the decommissioning of the camera to a 3rd party (Clinical Imaging Systems), however, they failed to remove the source prior to transporting/shipping the camera to a Clinical Imaging System's warehouse. The source has been removed from the camera and is currently secured in a locked room at the warehouse. Memorial Hospital has been working with Siemens to have a licensed service provider ship the source back to Memorial Hospital or directly to a licensed recipient for disposal. Colorado Event Number: CO230013 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 |
| ENS 56547 | 31 May 2023 11:26:00 | The following report was received by the Florida Bureau of Radiation Control (BRC): FSU (Florida State University) contacted BRC Radioactive Materials Licensing via written letter dated May 18th, 2023 regarding a request to add (Uranium) U-233, any form except aerosols, to their license #0032-10. BRC Tallahassee called BRC Orlando this morning at 0900 (EDT) to notify. During a recent inventory close-out process, they found approximately 1.71 mCi of U-233. After checking the U-233 against their license, it was noticed that the U-233 is currently not listed on their current license. After additional review of archival records, it was found that the listing of U-233 was a remnant of their license #0032-18. License #0032-18 was terminated in 2012. The material has not been used in decades. The U-233 will stay in their radioactive materials storage vault and will not be used for any research. The plan moving forward is to eventually transfer the U-233 to a new research laboratory at the Colorado School of Mines. An amendment to current license to add U-233 is needed for this transfer. Florida Event Number: FL23-080 |
| ENS 56521 | 17 May 2023 03:25:00 | The following information was provided by the licensee via email: On May 16, 2023, it was determined that a licensed operator violated the station's FFD policy. The employee's unescorted access at South Texas has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii). The NRC resident inspector has been notified. |
| ENS 56499 | 2 May 2023 18:09:00 | The following report was received from the State of Florida Bureau of Radiation Control (BRC) via email: At 1720 (EDT), BRC received a call from (the licensee). (The licensee) stated two Troxler (soil moisture density) gauges (Model Numbers 3440 and 3430; Serial Numbers 20750 and 77517; and sources 8mCi Cs-137 and 40mCi Am-241/Be) were stolen from their storage facility in Lake Placid, FL. (The) gauges were last signed in to the facility on the 28th of April and sat idle. (The) exact time of loss is not currently known, but (the licensee) went to retrieve the gauges on 5/2/23 at 1700 (EDT). Law enforcement was notified prior to BRC's contact, however had not yet arrived on the scene at the writing of this report. (The licensee) has been provided department emails to send police reports when they are received. Florida Incident Number: FL23-064 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 |
| ENS 56501 | 2 May 2023 22:41:00 | The following information was provided by the licensee via email: At approximately 1500 (EDT) on 5/2/2023, it was determined that the commercial telecommunications capacity was lost to the Palisades Nuclear Plant (PNP) control room and technical support center due to an issue with the telecommunications provider. After discovery of the condition it was discovered that this loss also included the emergency notification system (ENS). Communications link via the satellite phone was tested satisfactorly. In addition, if needed, the satellite phone would be used to initiate call-out of the emergency response organization. The condition did not affect the ENS or commercial telecommunications capabilities at the offsite Emergency Operations Facility. The telecommunications provider has not provided an estimated repair time. PNP will be notifying the NRC resident inspector.
The following information was provided by the licensee via email: This notification is being made to retract event EN 56501 that was reported on May 02, 2023. Based on further investigation, the Emergency Plan and Emergency Implementing Procedures provide an acceptable alternative routine communication system, which is satellite phones, for communicating with Federal, State, and local offsite agencies, that are in addition to the primary commercial telephone system. It was determined that no actual or potential loss of offsite communications capability existed per 10 CFR 50.72(b)(3)(xiii). This is consistent with NUREG 1022, Revision 3, Supplement 1, 'Event Report Guidelines 10 CFR 50.72(b)(3)(xiii),' and NEI 13-01, Revision 0, 'Reportable Action Levels for Loss of Emergency Preparedness Capabilities.' The NRC Decommissioning Inspector has been notified of the retraction. Commercial telecommunications to the plant were restored at approximately 0600 EDT on 5/3/2023. Notified R3DO (Orlikowski) |
| ENS 56584 | 22 June 2023 09:44:00 | The following information was provided by the licensee email: This telephone notification is provided in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to report an invalid actuation of Division 2 Primary Containment Isolation logic at the Monticello Nuclear Generating Plant (MNGP) that occurred while in a refueling outage. At approximately 0402 Central Daylight Time (CDT) on April 28, 2023 and at approximately 1611 and 2143 CDT on May 4, 2023, momentary losses of 'Y80 Division 2 Uninterruptible 120VAC Class 1E Distribution Panel', which provides power to Division 2 Primary Containment Isolation logic, resulted in a partial Primary Containment Group 2 Isolation (gas systems), initiation of the Standby Gas Treatment system, and the shift of Control Room ventilation to the high radiation mode. The momentary losses of 'Y80' were due to an intermittent, age-related degradation issue with the 'Uninterruptible Power Supply Y81, Division 2 120VAC Class 1E Inverter', which resulted in a temporary loss of output plus a lack of static switch transfer from the inverter supply to the alternate source as designed. The actuations were not initiated in response to actual plant conditions, these were not intentional manual initiations, and there were no parameters satisfying the requirements for initiation. Therefore, these events have been determined to be invalid actuations that were attributed to the same cause. All systems responded as designed to the actuation signal. Operations reset the partial Primary Containment Group 2 Isolation signal, shutdown the Standby Gas Treatment system, and restored Control Room ventilation per the procedure. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56430 | 23 March 2023 20:40:00 | The following information was provided by the licensee via email: At 1736 EDT on March 23, 2023, during overcurrent testing of the '2B' (Emergency Safeguards System) ESS Bus, the work group was re-installing tested relays and inadvertently caused a '2B' ESS Bus lockout. This resulted in the '2B' ESS Bus deenergizing and a valid start signal provided to the 'B' Emergency Diesel Generator (EDG). The 'B' EDG started and functioned as designed. This is being reported as an unplanned actuation of systems that mitigate the consequences of significant events in accordance with 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified. |
| ENS 56372 | 18 February 2023 17:12:00 | The following is a synopsis of information provided by the licensee: At 1522 EST on February 18, 2023, the Portsmouth Gaseous Diffusion Plant declared a Site Area Emergency after transport equipment contacted a uranium hexafluoride (UF6) cylinder in storage. The contact cracked a weld on a stiffening ring on the cylinder. Initial reports indicated there was a small amount of UF6 released. The release was minimal and contained on the facility. Staff were directed to shelter in place. No off-site release occurred, and no off-site protective actions were recommended. The licensee notified state and local authorities. No media press release is planned. At 1757 EST on February 18, 2023, the Site Area Emergency was terminated after the leak was sealed. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC |
| ENS 56329 | 1 February 2023 13:40:00 | The following information was provided by the licensee via email: At 0956 CST with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to a turbine trip. The trip was not complex with all safety related systems responding normally post-trip. During the trip, the non safety related '1A' 4160V bus lost power resulting in the loss of one Reactor Coolant Pump (RCP-1A). Operations responded and stabilized the plant. The '1A' 4160V bus was re-energized at 1031 CST. Decay heat is being removed by steam dumps to the main condenser. Farley Unit 2 is not affected. An automatic actuation of (Auxiliary Feedwater) AFW also occurred, which is an expected response from the reactor trip. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour report per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56331 | 1 February 2023 16:51:00 | 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 56314 | 18 January 2023 16:37:00 | The following report was received via email from the Texas Department of State Services (the Agency): On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews (working in Midland, TX) was unable to retract a 99.0 curie iridium - 192 (Ir-192) source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No: I-9981 Texas NMED No.: TX230002 |
| ENS 56299 | 5 January 2023 16:01:00 | The following report was received from the Nebraska Department of Health and Human Services via email: The Nebraska Radioactive Materials Program was notified on January 4, 2023, about 1700 (CST) by a representative of Olsson of a damaged InstroTek, Model 3500, portable moisture density gauge. An Authorized User (AU) from Olsson transported the nuclear density gauge to a job site near Plattsmouth, NE for compaction testing on backfill for a new grain bin. Upon arrival at the site, he assessed the work area for hazards and began gauge standardization away from the active work area. During the standard count, the AU returned to his work truck to grab testing equipment which was approximately 100 feet east of where the gauge was sitting. During that time, the AU witnessed a contractor on site that was driving a tele-handler run over the gauge and standard block, causing damage to the gauge. Emergency procedures from Olsson's Radiation Safety Program were immediately reviewed and put into action by the AU. The local and Corporate RSOs (Radiation Safety Officers) were contacted to help with the situation. All personnel were removed from the area and the area was blocked out with emergency tape. The local RSO arrived with survey equipment, took readings around the area, made phone calls with the corporate RSO and manufacturer, and determined it was safe to transport the gauge back to Olsson's permanent storage location at the field office. The AU was wearing his dosimetry badge and he does not believe that any other individual on site would have received any exposure. Nebraska Event Number: NE-23-0001 |
| ENS 56301 | 5 January 2023 16:38:00 | The following information was provided by the Ohio Department of Health (ODH) via email: The licensee informed ODH on Wednesday, 1/4/2023, that one of the IMS Model 5321 gauges at its plant in Canton, Ohio has a shutter stuck in the open position. The gauge contains nine (Cesium) Cs-137 sources with a maximum activity of 10 Curies each and each source has its own shutter. The other eight shutters are operating normally. The licensee tried cycling the stuck shutter and activating the air cut-off/bleed-off valve, but the shutter remained open. The manufacturer has a technician scheduled to come in Saturday, 1/7/2023, at the earliest to make the repair. The gauge is contained inside a caged area with a keycard lock mechanism and motion sensor. Since the gauge shutter cannot be closed, licensee management has sent a communication out to all badged employees who have access to the cage informing them to not enter until the manufacturer can come onsite and make the necessary repairs. The normal operating state for this device is with the shutter open. ODH has authorized the mill to continue operations until the manufacturer arrives to make repairs and standard radiation boundaries will continue to work for protection. Ohio Event Item Number: OH230001 |
| ENS 56333 | 2 February 2023 13:10:00 | The following information was received from the Minnesota Department (the Department) of Health via email: The Department was notified on January 13, 2023, of a lost 1.59 GBq (43 mCi) W-181 (tungsten-181) source in a Check-Cap C-scan colorectal cancer screening device. The Check-Cap C-scan was administered to a patient with the expectation the patient would recover the device at home when it exited the body. The device was not recovered and instead flushed down the toilet at the patient's residence. Minnesota Event Number: MN230001 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 |
| ENS 56244 | 28 November 2022 17:12:00 | The following report was received via email from the Texas Department of State Health Services (the Agency): On November 28, 2022, the licensee notified the Agency that it had discovered that the shutter on one of its Ohmart-Vega SH-F1A gauges had been stuck in the closed position since November 23, 2022. The gauge had been closed and locked out on November 22nd for work on the vessel. On November 23rd the gauge was placed back into service. Over the holiday weekend the unit operations had continued to get high readings which would indicate a buildup in the system or a closed shutter. On November 28th the gauge was checked. The licensee's radiation safety officer found the two bolts on the shutter handle were sheared and the shutter was in the fully closed position. No exposures have resulted from this event. An investigation is ongoing. Source: Cesium-137, 5 millicuries, SN: OV-0050 (this SN serves also as the gauge source holder SN). More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: I-9966 |
| ENS 56227 | 17 November 2022 16:30:00 | The following information was provided by the licensee via email: During an SIR (Selective Internal Radiation) Spheres treatment on November 17, 2022, a patient was to receive 10.8 milliCuries of Y-90 (Yttrium-90). A measurement of the residue radiological waste from the procedure indicated that the patient only received 38 percent of the intended dose or 4.33 milliCuries. The total dose delivered differs from the prescribed dose by 20 percent or more. The doctor drew up a dose of 11.4 milliCuries for the procedure. Static readings on the vial averaged 0.205 mR/hr. Post procedure readings averaged 0.127 mR/hr. These readings resulted in the fraction delivered of 38 percent or a total of 4.33 milliCuries. Corrective action is pending.
Following administration of Y-90 Sir Spheres on November 17, 2022, the treatment team determined that the faction of the assayed dose delivered to the patient was only 38 percent. The remaining 62 percent of the assayed dose of 11.4 mCi remained within the delivery system. This represents a delivery of 40 percent of the prescribed dose of 10.8 mCi. The microcatheter used was size 2.4F, which was appropriate for the clinical situation. The vascular access to the treatment location was unusually torturous. Two representatives from Sirtex advised during the procedure, rotating out part way through the procedure so one was present at all times, with no noted deviations from the recommended protocols. The event likely occurred due to microsphere blockage in the microcatheter, resulting from a torturous path to the delivery point required by the patient's vascular anatomy. Sirtex indicated that the spheres must have attached to the catheter walls due to a torturous path (excessive bends in the line). Notified R1DO (Cahill) and NMSS Events Notification via 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. |
| ENS 56225 | 16 November 2022 16:57:00 | The following information was provided by the licensee via fax: An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility. A 'vibratory' ground motion is felt in the Control Room, recognized as an earthquake, and verified by field personnel. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 11/16/2022 at 1445 MST, Urenco USA declared an Alert (EAL SA.1) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 1657 EST (1447 MST). No radioactive release had occurred. No structural damage had been detected. A 5.4 magnitude earthquake occurred in western Texas with an epicenter 90 miles southwest of Hobbs, New Mexico, a town close to the facility. Plant personnel are conducting walkdowns of the site. The licensee notified state and local authorities. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)
On 11/17/2022 at 1700 MST, Urenco USA terminated the Alert due to a seismic event felt onsite. Urenco USA met conditions for event termination. No damages were found upon completion of site walkdowns. The licensee has notified state and local authorities. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), IR (Crouch), NMSS (Lubinski) |
| ENS 56224 | 16 November 2022 16:02:00 | The following report was received via email from the Tennessee Division of Radiological Health: Medical Physicist for Holston Valley Medical Center reported that a patient was mistakenly given all fractions of a cervical treatment on November 14, 2022. The patient was scheduled for five 600 centigray (cGy) fractions of Ir-192 for a total of 3000 cGy. The medical physicist misread the prescription and gave the full 3000 cGy in the initial dose. As of November 15, 2022, the patient had not been notified. However, the patient will be returning on November 16, 2022, for the next treatment. Corrective actions or reports will be updated with a report within 30 days." Tennessee Event Number: TN-22-069 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 56287 | 28 December 2022 09:18:00 | The following information was provided by the licensee via email: This 60-day optional telephone notification is being made in lieu of an LER (Licensee Event Report) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). At approximately 0906 Eastern Time (EST) on November 9, 2022, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring and Post Accident Sampling isolation valves) occurred. In addition, per design, Reactor Building Ventilation isolated and Standby Gas Treatment started. It was determined that this condition was caused by faulty test equipment that was being used during preparation for the Main Stack Radiation Monitor High Radiation Response Time test. This test requires connecting a recording device to monitor for the test start signal on a Unit 2 relay associated with the Main Stack High Radiation signal. The recorder faulted which caused the associated fuse to blow and resulted in Unit 2 receiving a Main Stack High Radiation signal and Group 6 PCIV actuation. It was verified that the radiation monitor was not in trip electrically (i.e., there was no high radiation condition). The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation. During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public. The NRC Resident Inspector was notified. |