Semantic search

Jump to navigation Jump to search
 Entered dateEvent description
ENS 560988 September 2022 19:08:00The following was submitted by the TX Department of State Health Services (the Agency): On September 8, 2022, the Agency was notified by the licensee that on this day, the shutter on a Vega SH-F2 gauge containing a 500 milliCuries (original activity) cesium - 137 source failed to close during routine testing. Open is the normal operating position of this gauge. The licensee will contact the manufacture to repair the shutter. No individual received additional exposure due to this event. TX event number I-9954
ENS 5605719 August 2022 11:13:00The following information was received via email from the Arkansas Department of State Health, Radiation Control Program (the Agency): PETNET Solutions, Arkansas, reported to the Agency on August 18, 2022, that there had been a contamination event of materials with long-lived activation products, specifically Co-56, Mn-52, and Mn-54. This contamination event occurred in the cyclotron room where a target window exploded. Contamination spread to the unrestricted areas outside the Little Rock PETNET facility, i.e. in the hallways of the St. Vincent Hospital. A radiation safety team from the corporate office in Tennessee has been onsite since late Wednesday, August 17, 2022, working to decontaminate the St. Vincent areas. They have been successful in that decontamination effort and have alerted the St. Vincent RSO to make them aware of the situation. The Agency will be performing an onsite investigation on Friday morning, August 19, 2022. Arkansas Event Report ID number: AR-2022-04
ENS 5536520 July 2021 13:06:00A non-licensed employee 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 5520522 April 2021 15:41:00At 0925 Mountain Standard Time (MST) on April 22, 2021, Palo Verde Nuclear Generating Station staff received reports that Emergency Notification sirens were activated. Current information indicates that the inadvertent activation of the sirens was caused by an offsite agency during performance of a planned silent test that occurred at approximately 0916 MST. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). All sirens remain functional, and the NRC Resident Inspectors have been notified of the issue. Additional notifications will be made as needed.
ENS 5506112 January 2021 09:44:00The following information was received from New Jersey Department of Environmental Protection (the Agency) via email: On January 11, 2021, the Agency was notified by the licensee that during a vendor source exchange of the center's radiation oncology Iridium-192 remote afterloader source (approximately 5.2 Curies at time of incident), the service engineer, noted the failure of the source to be fully secured in its transport pig bucket. This was discovered because the service technician's personal monitor and the in-room monitor both indicated the presence of radiation. The service technician promptly left the vault, closed the door, notified the physicist on site, and the room was secured from further entry. This engineer, another service engineer, the vendor RSO and source recovery team then worked to fully secure the source as per their source exchange procedure. The estimated doses received during the incident are 52.8 mrem and 39.9 mrem to the service engineers involved in securing the source. Their dosimeter readings will be available in the future. No patients or hospital staff were exposed. The vendor will supply the hospital with a full report on the incident, including possible cause. Equipment/device involved, Isotope and activity, manufacturer, model and serial number, leak test results as applicable: Varian Medical Systems, VariSource ix HDR, serial number VS-321, Ir-192, 5.2 Ci (at time of incident), manufactured by Alpha Omega Services, model VS2000, serial number 02-01-2823-001-101420-11593-17. New jersey Incident No.: N/A Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
ENS 550259 December 2020 09:21:00The following information was received from the Texas Department of State Health Services (the Agency) via email: On December 8, 2020, the Agency received an e-mail from the licensee stating that during routine testing the shutters on two nuclear gauges were found stuck in the open position. The gauges are Vega model SH-F1 both containing 20 milliCuries (original activity) cesium-137 sources. The licensee reported there is no risk of radiation exposure to members of the general public or workers at the facility due to the failures. The licensee stated they were working on a plan to repair the gauges and would provide that information once the plan is completed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No: I-9815
ENS 550224 December 2020 15:44:00The following was received from the state of Louisiana via email: On December 04, 2020, Alpha-Omega Services RSO contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the commercial carrier. The source was being shipped to Stanford University Medical Center, 820 Quarry Road, Palo Alto, CA 94304. The source serial number is 02-01-2922-001-111120-11438-41. The activity of the Ir-192 source was 11.44 Ci (423.22 GBq) on November 13, 2020 when it was shipped. The source was last tracked in the commercial carrier Memphis, TN Hub on November 14, 2020 at 06:07 am CST. Louisiana Incident Number: LA20200011 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
ENS 550234 December 2020 16:21:00The following was received from the state of Arizona Department of Health Services (the Department) via email: The Department received notification from the licensee that seven approximately 0.4 milliCurie Iodine-125 seeds used for breast localization were discovered missing (during inventory on 12/1/2020). The Department has requested additional information and continues to investigate the event. Arizona Incident Number: 20-024. 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 5501230 November 2020 14:16:00A non-licensed employee supervisor had a confirmed positive for a controlled substance. The employee's access to the plant has been terminated. The licensee informed the NRC Resident Inspector.
ENS 550182 December 2020 17:48:00The following was received from the State of Washington via email: On Monday, November 30, 2020, at a construction site at 2800 MLK Jr South, Seattle, WA, a density gauge was run over by a mini dozer. The source was extended and in use at the time. When the device was run over, the handle that is used to extend and retract the source rod broke off from the gauge completely, leading to concern that the source rod had also broken off. Personnel on site were evacuated and the area secured. Because of the concern that the source rod had broken off, it was necessary to wait until a licensed entity that had the ability to handle the unshielded source arrived on site to continue recovery operations. Also, shortly after the incident, Northwest Technical Services (NTS), was hired for remedial action. When NTS personnel arrived, they were able to determine that the source rod had not detached as feared. A leak test to check the integrity of the source revealed no leakage and the source rod was able to be retracted back into the shielded gauge. Radiation readings and additional leak tests in the area were conducted to ensure there were no remaining safety concerns. There were none. The damaged source was taken to Northwest Technical Services in Snohomish, WA and has been secured while awaiting disposal. Washington Incident Number: WA-20-026.
ENS 5500824 November 2020 18:58:00The following information was received from the Texas Department of State Health Services (the Agency) via email: On November 24, 2020, the Agency was contacted by the radiation safety officer (RSO) of a Texas licensee reporting that two self-luminescent tritium exit signs were not able to be located. The signs are Sealed Source Inc. Isolite signs each containing 7.5 curies (original activity) of tritium manufactured in April of 2015. The RSO stated that the area they were in had some work done and that he believes the signs may have been thrown into construction dumpsters after being replaced. The signs were first discovered missing on November 11, 2020. The RSO has been actively searching for the signs but as of today he has determined that they are no longer at the facility. The RSO stated that he will attempt to determine the final disposition of the construction dumpsters believed to have contained the devices. Additional information will be provided as it is received. Texas Incident Number: 9814 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 5500925 November 2020 13:34:00The following information was received from State of New Jersey via email: The licensee reported on 11/24/20 that during a 6-month shutter check, one Cs-137 (50 mCi) fixed gauge shutter was found to be not closing completely. The gauge manufacturer was contacted and came on site to fix the shutter. Leak tests were taken before and after and found to be under 0.005 æCi. More information will be provided by the licensee. 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 5500724 November 2020 14:25:00The following was received from the State of Louisiana via email: Marathon Petroleum Company contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on November 24, 2020, concerning a stuck shutter. The fixed gauge is stuck open and determined on November 23, 2020 to be in this condition. The fixed gauge is an Ohmart/Vega Model Number SHGL-2, s/n for housing and source is 9853 CN. The source is Cs-137 with an activity of 5000 mR (185 GBq). There were no radiation exposures. A technician from BBP will be out at the facility on December 1, 2020 for repair. Louisiana Incident No.: LA20200009
ENS 5500624 November 2020 12:20:00The following information was received from the state of New York via fax: A medical licensee reported on 11/23/2020 that a Y90 microsphere procedure performed on Friday 11/20/2020 was later discovered to have had the catheter connected to the gallbladder instead of the liver as prescribed in the written directive. More information will be forthcoming but preliminary information shows that the microspheres were Sirtex SIR-Spheres. New York Incident Number: NYDOH-20-07. 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 5502610 December 2020 10:58:00This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid actuation of the 'B' train High Head Safety Injection Pump (3SIH*P1B), the 'B' train Low Pressure Safety Injection Pump (3RHS*P1B) and four Steam Generator Blowdown Containment isolation valves at Millstone Nuclear Power Station Unit 3. At 1908 EST on November 6, 2020, with Unit 3 in Mode 3, a partial invalid actuation of 'B' train Emergency Core Cooling System (ECCS) components occurred. The 'B' train SIH pump and the 'B' train RHS pump had started, and ran successfully on recirculation. Four Steam Generator Blowdown Containment isolation valves also closed. Due to this condition the 'B' Emergency Diesel Generator and the 'B' Emergency Generator Load Sequencer (EGLS) were declared inoperable and the required Technical Specification action statements were entered. Troubleshooting determined that this actuation was caused by a failure of one of the circuit boards in the 'B' train EGLS that caused a partial 'B' train 'SIS only' signal. Other 'B' Train components received the 'SIS only' signal but did not start because they were already running or were a backup to an already running component. Troubleshooting discovered a failed NAND gate on the 'B' Train EGLS XA93 circuit card. The card was replaced, retested, and the Technical Specification action statements were exited. The pumps and valves responded in accordance with plant design. No other equipment was affected during this event. There were no safety consequences or impacts on the health and safety of the public. The event was entered into the station's corrective action program. The actuation was not due to actual plant conditions or parameters meeting design criteria for an ECCS actuation. Therefore, this is considered an invalid actuation. The NRC Resident Inspector was notified.
ENS 5498910 November 2020 15:51:00The following information was received from the State of Kansas via email: On November 3, 2020, at 1100 CST, the Kansas Department of Health and Environment (KDHE) was notified that the Desert NDT LLC radiography crew experienced a possible misconnect at 1430 CST on November 2, 2020, at a job site in Liberal, KS. The two crew members performed an exposure using the Delta 880 exposure camera containing an Iridium-192 source with 51.9 curies (1902 GBq). After the exposure the crew noticed that they did not hear the source click back in place in the camera. Through surveys, the crew noted abnormally high readings at the front of the exposure device. The crew ensured 2 mR boundaries were appropriately set and that all personnel was clear of the area. The crew then called their radiation safety officer (RSO) explaining the problem. The site RSO from the Perryton, Texas (location) was notified to assist with the possible misconnect. The RSO arrived onsite at 1545 CST on the same date and was able to assess possible reasons for the disconnect and devised a plan to retrieve the source. After reducing the radiation area to a manageable level, he was able to disconnect the Source Guide Tube from the device to be able to remove it from the radiation area and inspect the device for further inspection and investigation as to why the disconnect had occurred. After disconnecting the controls from the device it was determined that the Assistant Radiographer had not connected the drive cable to the pig-tail of the source assembly creating a 'Misconnect.' Once the reason for the misconnect was discovered, the RSO replaced the controls on the device and moved forward with the retrieval and was able to connect the drive cable to the source and retract it into the shielded position. The RSO stated that he completed the retrieval at 1610 CST on November 2, 2020. There was no exposure to the general public or any other individuals other than the three crew members. The closest area for any member of the public to be exposed was at a roadway approximately 300 feet away. The RSO, who was authorized to perform source retrieval, received an exposure of 45 mR to his hands and 20 mR to his trunk. Surveys were taken using a ND-2000 survey meter, serial number 54261, and calibration date of July 28, 2020. The RSO wore a model 883 pocket dosimeter and alarm rate meter (ARM) model RA-500, serial number 71037, and calibration date of February 11, 2020. Landauer whole body badges were also worn during the retrieval process. KDHE staff will be performing a reactive inspection of this licensee on the next entry into Kansas and will provide additional details after that inspection. Kansas Incident Number: KS00006.
ENS 5501330 November 2020 15:58:00The following information was received from the State of Kansas, Department of Health & Environment via email: On 10/16/2020 Kansas licensee #27-B1008 ELI Wireline Services LLC was logging a gas storage well when the tool became stuck in 2 3/8" tubing at approximately 2100 feet from surface. Attempts to free the tool while still attached to the wireline were unsuccessful and the wireline was pulled resulting in the rope socket leaving the cable head, two weight bars, gamma ray neutron tool, and a 3 Curie AmBe-241 sealed source lodged inside the tubing. The licensee's attempts to retrieve the source have so far been unsuccessful, partly due to windy weather conditions and 1500 pounds of gas pressure on the well. The licensee contacted the state of Kansas on 10/21/2020 to report a stuck radioactive source downhole. The licensee made the decision to wait until spring when the field had less pressure and the weather was better to clean out the tubing to enable the fishing tool to reach the stuck logging tool. Kansas agreed with the delay on source recovery for better weather and required that a sign matching the requirements of K.A.R. 28-35-362 (with the exception of (2)(C) and (2)(H)(i)) be placed at the wellhead no later than December 24, 2020. At this time this incident is not considered an abandoned source, however, The state of Kansas determined that it was appropriate to go ahead and report to the HOO out of an abundance of caution in the event that the source is unable to be retrieved in the spring of 2021.
ENS 549399 October 2020 07:58:00The following event was received from the Florida Bureau of Radiation Control (BRC, ERCM) via email: The incident was reported by (the medical physicist (MP)), who is standing in for local physics administrator who is on vacation. A 50 year old female was being treated with Ir-192 High Dose Rate (HDR). The Authorized Radiation Therapist and Physician were in the room along with (an acting MP with a) temporary license TMP-1. The supervising MP was remote. The supervising MP told the facility that the acting MP was on the license as an AMP ((Authorized MP)), which is why the AMP was in the room. The AMP was actually not on the license. After treatment was complete, the error about the AMP not being on the license was discovered, and the report to the Florida BRC was made. The treatment plan was confirmed before treatment by the AMP. Treatment was delivered as prescribed. Per ERCM: The AMP's license is null and void and TMP-1 is expired. Florida Incident Number: FL20-116. THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL
ENS 549357 October 2020 10:25:00A non-licensed employee 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 licensee informed the NRC Resident Inspector.
ENS 5492430 September 2020 16:54:00

EN Revision Imported Date : 10/2/2020 AGREEMENT STATE REPORT - VEHICLE RAN OVER PORTABLE MOISTURE GAUGE This is a summary of a call from the state of Mississippi Division of Radiological Health via phone: A portable moisture density gauge, containing 9 mCi Cs-137 and 44 mCi Am-241/Be sealed sources, was run over by a vehicle at a construction site in Clinton, MS. No visible damage of the gauge was identified. The licensee's survey results were normal for a retracted source. The gauge was returned to a local office and the state will also perform a survey once they are on site. There was no exposure to personnel.

  • * * UPDATE ON 10/01/2020 AT 1957 EDT FROM ART ROBERT SIMS TO BRIAN P. SMITH * * *

The updated report was sent from the state of Mississippi Division of Radiological Health via email: Off Norrell Road, off MS. 1-20 Clinton Mississippi Continental Tire Construction site off-ramp, the gauge user was on a noisy construction site with heavy equipment and ear protection requirements. The gauge user was taking a measurement and the high elevated Rubber Tire Roller used to pack asphalt did not see the gauge user. The gauge user yelled at him trying to get him to stop, but due to the noise and the driver not seeing him, the rubber tire roller ran over edge of Humboldt Moisture Density Gauge model 5001 Ser. No. 9624, only damaging the outer housing. The RSO was contacted, used a survey meter Troxalert Model 01754 calibrated 01/10/2020, and received readings of 6 mR/hr which are consistent with previous readings that indicate the source was in the shielded position. The gauge is at the RSO's office and is being sent to Humboldt for electronics and housing repair and a wipe test. The incident was an accident. No violations could be issued to the licensee due to gauge user being present taking moisture readings and the driver of the rubber tire packer just did not see him. Mississippi Event Number MS-200003

Notified R4DO (Silva), NMSS Events Notification (e-mail)  

ENS 5499010 November 2020 16:27:00The following was received from the Nebraska Department of Health and Human Services (the Department) via email: On November 2, 2020, the Department received a call from a licensee about disposal of a sealed source device. The licensee was getting ready to dispose of their device and was informed by their surplus department that it had been accidentally sold at a surplus auction on September 17, 2020. Sale information was retrieved from auction records on November 3, 2020, and the purchaser was located and contacted. The device had been delivered to the purchaser in Columbus, Ohio and the purchaser is working with the licensee to properly dispose of the device. The device is to be retrieved from Columbus, Ohio by the disposal company, but a date has not yet been set. The licensee will notify the Department when disposal arrangements have been finalized. Nebraska Incident Number: NE200009. 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 5477510 July 2020 20:18:00The following report was received from the State of California via email: On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health California 5010 report no: 071020 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.
Retrieved from "https://kanterella.com/Special:Ask/-5B-5BNRC-20officer::Solomon-20Sahle-5D-5D-20-5B-5BCategory:ENS-20Notification-5D-5D/-3FEntered-20date/-3FEvent-20description/mainlabel%3D/order%3Ddescending/sort%3Dstart-20date/offset%3D0/format%3Dtable/searchlabel%3DNRC-20Officer:/default%3DNRC-20Officer*:"