Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56283 | 21 December 2022 13:32:00 | The following information was provided by the licensee via email: This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid specific system actuation of the Emergency Service Water System (ESW). On 11/2/2022, during normal reactor operations, multiple main control room alarms were received for D12 Emergency Diesel Generator (EDG) running and Unit 1 Division 2 Safeguard Battery Ground. The D12 EDG did not start; however, the 'B' ESW Pump auto started. Subsequent troubleshooting determined that the cause of the D12 EDG running alarms and the inadvertent auto start of the 'B' ESW Pump was a malfunction on the D12 EDG speed switch. This event is considered an invalid system actuation because the 'B' ESW Pump started in response to a false signal that the D12 EDG was running when D12 EDG did not start. This was a complete actuation of the ESW System and the system functioned as expected in response to the actuation. The affected ESW Pump was shut down in accordance with plant procedures and the degraded D12 EDG speed switch was replaced. There was no impact on the health and safety of the public or plant personnel. The licensee notified the NRC Resident Inspector. |
| ENS 55886 | 6 May 2022 17:08:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9931 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 55848 | 19 April 2022 18:02:00 | The following information was provided by the licensee via email: A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated. The licensee notified the NRC Resident Inspector. |
| ENS 55849 | 19 April 2022 19:45:00 | The following was received from the Washington Office of Radiation Protection via email: Incident took place on 4/15/22 at approximately 0800 PDT Wallula, WA. A fixed gauge (KayRay model 7062 bp; 50mCi Cs-137) was found unmounted and uncontrolled, nearby it's normally installed location. Source is intact and shutter mechanism has remained in the locked/closed position. No over exposure or spread of contamination. The fixed gauge is currently reinstalled at it's normal location, pending further investigation and report. Incident Number: WA-22-010 |
| ENS 55690 | 5 January 2022 13:36:00 | The following information was provided by the licensee via email: At 0907 CST, a small fire was reported in the Intake Structure at Fort Calhoun Station. Offsite fire departments were notified at 0909 CST and responded at 0922 CST. Fire was confirmed extinguished at 0949 CST. Fire was extinguished using offsite resources per the Station Fire Plan. There were no injuries reported. The fire occurred in the Non-Radiological area of the plant and there was no release of radioactivity or hazardous materials. |
| ENS 55663 | 17 December 2021 13:51:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection (the department) via email: On December 16, 2021, the licensee informed the department that a nuclear density gauge had been damaged at a job site. While a technician was carrying the Troxler gauge, they tripped and fell on top of the gauge handle. This broke off the handle about half-way from the top to the gauge. The portable gauge was a Troxler, 3400 series, Serial Number 15717, containing 8 millicuries of Cs-137 and 40 millicuries Am-241:Be. The area was secured, and the Radiation Safety Officer (RSO) called a third party (Applied Health Physics) for assistance. Applied Health Physics and the RSO determined that the source was secured in the shielded position, and gauge was not leaking. Applied Health Physics did site surveys and determined there was no dose to any employees or anyone on the job site. Applied Health Physics secured the handle to the gauge, and it was transported back to Construction Engineering Consultants, Inc. Pittsburgh office. Once at the office the gauge was placed in their office vault and has been taken out of service. It will be held there until it can be sent to the manufacturer for disposal. Applied Health Physics did a leak test on site that day and the sample results showed no evidence of radiological material. There was no exposure to workers or the public. Event Report ID No: PA210023 |
| ENS 55571 | 11 November 2021 11:55:00 | The following was received from the Texas Department of State Health Services (the Agency): On November 10, 2021, the Agency received notification from (the Radiation Safety Officer) RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found. Texas Incident: I-9895 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 55504 | 4 October 2021 08:05:00 | The 'A' Steam Generator Narrow Range Water Level went less than 17 percent causing an Auxiliary Feed Water System valid actuation signal. The Auxiliary Feed Water System was in service at the time of the event providing decay heat removal. There was no adverse effect on plant systems. The Steam Generator Narrow Range Water Level was restored to normal operating band. This is being reported per 10 CFR 50.72(b)(3)(iv)(A), which states, 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' (Reactor Coolant System) RCS Pressure 340 pounds and RCS Temperature 340 Degrees F. The NRC Resident Inspector was notified. |
| ENS 55405 | 13 August 2021 13:22:00 | The following is a summary of a report by Customs and Border Patrol received via telephone: Five sources were stolen from the back of a truck while it was parked in a hotel lot in the Miami area, after the lock on the truck was broken. The sources were being transported to calibrate Radiation Portal Monitors at Customs and Border Patrol offices in the Miami area. The theft was reported to the US NRC Region 1 Office and the Miami-Dade Police Department (report number: PD210812-254442). Source details: Cf-252, 5.16 microCuries (S/N: N7- 402); Co-57, 75.44 microCuries (S/N: 2187-53-6); Co-60, 9.3 microCuries (S/N: 2185-40-6); Ba-133, 6.7 microCuries (S/N: 1794-56-5); and Cs-137, 6.79 microCuries (S/N: 1288-76-5).
The following is a summary of a report by Customs and Border Patrol received via email: At approximately 0900 EDT on August 12, 2021, the licensee discovered that five sources were stolen out of their truck that was parked at the Element Miami International Airport Hotel. The sources were stored in a shielded pelican case and are low activity sealed sources. There is no significant external radiation exposure risk and the sources are extremely robust reducing the potential for any internal exposure if the capsule were breached. A report was filed with local law enforcement. 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 55389 | 30 July 2021 16:57:00 | The following was received from the Minnesota Department of Health via email: The Mayo Clinic Rochester, MN had a medical event in which the total dose differs from the prescribed dose by greater than 20 percent and the dose difference to the whole body exceeds 5 rem. Under clinical trials on 7/29/2021, a patient who was prescribed 11.2 mCi of I-131 as an infusion of IOMAB-B Therapy, only received 5.74 mCi. The licensee reports an issue with air in the tubing that prevented the entire administration of the treatment. They are continuing to investigate and will submit a final report within 15 days. 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 55387 | 30 July 2021 15:10:00 | The following was received from the Kentucky Department of Radiation Control, Radiation Health Branch (RHB) via email: At approximately 1230 CDT on 7/29/21 the Hospital (Radiation Safety Officer) RSO called RHB to report a failure of a Therasphere Y-90 administration kit. Authorized User (AU) indicated an almost immediate failure to administer the dose. There was no flow into the administration catheter. Saline observed exiting the administration set up into an overflow vial. After adjusting the pressure and a second attempt failed, a call was placed to the administration kit representative. Three more attempts failed. The AU decided to stop the process and remove the administration catheter. Patient procedure was stopped. Not rescheduled at this time. A survey of the vial and administration set up, and multiple patient surveys seem to indicate that no dose was administered to the patient. Y-90 set up and vials were packaged and stored into appropriate waste. No contamination, no release of material. No patient administration. Expected 4.15 GBq and received none. Licensee suspects an administration set up kit failure. Licensee will provide full reports to the RHB staff within 15 days. KY Event Report ID: 210002 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 55381 | 28 July 2021 11:19:00 | The following was received via email from the Georgia Radioactive Materials Program: A gauge was reported hit by a bulldozer (while on site) on 7/27/21. The rod was not exposed and there is no contamination leaking. Incident #: 43 |
| ENS 55367 | 21 July 2021 10:00:00 | The following was received from the Ohio Bureau of Radiation Protection via email: Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via (the common carrier) on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by (the common carrier). (The common carrier) is aware of the situation and believes that the package was delayed at their facility. On July 20, (the common carrier) informed Prime NDT Services, Inc. that the package could not be located. The State of Tennessee has been informed. Ohio Item Number: OH210007 Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
The following update was received via an email from the Ohio Department of Health Radiation Protection: On July 23, 2021 Prime NDT reported that the source has been located. (The common carrier) indicated that the source was located in their Canton, Ohio facility. Contrary to an earlier report, the source was never transported to (the common carrier) in Memphis, TN. Prime NDT retrieved the source from (the common carrier) facility in Canton. Notified R3DO (Hanna), INES-National Officer (Smith), ILTAB (Richardson), IR MOC (Grant), NMSS Day (Rivera-Capella), NMSS Events Notification (email), CNSC Canada (email), DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email). THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 55353 | 14 July 2021 16:03:00 | The following was received from the licensee via email: Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, which holds Permit Number 13-00694-03 under the VA master materials license, reported discovery of a medical event to NHPP (VA National Health Physics Program) at approximately 1045 EDT, July 14, 2021. A Y-90 microsphere therapy administration for liver cancer was performed on July 14, 2021. The dosage was intended for two segments of the left lobe of the liver. Post implant surveys of the administration set found an elevated amount of Y-90 present. Measurements and calculations indicated the patient had received about 63 percent of the prescribed activity. The patient has been notified. There is no expectation at this time of harm to the patient. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified our NRC Region III Project Manager, Bryan Parker. This event is reportable pursuant to 10 CFR 35.3045. 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 55339 | 4 July 2021 15:59:00 | At 0911 EDT on July 4, 2021, a failure occurred on 2 out of 3 of the required seismic monitoring instruments that feed the Operational Basis Earthquake (OBE) annunciator. The failure would prevent an OBE EXCEEDED alarm on the Seismic Monitoring Panel in the Control Room. This results in a major loss of emergency assessment capability. Corrective actions are being pursued to restore the seismic monitoring instruments. Compensatory measures are in place to assure adequate monitoring capability. This is an eight-hour, non-emergency notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the unplanned failure of the required seismic instruments affects the ability to assess a seismic event greater than the OBE. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55338 | 3 July 2021 17:44:00 | On July 03, 2021, at approximately 1011 CDT, a Security Force Supervisor at South Texas Project Electric Generating Station (STPEGS) was informed by a security officer that they had located what appeared to be drug paraphernalia inside the Protected Area. At 1033 CDT Local Law Enforcement was contacted and responded to STPEGS. At 1130 CDT the Matagorda County Sheriff's office took the item into evidence for testing to determine if there was any presence of a controlled substance. At 1311 CDT, the Matagorda County Sheriff's office notified STP Nuclear Operating Company (STPNOC) that the item tested positive for the presence of a controlled substance. At 1330 CDT the Unit 1 Shift Manager was notified. This event is being reported in accordance with 10 CFR 26.719(b)(1) for discovery or presence of illegal drugs within the protected area. STPNOC is continuing to investigate this incident. The Resident Inspector has been notified. |
| ENS 55336 | 2 July 2021 13:51:00 | The following was received from the licensee via email: A metallurgy laboratory (Met Lab) sample was determined to be missing from its prescribed location in the Physical Test Lab on June 30, 2021 at approximately 1330 EDT. A search for the item was immediately initiated per requirements. As of 1300 EDT on July 2, 2021, the item has not been located and as a result, formal notification of a missing item is being made to the NRC per Chapter 3 of BWXT NOG-L's Fundamental Nuclear Material Control Plan (FNMCP). 10 CFR 74.51 requirements do not apply since the item does not contain Strategic Special Nuclear Material (SSNM). The search for the item has been concluded and an investigation into the disposition has been initiated. The missing item was categorized as low enriched uranium and contained 0.03 grams of U-235. The Resident Inspector will be notified. |
| ENS 55335 | 2 July 2021 12:29:00 | The following is a summary of a phone call with the licensee: During a recent NRC inspection, the Radiation Safety Officer (RSO) and the NRC inspector determined that 2 Exit Signs (H-3; 0.352 Bq each) were missing and could not be located. The RSO has been searching since the inspection and has yet to locate the signs. The RSO noted that the exit signs were ordered in 2009 but was unable to find any removal work orders and is unaware of any effort to dispose of the signs. The RSO is unsure how long the signs have been missing. The licensee notified the NRC Region III Office. 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 55316 | 17 June 2021 18:07:00 | The following was received from the New Jersey Department of Environmental Protection (DEP) via email: On June 16, 2021, the DEP was notified that family members were cleaning out the home of a deceased relative, and discovered an item marked "radioactive." The DEP responded on June 17, 2021. The item in question appeared to be some sort of tile, or piece of rock, and was identified as containing Ra-226. There was some removable activity on this item. It was re-wrapped in the lead sheeting it was found in and placed in a plastic bucket, sealed, labelled, and secured in a safe location in the basement (where it was originally discovered), pending proper disposal. The on-contact reading was 4 mR/hr. |
| ENS 55306 | 15 June 2021 15:38:00 | At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4). No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance. The licensee notified the NRC Region IV Office. |
| ENS 55310 | 16 June 2021 13:10:00 | The following was received from the Illinois Emergency Management Agency (the Agency) via email: University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours. IEMA inspectors will perform a reactive inspection on June 17, 2021. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated once additional details become available on 6/17/21. Item Number: IL210019 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 55315 | 17 June 2021 18:07:00 | The following was received from the New Jersey Department of Environmental Protection (DEP) via email: On Tuesday evening, June 15, 2021, the DEP was notified that a member of the public had come to the Mountain Lakes police HQ to report that he had in his possession some radioactive material that he had obtained 60 years ago when he worked for Westinghouse as an engineer. The material was reported to be "Nuclear Reactor grade U-238 with 5 percent U-235 enriched". The citizen further stated that the material is wrapped in lead foil and placed in a lead pipe with the ends pinched over. The material allegedly consists of three or four rejected pellets, approximately 3/8 inch diameter. These were rejected because of dimensional irregularities. They are allegedly doughnut shaped with a hole in the center. They were reportedly to be used in Westinghouse nuclear reactors/steam power. The citizen stated that the material in question has been stored for decades in a lead pipe, sealed off at the ends, and then tightly wrapped in lead sheeting. It was also clearly labelled with the word "Radioactive" and then placed inside a large can, which has been securely stored in the citizen's garage for several decades. DEP personnel responded to the citizen's home on June 17, 2021. The material was found stored as the citizen had previously described. The container was not opened. There was no detectable removable contamination on the outside of the container. The material was returned to the garage where it will be secured pending proper disposal. |
| ENS 55304 | 12 June 2021 22:00:00 | At time 1725 CDT on 06/12/21, Main Steam Line 2-03 Radiation Monitor 2-RE-2327 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-03 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-03. Corrective actions are being pursued to restore 2-RE-2327 to functional status. The NRC Resident Inspector has been notified. |
| ENS 55303 | 11 June 2021 18:06:00 | At 1710 EDT on June 11, 2021, a Technical Specification required shutdown was initiated at Plant Hatch Unit 1. Technical Specification Condition 3.4.4.B unidentified LEAKAGE increase not within limits, was entered due to a greater than 2 gpm increase in unidentified LEAKAGE within the previous 24 hour period in MODE 1. This specification was entered on June 11, 2021, at 1615 EDT with a REQUIRED ACTION to restore leakage increase within limits within 4 hours. This REQUIRED ACTION could not be completed within the COMPLETION TIME; therefore, a Technical Specification required shutdown was initiated, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
Upon further review of the leakage rates, it was determined that at 1900 EDT on 6/11/2021 the drywell floor drain unidentified leakage increased greater than 2 gpm within the previous 24 hours while in MODE 1. Technical Specification (TS) 3.4.4.B was entered to reduce leakage increase to within limits within 4 hours. At 2000 EDT on 6/11/2021 unidentified leakage was reduced below the 2 gpm increase within the previous 24 hours due to actions taken to lower reactor power and pressure. Therefore, the TS required shutdown per TS 3.4.4.C was not applicable. Thus Event Report 55303 is being retracted. The NRC resident has been notified of the retraction. Notified R2DO (Miller). |
| ENS 55313 | 17 June 2021 11:58:00 | The following was submitted by Alabama Department of Radiation Control via email: The licensee reported that a patient was treated with fraction 2 of 3 on Friday 6/11/2021 using a vaginal cylinder. Once the fraction was completed, the treatment team noted that the vaginal cylinder had been displaced about 6 cm, a shift of about 5 cm. Unknown when the cylinder shifted during treatment. Licensee estimated a dose difference of approximately 5.58 Gray. Alabama Event 21-19 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 55293 | 5 June 2021 11:19:00 | The following was received from the Florida Department of Health (FDH) via email: Source: Co-60, Gamma-Knife treatment Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original (Adventist Health Orlando) Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different (Adventist Health Orlando) Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called (FDH) at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient. The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident. Florida Event Number: FL21-074 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 55280 | 27 May 2021 22:11:00 | The following was received from the Massachusetts Radiation Control Program via email: At 1551 EDT on May 27, 2021, the Massachusetts Radiation Control Program received a phone call from the Radiation Safety Officer (RSO) of Thermo Scientific Portable Analytical Instruments, License Number 55-0238. The RSO stated that a source was removed from the licensee's manufactured device that was sent to them for servicing. During this receipt procedure, a wipe sample taken on the device resulted in positive contamination. The Nickel-63 source was found to be leaking and the wipe test indicated a removable contamination level of 0.0728 microcurie. The limit for reporting the activity is 0.005 microcurie. Further information will be forthcoming as the event is under investigation.
The following update was received from the Massachusetts Radiation Control Program (MRCP) via email: The licensee notified the MRCP at 1202 (EDT) on May 28, 2021 to correct and update its earlier report. The sealed source isotope of interest is Iron-55 (Fe-55), not Nickel-63 as reported earlier, and the source activity is 20 millicuries. (The) Source was contained within an X-ray fluorescence device Model XLi 969, SN 5249. The customer had shipped the device to the licensee for decommissioning rather than service/repair. The accompanying leak test result prior to shipment was negative for contamination. Wipe survey results for areas within the licensee's facility where the device had been were negative for contamination. End of update. Notified R1DO (Bower) and NMSS Events Notification
The following update was received from the MRCP via email: The only update to this event is the MA docket number as referenced in the subject above (MA Event Docket 17-4568). There are currently no other updates to this event at the moment. MA Event Docket: 17-4568 Notified R1DO (Lilliendahl) and NMSS Events Notification |
| ENS 55274 | 25 May 2021 21:00:00 | The following was received from the South Carolina Department of Health and Environmental Control (the Department) via email: The South Carolina Department of Health and Environmental Control was notified on 05/25/21, that a strontium-90 medical eye applicator was lost or missing. The eye applicator is an Atlantic Research Corporation Model B-1 eye applicator, serial number 300, with a maximum activity of 50 millicuries. The licensee is reporting that the last inventory listed the source activity at 15.25 millicuries. During a recent inspection conducted by the Department, the licensee was unable to provide disposal records of the medical eye applicator. The licensee is now reporting the loss of the strontium-90 medical eye applicator. This event is still under investigation by the South Carolina Department of Health and Environmental Control. 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 55275 | 25 May 2021 21:38:00 | At 1751 EDT on May 25, 2021, it was determined the local leak rate test (LLRT) for the 2EMF-IN containment penetration did not meet 10 CFR 50 Appendix J requirements for both the inboard and outboard containment isolation valves (2MISV5230 and 2MISV5231). The LLRT was performed during the previous refueling outage at which time primary containment was not required to be operable. The leakage assigned to the penetration also resulted in total leakage exceeding the allowed overall leakage. The valves were repaired and retested satisfactory prior to entering the mode of applicability, This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A), There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55276 | 26 May 2021 18:10:00 | Event meets ACD2-RG-044 App. B N.1 'The licensee shall notify the NRC Operations Center of any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.' Received preliminary notification from TestAmerica Colorado that there was an exceedance of the Total Suspended Solids NPDES (National Pollution Discharge Elimination System) permit limit at Outfall 013. This was not unexpected with the current state of the settling pond above Outfall 013. An Ohio EPA (OEPA) 24 Hour non-compliance notification form was filled out and sent it to our OEPA NPDES inspector. Notification concurrent to the OEPA notification. |
| ENS 55307 | 15 June 2021 15:51:00 | The following was received from the Colorado Department of Health via email: A package of radium-223 (Xofigo) was lost in transit. The package was shipped on 5/22/21 containing 112.4 microCi radium-223. The final destination of the package was Saint Paul, MN; however, the last scan of the package by (the common carrier) was on 5/23/21 in Memphis, TN. Cardinal Health notified the Colorado radioactive materials unit on 6/11/21 that a package was missing and provided additional information (including isotope, activity, assay date, and tracking number) on 6/15/21. The activity of the package as of 6/11/21 (initial report date to Colorado) was approximately 33.5 microCi. Event Report ID No.: CO210016 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 55317 | 17 June 2021 17:20:00 | The following was received from the Minnesota Department of Health via email: On 5/21/2021 TSI, Inc. received two of three boxes containing radioactive material shipped from NRD, LLC, 2937 Alt Boulevard, Grand Island, NY, 14072. The third package, containing paperwork for 1 NRD model P-2042 static eliminator with an activity of 5 millicuries of Po-210, was received repackaged on the same date. TSI, Inc. contacted NRD and (the common carrier) to inquire about the status of the missing static eliminator. The (common carrier) website indicates that they were unable to deliver the package in question. TSI contacted (the common carrier) who has to date been unable to locate the static eliminator. TSI plans to request that a formal investigation be performed by (the common carrier). The investigation was ongoing at the time of this notification. State Event Report ID No.: MN-21-0004 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 55265 | 19 May 2021 08:35:00 | At 0315 MST on May 19, 2021, Unit 2 reactor automatically tripped during testing of the Plant Protection System. The Reactor Protection System actuated to trip the reactor on High Pressurizer Pressure, although no plant protection setpoints were exceeded. Main Steam Isolation Signal (MSIS), Safety Injection Actuation Signal (SIAS), and Containment Isolation Actuation Signal (CIAS) were received. No injection of water into the Reactor Coolant System occurred. Auxiliary Feedwater Actuation Signals (AFAS) 1 and 2 actuated on low Steam Generator water level post trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A). Following the reactor trip, all (Control Element Assemblies) CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generator heat removal is via the class 1 E powered motor driven auxiliary feedwater pump and Atmospheric Dump Valves. The NRC Senior Resident Inspector has been informed.
The Unit 2 reactor tripped because of actual High Pressurizer Pressure that occurred as a result of a Main Steam Isolation Signal actuation. At 0337 MST, both trains of Low Pressure and High Pressure Safety Injection (LPSI and HPSI) were made inoperable when the injection valves were overridden and closed in accordance with station procedures. At 0346 MST, in accordance with station procedures, both trains of Containment Spray, LPSI, and HPSI pumps were overridden and stopped, rendering Containment Spray inoperable as well. This represents a condition that would have prevented the fulfillment of a safety function required to mitigate the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D). Additionally, at the time of the Safety Injection Actuation Signal (0315 MST), both trains of Emergency Diesel Generators actuated as required and both 4160 VAC busses remained energized from off-site power. The NRC Senior Resident Inspector has been informed. Notified R4DO (Young)
The inoperability of both trains of Low Pressure and High Pressure Safety Injection (LPSI and HPSI) and both trains of Containment Spray (CS) following the Unit 2 reactor trip has been determined to be an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B). Additionally, inoperability of both trains of HPSI resulted in a reportable condition that could prevent fulfillment of its credited safety function to maintain the reactor in a safe shutdown condition per 10 CFR 50. 72(b)(3)(v)(A). The additional reporting criteria were discovered during review of the event and corresponding safety analyses. The NRC Senior Resident Inspector has been informed. Notified R4DO (Werner) |
| ENS 55252 | 12 May 2021 15:41:00 | With Reactor power at approximately 8 percent following a refueling outage, Steam Generator levels began to oscillate while in automatic control. Manual control of Main Feedwater Regulating Valves was unable to stabilize steam generator levels prior to reaching the "C" Steam Generator Low Level Reactor Trip setpoint. Reactor Trip, Main Feedwater Isolation and Auxiliary Feedwater Actuation automatically actuated. The plant is stable in Mode 3 at Hot Standby. All equipment has responded as expected. The Resident has been contacted. |
| ENS 55249 | 11 May 2021 18:33:00 | The following was received from the California Radiation Control Program via email: On 05/11/21 the California Office of Emergency Services (Cal OES) contacted (the Radiologic Health Branch) RHB to report a moisture density gauge that was discovered by (the California Highway Patrol) CHP in Santa Cruz, CA. The message stated that while CHP and (California Department of Transportation) CALTRANS were removing a transient encampment, a Soil Density Gauge (Troxler Model 3430, S/N #38287, containing 9 mCi of Cs-137 and 44 mCi of Am-241) was discovered at the site and the device does not appear to be damaged. CHP contacted the gauge vendor, Troxler, and was able to locate the licensee (Dees and Associates, Inc) and inform them of the stolen gauge. CHP took possession of the gauge and (the Radiation Safety Officer) RSO had already picked up the gauge from the CHP facility. According to the RSO, they have noticed a gauge stolen from their storage on 4/15/21. She had immediately notified Santa Cruz Police Department (Case # 21S-02156) and Troxler of the theft at the time of the incident. RHB was unaware of the theft until the Cal OES notification on 5/11/21. California 5010 Number: 051121 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 55255 | 12 May 2021 16:45:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9848 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 55246 | 10 May 2021 15:14:00 | The following was received from the New York State Department of Health (the Department) via email: A regional inspector for the Department received an email at 0341 EDT on 5/7/21 from the RSO of a materials testing lab stating that a Troxler model 4640 thin (layer density gauge), serial number 722, containing 40 mCi of Am-241/Be and 11 mCi of Cs-137, was stolen from a job site in Bronx, NY. The operator left the device unattended for a short period of time and returned to find it missing. The device was in its locked position when it was taken. The area was canvassed, and the police were notified. On 5/7/21, the licensee received a phone call from (an individual) stating that they had the device and wanted the reward. The licensee paid the reward and the device is back in the possession of the licensee. The device appears to be in good shape, but it will be leak tested before it is put back into operation. Event Report ID No.: NYDOH-21-02 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 55250 | 12 May 2021 11:27:00 | The following was received from the Alabama Office of Radiation Control (the Agency) via email: An Agency inspector performed an inspection of Wallace State Community College, registrant 554 GL (Generic License), in Hanceville, AL on 4/27/2021. The registrant's GL device was not located during the inspection. The registrant stated the device was moved/disposed in 2019. The registrant was unable to provide documentation of disposal. The inspector followed up with Perkin Elmer (manufacturer); the Perkin Elmer representative stated that no documentation of receipt/disposal of this device was/is present. No further information is available at this time. Device description: Perkin Elmer model N610-0063 s/n 3345, source model N610-0063, s/n 3345, with 15 milliCuries of nickel-63 as of 9/1/2000. Alabama Incident 21-16 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 55199 | 19 April 2021 17:53:00 | The following was received from the Illinois Emergency Management Agency (the Agency) via email: (The licensee) contacted the Agency this afternoon to report a medical underdose of Y-90 that occurred today, April 19, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient. (The) Radiation Safety Officer for the licensee contacted the Agency at 1515 CDT on April 19, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer received only 63 percent of the dose prescribed in the written directive. The Agency understands this to be one of three fractions delivered. Additional data is forthcoming. Reportedly, the underdosing was due to a leakage of Y-90 microspheres in the connection between the Therasphere tubing and the microcatheter. The leakage resulted in area and personnel contamination which was promptly and successfully addressed by on-site radiation safety staff. No skin doses are reported or anticipated. (The Agency) will dispatch staff to the site tomorrow for a reactionary inspection. 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 55196 | 16 April 2021 15:21:00 | The following is a summary of a call from the Department of Veteran Affairs: During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCurries of the prescribed 8.1 milliCurrie dose, for an underdosage of 23 percent. The patient is aware of the underdosage. The cause of the underdosage is currently under investigation. 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 55183 | 8 April 2021 19:47:00 | The follow was received from the Wisconsin Department of Health Services (Wisconsin DHS) via email: On April 8, 2021, the licensee's (Radiation Safety Officer) RSO reported a missing QSA global model 880 D exposure device containing a 28.9 Ci selenium-75 source. The package was shipped Monday April 5, 2021 via (the common carrier) from Neenah, WI to another Acuren location in Kingsport, TN. The package was shipped `overnight' with the intent to be delivered on Tuesday April 6, 2021. The package was reported delayed by (the common carrier) at Memphis, TN facility during the week. Then package arrived on Thursday April 8, 2021, damaged and without the shipped contents. Package weight information gathered as (the common carrier) handled the packaged indicates that the package contents were separated before final delivery, the exact location is unknown at the time of this report. The licensee is in contact with (the common carrier) and device manufacture QSA to locate the device and source. Wisconsin DHS will monitor efforts to locate the device and coordinated with other jurisdictions as necessary. Event Report No.: WI210002 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 |
| ENS 55176 | 7 April 2021 16:46:00 | The following was received from the Texas Department of State Health Services via email: On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The (Radiation Safety Officer) RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300. Texas Incident #: I-9837 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 55150 | 23 March 2021 07:38:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On March 22, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that earlier that day the shutter on a Berthold LD 8010 containing a 20 millicurie cesium-137 (original activity) source had failed to close. The gauge is installed on an inline section of pipe used in well fracking. The RSO stated that the roll pin for the shutter had failed and the operating arm would not rotate the shutter. The gauge was removed from the pipe and the operator was able to close the shutter. The RSO stated no overexposures occurred due to the event. The RSO stated a radiation survey of the gauge indicated dose rates were normal. The gauge was secured in a trailer on-site. The RSO stated the manufacturer was contacted and gauge will be packaged in a type 'A' container and sent to the manufacturer for repair. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9832 |
| ENS 55147 | 21 March 2021 23:57:00 | At 2216 EDT on 3/21/2021, Calvert Cliffs Unit 2 was manually tripped from 37 percent power due to lowering level in the 21 Steam Generator. All systems responded per design. Main Feedwater was secured and Auxiliary Feedwater was manually initiated. The Site Senior Resident has been notified. The cause of the lowering level in the 21 Steam Generator is under investigation. |
| ENS 55146 | 20 March 2021 04:55:00 | At 20:30 CDT on March 19, 2021, with the Unit 1 in Mode 5 at 0 percent power, an actuation of the Unit 1 Emergency Diesel Generator (EDG) occurred during outage activities on Transformer 12 (T-12) resulting in a trip. The cause of the Unit 1 EDG auto-start was bus undervoltage as a result of the T-12 trip. The Unit 1 EDG automatically started as designed when the Bus 14-1 undervoltage signal was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Unit 1 EDG. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55182 | 2 April 2021 10:10:00 | The following is a summary of information received from the U.S. Navy via phone and email: On March 5, 2021, the it was discovered that IBIS units (400 micro Ci total) had not been properly removed from 4 helicopter blades that were sent for recycling. The IBIS units were discovered when the detectors alarmed at the recycling facility in Bedford, IN. The blades were redirected to the Army Joint Munitions Command Morris Consolidation facility in Rock Island, IL for proper disposal. Based on the shipping paperwork, the helicopter blades that contained the four IBIS were received at the recycling facility on 11/17/2020, and were picked up from the facility on 3/16/2021. The highest reading was 0.7 mR/hr on contact without the cover installed for one blade. For the 3 other blades in their casing, needle deflection was observed, but had no appreciable dose rate. It is not likely that personnel spent an appreciable amount of time in the vicinity of the helicopter blades. 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 55314 | 17 June 2021 14:26:00 | The following is a summary of a report received from the vendor via email: The vendor notified the NRC that the hydraulic loss coefficient used to calculate the pressure loss and flow rate into the Side Entry Orifice (SEO) at the fuel bundle entrance in BWR/6 plants may have been underpredicted. The SEO loss coefficient was underpredicted for some fuel bundle locations, which could result in an overprediction of MCPR margin in core monitoring applications. The overprediction was a result of not originally including in the assessment flow area restrictions associated with instrument support structures in the cross beams (structural supports underneath the core plate) in BWR/6 plant designs. BWR/2-5 plants built by GE have a different core support structure that is more open so that multiple SEO losses are not applied to evaluations for those plants. However, there are currently no US ABWR plants in operation that would potentially be affected by this evaluation. The potential error in the core monitoring system does not affect the NRC certified design of the ABWR or the GEH ABWR design certification renewal application currently under review. The unique core support structure design of the BWR6 and ABWR is not shared by earlier BWR plants or the ESBWR. Potentially Affected Plants: Grand Gulf, River Bend, Clinton, Perry Point of Contact: Michelle Catts GE Hitachi Nuclear Energy Safety Evaluation Program Manager 3901 Castle Hayne Road, Wilmington, NC 28401 |
| ENS 55174 | 6 April 2021 12:31:00 | Meggitt Safety Systems, Inc. (Meggitt) has recently identified situations where the appropriate amount of testing was not performed to verify the acceptability of critical characteristics for commercially procured materials for use in safety related products in the Nuclear Cable Product Line. On February 5, 2021 during an internal audit, it was discovered that material verification for critical characteristics for several components had not been performed in accordance with Meggitt Engineering Document (ER94113 Rev T). These components are used on Meggitt nuclear safety related cables for in-containment instrumentation and control cables. These are also used on fire-resistant (Appendix R) power and control cables. The safety function of the in-containment and Appendix R cables is to reliably interconnect the detection/sensing device to the plant instrumentation during normal and (Loss of Coolant Accident) LOCA conditions and to interconnect the remote control location to critical devices during normal and abnormal/fire conditions respectively. Without the material verification there is a potential that the cables would not perform their Safety function properly. Meggitt is revalidating materials and engaging suppliers to satisfy critical characteristics verification requirements. Meggitt's preliminary assessment is that there is no impact to the safety function, however the COVID-19 pandemic has impacted our ability to complete our investigation. As a result, Meggitt is unable to meet the 60 day requirement and requests an additional 60 days to complete the Part 21 Safety Evaluation. The expected completion date is June 4, 2021. Contact Information: Jim Healy Senior Vice-President and General Manager Meggitt Safety Systems, Inc. 1785 Voyager Ave Simi Valley, CA 93063 (805) 581-8608
Meggitt's evaluation has been concluded with satisfactory results. There is no safety hazard on delivered nuclear cables as a result of inadequate constituent component material verification, nor does the failure to comply potentially cause a substantial safety hazard. These conditions are not reportable under Meggitt Airframe Systems procedure SOP 6045 and regulation 10CFR Part 21 and 10 CFR 50.55(e). Notified R1DO (Bickett), R2DO (Miller), R3DO (Dickson), R4DO (Groom), and Part 21 Reactors Group (by email). |
| ENS 55021 | 4 December 2020 08:20:00 | The following was received from the Virginia Radioactive Materials Program via email: On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system. Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received. Event Report ID No.: VA20006 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 retraction was received from the Commonwealth of Virginia via email: On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report. Notified R1DO (Bower) and NMSS Event Notification via email. |
| ENS 55014 | 30 November 2020 18:13:00 | The following was received from the state of Utah via email: The licensee indicated that while conducting an inventory of their radioactive devices it was discovered that a small Static Control Device (SCD) was missing containing an estimated 16.27 mCi, Po-210 source, manufacturer: NRD, model: 1U400. The source was licensed and distributed under a general license. The licensee believes the SCD may have been disposed of as lab waste, been moved to a different location within the building, or was inadvertently added to a field project kit that has not been located. The current location of the device is unknown. Event Report ID No.: UT 200002 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 |