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ENS 5640610 March 2023 15:52:00The following information was received from the Arkansas Department of Health via email: The Arkansas Department of Health, Radiation Control Section (the Section), was notified on February 28, 2023, via a letter received from Anchor Packaging Company in Paragould, Arkansas, of two generally licensed fixed gauges that were determined to not be located on-site (GL-0010). The Section called the manufacturer on March 1, 2023, then received information on March 10, 2023, that they had no record of the gauges ever being returned to them. These gauges each contain 5.55 GBq (150 milliCuries) Am-241 -- NDC device model 102 (device SN 2844) and NDC device model 103X (device SN 13264, source SN 3576CW). Causes of the event are the following: the lack of effective procedures that stress the general licensee requirements, specifically those that aid accountability of sources; failure to ensure the appointing and support of the individual responsible for having knowledge of the regulations/requirements; and lack of training (though not required) needed to identify radioactive material/general license labeling and then to know what steps to take. The Section is currently working with the licensee regarding corrective actions due to a previous missing devices event, 55793. Event Number: AR-2023-001 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 5640710 March 2023 16:43:00The following information was provided by the Tennessee Division of Radiological Health via email: The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and (the physician) connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows: 1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy 2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy Corrective actions will be sent with the follow-up NMED report. State Event Report ID NO.: TN-23-013 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 5627716 December 2022 19:16:00

The following information was provided by the licensee via fax and phone call: 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 release of hazardous material has not occurred. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 12/16/2022 at 1645 MST, Urenco USA declared an Alert due to seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 1916 EST (1716 MST). No radioactive release has occurred. A 5.4 magnitude earthquake occurred in western Texas with an epicenter 20 km north-northwest of Midland, Texas. 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)

  • * * UPDATE ON 12/17/2022 AT 1400 MST FROM DANEIL MOLINAR TO BRIAN LIN* * *

On 12/17/2022 at 1400 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 (Ulses), NMSS (Helton)

ENS 5585422 April 2022 16:10:00

The following was received from the Utah Department of Environmental Quality via email: On April 18, 2022, Licensee personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The excavations for sumps extended into the groundwater and were not included on the conditionally approved plans. The smell triggered an investigation where groundwater samples were collected for both chemical and radiological analysis. One sample indicated a concentration of 12,000 pCi/L of uranium (preliminary findings). The presence of uranium in the groundwater was unanticipated. Subsequently, the Division of Waste Management and Radiation Control has communicated to the licensee to characterize the nature and extent of the contamination. The Division is waiting for additional information from the licensee. Event Report ID No.: UT220003

  • * * UPDATE AT 1612 EDT ON MAY 16, 2022, FROM JALYNN KNUDSEN TO BRIAN P. SMITH * * *

The following update was received from the Utah Department of Environmental Quality (the agency) via email: On April 18, 2022, (Licensee) personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The (Licensee) did not anticipate encountering groundwater at the depth of excavation. Upon encountering the groundwater and observing a hydrocarbon odor, the Licensee collected groundwater samples for both organic and radiological analysis. The preliminary screening of one sample indicated a potentially high concentration of uranium. The preliminary result of the analysis was reported to the agency with the intent to conduct additional confirmatory work. The Licensee contends that the initial high concentrations were in error due to improper analytical methodology. These results were presented to the agency prior to confirmation. Results of further investigation by the Licensee indicate that the contaminant was thorium, not uranium, and that all radionuclides were below detection limits. The agency collected confirmatory samples for analysis and is awaiting results of both organic and radiological analysis. The Licensee is preparing an investigation plan to fully characterize the nature and extent of the contamination. Event Report ID No.: UT220003 (updated) Notified R4DO (Gepford) and NMSS Events Notification (email).

ENS 5566417 December 2021 17:09:00The following information was provided by the state of Colorado via email: During the morning of 12/17/2021, a portable gauge user noticed their truck had been broken into (in Westminster, CO) and a portable gauge was stolen from the truck. The portable gauge is a Troxler model 3430, serial number 32370, containing 9 mCi cesium-137 and 44 mCi americium-241:beryllium. The stolen gauge has been reported to the local law enforcement. Event Report ID No.: CO210043 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 5566217 December 2021 12:53:00The following information was provided by the licensee via phone conversation: During an NRC inspection, the Testing Engineering and Consultants, Inc. reviewed their materials accountability records and determined two portable Troxler moisture density gauges (s/n 14195 and 14198; 8 mCi Cs-137 and 40 mCi Am-241/Be each) were missing. The two gauges had last been leak tested in January 2021. 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 5567223 December 2021 10:05:00The following information was provided by the Nebraska Department of Health and Human Services via email: During annual inventory inspection, two devices were found missing and new non-radioactive exit lights had been installed. Further investigation found that on October 11, 2021, Slater Electric of Grand Island, NE was hired to install the devices. Removal of the tritium (23 curies) devices was not part of the scope of work, but Slater took it upon themselves to remove the old devices and disposed of them in the garbage at their shop in Grand Island, NE which has since went to the landfill. To avoid future instances, Aurora Cooperative discussed with Slater Electric the importance of proper disposal of the signs containing radioactive material and steps to take if hired to do such work again. No further follow up is needed. Item Number: NE210004 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 548939 September 2020 16:28:00The following was received from the State of Wisconsin Department of Health Services (the Department) via email: On September 9, 2020, the licensee reported a missing 7.5 Ci Mo-99/Tc-99m generator, which was subsequently found, to the Department. The facility receives a generator every Sunday evening. On September 8, the licensee became aware that this week's generator was missing and initiated search efforts. The licensee confirmed with the generator supplier that a generator was delivered on September 6. The licensee reviewed security footage and determined that the generator was delivered at 2115 CDT on September 6. The licensee reviewed additional camera footage and determined that a different courier service requested access to the nuclear medicine hot lab about an hour later and took the package that had been delivered at 2115 CDT. The licensee contacted the second courier service and determined that the missing generator was found in the courier's warehouse on September 9. The generator has been returned to the licensee. The licensee is evaluating potential dose to members of the public. The Department will perform a follow-up investigation. Event Report No.: WI200006 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 5467217 April 2020 12:37:00The following is a summary of information received via telephone: On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device. 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 5466111 April 2020 01:03:00At 2125 EDT on April 10, 2020, with Unit 3 in Mode 1 at approximately 32 percent power, the reactor was manually tripped due to a tube leak in the 3F1 feedwater heater. The trip occurred during a planned shutdown for a refueling outage. The trip was not complicated, with all systems responding normally post-trip. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Units 1 and 2 were not affected. 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). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5461826 March 2020 14:25:00

The following was received via email: (The licensee) notified the (Florida Bureau of Radiation Control) BRC that a Soil Moisture Density Gauge was 'bumped over' at a construction site in (Clearwater, FL) by a machine while in use during a standard count. (The licensee) claims there was no damage to the sources, only damage to the case. The area has been cordoned off, no information on site exclusion prior to the impact has been reported. The (Radiation Safety Officer) RSO has not returned phone calls at this time. The (Florida State Watch Office) FL SWO and (Department of Environmental Protection) DEP have contacted the BRC about this incident. An inspector from (the Florida western office) is requested at this time. Florida Incident Report Number: FL20-045

  • * * UPDATE ON 03/26/2020 AT 1533 EDT FROM MARK SEIDENSTICKER TO CATY NOLAN * * *

The following was received via phone call: The gauge was bumped and dragged approximately 10 feet at the construction site during a calibration. The source was retracted. There was no release or visible damage. Notified R4DO (Kellar) and NMSS Events (via email).

ENS 545769 March 2020 13:08:00The following information was received via email: The licensee reported a stuck open shutter on an IMS model 5221-02 fixed gauging device. The manufacturer arrived on site 2/26/2020 and determined the cause to be a faulty solenoid valve on the air supply to the shutter. The valve was replaced and shutter was then determined to be working properly. Iowa Item Number: IA200001
ENS 544612 January 2020 13:47:00The following is a summary of information received from Alliance Health Services (Alliance) via the phone: At approximately 0800 CST on January 2, 2020, a mobile PET CT scanner unit was received by Alliance from CardioNavix at the Henry Ford Medical Center in West Bloomfield, MI with rubidium-82 contamination on the top exterior surface of the generator cart. The initial wipes on the surface of the generator cart were 17,697 dpm and 112,368 dpm (2 different areas of the top of the cart). No other contamination was found. The contaminated generator cart is located inside the mobile unit with limited access. The unit has not been used since the discovery of contamination. No personnel were contaminated. The licensee notified CardioNavix and the unit will be picked up by CardioNavix later today.
ENS 5444817 December 2019 10:44:00

EN Revision Imported Date : 1/10/2020 AGREEMENT STATE REPORT - HIGH DOSE RATE APPLICATOR DISLODGED The following was received from the PA Department Bureau of Radiation Protection (DEP) via fax: On December 16, 2019, the medical physicist for the licensee verbally reported that during an HDR (high dose rate) treatment using a Varian Model VariSource IX with a Tandem & Ovoid applicator, the applicator was found dislodged at the end of the treatment period. This was fraction 4 of 5 planned fractions. It is unknown at this time how long the applicator was not in the planned position or what caused it to move. The prescribed dose was 600 cGy from a 5.126 Ci Iridium-192 source. No further information is available at this time. The DEP will update this event as soon as more information is provided. Event Report ID No: PA190029 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.

  • * * UPDATE ON 1/9/20 AT 1:17 PM FROM JOHN CHIPPO TO KARL DIEDERICH * * *

The following information was received from the Agreement State via fax: The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event. Notified R1DO (Schroeder) and NMSS group (via e-mail).

ENS 5438815 November 2019 13:56:00

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE The following was received from the Maine Radiation Control Program via fax: At 0857 (EST on November 15, 2019,) NETCo, Inc. notified the state of Maine Radiation Control Progam (the State) that they had received leak test results from their vendor (Radiation Safety & Control Services) RSCS. One the test results indicated the Ni-63 source in a replacement component to a SAFRAN Morpho Detection Trace device was leaking. Two additional tests on components with Ni-63 sources reported detectable activity but less than 0.0005 microCi. The source contains 10.0 mCi of Ni-63 and the leak test result was 0.1968 microCi on the leaking source. The RSO at NETCo has surveyed the work area where the leak tests were performed along with the storage container and bag that they arrived in. No detectable activity was found. NETCo will be also performing smear tests of all the areas that came in contact with the sources. The sources (components) in question will be put in a one gallon paint can awaiting proper disposal in our locked cabinet.

The State has sent an inspector to perform additional surveys. Licensee will be providing a full report to the State as information becomes available.

  • * * UPDATE ON 12/17/19 AT 1415 FROM TOM HILLMAN TO OSSY FONT * * *

The following was received from the State via email: The licensee and the State performed surveys and wipe samples. All surveys results were not above background. Wipe samples were all below 0.005 microCi. The wipe on the leaking source was slightly elevated but below the 0.005 microCi. The license notified the shipper of the sources, a radiation officer at Beaver Valley Power Plant. The sources were shipped for disposal and plans for disposal will continue. The state has closed the event. Notified R1DO (Werkheiser) and NMSS Events Notification. Maine Event Report ID No.: ME 19-002

ENS 543673 November 2019 09:23:00

EN Revision Text: PLANNED LOSS OF EMERGENCY RESPONSE FACILITIES AND EQUIPMENT At 0800 CST on November 3, 2019, Comanche Peak began a planned modification on the Unit 2 Plant Computer System. During this modification, the ability to perform emergency assessment in the Technical Support Center (TSC) and the Emergency Operations Facility (EOF) will be impacted. Since the ability to perform emergency assessment is not expected to be restored within 72 hours, this is reportable per 10 CFR 50.72(b)(3)(xiii) as an event that results in a loss of emergency assessment capability. During this modification, the Control Room will continue to have the ability to perform emergency assessment. If an Alert, Site Area Emergency, or General Emergency is declared during this modification, communicators dedicated to performing emergency assessment will be stationed in the Control Room, TSC, and EOF. The Plant Computer System modification is scheduled to be completed on November 24, 2019 and a follow-up ENS notification will be made once the Unit 2 Plant Computer System is declared functional. The NRC Resident Inspector has been informed.

  • * * UPDATE FROM MATT KARL TO HOWIE CROUCH AT 1104 EST ON 12/10/19 * * *

Unit 2 Plant Computer System has returned to service at 0756 CST on 12/10/19. The NRC Resident Inspector has been notified. Notified R4DO (Groom).

ENS 5434724 October 2019 16:24:00Holtec Decommissioning International has notified the State of New Jersey that during the conduct of Industrial Site Remediation Act (ISRA) non-radiological site investigation field sampling and analysis activities at the Oyster Creek site, soil and groundwater exceedances to New Jersey Default Impact to Groundwater Soil Levels, Residential Direct Contact Soil Remediation, Non-Residential Direct Contact Soil Remediation and Class IIA Groundwater Quality Standards were identified. These exceedances are reportable under New Jersey Administrative Code NJAC 7:26C. That notification was made at 1524 EDT. The NRC Regional Inspector and the State of New Jersey were notified.
ENS 543104 October 2019 15:57:00The following is a synopsis of information received via phone: On October 3, 2019, at approximately 1900 EDT, a CPN nuclear density gauge containing 10 mCi of Cs-137 and 50 mCi of Am-241 was discovered to be stolen when the person in possession of the gauge found the storage box on his truck open and the gauge not inside. Local law enforcement was notified and subsequently recovered the gauge on October 4, 2019 at 0800 EDT. The gauge did not appear to be damaged and the lock was still intact. The gauge is now in the possession of the licensee. 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 5429124 September 2019 15:02:00On September 24, 2019, at 0930 EDT, a non-licensed employee contract supervisor had a confirmed positive test result for illegal drugs during a random test. The employee's access to the plant has been denied. The licensee has notified the NRC Resident Inspector.
ENS 5428923 September 2019 14:15:00

At 1106 CDT Braidwood Unit 1 experienced an automatic reactor trip due to lowering steam generator water levels following closure of the 1B steam generator feed water regulating valve.

The cause of the 1B steam generator feedwater regulating valve failing closed is unknown at this time and is under investigation.

Both trains of auxiliary feedwater started automatically following the reactor trip to maintain steam generator water levels.

All systems responded as expected with the exception of intermediate range nuclear instrument N-36 which was identified as being undercompensated following the reactor trip. Both source range nuclear instruments were manually energized in accordance with station procedures. Steam generator power operated relief valves lifted momentarily and reseated as designed in response to the secondary transient due to the reactor trip. The main steam dump valves are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by offsite power with the diesel generators in stand by and all safety systems available. There is no impact to Unit 2. This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4 hour notification, and per 10 CFR 50.72(b)(3)(iv)(A) for an automatic actuation of the auxiliary feedwater system, 8 hour notification. The NRC Resident Inspector has been informed.

ENS 5435024 October 2019 17:04:00The following is a summary of information that was received via facsimile: Engine Systems, Inc. (ESI) was notified by a nuclear customer that three of 20 recently installed fuel injectors seized after a short amount of engine run time. Examination of the plunger and bushing (P&B) from each injector identified particles consistent with the base material of the P&B embedded in the scar marks associated with seizures. The root cause of the seizures is attributed to residual machining debris from the manufacturing process. This batch of injectors had been refurbished in 2013 and the P&Bs were replaced as part of the rework activity. These part number mechanical unit fuel injectors are used on various model EMD 645 diesel engines. The engine utilizes one injector per cylinder; therefore, failure of one injector will render the associated cylinder inoperable. An EMD 645 engine will typically tolerate one inoperable cylinder and maintain rated load; however, multiple inoperable cylinders (as in the case of multiple fuel injectors) will further decrease engine output and likely prevent the engine from carrying out its required load. This adversely affects the ability of the emergency diesel generator set to perform its safety-related function. This issue only applies to injectors in inventory that have not been installed, which should be returned to ESI. For injectors that have been installed in an engine and have accumulated more than two hours of run time, then the injector is not susceptible to seizure from this type of issue and no further action is required. It has been shown that P&B seizures related to foreign material occur within the first two hours of engine operation. The affected part numbers are 40084714, 40084715, 40084720, 40084724, 40084725, 40099335, 5228895-RR, 5229250-RR, 5229315-RR, 5229325-RR, 40084714-RR, 40084720-RR, 40084723-RR, 40084724-RR, 40099335-RR. A list of affected customers by injector part number is contained in Appendix A of the Part 21 report, which include Crystal River, Turkey Point, Exelon Generation Company, Beaver Valley, Watts Bar, Clinton, Saint Lucie, Sequoyah, Cooper, Southern California Edison, Davis-Besse, Oconee, Point Beach, Kewaunee, Dresden, Surry, GE Company, Browns Ferry, Energy Northwest, Oyster Creek, Arkansas Nuclear One, Monticello, Nine Mile Point, Entergy Operations Inc., Tennessee Valley Authority, LaSalle, Perry, Quad Cities, Fitzpatrick, and River Bend.
ENS 542576 September 2019 02:47:00

EN Revision Text: CONTAINMENT PENETRATION DISCOVERED NOT ISOLATED At 2115 CDT on 9/5/2019, an inside containment test connection and inoperable outside containment isolation valve were discovered to be open for a containment air sample penetration. This resulted in the containment penetration not being isolated. The inside containment test connection was closed at 2322 CDT on 9/5/2019.

This event is being reported under 10 CFR 50.72(b)(3)(v)(C) and (D) and 10 CFR 50.72(b)(3)(ii)(B).

There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

  • * * UPDATE FROM PAUL BURTON TO HOWIE CROUCH AT 1342 EST ON 11/7/19 * * *

This event was originally reported on September 6, 2019 under 10 CFR 50.72(b)(3)(v)(C) and (D) and 10 CFR 50.72(b)(3)(ii)(B). Upon completion of the investigation of the event, it was determined that the event had insignificant safety consequences because the containment breach was disconnected from the Reactor Coolant System by a series of closed valves for the duration of the event. Additionally, the lines to the inside containment connection and the outside inoperable containment isolation valve that was found to be open as well as the main line connecting and passing through the penetration were one-inch diameter lines. Analysis determined that containment breaches that are less than a three-inch diameter do not lead to a large radiation release. The event did not place the plant in an unanalyzed condition that significantly degrades plant safety. Therefore, 10 CFR 50.72(b)(3)(ii)(B) did not apply to this event and this notification is to retract reporting under that criterion. The licensee notified the NRC Resident Inspector. Notified R4DO (Drake).

ENS 542586 September 2019 10:29:00The following was received from Kentucky Department of Health Radiation Branch (KY RHB) via email: KY RHB was notified by telephone on 9/3/19 that at approximately 1230 EDT on 8/30/19, while performing radiography in a pipe rack, radiographers were unable to retract a 38.7 Curie Ir-192 (AEA/QSA A424-9, Serial No. 82580G) source into the exposure device (QSA 880D Serial No. D11651) using the crank mechanism. During the retracting process the cover plate on the drive became loose, enabling the internal drive cable to depart the gear system in the handle of the drive cable mechanism. Since the issue with the drive cable could not be repaired, the incident became a retrieval situation, and the crew made appropriate notifications to the Radiation Safety Officer, manager and on-site contact. The crew established a new 2 mR boundary as required and confirmed that the area was secure. The drive cable was removed from the handle, and the source was manually retracted into the exposure device. The source was secured in the exposure device at 1435 EDT. During the 2-hours while the source was exposed, there were no overexposures to the public. The radiographer and assistant received exposures of 80 mR and 130 mR respectively and the manager received an exposure of 5 mR. It was determined that the root cause of the incident was that the crew did not properly inspect the equipment before commencing non-destructive testing activities. It was discovered that the drive cable handle was missing four of the six screws that secure the cover plate on. This caused the drive cable to slip off the gear and partially lift the cover plate. The drive cables were immediately taken out of service and replaced with properly functioning equipment. Event Report ID No.: KY190009
ENS 5424730 August 2019 10:51:00

The following is a summary of information received from the Department of Environmental Quality (DEQ) via email: At about 0910 (CDT) on 8/30/19, DEQ received a call from W2 Engineering, Oklahoma license OK-32142-01. W2 Engineering holds an Oklahoma license for portable gauges and is based in Oklahoma City. (W2 Engineering) reported that it had lost contact with one of the technicians who had been driving one of the company's vehicles with a Humboldt portable gauge (s/n 8700) in it. The last known location for (the technician) (and presumably the gauge) was at 0856 (CDT) Thursday when (the technician) made a purchase at Perry, Oklahoma. (The technician) had not made contact since then, nor had (the individual) responded to numerous messages and efforts to contact. (W2 Engineering) now considers the gauge out of the licensee's control. (W2 Engineering) has advised the (Oklahoma Highway Police), and they say the vehicle is not known to be in any of their impound yards. (W2 Engineering) has filed a report with Oklahoma City police, and a police officer is on site taking the report now. This report is based on an initial phone notification, and more information will be added when it becomes available.

  • * * UPDATE FROM MIKE BRODERICK TO DONALD NORWOOD AT 1717 EDT ON 9/1/2019 * * *

The following information was received via E-mail: The gauge missing from W2 engineering has been recovered along with the vehicle in Blackwell, Oklahoma. More details will be provided as they become available." Notified R4DO (Drake) and the NMSS Events Notification E-mail group. 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 5423823 August 2019 12:06:00Fisher Controls issued FIN 2019-01 for all Fisher type 7600, 7700, 7800, 9100, 9200, and 9500 series butterfly valves that use taper pins to secure the valve shaft to the valve disk. This does not apply to valve constructions that use straight pins or grooved straight pins. Fisher was notified on June 25, 2019 of one instance where a taper pin became loose due to incorrect installation within the valve. Fisher recommends the owners of these valve assemblies perform normal maintenance at regular intervals in order to inspect the valve assembly and replace worn, aged, and damaged parts, as well as verifying that the taper pins are correctly installed and reset them if necessary. For technical questions, please contact: Jacob Clos Quality Manager Emerson Automation Solutions Fisher Controls International LLC 301 South First Avenue Marshalltown, IA 50158 Phone: (641) 754-2108 Jacob.Clos@Emerson.com
ENS 5423622 August 2019 16:41:00The following is a summary of information received from Engine Systems, INC (ESI) via facsimile: The basic component, a fuel injector, P/N 5229250, S/N R2200, was sent to ESI for failure analysis and the spray tip was found to have a through wall crack. Inspections determined the fuel feed holes in the body of the spray tip were incorrectly drilled, resulting in one of the holes not properly penetrating the reservoir. A cracked spray tip would inhibit proper combustion of fuel within the corresponding power cylinder which could affect the carrying capability of the diesel engine. This could impact the operability of the diesel engine, thereby, preventing the emergency diesel generator set from performing its safety-related function. It is the belief of ESI that the extent of condition is limited to the single spray tip. Based on the age of the tip (repair kit purchase order (PO) date is 2001), if other tips contained the same discrepancy, it is highly likely they would have been detected or replaced. There were 20 tips in the same batch as the failed spray tip. The end user of the PO is Nine Mile Point. ESI suggests that the customer perform an inspection on the remaining 19 injectors. ESI has discontinued the affected injector repair kit.
ENS 5423522 August 2019 15:10:00

The following information was received from the Massachusetts Radiation Control Program via email: On 08/08/19, a package containing 20 mCi of P-32 was sent by PerkinElmer, Inc. (the 'licensee') to the University of Sherbrooke in Ontario, Canada (the 'customer') via the common courier which was scheduled to arrive on 08/09/19. The package never arrived. The customer notified the licensee by telephone on 08/21/19 at 1100 (EDT) of the missing package. The licensee contacted the common courier on 08/21/19 to gain more information and to try and locate the package. The common courier acknowledged they would attempt to locate the package and would call the licensee back. The common courier did not contact the licensee so on 08/22/19 at 1030 (EDT) the licensee contacted the common courier again and discovered the package could not be located and was declared missing. The licensee notified the Massachusetts Radiation Control Program (the 'Agency') by telephone on 08/22/19 at 1200 (EDT) to report a missing package containing radioactive material. The Agency considers this event to be open.

  • * * UPDATE ON 08/23/2019 AT 1154 EDT FROM THE MASSACHUSETTS RADIATION CONTROL PROGRAM TO CATY NOLAN * * *

The activity amount in the original report was erroneously reported as 20 mCi. The correct activity is 737 microCuries. Notified R1DO (Werkheiser), and ILTAB and NMSS Events (via email). 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 5421713 August 2019 16:15:00The following was received from the Maryland Department of the Environment Radiological Health Program (MDE RHP) via phone: On August 12, 2019, at approximately 1330 (EDT) hours, the Maryland Department of the Environment (MDE) Hazardous Waste Enforcement Division contacted the MDE Radiological Health Program (RHP) concerning a vehicular accident that involved a nuclear density gauge. The initial transportation accident, as logged in at 1300 hours, indicated the accident location near the 70-mile marker on west-bound I-70, near Lisbon, MD. The vehicle, identified as a box truck, was carrying a density gauge that was ejected during the accident. The gauge was observed not in its transportation case at time of arrival of Fire/EMS and Maryland State police. The company Radiation Safety Officer from Francis O. Day, Inc. responded to the scene and verified that the source was in the shielded position. The gauge was taken to Northeast Technical Services for evaluation. The gauge was identified as a Troxler model 4640 surface thin-layer gauge, S/N 2399. This gauge has a Cs-137 sealed source with a nominal activity of 8 mCi and was last leak tested on July 14, 2019. The State trooper on scene stated that the vehicle was actually a pickup truck. The transportation case was ejected from the pickup truck along with the truck cap and the driver. The gauge left the confines of the transportation case and came to rest approximately 10 feet from the case. The chain that held the case to the truck bed broke. The driver did not survive the accident. MDE/RHP will further investigate this event.
ENS 5421512 August 2019 17:47:00

The following is a summary of the information received from Flowserve via facsimile: Contrary to the requirements of ASME Section III & ASME NQA-1 Requirement 2, an employee of Flowserve was found to have performed Non-Destructive Examinations (Liquid Penetrant Testing - PTs) without the required certificate in accordance with ASNT SNT-TC-1A, and Flowserve's written practice. The employee was trained and tested in accordance with the written practice and ASNT requirements. Although the individual section scores were found to pass the (70 percent) minimum, the composite test requirements failed to meet the minimum 80 percent requirement. Actual composite score achieved was 79.176 percent. The extent of exposure to this condition was on examinations completed between 10/22/18 and 11/21/18. There were ten examinations, totaling 22 pieces that were completed by the employee without oversight/signature by another certified individual. The scope of impacted valves/components encompasses body, stem, cover, yoke, pin wedge, and disk. Licensees affected include Exelon Company, Pinnacle West Capital Corp, Bruce Power, Xcel Energy, Alabama Power, Entergy Nuclear Operations Inc., and FirstEnergy. Flowserve issues a corrective action, and is currently in the process of determining the root cause and prevention action measures. This will include identifying the affected valves via communications with affected customers.

  • * * UPDATE ON 09/06/2019 AT 1345 EDT FROM KEVIN WORTH TO JEFFREY WHITED * * *

The following is a synopsis of a letter received from Flowserve: On 09/06/19, Flowserve issued its Final Report for the Part 21, noting the scope of the valves/components affected by the issue described above. Flowserve also noted the corrective actions that were taken to address the issue and detailed the specific actions taken for the individual components. Notified R1DO (Carfang), R2DO (Shaeffer), R3DO(Edwards), R4DO(O'Keefe), and Part 21/50.55 Reactors Group (e-mail).

ENS 542109 August 2019 14:54:00The following was received from the Wisconsin Radiation Protection Section via email: On 8/9/19, the Department (State of Wisconsin Department of Health Services) was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit. The patient will be notified. Wisconsin Event Report ID: WI190009 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 542048 August 2019 12:38:00A 0.78 Curie (today's activity) Ir-192 source was lost during shipment from the Mayo Clinic in Rochester, MN to Alpha-Omega Services in Vinton, LA. The last known location was Memphis, TN with the common carrier. Its original shipment date was February 8, 2019. The licensee contacted the common carrier upon suspicion of loss on June 4, 2019. On August 7, 2019, the source had not been located and was deemed lost. 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 542068 August 2019 17:03:00Pursuant to 10 CFR 21.21(d)(3)(i), this is a non-emergency notification by Energy Northwest concerning a defect on a control power transformer (CPT) resulting in a failed starter coil while in service at Columbia Generating Station. The defect was associated with a CPT provided by Spectrum Technologies (model Micron B150-2957-1). On June 14, 2019, a failure analysis was completed that determined that the failure of the coil occurred because the starter coil was exposed to chronic elevated temperatures. These elevated temperatures were caused by the associated control power transformer (CPT) secondary voltage being maintained outside the coil's rated voltage range. Previously on June 10, 2019, it was determined that the CPT installed in the Spectrum Technologies motor starter assembly did not meet procurement specifications resulting in a turns ratio that produced higher voltages on the motor starter coil than its rated voltage. This led to overheating and breakdown of the coil insulation that created a short between two windings. On August 5, 2019, Energy Northwest completed a Part 21 evaluation in accordance with 10 CFR 21.21(a)(1) and determined that this deviation could create a substantial safety hazard as defined in 10 CFR 21.3. The NRC Resident Inspector has been notified. The licensee has 14 Spectrum transformers that are continuously energized that could be affected. The one transformer that experienced the failure was out of service for maintenance at the time of discovery. Four other coils were inspected for extent of condition and no more failures were found.
ENS 5416917 July 2019 10:24:00Vanderbilt University Medical Center had a misadministration on 7/16/19. A patient was supposed to receive 14 mCi of I-131 NaI, but the technologist administered 33 mCi of I-131 NaI. The technologist will send a written report within the 15 day requirement. Item Number: TN-19-098 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 541559 July 2019 14:19:00The following was received from the Commonwealth of Massachusetts via email: This shipment containing scrap metal with radioactive material was first discovered at Sims Metal Management in North Haven, CT on June 27, 2019. As a result, SP 10656 Number CT-MA-19-01 was issued by members of the Connecticut Department of Energy and Environmental Protection and the shipment was sent back to Joseph Freedman Company in Springfield, MA. The material was received at the licensee and the radioactive items were removed, isolated, and stored in a locked 55 gallon drum on site in a secure area for further analysis. The site hired a contract health physics service to aid in the identification of the material and to perform radiation surveys. That occurred on 7/8/19. Two devices were discovered. The contractor provided survey information and attempted isotope identification for the two devices. One source was identified as Ra-226 and the other could not be clearly identified. Since the identification of one of the two sources was in question, the Massachusetts Radiation Control Program Director visited the site on 7/9/19 carrying multiple survey instruments for additional measurements and for visual inspection of the two units. One of the devices was identified as a Pyralarm Demonstrator Unit manufactured by Pyrotronics, Inc. The isotope was identified as Ra-226 with an approximate activity of 56 microCuries. The other device appeared to be an industrial nuclear gauge, but there were no legible markings on it other than a Radioactive Material sticker. The isotope identified was Am-241 with an approximate activity of 15 milliCuries as determined on 7/9/19. The spectra for this source contained peak energy channels in addition to the Am-241 peak that could not be readily identified given the proposed use of the device. It is possible other isotopes are there and we will continue to evaluate with the contractor until appropriate disposal by a licensed waste broker. Dose rates provided for the Pyralarm smoke detector containing Ra-226 were 37 mR/hr at one centimeter, 0.275 mR/hr at 30 centimeters and 0.42 mR/hr at one meter inclusive of approximately 0.5 cm of lead shielding. Dose rates for the unidentified gauge containing Am-241 were measured as 85 mR/hr at 2.5 centimeters and 2.8 mR/hr at 30 centimeters. The highest dose rate on contact with the storage drum containing the two devices was 0.550 mR/hr. Wipe surveys were taken on all surfaces by the contractor and there was no radioactive contamination found. These devices were discarded by unknown persons and are pending disposal by a licensed waste broker. 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 542058 August 2019 13:26:00This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Engineered Safety Feature actuation signal. On June 25, 2019, at Waterford 3, while performing an emergent replacement of relays on the Engineered Safety Features Actuation System Train A that affected Shield Building Ventilation Train A and HVAC Equipment Room Supply Fan AH-1 3A, unintentional contact was made between two contacts on the relay, resulting in an inadvertent initiation of other relays in the sequencer circuit. This caused the starting of Low Pressure Safety Injection Pump A, Switchgear Ventilation Fan A, and Boric Acid Makeup pumps. This was a partial actuation of Engineered Safety Features Actuation System Train A. Affected plant systems started and functioned successfully. This inadvertent actuation was caused by human error and was not a valid signal resulting from parameter inputs. The 1992 Statements of Consideration define an invalid signal to include human error. Therefore, this actuation is considered invalid. This event was entered into the Waterford 3 corrective action program for resolution. This event did not result in any adverse impact to the health and safety of the public. In accordance with 10 CFR 50.73(a)(1), a telephone notification is being made in lieu of submitting a written Licensee Event Report. The NRC Senior Resident Inspector has been notified.
ENS 5413226 June 2019 15:45:00The following was received from the North Carolina Radioactive Materials Branch via email: On 6/24/19, a patient underwent a Xofigo therapy treatment and did not receive the full dose as prescribed but had to return the following day to receive the full dose on 6/25/19. Due to the size of the patient and the fact that Xofigo doses typically arrive to the licensee in 10cc syringes, (in order) to accommodate the patient with the correct dose, the dose prescribed to the patient was split between two doses/syringes. On 6/24/19, licensee personnel delivered the first dose of 119.19 microCuries (Ra-223) which was approximately 50 percent of the prescribed dose. It was discovered after the patient was discharged that the remaining dose was still in the hot lab. The prescribing physician was immediately notified and the patient returned the following day, 6/25/19, and received the second dose of 114.5 microCuries (Ra-223). NC Radiation protection is currently investigation this incident and will follow up to close and complete this report." NC tracking number: 190021 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 5412924 June 2019 17:37:00The following is a synopsis of a report received from the Utah Department of Environmental Quality (the Agency) via email: At 1102 (MDT) on June 24, 2019, the Agency received a phone call from an individual who found a yellow box with radiation symbols on the outside of the box. Upon arrival at the individual's home, the Agency saw a yellow Troxler transportation case next to the driveway. The individual stated that the case was found on June 22, 2019. The Agency inspected the case and measured a contact dose rate of 40 microCuries/hr on the outside with a Bicron dose rate meter. There were no locks on the outside of the case. The Agency then opened the case and found a Troxler Model 3430, Serial Number 64033, containing 8 mCi of Cs-137 and 40 mCi of Am-241/Be. Although the source was in the shielded position, there was no lock to secure the source in the shielded position. The case was not labeled with any name or contact information. The Agency took control of the gauge and brought it back to the office and secured it. A calibration sheet was found and used to determine the owner of the gauge. It was confirmed that the gauge belonged to Transportation Alliance Engineering. The agency will conduct an inspection. Utah Event Report ID #: UT190003
ENS 5412824 June 2019 15:19:00

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE DURING RADIOGRAPHY The following report was received from the Texas Department of State Health Services (the Agency) via email: The licensee called (the Agency) to report an event involving a radiographer and trainee. They were conducting (non-destructive testing) NDT on pipe, shooting 8 second shots with a 76.3 Curie Ir-192 source and a QSA Global D888 camera. The radiographer went to the darkroom to complete some paperwork. The trainee took down film and moved the collimator to the next shot location. It was about then (the trainee) realized (the trainee) had not retracted the source. (The trainee) reported the mistake to the radiographer trainer. The trainee did not have dosimetry and did not conduct a camera survey prior to moving the camera. Both the trainer and trainee were issued RadEye G's so they did not have direct reading dosimeters. (The trainer and trainee) took the trainee's dosimeter that was left in the truck and decided to expose it to the source for a few seconds. Then they reported that (the trainee) received 145 mrem on his dosimeter. When the RSO questioned them, they told (the RSO) what had happened and (the RSO) then conducted a time dose study. Based on reenactment, the RSO determined the trainee was exposed to the source about 6 seconds. The calculations indicated the trainee may have received 1456 rem to the hand. (The RSO) didn't take credit for the collimator shielding and used 5.9 R/hr/Curie at 1 foot as the basis for the calculation. The radiographer and trainee have been placed on administrative leave pending a decision from the company's review board. (The Agency) told (the licensee) that it would be investigating this event and that it will want to interview the radiographer and trainee. The Agency believes the calculated dose may be high but will follow-up during the investigation. Texas Incident #: 9691

  • * * UPDATE ON 06/27/2019 AT 1531 EDT FROM KAREN BLANCHARD TO JEFFREY WHITED * * *

The following report was received from the Texas Department of State Health Services (the Agency) via email: During an investigation, the Agency learned there had been a miscommunication in the dose the licensee reported for the radiographer trainee's hand. The dose was not 1456 rem. The licensee is working with a consultant to make both a hand and whole body dose calculation. With the information provided, it appears the calculated dose to the radiographer trainee's hand should be less than 10 rem, which is below the regulatory reporting limit. The licensee will continue to monitor the radiographer trainee's hand. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Groom) NMSS (Rivera-Capella) and NMSS Events and INES (Milligan) via e-mail.

  • * * RETRACTION ON 8/1/19 AT 1725 EDT FROM KAREN BLANCHARD TO MICHAEL BLOODGOOD * * *

The following retraction information was obtained from the state of Texas via email: Miscommunication during initial incident reporting. Exposure was well below reporting requirement/no overexposure. Notified R4DO (Groom) and NMSS Event Notifications via email.

ENS 5412017 June 2019 11:08:00

The following was received by email from the Commonwealth of Pennsylvania: On Friday, June 14, 2019, the licensee experienced an equipment failure event during a brachytherapy treatment where the source failed to retract from the patient at the end of the treatment time. The catheter was immediately manually removed from the patient and placed in the emergency container and locked up. No harm is expected to the patient and no overexposures occurred. The HDR (High Dose Rate) unit, an Elekta Flexitron Model 136149A02, contained an iridium-192 source less than 12 Curies. The vendor, Best Vascular, was immediately notified and will be on site today, June 17, 2019, to retrieve the source and repair the device. The DEP (PA Department of Environmental Protection) will update this event as soon as more information is provided. The DEP will perform a reactive inspection. More information will be provided as received. PA Event Report ID No: PA-190014

  • * * UPDATE FROM JOHN CHIPPO TO OSSY FONT ON 6/19/19 AT 1002 (EDT) * * *

The following information was received from the DEP via fax: On Monday, June 17, 2019, a service engineer from Best Vascular was able to drive the sources into the catheter and retract them into the device several times without incident. The licensee now believes the CVBT (CardioVascular BrachyTherapy) catheter was not fully seated into the device, causing a small leak and a subsequent pressure differential which does not allow the source to fully retract into the device. The cause of the event is believed to be operator error. The DEP will perform a reactive inspection. Notified R1DO (Greives) 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 5408724 May 2019 17:12:00At 1310 CDT on 5/24/2019, Wolf Creek experienced a loss of offsite power to the safety-related NB02 bus, due to an external fire on a bushing on the startup transformer. The NB02 bus was reenergized when the 'B' Emergency Diesel Generator started and the output breaker automatically closed. The shutdown sequencer automatically started equipment as expected. Due to the undervoltage condition on the NB02 bus, an AFAS-T (Auxiliary Feedwater Actuation Signal) signal was generated which started the turbine driven auxiliary feedwater pump. Turbine load was reduced to maintain reactor power less than 100% in response to the start of turbine driven and 'B' motor driven auxiliary feedwater pumps. The fire was extinguished using a fire extinguisher at 1320 CDT. The unit is stable at 97% power. The NB02 bus remains on the 'B' Emergency Diesel Generator (EDG). The other EDG is operable in standby. The NRC Resident Inspector was notified.
ENS 5408524 May 2019 13:09:00At 0730 (EDT) on May 24, 2019, it was discovered that the Low-Pressure Core Spray System was inoperable. At Perry, the Low-Pressure Core Spray system is considered a single train system in Modes 1, 2, and 3; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). Inoperability of the Low-Pressure Core Spray system was caused by Emergency Service Water Pump A inoperability. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5408624 May 2019 16:22:00

The following is a synopsis of an event received via phone call: During a shipment from Pasadena, TX to Billings, MT, a 4 milliCurie Cobalt-60 (Co-60) source was lost in transit. The last known location was Memphis, TN. It was shipped on May 17, 2019 and was identified lost on May 22, 2019. The shipper and the common carrier are investigating.

  • * * UPDATE ON 05/25/2019 AT 1045 EDT FROM MONTY POPE TO JOANNA BRIDGE * * *

The following is a summary of a phone call with Mr. Pope: On May 24, 2019, the source that was misplaced by the common carrier was able to be located. New shipping documents are being generated. Notified R1RDO (Arner), R4RDO (GEPFORD), ILTAB (e-mail), NMSS Events (e-mail) and CNSNS Mexico (email). 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.p

ENS 540463 May 2019 16:43:00A non-licensed contract supervisor had a confirmed positive during a for-cause fitness-for-duty test. The individual's authorization for site access has been terminated. The NRC Resident has been notified.
ENS 5401220 April 2019 09:54:00At 0507 (CDT on April 20, 2019), the DAEC (Duane Arnold Energy Center) experienced a trip of both reactor feed pumps. Operators inserted a manual scram. All control rods inserted, as required. As a result of the feed pump trips and scram, HPCI and RCIC automatically injected. Also, containment isolations occurred, as expected for this event. All systems responded as designed. Operators are currently taking the unit to cold shutdown conditions. Vessel level is being controlled by RCIC with Condensate System available. Pressure is being controlled using Main Steam Line drains and the Main Condenser is available. Normal electrical lineup remains. The cause of the reactor feed pumps tripping is believed to be an instrument air leak to flow control valves, causing loss of suction to both feed pumps. The licensee notified the NRC Resident Inspector.
ENS 5399612 April 2019 13:21:00

The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email: On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient. There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing). The licensee will follow-up with a formal report.

  • * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/29/20 AT 1553 EDT * * *

The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis. The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment. NMED Item: 190182 Notified R1DO (Schroeder) and NMSS Events Notification (email).

  • * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 EDT * * *

The state of Georgia has amended the original report and the update from 4/29/20 as follows: -the prescribed dose was 122 Gy -the delivered dose was 78.8 Gy -the difference is 64.5 percent. This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database. Notified R1DO (Schroeder) and NMSS Events Notification (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 539681 April 2019 06:40:00

At 2006 (MST), on 3/31/2019, the Palo Verde Nuclear Generating Station Unit 1 Shift Manager was informed that leakage was measured from the Train A Emergency Core Cooling System (ECCS) piping at approximately 100 ml/minute through a High Pressure Safety Injection (HPSI) A drain valve. This value exceeds the assumed 3000 ml/hour ECCS leakage for a large break loss of coolant accident analysis. At 0230 (MST) on April 1, 2019, the valve was flushed and the leakage reduced to 10 ml/minute (600 ml/hour) and was no longer above the limit of the safety analysis. This condition is being reported as an unanalyzed condition per 10 CFR 50.72(b)3)(ii)(B) and a condition that could have prevented the fulfillment of a safety function to the control the release of radioactive material per 10 CFR 50.72(b)(3)(v)(C). This event did not result in an abnormal release of radioactive material. Notification received by Caty Nolan and emailed to HOO.HOC@NRC.GOV The NRC asked a followup question: Why was the criterion for Control of Radioactive Material selected? per the PVNGS Unit 1 Shift Manager, this criterion was selected due to the potential of exceeding offsite dose projections, post recirculation, following a Design Basis Accident. The resident inspector has been notified.

  • * * UPDATE ON 05/15/19 AT 1417 EDT FROM SEAN DORNSEIF TO BETHANY CECERE * * *

An engineering evaluation concluded that the as-found ECCS leakage would not have degraded the performance of the Pump Room Exhaust Air Cleanup system; therefore, it remained operable. The evaluation also concluded that the as-found leakage was within the analysis margins for HPSI pump hydraulic performance and containment flood level following a Large Break Loss of Coolant Accident; therefore, the ECCS also remained operable. Based on the above information, the condition identified on March 31, 2019, was an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B), but did not prevent the fulfillment of the safety function of the structures or systems that are needed to control the release of radioactive material per 10 CFR 50.72(b)(3)(v)(C). The NRC resident inspectors have been informed. Notified R4DO (Proulx).

ENS 5396731 March 2019 00:17:00At 2130 (EDT) on March 30, 2019, with Unit 2 in Mode 1 at 30 percent reactor power, the reactor was manually tripped due to a main steam isolation valve failing closed. The trip was not complex, with all systems responding normally. Operations stabilized the plant in Mode 3. Decay heat is being removed through the main steam lines through the steam dumps and into the condenser. The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A). Unit 1 was not affected. There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspectors have been notified.
ENS 5399211 April 2019 18:19:00The following is a synopsis from a phone call: At Brooke Army Medical Center, two I-125 seeds were lost on October 16, 2018. One source was 156 microCuries and the second source was 158 microCuries, totaling approximately 314 microCuries at the time. The sources were not realized missing until March 13, 2019, when the activity would have been approximately 28 microCuries each, totaling 56 microCuries. Investigation is ongoing and actions to prevent recurrence are being implemented. There was no significant exposure above dose limits. 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 5392611 March 2019 13:55:00

The following is a summary of the phone call with the state of Oregon: On March 5, 2019, the licensee realized that a 9.4 Curie Ir-192 industrial radiography source was missing when the scheduled shipment was not received on March 4, 2019. Last known location was Memphis, TN on March 1, 2019.

  • * * UPDATE AT 1110 EDT ON 3/13/2019 FROM DARYL LEON TO MARK ABRAMOVITZ * * *

The following report was received via e-mail: On March 11 at 11:38 AM (PDT), the licensee (OWL) emailed and stated that the lost package and source have been found after an extended telecon (1 hour) with the carrier. No location given in email but a statement that (the common carrier) had held the shipment because they needed a copy of the shipping papers to send it on to its destination (QSA in Baton Rouge, LA). OWL emailed a copy of the shipping papers to (the common carrier) and the package was released to continue on to QSA. On March 12 at 9:15 AM (PDT), (the state of Oregon) contacted the licensee (OWL) by phone. The package and source were found by (the common carrier) in their Memphis, TN shipping center. (The common carrier) did not have shipping papers for the package when received in Memphis and placed it into their 'Overgoods' department where 'lost dangerous goods' are taken and held if there is a paperwork issue preventing a shipment from continuing on its way. The package in this case was released on March 11th as previously indicated and arrived at QSA in Baton Rouge at 10:02 AM (CDT). Notified the R4DO (Groom), and NMSS Events Resource and ILTAB (via e-mail). THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

ENS 539041 March 2019 13:53:00The following report was received from the Kentucky Department of Public Health via email: The University of Kentucky RSO (Radiation Safety Officer) reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy. The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days. Kentucky Event Report ID No.: Ky190002. 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.