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| Discovered date | Reporting criterion | Title | Description | LER | |
|---|---|---|---|---|---|
| ENS 56466 | 4 April 2023 18:00:00 | Agreement State | Leaking Source | The following information was provided by the Utah Division of Waste Management and Radiation Control (DWMRC) via email: The University of Utah contacted the DWMRC to report that they had found that an Isotope Products Laboratories, Cs-137 Resin Vial Source, Source Number 988-97-3 with an assayed activity of 208.9 microcuries (assay date May 1, 2004), was leaking. A routine quarterly leak test was taken of the sealed source. When counted with a PerkinElmer 2480 Wizard2 radiation detector, the wipe showed an elevated reading. The wipe results showed 4531 cpm (background 32 cpm). The technologist who performed the wipe contacted the licensee's Radiological Health Department. The technologist was told to count the wipe in the well counter (Biodex AtomLab 500). The well counter on the Cs-137 channel showed there was 0.6 microcuries with a 0.3 microcuries background on the sample for a leak test result of 0.3 microcuries. Since there was no obvious leak in the resin vial, the licensee suspected it had been contaminated with short lived radioisotopes. The source was doubly bagged and isolated in storage until the next day when it was again verified to be above background. On April 11, 2023, it was retested. The leak test was performed with both an alcohol pad and a gauze pad. The results of these samples were counted with the PerkinElmer instrument, but not the well counter. The result of the wipes was 4248 cpm and 7303 cpm respectively (PerkinElmer 2480 Wizard2 radiation detector for both tests was 32 cpm). This showed it was not a short-lived isotope and the source was leaking. The individual stated that when he performed the wipe test on April 11, 2023, he heard the plastic vial crack and the crack opened while the wipe was being taken but returned to a 'closed position' when the wipe was completed. He immediately returned the wipe to the baggies and put it in storage. Since the wipes taken verified the original assessment was correct, the licensee stated that the source would be placed with their waste and disposed in their normal waste shipments to a licensed radioactive waste disposal site. After the initial finding on April 4, 2023, radiation surveys of the area and equipment were conducted to verify that no contamination was present. No contamination was found, and the area and equipment were released for use. The licensee stated that the vial appeared to be slightly yellowed around the crack and believes the plastic may have cracked due to radiation fatigue. The licensee had ordered two of these sources in 2004. The other source was in use at one of the licensee's other medical facilities but was removed from service and will be disposed of with the leaking source as a precaution. Utah Event Report ID Number: UT 23-0004 | |
| ENS 56267 | 6 December 2022 17:30:00 | Non | Technical Specification Violation | The following information was provided by the licensee via email: On December 6th, 2022, University of Utah Training Reactor (UUTR) was in the process of performing a research sample irradiation. The sample was known to have a negative reactivity worth and was therefore placed in the reactor prior to reactor startup. Upon commencing reactor startup procedures, the reactor operator subsequently terminated the startup attempt after noting that the sample appeared to demonstrate a larger negative reactivity worth than what was initially anticipated. After investigating, we identified that there was an inconsistency/miscommunication regarding the sample materials specifications, and the actual negative sample reactivity worth was a larger negative value than that of the original estimate. Immediately afterwards, we performed an updated materials assessment of the sample, which, following reactor calculations, revealed that the sample indeed demonstrated a larger negativity reactivity worth than was originally predicted. As a result, this report is being submitted in accordance with UUTR Technical Specification (TS) 6.7.2 due to 'observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy could have caused the existence or development of an unsafe condition with regard to reactor operation.' In accordance with UUTR TS, the reactor was secured, and Utah Nuclear Engineering Program Director notified, and operations shall not resume unless authorized by the Director. The NRC Project manager was notified. | |
| ENS 55914 | 24 May 2022 17:15:00 | Non | Degradation to a Fuel Element Cladding | The following information was provided by the University Of Utah Training Reactor (UUTR) via email: This is a written report to NRC regarding minor damage to a fuel element identified during routine fuel inspection operations, filed per UUTR Technical Specification para 6.7.2, 'Special Reports' noting degradation in a reactor fuel element cladding. On Tuesday, May 24 2022, at 1115 (MDT), during a routine UUTR bi-annual fuel inspection, one stainless steel U-235 TRIGA fuel element removed from core position D-14, element number 4138E, was noted to have low-level surface pitting and severe discoloration at several locations along the element length. When this fuel element was moved toward the inspection apparatus, at one of the pitted locations on the surface of the fuel element, a small stream of clear bubbles began to evolve. This was captured on high resolution video; the bubbles were presumed to be fission gas. Reinspection of this same fuel element one hour later with high resolution video showed no evolution of gas bubbles, and the element remained intact. Radiation levels throughout the facility remained constant and consistent with background levels. Response to this Event: After initial observation of the pitting and bubble evolution, the fuel element number 4138E was placed in a fuel element storage rack; local radiation levels remained at measured background levels at all times from multiple instruments. On the facility continuous air monitor, no noted deviations from background levels were observed over the entire period of concern. Radiation readings throughout the duration of this observation remained at background levels, and no significant issues or safety concerns were noted; the reactor and facility remain secure, and fuel inspection operations will continue over the next week. Follow-up Actions: UUTR reactor personnel will permanently remove fuel element number 4138E from service, and continue to monitor for any instance of elevated radiation levels from the reactor pool. All levels remain stable at background levels. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The Non-Power Reactor Project Manager will be notified and the Utah State Radiation Safety Officer was notified. The estimated time for restart is one week. | |
| ENS 55482 | 9 September 2021 18:00:00 | Agreement State | Loss of Control of Radioactive Material | The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email: On August 27, 2021, local heavy rain infiltrated the Merrill Engineering Building, causing flooding on the first and third floors. The first floor also included some radioactive materials labs. While stripping the labs on September 9, 2021, in preparation for repair, the contractor violated policy and failed to notify the lab owners before moving material from the lab. Included in the material removed from the lab was a safe containing 13 exempt calibration sources and one 0.006 milliCurie U-235 ceramic source. The safe was moved to an onsite trailer that was under control of the contractor and not the University. When the lab owner returned to the lab later in the day they immediately reported the sources missing. Investigation by licensee personnel lead them to where the sources were being stored. The sources were out of the licensee's exclusive control for 1 to 3 hours. The sources were re-secured and placed under the licensee's exclusive control closing the incident. The report was not determined to be reportable until the Division was able to conduct its on site investigation on September 20, 2021. Utah Event Report ID Number: UT 210005 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 52673 | 10 April 2017 06:00:00 | Agreement State | Agreement State Report - Leaking Tritium Exit Sign | The following information was received from the State of Utah via email: (University) Radiological Health personnel responded to an incident involving a damaged tritium exit sign at the University Guest House. It was determined the damaged exit sign was leaking tritium and the licensee notified the (Utah) Division of Waste Management and Radiation Control. This incident report is the initial notification of the NRC Operations Center. Utah Event Report: UT170003 | |
| ENS 51714 | 2 February 2016 07:00:00 | Agreement State | Lost Tritium Exit Sign | The following was received from Utah via email: On February 2, 2016, the licensee (University of Utah) was performing a 6-month inventory of the H-3 exit signs, when the individual performing the inventory noticed that one of the licensee's signs was missing. The licensee left a message with the University's facilities management office to see if the sign was removed by them. On February 5, 2016, the licensee was informed by the management group that they had not removed the sign. The licensee then determined that the sign was missing and presumed stolen. The licensee then notified the DWMRC (Utah Department of Environmental Quality, Division of Waste Management and Radiation Control) of the missing sign. The licensee will continue to investigate the incident, and will submit a written report to the DWMRC. The DWMRC will possibly perform an investigation on February 8, 2016. Manufacturer: unknown (possibly Safety Lite Corporation) Model: unknown Serial #: T3478 Possibly acquired by the licensee in 2003. Activity: unknown (presumed >20 Ci of H-3) Utah Event # UT160001 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 42121 | 5 November 2005 19:50:00 | Agreement State | Agreement State - Missing Am-241 Source | The University of Utah moved its Radiation Health Department between buildings. An Am-241 source on a disk in a glass vial was last inventoried and leak checked on May 12, 2005 i.e. prior to the move. The inventory on November 3, 2005 (Thursday) found one source missing. The sources are kept in a locked room and stored in a locked pig. The university is performing an inventory on November 5, 2005 (Saturday) and may perform additional inventories. This information will be placed in NMED on Monday, November 7, 2005. Source: Am-241, 477 milliCuries
The Source is model # SWA-259, purchased January 1977 and is the size of a nickel.
Received notification from the licensee that a Radiation Safety Analyst found the missing Am-241 source at 11:07 MST on 11/07/05. An updated description was given as 1.5 inches long and wrapped in a sheet of lead. The RSO was present when the source was found. Notified R4DO (Shaffer), NMSS (Morell), and TAS email (Perez).
The State of Utah has determined that the update on 11/7/05 reporting that the missing source had been located was incorrect. Further investigation by the University of Utah authorities has determined that the original source description was correct. The source is a nickel-sized slug in a glass vial and not the 1.5 inch source discussed in the 11/7/05 update. Recollection by individuals that had used the source confirmed the source appearance and the discolored "darkened" vial that held the source. The source number was also corrected to SNA-259 The licensee has informed both campus police and the FBI of the missing material. Notified R4DO (Whitten), NMSS (Collins), and TAS (Perez) via email.
The State provided the following information via email: The State of Utah reports that the source has been found. This time verified and sure. It was found in a secure facility. It had rolled under a pallet in the secured waste facility. The investigation as to how it got there is continuing. Notified R4DO (Shaffer), NMSS (Collins), and TAS (Whitney) via email. 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. | |
| ENS 41925 | 4 August 2005 18:30:00 | Agreement State | Agreement State Report - Medical Event | The State provided the following information via facsimile: This event involved an HDR brachytherapy unit (Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277). The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event. Event Report ID Number: UT-05-0006 |