Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56874 | 29 November 2023 11:29:00 | The following information was provided by the Iowa Department of Health and Human Services (HHS) via email: Arconic Davenport possesses an (Isotope Measuring Systems) IMS model 5221-02, profile thickness gauge for measuring thickness of aluminum on the production line. The C-frame gauge contains 5 independent source housings, with each housing containing a 5 curie, Americium-241 sealed source. The C-frame gauge is constructed from steel and is suspended from a monorail which allows the device to be moved off-line to a restricted access calibration area. The shutter is opened and closed by a pneumatic cylinder that is controlled from a remote location. In the afternoon of November 28, 2023, it was determined that shutter number 1 of the C-frame gauge had failed to fully close. This was determined when an automated attempt to close all 5 shutters on the gauge (failed), and the computer indicated that shutter number 1 was not fully closed. Per the licensee's procedures, the C-frame gauge was removed from the line using the monorail to the secured calibration house. Radiation surveys of the outside wall adjacent to the shutter 1 position were above background with a maximum dose rate of approximately 0.1 mR/hr. The licensee has contacted their service provider to perform repair work (identify and fix the equipment problem) which is tentatively scheduled for November 29, 2023. No reported overexposures and no release or contamination of radioactive material occurred because of this incident (most recent negative leak test was November 2, 2023). Iowa HHS will update this report once additional information is provided (cause, corrective actions, etc.). Iowa Item Number: IA230004 |
| ENS 56865 | 19 November 2023 14:44:00 | The following information was provided by the licensee via phone and fax: On November 18, 2023, the presence of alcohol was discovered inside the protected area. In accordance with the Constellation Fitness For Duty (FFD) Program, the individual has been escorted offsite and access to the plant denied pending the results of an investigation. This event is being reported under 10 CFR 26.719(b)(1) as it represents a significant FFD violation. The NRC Resident Inspector has been notified. |
| ENS 56859 | 16 November 2023 15:20:00 | The following information was provided by the licensee via phone and in accordance with Headquarters Operations Officers Report Guidance: On November 11, 2023, at about 1330 EST, at the Cleveland Cliffs Steel Corporation in Dearborn Michigan, the licensee staff noted that the indicating light for a 1 curie Am-241 thickness gauge shutter position was malfunctioning. The light indicated open continuously even though the shutter was closing normally. Operation of the plant continued and the shutter remained in its normally open position measuring the product steel thickness. Shutter position was subsequently checked by radiation measurements to confirm that the indicating light was not indicating correctly. No abnormal exposure resulted and the vendor will troubleshoot and repair. The location of the gauge is not normally manned.
The following update was received from the licensee via email: Today, a Thermo Fisher Scientific technician came on site to diagnose the shutter position indicator light issue. It was found that the shutter arm flag was bad. The technician replaced the shutter arm flag with a new one and verified that the unit was properly working. No Cleveland Cliffs employees nor the Thermo Fisher Scientific technician were exposed at any time during the event. Notified R3DO (Feliz-Adorno) and NMSS Event Notifications (E-mail). |
| ENS 56823 | 30 October 2023 21:10:00 | The following information was provided by the Wisconsin Department of Health Services (the Department) via email and telephone: On October 30, 2023, at 1830 CDT, the Department received a notification from the licensee that a CPN MC1DRP gauge containing up to 10 mCi of Cesium-137 and 50 mCi of Americium-241 had been out of their control since 1435 CDT when the vehicle containing the gauge was stolen. Local law enforcement has been notified. The Department will monitor and update. Event Report Number: WI230019
The missing gauge was recovered around 0800 (CDT) on October 31, 2023 and is now in the custody of the licensee. The gauge had no visual damage. The Department will follow up with the licensee. Notified R3DO (Dickson), ILTAB and NMSS Events notification by 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 56820 | 27 October 2023 13:31:00 | The following information was provided by the Ohio Department of Health (ODH) via email: ODH received a notification last night (on 26 October, 2023), that NDC Technologies, Inc. (NDC) discovered a 25 mCi Americium-241 (Am-241) source was missing from their inventory. NDC is located in Dayton. The licensee has conducted three inventories of all sources, reviewed all shipping logs, and have searched (both visually and with a survey meter) areas, floors, and drawers where devices are built and stored. The source may have mistakenly been put into a trashcan or sent, still mounted in the sodium iodine crystal, for disposal. The last disposal was on July 12, 2023, and the licensee has contacted the disposal company and will speak with them further today. ODH will be sending an inspector to further investigate. NMED report number: OH230010 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 56810 | 22 October 2023 01:43:00 | The following information was provided by the licensee via phone and email: On October 21, 2023, at 2048 EDT, reactor recirculation pump (RRP) 12 tripped. The cause for the trip is under investigation. Following the RRP trip, the average power range monitors (APRMs) flow bias trips were inoperable due to reverse flow through RRP 12. The APRMs were restored to operable on October 21, 2023, at 2058 EDT, when the RRP 12 discharge blocking valve was closed. This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(v)(A) which states: "Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition." The NRC Resident Inspector has been notified. |
| ENS 56788 | 11 October 2023 16:23:00 | The following information was provided by the licensee via phone: On October 10, 2023, at about 1000 EDT in College Park, Maryland, the licensee was performing industrial radiography on pipe welds in a ditch using a QSA Global 880 machine with a 54 curie Ir-192 source. The licensee, Testing Technologies Inc, is headquartered in Virginia but operates in Maryland under an NRC license. While attempting to retract the source, it became detached from the drive cable. The licensee shielded the area until they eventually retrieved the source to its safe storage position later that afternoon. No exposure to workers or public occurred from this event. The source detachment was reported to the manufacturer and is under investigation.
The following is a synopsis of information provided by the license via email: The radiography was being performed in a 14 foot deep trench. While conducting an exposure the crank moved only 1/2 turn, the radiographer attempted to retract the source but was unsuccessful. The area was secured, with boundaries at 2 millirem/hr. The Radiation Safety Officer (RSO) was contacted at 0940. He arrived approximately 30 minutes later. After assessing the situation, additional equipment and shielding were brought to the site. Six entries to the restricted area were made by the RSO with a total dose of: whole body =130 millirem, left hand = 205 millirem, right hand = 130 millirem. The RSO is the only individual who entered the area during the retrieval operation. No other employee or member of the public were exposed. The serial number of the unit is: 6011. TTI has also notified the State of VA Dept. of Health, State of Maryland Department of the Environment, QSA Global (the manufacturer), and the University of Maryland RSO. Notified R1DO (Carfang) and NMSS Events Notification via email. |
| ENS 56759 | 27 September 2023 15:28:00 | The following information was provided by the licensee via fax: (On 09/27/2023) at 1041 CDT, with the plant at 75 percent power and main turbine control valve testing in progress, a reactor pressure transient resulted in a reactor steam dome high pressure scram and subsequent group 1 primary containment isolation of the main steam lines (MSL). All main steam isolation valves closed as a result of the group 1 isolation signal. Additionally, a group 2 containment isolation signal was received due to reactor pressure vessel (RPV) level less than plus 9 inches during the transient. Operations personnel responded and stabilized the plant. The high-pressure coolant injection (HPCI) system was placed in service to control RPV pressure. HPCI did not inject into the RPV and was not needed to control RPV water level. The cause of the initial pressure transient is under investigation. The NRC Resident Inspector has been notified.
The utility notified the State of Minnesota and Wright and Sherburne counties. Notified R3DO (Orlikowski) |
| ENS 56758 | 26 September 2023 15:35:00 | The following information is a summary of the information provided by the licensee via telephone: On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed. 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 56749 | 20 September 2023 12:21:00 | The following information was provided by the Pennsylvania Bureau of Radiation Protection (DEP): On September 19, 2023, a licensee vehicle was involved in an automobile accident during which a nuclear density gauge ejected from the vehicle. State Police recovered the device. The licensee reported to the scene and recovered the device. There was no damage to the gauge itself. The only damage incurred was to the transportation box. The side handle was ripped off as a result of the accident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided. Troxler Model Number: 3440 Serial Number: 35195 Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries Pennsylvania Report Number: PA230025 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 56746 | 19 September 2023 13:03:00 | The following information was received from the Colorado Department of Public Health and Environment via email: After completing a Yttrium-90 TheraSpheres treatment, (medical personnel) were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event. Colorado Event Report ID: CO 230032 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 56747 | 19 September 2023 15:56:00 | The following information was provided by the licensee via email, facsimile, and phone: The Ohio Environmental Protection Agency was notified at approximately 1402 EDT on 09-19-2023, that the (National Pollutant Database) limit for chlorine at Outfall 012 (X-2230M Holding Pond) of 0.019 mg/L was exceeded on 09-18-2023, with a result of 0.109 mg/L with the elevated level being confirmed by a sample on the morning of 09-19-2023. Centrus American Centrifuge Operating is currently investigating to determine the cause of the exceedance. NRC Region 2 was notified. Centrus event number: CN 11437. |
| ENS 56708 | 1 September 2023 18:39:00 | The following was provided by the Texas Department of State Health Services (the Department) via phone and email: On September 1, 2023, the Department was notified by a general licensee that a generally licensed NRD, LLC device containing 10 microcuries (original activity on June 8, 2022) of polonium-210 was lost. This is greater than 10 times the Appendix C value of 0.1 microcuries. The device was to be disposed of after the general licensee switched to another non-radioactive material method of eliminating static. However, the device was believed to have been thrown away in municipal waste before this could happen and was last seen on May 12, 2023. The device is not expected to provide significant dose to anyone. The licensee does not believe this device would pose a safety or health risk to the public. Further information will be provided per SA-300. Texas NMED: TX 230038 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 56697 | 25 August 2023 15:50:00 | The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency): The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the (common carrier). The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the (common carrier) for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various (common carrier) personnel, it has been established that the package cannot be located. A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels.
The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed. Illinois Item Number: IL230021 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 56789 | 12 October 2023 12:17:00 | The following information was provided by the licensee via email: Donald C. Cook Nuclear Power Plant completed an internal Part 21 evaluation concerning an issue with an Emergency Diesel Generator (EDG) Digital Reference Unit (DRU) supplied by Engine Systems Incorporated (Appendix B Supplier for Woodward Governors). (On August 8, 2023,) a potential defect was identified (during a surveillance test) concerning a marginal solder joint on the DRU electronic circuit board that can result in a loss of continuity between the termination strip and the electronic board, causing a loss of setpoint output from the DRU to the Electronic Governor, and a subsequent loss of fuel to the EDG and inability to support any load. A formal failure analysis is ongoing at the time of this notification. A written notification will be provided within 30 days. Affected known plants include only Donald C. Cook Nuclear Power Plant Units 1 and 2 at the time of notification. The NRC Resident has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The EDG DRU was replaced after discovery of the potential defect and the EDG is currently operable. |
| ENS 56670 | 9 August 2023 16:26:00 | The following information was provided by the licensee via mail: It was determined that the Urenco United States of America (UUSA) safety analysis did not analyze for stacked, criticality safe (CSA) containers when not in an engineered storage array. This potentially results in an inadequate analysis. Urenco USA stores CSA containers in isolation on the floor and spaces them 60 centimeters apart, prior to performing IROFS (Items Relied on For Safety) 58a mass determination and placing a container in an array. However, an analysis has not determined whether dropping a container, or stacking a container, onto another container stored in this way, could result in exceeding the Code of Federal Regulations Title 10 Part 70.61 requirements. Currently, there are no containers stacked in this way. Urenco USA has stopped all work regarding moving the containers in areas affected by accident sequence DS1-9. The plant is in a safe and stable condition. |
| ENS 56646 | 31 July 2023 12:01:00 | The following summary information was provided by the licensee via telephone: On 7/31/2023 at about 0730 MDT, employees of the City of Great Falls were standardizing a Troxler moisture density gauge (contained 9 millicuries of cesium-137 and 44 millicuries of americium-241) with the gauge on an asphalt lot and the source in its cage; as per standard practice. A loader truck inadvertently hit the gauge but was halted before it ran over the gauge. Some plastic on the gauge was damaged. The licensee halted operations and restricted access. Subsequently, radiation levels of 0.294 millirem per hour at 1 foot and 0.004 millirem per hour at 4 feet were measured, which were essentially background levels. No overexposure or other personnel injury were reported. |
| ENS 56672 | 9 August 2023 17:42:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On August 9, 2023, the Department was notified by a licensee of radioactive material lost in shipment. The material was 1.82 GBq (49 mCi) of Y-90 Theraspheres which is greater than 1000 times the Appendix C value for Y-90 (10 microcuries). The owner of the material is the manufacturer of the microspheres. The manufacturer ships the material to the Texas licensee who is located near a major airline hub. The Texas licensee then stores the material until the owner sends an order for rapid shipping to a medical facility. At which point, the Texas licensee ships the material via a common carrier to the address on the order. The manufacturer is responsible for confirming the facility receiving the package has a radioactive material license. On July 27, 2023 the Texas licensee received an order from the manufacturer to ship four sets of Theraspheres to a licensee in Florida. The four sets were each in separate type A packages. The Texas licensee has closed circuit television of the common carrier picking up the four packages which were sent 'Priority Overnight'. On July 28, 2023, three of the packages arrived at the Florida licensee. The Texas licensee contacted the common carrier asking about the fourth package which has a tracking number of (deleted). After some investigation, the common carrier reported that the package had not left their Irving, TX facility near the Dallas Fort Worth airport. Three of the packages had scans leaving that facility but not the fourth and missing package. A transit facility in Greensboro, NC reported that they did not have the package. They reported scanning three packages on the way to the Florida licensee. On August 3, 2023, the common carrier advised the Texas licensee that they had closed the lost claim and were no longer looking for the package. The Department has asked the Texas licensee to contact the dangerous goods section of the common carrier and request their assistance. This Department has also notified the Florida Radiation Control program of the incident. This Department is waiting for contact information for the radiation safety officer of the manufacturer and owner of the material. Once obtained the Department will notify the appropriate state agency. Further information will be provided per SA-300. Texas Incident number: 10045 Texas NMED number TX230037 This event was also reported by the State of Florida under EN 56671. 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 56669 | 9 August 2023 11:38:00 | The following information was provided by the Wisconsin Department of Health Services (the Department) via email: On August 9, 2023, the Department was notified by the licensee of a yttrium-90 (Y-90) TheraSphere medical event that had occurred on July 13, 2023. The licensee's radiation safety officer performed a records review on August 2, 2023, and identified a written directive indicating a potential underdose to the patient. After confirming that the documentation was correct on August 8, 2023, the licensee determined that a reportable event had occurred. The prescribed activity to the patient was 1.07 GBq. The licensee initially calculated a delivered activity of .86 GBq based on pre- and post-administration surveys. The radiation safety officer was not able to replicate this calculation and determined that the delivered activity was approximately .781 GBq. This is a delivered activity of 72.99 percent. Utilizing the TheraSphere worksheet, the licensee calculated that the patient received 73.4 percent of the prescribed dose. The licensee will be notifying the patient. There is no anticipated harm to the patient, or exposure to any additional individuals. Event Report ID No.: WI230006 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 56554 | 5 June 2023 11:17:00 | The following information was provided by the Pennsylvania Department of Radiation Protection (DEP) via email: On June 1, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. The vehicle was located and returned to the employee within a few hours. The gauge was still properly stored in the trunk and untouched with no evidence that the trunk lock, gauge chain, chain lock, or gauge case had been tampered with. The DEP has been in contact with the licensee and will update this event as soon as more information is provided. Troxler Model Number: 3430 Serial Number: 29846 Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries Event Report ID No: 230017 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 56549 | 1 June 2023 15:34:00 | The following was received by email from the Minnesota Department of Health: An Iodine-125 localization seed (approximately 270 microcuries) was lost following removal from the specimen. The seed is suspected to have been placed on a surgical towel and never put into the source vial. Prior to discovery of the missing seed, the pathology department linens were taken to a laundry facility where the towel was washed. The licensee surveyed the pathology department and the laundry facility and were not able to find the seed. State event report number: MN230003 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 56532 | 22 May 2023 16:24:00 | The following information was provided by the licensee via email: A non-licensed contract supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56748 | 19 September 2023 18:20:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse. By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation. To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations. Texas Incident Number: 10021 Texas NMED Number: TX230028 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 56503 | 4 May 2023 12:25:00 | The following summary was provided by the licensee via phone: On May 4, 2023 at 1145 EDT, the licensee found contact dose rates of 215 and 555 millirem-per-hour at 2 separate spots on the top of an exclusive use package during receipt survey. These dose rates are above the 200 millirem-per-hour allowable. No loose surface contamination was identified. The package contains tools from Holtec and was intact on delivery. The package has subsequently been secured in a locked radiation storage building. No overexposure or unauthorized exposure resulted to plant personnel. The licensee suspects shielding, internal to the package, may have shifted and the licensee will investigate further. Dose rates at one foot from the package were recorded at 65 millirem per hour. |
| ENS 56507 | 6 May 2023 15:34:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On May 5, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 4, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion. Two nuclear gauges both containing 20 millicurie cesium-137 sources may have been involved in the event. The licensee has not been able to inspect the gauges due to structural safety concerns therefore the condition of the of the two gauges is unknown. The two gauges are located very close to each other. The licensee hopes to get eyes on the two gauges tomorrow or Monday. The gauges do not present an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300. Texas Incident number: I-10016 NMED number: TX230021
The following information was provided by the Texas Department of State Health Services (the Agency) via email: On May 8, 2023, the Agency was notified that the licensee has not been able to inspect the gauges. The licensee is still working on isolating hydrocarbon gasses that are being released in the area. There is a concern that the fire could reignite. The licensee does not know when they will be able to access the area. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Werner) and NMSS Events Notification via email.
The following information was provided by the Agency via email: On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion. On May 10, 2023, the Agency was notified by the licensee's service provider (SP) that the licensee was able to use a drone to inspect the area of the fire. The SP stated that they were able to see one of the gauges which was still located in the same position it was in before the fire. The second gauge could not be located due to all the debris in the area. The SP stated the gauges original position was on a pipe six feet above the ground. They believe the pipe may have fallen to the ground and the gauge went with it. The SP stated the licensee did perform a radiation survey outside the exclusion area in the area where the gauges are located, and the readings were background. The SP did not know how close they would have been to the gauges. The licensee is making plans to enter the area, but the weather is causing delays as they have to shut down outside activities anytime there is lightning within 10 miles of the plant. The SP stated they did not have a date or time when they will be able to access the gauges. The SP stated they have discussed how they will conduct contamination surveys and radiation surveys once they gain access to the area. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Werner) and NMSS Events Notification via email.
The following information was provided by the Agency via email: On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion. On May 11, 2023, the Agency was contacted by the licensee's service provider (SP). The SP stated the licensee had made an entry into the area affected by the fire and was able to visually inspect the gauges from an unknown distance. One gauge (unknown which one) was free of soot and was still the same color as it was before the fire. The other gauge had soot on it. The gauge that was mounted 6 feet off the ground on a pipe was observed in the same location as it was before the fire and had not been knocked to the ground with debris as previously thought. The dose rates in the areas the individuals were in were reported as background. The licensee plans to reenter the area tomorrow afternoon and perform radiation surveys and take swipes on the gauges. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Werner) and NMSS Events Notification via email.
The following information was provided by the Agency via email: On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion. On May 13, 2023, the licensee reported both sources had no removable contamination and they have both been safely removed and placed in a low occupancy and secure temporary storage location. The licensee reported the gauge shielding had been degraded and the gauges were wrapped in lead before they were placed in the storage location. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Werner) and NMSS Events Notification via email. |
| ENS 56498 | 2 May 2023 17:04:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On May 2, 2023, the Agency was notified by the licensee that they were unable to locate a 200 millicurie cobalt - 60 source. The licensee stated that the company had three locations in the United States, one in California, one in Louisiana, and one in Texas. In January of 2023, the company decided to close its offices. The company transferred all its sources to the Texas location. The sources were then sent to a source disposal company in Texas. During the last transfer of sources, the cobalt source could not be found. The licensee searched for the source at the Texas facility but could not find it. The process of locating where the source might be is complicated by the fact that the licensee had laid off most of the employees. The Radiation Safety Officer (RSO) was included in the layoff. The individual tasked by the company to dispose of the sources contacted a few of the previous employees and was told that the source was transferred to the location in Louisiana. (The Agency) asked if they had the documents for the transfer. He stated they had given all the documents to the Louisiana location. He did not have a copy of the forms. He said the source itself is about half the size of a magic marker. He said it is normally stored in a lead box in a sea van. He said that they would search their paperwork including the sign-out log in Louisiana to see if they can confirm the source was there. The Agency advised the individual to go to Louisiana and search for the source in and around the storage area. He was also advised to get someone added to their license as RSO. Additional information will be provided as it is received in accordance with SA-300 Texas Incident Number: 10014 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 56500 | 2 May 2023 19:20:00 | The following information was provided by the Oregon Health Authority via email: Upon completion of (Yttrium) Y-90 Therasphere delivery (to a patient) and completion of post-treatment template measurements, it was noted that the delivery ratio appeared to be below 80%. The technologist who was involved in delivery contacted the authorized user who came and reviewed the information. Both the authorized user and Boston Scientific representative, who was present during delivery, felt that an error had been made in post-treatment measurements, so they were repeated both that day and the following. Nuclear medicine staff performed (single photon emission computed tomography with a computed tomography) SPECT/CT imaging of the Nalgene container. This imaging was reviewed on 5/1/23 and it was determined that activity was remaining in the delivery set tubing. Imaging was reviewed with the Assistant (radiation safety officer) RSO, and it was determined that a Medical Event had occurred. Per (the assistant RSO), the Medical Event was reported to the Oregon Health Authority on 5/2/23. The Authorized User, communicated the situation with the patient and is confident that no adverse effect has occurred based on calculated treatment thresholds and tumor burden. The authorized user reviewed the SPECT/CT imaging and will participate in mitigation. 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 56475 | 18 April 2023 17:03:00 | The following synopsis of information was provided by the Massachusetts Radiation Control Program (the Agency) via email: At 1900 EDT on April 17, 2023, Lantheus Medical Imaging, Inc. (the Licensee) reported that at 1500 EDT on that day it had discovered a package containing a 15 Curie Mo-99/Tc-99m generator was not delivered to RLS in Van Nuys, CA (the intended recipient). On April 18 at 1200 EDT, the Licensee learned that the package was still in the delivery truck in California. The driver had two deliveries to make on April 17, 2023, but only made one of the deliveries, leaving the package containing the generator in his vehicle overnight. Once the package was found, it was delivered to its intended recipient. The reporting requirement is immediate per 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. MA Number.: TBD The Agency considers this event to be open. 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 56473 | 17 April 2023 10:22:00 | The following summary was provided by the licensee via phone and email: At approximately 2100 CDT on 04/16/23, the radiography crew began to setup a radiograph using a SPEC-150 camera on the East Cellar Mezzanine deck on an offshore oil rig near the state of Louisiana. The radiograph began at approximately 2120 CDT. After a 3 minute exposure, the crew attempted to retrieve the source back to its shielded position in the camera. During this time, the crew noticed that the camera's source lock/plunger was not engaging. After several attempts to expose and retract the source with hopes of a proper lock engagement, the crew determined that the source was unable to return to the shielded position. The crew expanded the 2 mR/hr boundaries on all affected areas and decks with a survey meter in hand. After unsuccessful attempts to retrieve the source, the technician was finally able to fully unscrew the crank hex out of the handle. Once the inside wire was exposed, the technician manually pulled the wire and was able to get the source back into its fully shielded and locked position. No crew members were injured, and there were no overexposures during this incident. |
| ENS 56468 | 13 April 2023 22:48:00 | The following information was provided by the licensee via phone and email: At 1905 (EDT), a security force member discovered what appeared to be a sewage leak along the gravel roadway northwest of the gatehouse entrance. The affected area was approximately 12' X 15'. The water was slowly bubbling up from the ground about 20' along one of our access roads. Large absorbent spill containment barriers were placed at the scene to minimize the incident. Water usage was stopped within our facility, and sewer pumps isolated. The Maine State Department of Environmental Protection (DEP) was notified of the incident (DEP spill # 23-0004705). The area was inspected at approximately 2130 (EDT), and water discharge was no longer observed. Maine Yankee site management is currently in the process of contacting contractors to resolve the issue. The site is safe and secure. The concrete cask heat removal system is operable, and the temperature monitoring system is functional. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee notified Region 1 personnel. |
| ENS 56467 | 13 April 2023 16:50:00 | The following information was provided by the licensee via phone and email: While finishing the renewal of our license, I was not able to account for one device found in a 2016 inventory, the number of devices matched the number of devices listed on our 2016 license. Both the license and inventory from 2016 listed 10 devices, I could only account for 9 devices. On the 11th of April, documentation was found in our property management system that listed the device as transferred to an outside agency, agency is unknown. The last leak test preformed on this device was in 2013, so the condition of the shielding in 2016 is not known, when it was transferred. The missing device is a Troxler model 3411 device serial number is 13760. The device contains two sources americium-241 with 44 millicuries at 1.480 giga becquerels (SN 47-9073), and cesium-137 with 9 millicuries at 0.296 giga becquerels (SN 50-2578) 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.pdfThe following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: |
| ENS 56472 | 17 April 2023 16:05:00 | The following information was provided by the California Radiation Control Program via email: Industrial Nuclear Company (INC) (located in California) shipped three nominal 103 Curie Ir-192 radiography sources to Miami for export to a customer in Venezuela on 9/27/22. The sources did not reach the Venezuelan customer. The sources were reported missing by INC on 4/10/23 (the sources were never 'lost' as their whereabouts were known to be in custody). The sources have been recovered from a common carrier warehouse in the Miami area by the Florida Radiation Control Bureau and Florida law enforcement on 4/14/23. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: A previous notification of this matter was made to the Headquarters Operations Officer (HOO) by the Florida Radiation Control Program on 4/10/23. On 4/10/2023 at 1300 EDT, the HOO also received a phone call from INC regarding a potentially abandoned radioactive source that was originally intended to be shipped to Venezuela but was in possession of the common carrier in Doral, FL. The state of Florida provided preliminary information on the incident and will provide additional information as it becomes available. 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 56405 | 10 March 2023 14:55:00 | The following was received from the state of Wisconsin Department of Health Services (WI DHS) via phone and email: On 2/16/2023, WI DHS was notified that a citizen was in possession of a package labeled radioactive on their farm and that they had been in possession of the package for almost a year. The label on the package indicated that it contained 8.15 GBq (220 milliCuries) of Mo-99. The label on the box indicated that the intended destination was Medi-Ray. The shipper was unknown. On 03/01/2023, WI DHS took possession of the package and determined that it contained a Lantheus Mo-99/Tc-99m generator. The generator label indicated that it originally contained 277.5 GBq (7.5 Curies) Mo-99, with a calibration date of 04/03/2022. WI DHS confirmed that the package contents are no longer radioactive. WI DHS consulted with the NRC and determined that the event was not reportable based on the information known at the time, the lack of radioactive contents, an unidentified licensee, and an unknown common carrier. On 03/09/2023, WI DHS was contacted by a Lantheus representative who determined, based on the lot number, that the package was most likely originally distributed to the Medical College of Wisconsin (WI RAM license number: 079-1104-01). On 03/09/2023, WI DHS contacted the licensee to confirm if they had shipped the recovered package. On 03/09/2023, the licensee confirmed that they had possessed a generator from the identified lot number and that their records indicated a return shipment containing that generator should have been picked up for transfer to Medi-Ray by the common carrier on 04/17/2022. On 03/09/2023, Medical College of Wisconsin made an official telephone notification of a reportable event of the loss of 220 milliCuries of Mo-99. This investigation remains open and WI DHS is working with Medi-Ray to dispose of the generator. Wisconsin Report ID: W1230003 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 56391 | 7 March 2023 14:38:00 | The following information was received from the Louisiana Radiation Protection Division (the Department) via email: On March 7, 2023, Boise Packaging and Newsprint, LLC notified the Department that there was an equipment malfunction. The pivot pin connecting the shutter handle rusted out and failed. The fixed gauge was an Ohmart Model SHRM-B serial number 1301/1830. The source was 80 mCi of Cs-137. A third party licensee was contacted to come out and fix the Ohmart gauge. Louisiana Report ID: LA20230003 |
| ENS 56400 | 9 March 2023 15:36:00 | The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email: Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable. Reference Number OH 2023-006 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 56386 | 3 March 2023 09:48:00 | The following information was provided by the licensee via phone and email: A non-licensed supervisor tested positive in accordance with the FFD (fitness-for-duty) testing program. The individual's authorization for site access has been terminated. The NRC Senior Resident Inspector has been notified. |
| ENS 56380 | 23 February 2023 14:03:00 | The following information was obtained from the Ohio Bureau of Radiological Protection via email: On 2/17/2023, the licensee's (Alternate Radiation Safety Officer) ARSO entered the radioactive material storage room where a technician was opening the housing on a device containing a Kr-85 source. Upon the initial attempt to withdraw a bolt of the device housing, an area radiation monitor began to alarm. The ARSO and the technician took a second reading with a Victoreen 451 (radiation detector) to confirm that it was Kr-85 gas leakage and exited the room. A radiation survey meter indicated that there was no contamination on either person. Removable swipes of the area outside of the room also were indicative of no contamination. The entry door was sealed and access restricted until additional information was available. Follow-up entries were completed by the ARSO on 2/20/2023 and 2/21/2023 using 1 meter by 1 meter grids to identify specific areas of testing for removable contamination. Radiation and contamination survey results identified no readings above background. The licensee did not report results of any personnel testing or estimates of uptake. The licensee is investigating the cause of the Kr-85 leak. (Ohio Department of Health) ODH will travel to the site to conduct an investigation on 02/28/2023. Ohio Item Number: OH230003 |
| ENS 56388 | 3 March 2023 11:08:00 | The following information was provided by United Controls International via email: Schneider Electric part number: ASP840-000 Modicon Primary/Secondary Power Supply units failed to operate several days after installation at Dominion's Surry Power Station with hard failures that shutdown the associated programable logic controller. The units were returned to UCI and initial observations indicated heavy shipping damage that was not present when initially supplied. Further evaluation of the damaged components requires manufacturer evaluation due to item complexity and proprietary design documentation. Investigation into the root cause(s) of the failures is ongoing. Evaluation of whether these failures represent deviations or failures to comply that would be associated with substantial safety hazards will be complete by July 2, 2023. For questions concerning this potential 10 CFR 21 issue, please contact: Anu Kulkarni Quality Assurance Manager United Controls International (470) 610-0851 |