Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57202 | 1 July 2024 14:13:00 | The following information was provided by San Onofre Nuclear Generating Station (SONGS) via email: At 2200 PDT on June 30, 2024, the California Office of Emergency Services (CAL OES) received a hazardous material spill report from BNSF Railway. BNSF reported a leak from a rail car that was transporting 'radioactive material surface contaminated objects'. BNSF contacted the local fire department to investigate the leaking material. This rail car was transporting the decommissioned Unit 2 pressurizer. Informational surveys conducted by a third party have determined that the leaked material did not involve contamination above background levels. Currently, there are SONGS radiation protection personnel en-route to investigate the reported leak. At 0734 PDT on July 1, 2024, SONGS personnel identified through the CAL OES website that BNSF had reported a hazardous spill to CAL OES. This is a 4-hour report due to a notification made to a government agency. Notification has been made to Region IV due to SONGS not having a NRC resident.
The following information was provided by the licensee via phone and email: Additional radiological surveys performed by SONGS radiation protection personnel have confirmed that there is no detectable contamination in the leaked material. Notified R4DO (Agrawal) |
| ENS 57199 | 28 June 2024 16:28:00 | The following information was provided by the licensee via email: This condition is being reported in accordance with 10 CFR50.72(b)(3)(v) as a condition that could have prevented fulfillment of a safety function. On 6/27/2024 at 2158 CDT, (technical specification) TS 3.5.1 condition 'D' (both divisions of (low pressure coolant injection) LPCI inoperable) was entered for surveillance testing. On 6/28/2024 at 0110 CDT, MO-2012 (residual heat removal) RHR Division 1 LPCI injection outboard valve was attempted to be cycled. It was discovered to be inoperable resulting in an inability to exit TS 3.5.1 'D'. Initial review of this condition for immediate reportability under 50.72(b)(3)(v) event or a condition that could have prevented fulfillment of a safety function, concluded the condition was not reportable based on the operability of other emergency core cooling systems (ECCS). Specifically, core spray and high pressure coolant injection were both operable to perform the function of emergency core cooling. Subsequent reviews determined that the reportability decision under 50.72(b)(3)(v) as an event or condition that could have prevented fulfillment of a safety function should be based on the safety function at the LPCI system level, rather than at the ECCS system level. The decision to report the inoperability of LPCI under 50.72(b)(3)(v) was made at 1030 CDT on 6/28/2024. The NRC Resident Inspector has been notified. |
| ENS 57179 | 18 June 2024 15:58:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: Alton Steel Inc. contacted the Agency on June 17, 2024, to advise of an incident in which molten steel impacted and damaged a 2.3 mCi Co-60 sealed source. This incident reportedly occurred on June 14, 2024, and results from the same ongoing conditions (source susceptible to molten steel flowing down the dip tube) identified in the licensee's March 2024 incident (refer to EN 57016). The licensee is still working with the source manufacturer to identify an engineered solution. The source and casting mold lid were collectively moved into a restricted area under the oversight of the radiation safety officer. The damaged source was then secured pending a site visit by the source manufacturer's authorized representative on June 18, 2024. The licensee missed the reporting timeline (24 hours). Agency staff will be on site the morning of June 20, 2024, for a reactive inspection. That inspection will assess contamination potential, discuss reporting timelines (reportedly missed due to multiple heat injuries and facility damage), address ongoing susceptibility of sources to damage, review contaminated area remediation timelines, and address proposed corrective actions for the April 19, 2024, Notice of Violation. Based on the information available at this time, there does not appear to be any impact to public health and safety. A description of the event indicates licensed material was not dispersed or incorporated into any product. This will collectively be assessed and this report (will be) updated thereafter." Illinois Item Number: IL240014 THIS MATERIAL EVENT CONTAINS A 'Not Recorded' LEVEL OF RADIOACTIVE MATERIAL |
| ENS 57173 | 14 June 2024 12:28:00 | The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email: On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided. Manufacturer and Model Number: Troxler Electronic Laboratories Model Number: 3440 Serial Number: 35459 Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries. PA Event Report ID No: PA240012 Surrounding States and the Pennsylvania emergency response team have been notified.
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email: On June 24, 2024, the car and gauge were recovered. The gauge was still inside of the vehicle with no damage or evidence of tampering. Survey meter readings of the gauge showed normal levels and it was returned to the licensee. Representatives of the Philadelphia Fire Company accompanied the licensee to retrieve the gauge. Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (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 57185 | 20 June 2024 15:22:00 | The following is a summary of information provided by the New York State Department of Health (NYSDOH) via email: NYSDOH received an email from the radiation safety officer of NRD on 6/11/2024 to indicate that a non-routine bioassay was started for an employee due to hand contamination. The employee's hand was decontaminated with soap and water and a whole-body frisk and nasal swabs were conducted. The whole-body count and nasal swabs were less than background. (After NYSDOH inquiry, the licensee subsequently reported that) the incident occurred on 6/10/2024 at 1630 EDT and was identified when the employee was leaving the facility. As a standard procedure implemented by license condition, the employee was frisking hands and feet for potential removable contamination. It was discovered upon frisking that the employee had 758 disintegrations per minute of suspected Am-241 on the palm of their left hand when leaving the facility. This amount of alpha skin contamination is 63 times the incident levels established on the license. (The employee) was transferring contaminated personal protective equipment (PPE) bags into a B25 (shielded waste) container. (The employee is believed to have) incorrectly doffed gloves. No other individuals had contamination present. A survey was performed of the area showing no contamination in excess of background levels on the surfaces, including the external surface of the B25 container. NRD is still performing an investigation, reporting their findings, and providing NYSDOH with bioassay data for this employee. It is unclear if this event truly meets the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH wishes to voluntarily report this event in the event (it is reportable,) regardless of applicability. NYSDOH will provide updates as appropriate regarding this incident. NYSDOH Incident Number 1489 |
| ENS 57178 | 18 June 2024 12:46:00 | The following information was provided by the Arkansas Department of Health, Radiation Control, Radioactive Materials Program (the Agency) via email: The Agency was notified by the Radiation Safety Officer (RSO) for the University of Arkansas for Medical Sciences on Friday afternoon, June 7, 2024, to advise of a possible Y-90 TheraSphere misadministration where the patient did not receive all the prescribed dose. The administration was two doses to segment 5 of the patient's liver. The discovery was made when the tubing and waste from the procedure was surveyed after it was returned to the lab. The written report was received on Friday afternoon, June 14, 2024. On June 17, 2024, the Agency reviewed the information provided and determined that this event is a misadministration due to the following: The administered doses both differed from their respective prescribed doses by more than 0.5 Sv (50 rem) to an organ. The delivered dose of 95 Gy (9500 rem) was 198 Gy (19800 rem) less than the (prescribed) dose of 293 Gy (29300 rem) for dose number one; the delivered dose of 105 Gy (10500 rem) was 21 Gy (2100 rem) less than the (prescribed) dose of 126 Gy (12600 rem) for dose number two. (For) dose number one only, the total dose delivered differs from the prescribed dose by twenty percent or more. Dose number one was outside the treatment prescription range; 68 percent of the prescribed dose was not received. Therefore, (dose) number one is considered to be a misadministration in accordance with current emerging medical technology licensing guidance. Dose number two was just inside the treatment prescription range; 17 percent of the prescribed dose was not received. The referring physician and (the) patient were notified, and the patient has been scheduled for an additional treatment. The investigation is ongoing, and reporting will proceed in accordance with SA-300. Arkansas Event number: AR-2024-004 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 57184 | 20 June 2024 15:22:00 | The following information was provided by the New York State Department of Health (NYSDOH) via email: NYSDOH received a call from the radiation safety officer of NRD on May 8, 2024, regarding a worker that had detectable amounts of contamination on their hand upon exiting a restricted area (smoke detector assembly). (The smoke detector assembly) area is not classified as an airborne radioactive materials area therefore the only personal protective equipment (PPE) required is coveralls, booties, gloves, and dust masks (to (discourage) touching of mouth/nose with gloved hands). Additionally, there is no continuous air monitoring in these areas. The individual had surveyed themselves upon leaving the assembly lab (Am-241 would be the target isotope) and it was determined that only one hand (dominant hand) had been contaminated. The contamination on their hands was determined to be 242 disintegrations per minute per one hundred centimeters squared (DPM/100cm^2). Following detection, the individual underwent a full body frisk and survey by environmental health and safety and underwent nasal swabs, all of which returned results below background. The individual will be placed on special bioassay collection as a confirmatory measure. Following the detection of contamination on this individual's hand, they were instructed to wash and scrub the affected areas on their palm and fingers. Following this decontamination, the individual was resurveyed and the surveys showed that the contamination had been successfully removed. NRD, LLC was able to interview the individual and discovered that upon leaving the assembly lab, the worker had doffed PPE, including gloves, and removed a layer of the sticky mat for the room with their bare hands. Following removal and disposal of the sticky pad layer, the individual surveyed their hands and feet which led to the discovery of contamination on their hands. NRD, LLC performed a large area removable (contamination) survey of the area in which this event occurred and found no contamination in excess of action limits requiring decontamination. Urinalysis results (24-hour cumulative collection) indicated undetectable concentration of Am-241 in the individual's urine, therefore no intake was suspected from this event. NRD's investigation determined that the cause of this event was improper following of procedures by the worker. Corrective actions included retraining of the employee and other staff within smoke (detector) assembly (area). This incident is now closed. NY Incident Number: 1484 |