Semantic search
| Entered date | Event description | |
|---|---|---|
| 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 56299 | 5 January 2023 16:01:00 | The following report was received from the Nebraska Department of Health and Human Services via email: The Nebraska Radioactive Materials Program was notified on January 4, 2023, about 1700 (CST) by a representative of Olsson of a damaged InstroTek, Model 3500, portable moisture density gauge. An Authorized User (AU) from Olsson transported the nuclear density gauge to a job site near Plattsmouth, NE for compaction testing on backfill for a new grain bin. Upon arrival at the site, he assessed the work area for hazards and began gauge standardization away from the active work area. During the standard count, the AU returned to his work truck to grab testing equipment which was approximately 100 feet east of where the gauge was sitting. During that time, the AU witnessed a contractor on site that was driving a tele-handler run over the gauge and standard block, causing damage to the gauge. Emergency procedures from Olsson's Radiation Safety Program were immediately reviewed and put into action by the AU. The local and Corporate RSOs (Radiation Safety Officers) were contacted to help with the situation. All personnel were removed from the area and the area was blocked out with emergency tape. The local RSO arrived with survey equipment, took readings around the area, made phone calls with the corporate RSO and manufacturer, and determined it was safe to transport the gauge back to Olsson's permanent storage location at the field office. The AU was wearing his dosimetry badge and he does not believe that any other individual on site would have received any exposure. Nebraska Event Number: NE-23-0001 |
| ENS 55965 | 27 June 2022 16:25:00 | The following is a synopsis of information received from the state of Nebraska via phone: This report is being made in accordance with the corresponding 10 CFR 36.83(a)(10) requirement if "Pool water conductivity exceeding 100 microsiemens per centimeter" occurs. On 6/22/22, the licensee began having problems with the irradiator pool heat exchanger and condenser. On 6/23/22, the licensee noticed that the pool water was cloudy and conductivity began to increase. Conductivity exceeded 20 microsiemens per centimeter and the licensee began investigating to determine the cause. On 6/26/22, the licensee identified that conductivity had exceeded 100 microsiemens per centimeter and found a pinhole sized leak in the heat exchanger that was leaking Freon and oil into the pool. The highest conductivity noted was 160 microsiemens per centimeter. The licensee is currently filtering the pool water. They are also working to have the heat exchanger replaced. There was no excess external radiation received by any workers. |
| ENS 55270 | 22 May 2021 13:03:00 | The following is a summary of a phone conversation with the State of Nebraska Radioactive Materials Program: On May 21, 2021, at 1600 (CDT), while performing a start up of the irradiator, the licensee noticed a fault on the control panel of the smoke detector. Troubleshooting revealed there was an issue with a circuit board in the fire system which was causing the fault. Replacement of the circuit board is in progress and is expected to be completed on May 25, 2021. The redundant heat and smoke detector in the vault does not provide an automatic shutdown of the irradiator in case of an emergency. Compensatory measures are in place which include stationing a fire watch. |
| ENS 54622 | 27 March 2020 15:20:00 | The following is a synopsis of information provided by the Nebraska, Department of Health & Human Services, via phone notification: Licensee reported to the Nebraska Department of Health and Human Services on March, 24, 2020, that during their 6 month check of the shutter functionality on March 5, 2020, the shutter on a density gauge would not close all the way. The density gauge is an Ohmart/Vega Corporation model SH-F2 density gauge with a Cs-137 500 milliCurie source. The serial number for the gauge is 9103GK. The gauge is installed in a process system and provides no threat to personnel. The licensee has contacted the gauge manufacturer for repair. Nebraska report number NE20004 |
| ENS 54434 | 10 December 2019 13:25:00 | This is a summary of information received from the state of Nebraska via a phone call: On November 12, 2019, the licensee packaged low level waste into 55-gallon barrels to be shipped to a disposal facility. On December 3, 2019, the disposal facility arrived to pick up the waste and discovered that one of the barrels was missing. The missing barrel contained 11 mCi of C-14. It is believed that the waste was improperly disposed of in another waste stream. The investigation is ongoing at this time and the event is open with the state of Nebraska. Nebraska incident number: NE190004 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 53667 | 15 October 2018 13:45:00 | The following was received from the State of Nebraska via email: This morning at approximately 1030 (CDT), the State of Nebraska was contacted by the RSO of Becton, Dickinson and Company located in Holdrege, NE (NE license # 37-03-01) concerning a 24 hour reportable event. I believe the reporting requirement could be 10 CFR 36.83(a)(1), source stuck in the unshielded position or 10 CFR 36.83(a)(4), failure of the cable or drive mechanism used to move the source rack. Event: Approximately 1930 (CDT) on the night of October 14, 2018, there was an alarm of the source positioning indicators alerting the operators of a moving source. When the source rack failed to reach the rack down position in the allotted time period, a fault was recorded at the control panel. It appeared that the rack was stuck in the up position. The RSO called in at approximately 1940 (CDT) to help investigate the situation. Soon after arriving at the facility, (the RSO) placed a call into MDS Nordion for help with the situation. During the 2 hour time period for MDS Nordion to call back, (the RSO) successfully returned source rack #2 to the shielded position and tried to lower the source rack #1 to its shielded position but was unable to lower source rack #1. They also did some preliminary investigations and assumed that one of the guide cables for source rack #1 had busted. Once MDS Nordion returned their call, it was verified that the guide cable for source rack #1 had busted. MDS Nordion had the operators raise source rack #2 and with source rack #2 in its up position, lower source rack #1. After a couple attempts, they were successful in lowering the source rack #1 to its shielded position. Once source rack #1 was in its shielded position, the operators lowered the source rack #2 to its shielded position. Both were verified by the source down positioning switch. Note: After about 3.5 hours of the sources being stuck in the up position, the rack deluge system (rack sprinkler system) was deployed as a precautionary step to cool the sources and the product close to the sources. The overall time the sources were in the up position was approximately 5 hours. This was Nordion Model JS-8900 commercial irradiator. It was reported that nobody entered the vault while the sources were in the up position and that there is no reason to believe that any addition exposure to the workers was involved in this incident. |
| ENS 52737 | 8 May 2017 10:48:00 | According to 180 NAC 3-026.02 (NRC 10 CFR 30.50) this is the twenty four hour report to the HOO (NRC Headquarters Operations Officer) due to an event in which equipment is disabled or fails to function as designed and is required to regulation or license condition and no redundant equipment was available and operable to perform the required safety function. The RSO (Radiation Safety Officer), called to report that on May 6th, (2017) at approximately 0645 (CDT) in the morning, Becton Dickinson had a source rack time-out alarm. The Source Rack down switched failed to indicate the rack reached the down position. Upon initial investigations they determined the source was in the down and shielded position. With the help of their service company, Nordion, they bypassed the door interlock and with survey instruments, they ensured the sources were down in the shielded position. No exposure to personnel occurred. Upon initial visual inspection, it appears there may have been a broken (electrical) cable that caused the alarm. Nordion is expected to be on-site today, Monday, May 8, to fix the problem. Will update when we receive the written report. |
| ENS 52311 | 20 October 2016 15:16:00 | On the morning of 10/13/16, a patient received a diagnostic 0.297 mCi I-125 seed implant to characterize a breast lesion. That afternoon, the tissue and implanted seed were removed and sent to pathology for assessment. The bio-waste was received in pathology as a non-radioactive sample contrary to hospital procedures. A subsequent search of the pathology lab could not locate the missing source. The State of Nebraska was notified of the incident on 10/19/16.
The following was received from the State of Nebraska via email: A Radioactive Seed Localization (RSL) procedure was performed on Thursday October 13, 2016, and contrary to procedures, the seed was sent to Pathology without an escort from the radiation safety office. Since there was no presence from radiation safety, pathology treated the excised sample as non-radioactive. It was not until the next day on Friday, the Thursday's RSL procedure was made known to the Radiation Safety Office. During Friday's procedure, the CNMT inquired why the paperwork from the Thursday's procedures was not picked up. This alerted Radiation Safety that a seed was sent to pathology without their presence to retrieve the seed and that there may be a misplaced seed. With the help from a radiologist, Radiation Safety reviewed the x-ray from the excised tissue to ensure the seed was removed from the patient. The x-ray did in fact indicate the seed was removed from the patient. Since the tissue is sent to the pathology lab, Radiation Safety surveyed the pathology lab and it's personnel intensively. They source could not be found. Radiation Safety has two theories where the source may have ended up. Down the sink or in a 20 gallon biological waste container. The Licensee is changing the name of the lumpectomy procedure to make a clear distinction between a non-radioactive lumpectomy and a lumpectomy that includes a radioactive material source. This will alert the staff that the radioactive seed needs to have Radiation Safety escort the seed to pathology. It will also alert the pathology staff of the radioactive seed and to ensure to locate and separate the seed from the sample prior to dissecting the tissue. Another precaution is that the mammography tech is going to label the sample container/slide with a 'Caution, Radioactive Materials' label to confirm the seed has been found and to also alert the pathology staff of the presence of the radioactive seed. Training of these changes has been performed and Radiation Safety will keep a close watch on the next procedures to ensure the new procedure has been implemented. Item Number: NE160001 Notified R4DO (Kellar) and NMSS Events Notification via email. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 50780 | 30 January 2015 16:31:00 | While attempting to close the shutter on a Kay-Ray fixed gauge at a coal fired power plant located at 24th and Craig Street in Omaha, NE, the cable operating the shutter mechanism broke. The gauge contained 50 mCi of Cs-137. Plant operators manually closed the gauge shutter. There were no exposures to workers in the area. The state will provide additional information when it is available.
The following event update was received from the State of Nebraska via email: The Nebraska Department of Health and Human Services, Radioactive Materials Program, was notified at 1455 hours (CST) on 01/30/2015 by the Tech. Supervisor, at Omaha Public Power District that a Kay Ray fixed gauge Model Number 7080, housing serial number 16784Y, source shutter failed to close. The device originally installed in 1984 with approximately 50 millicuries Cesium 137 now contains approximately 25 millicuries. The gauge which is part of a hopper level sensor is mounted between two fly ash hoppers approximately 20 feet off of the floor. The source closure mechanism on the gauge is connected to a handle located at floor level by a flexible cable. The closure cable are secured so that when the floor handle is operated, the control cable slides inside of the sheath thus opening/closing the shutter. One of the station's chemists was restoring the source to service following a maintenance outage. The 'external' source closure mechanism for Unit 4 precipitator was being placed in the open position when a metallic snap was heard when opening the source shutter. The source handle was half way to the open position when this noise was heard. The operator then proceeded to check the cables function by trying to move the shutter to the closed position . The source shutter did not move. Scaffolding was erected and an inspection of the device showed the source shutter was in the open position and that the cable was not connected to the gauge operating mechanism. The source shutter mechanism was moved manually to the closed position and the cable reattached and tested several times using the remote actuator. All functions were noted to be in working condition. No personnel were unintentionally exposed to radiation during this event. Cause: Defective or Failed Part. Corrective Action Information: Equipment maintenance and repairs made without engineering change to the system. Device/Associated Equipment: Kay-Ray/Sensall/Fixed Gauge, Model Number 7080, Serial Number 16784Y. Source of Radiation: Amersham, Sealed Source Gauge, Model CDC 800, Serial Number 15112-V, with a CS-137 .025 Ci source Nebraska Item Number: NE150001 Notified the R4DO (Miller) and NMSS Events Notification via email. |
| ENS 48697 | 24 January 2013 16:07:00 | On January 21, 2013, a patient was undergoing a radioactive procedure using a 275 microCurie I-125 seed as well as a resection procedure for a breast tumor. The seed was implanted on the surface of the skin and taped into place. During post-surgical clean-up after the resection procedure was performed, the iodine seed was lost. It is believed it was removed with the tape and thrown away as medical waste. After discovery of the loss, the patient, her car, her home and her clothing were surveyed with negative results. The surgical suite and all bedding and gowns used were surveyed with negative results. The surgical waste had already been removed by the time the suite was surveyed. The licensee believes the seed is in the local landfill and has considered it to be lost. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 45752 | 8 March 2010 20:03:00 | At 1705 hours on 03/08/2010, the USEC-GS Plant Shift Superintendents' (PSS) Office at Portsmouth was notified of an inadvertent release of radioactively contaminated materials to an off-site location in Pike County, OH. The contamination was the result of a contractor neutralizing a fluorine service pipe connecting the X-326 building with the X-760 building. The X-760 building has been "de-leased" by USEC back to the Department of Energy (DOE) and is being prepared for decommission and demolition. The contaminated items consisted of five (5) 5-gallon buckets containing some rusty solution. The highest contamination levels were on one (1) bucket with 14K Beta removable and 50K Beta fixed. All other tools and personal protective equipment were monitored and found to be uncontaminated. There is a filtering unit located in Atlanta, GA that remains to be surveyed. A team of USEC health physics personnel is preparing to travel to the contractor's facility in Atlanta to complete the surveys. This event has been classified as reportable in accordance with procedure UE2-RA-RE1030, Portsmouth GDP SAR 6.9, and 10CFR76. No 10CFR20 exposure limits were reached or exceeded. The licensee notified the NRC Resident Inspector. |
| ENS 45519 | 24 November 2009 15:14:00 | The following report was received via E-mail: At or around 6:45 PM on November 23, 2009 the irradiator at Becton Dickinson in Broken Bow, NE experienced a box jam. The master timer timed out and sent the source into the pool as normal. The source movement bell continued to ring beyond the normal time. The operator on duty entered the control room and noted that the fault indicator lights for source switch, source pass time out were activated. Both source up and source down indicator lights were on. The operator went to the source cylinder room on the roof and verified that physically the cylinder had traveled to the full down position. The source cable was determined to be tight as normal. The area was also surveyed for any radiation above background. None was noted. The operator then called the RSO and informed him of the situation. The RSO came to the plant. Since the source up indicator was activated, the area monitor was disabled. The cell door was manually opened and the air to the source cylinder disabled. Two operators along with the RSO slowly entered the cell with two survey meters. No radiation above background was detected. It was determined that the source up switch plunger had become stuck in the closed position. This plunger was removed, cleaned and lubricated. No other machine issues were noted and normal operation ensued. Reporting Requirement: 30.509(b)(2) - events involving failure or disability to function when equipment is required to be available and operable and no redundant equipment is available and operable, includes source disconnection and failure to retract source. Nebraska Item Number: NE090017 |
| ENS 44510 | 22 September 2008 14:41:00 | Licensee was testing the smoke detector outside the vault that houses the irradiator. The detector failed to operate. The irradiator (1645 kCi of Co-60) was not in operation at the time of the test. This is being reported under 10 CFR 30.50 (b)(2). NE Report # NE080009 |