Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56906 | 22 December 2023 10:56:00 | The following information was provided by the Louisiana Department of Environmental Quality (DEQ) via email: On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved. No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024. A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific. Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration. LA Event Report ID No.: LA20230013 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 56643 | 28 July 2023 15:21:00 | The following information was provided by the licensee via email: This notification is being made per the requirements of technical specification 6.7.2 During the facility's routine 2023 fuel inspection on July 27th, 2023, it was discovered that a stainless steel clad standard TRIGA 20/20 element did not pass its visual inspection. The visual inspection of the element, made via an underwater camera with approximately 2 times optical magnification, showed inward pitting and unusual discoloration in the cladding of the fueled section of the element. The elongation and transverse bend of the element were measured and were within tolerance per the facility's technical specifications. The cause of this pitting is unknown at this time. The element has been permanently retired from service and placed in an in-tank fuel storage rack. No unusual radiation readings were observed leading up to the inspection or during the inspection. Therefore, it is very likely that the integrity of the cladding has not been compromised and no fission products have escaped as a result of the pitting. Though not required by the facility's technical specifications, (McClellan Nuclear Research Center) (MNRC) staff is proceeding with the inspection of all adjacent fuel elements and all other standard elements that have not been inspected within the last year. This inspection corresponds to approximately 85% of all in-core elements. The expected completion date of this inspection is August 2nd. Detailed results of this inspection will be provided in an incident report to the NRC no later than August 10, 2023. |
| ENS 53456 | 12 June 2018 22:11:00 | On June 12, 2018, at 1500 CDT, a Reactor Coolant System (RCS) Pressure Boundary leak was identified during a Mode 3, hot shutdown walkdown on a High Pressure Injection Line (HPI) to Reactor Coolant Pump (P32C) drain line weld near MU-1066A HPI Line Drain Valve and MU-1066B HPI Line Drain Valve. The 3/4 inch drain line containing drain valves MU-1066A and MU-1066B on the 'C' HPI header (CCA-5 pipe class) has a through-wall defect on the pipe stub or welds between the sockolet and valve MU-1066A. The leak location is in the ASME Class I RCS Pressure Boundary. The hot shutdown walkdown was being performed as part of a planned outage to investigate excessive Reactor Building Sump inleakage. Total unidentified RCS leakage prior to the investigation was determined to be at 0.165 gpm. After the initial investigation of the leakage, the following Tech Specs (TS) were determined be applicable: TS 3.4.5 - RCS Loops Mode 3, TS 3.4.13 - RCS Leakage, TS 3.5.2 - ECCS. Unit 1 is currently in Mode 3 and in progress of an RCS cooldown to comply with Tech Spec requirements. The licensee notified the NRC Resident Inspector. |
| ENS 56096 | 8 September 2022 14:07:00 | The following information was received by email from the state of Louisiana Department of Environmental Quality (the Department/LDEQ): On September 7, 2022, at approximately 1456 CDT, (the) Site Environmental Coordinator and Radiation Safety Officer (RSO) for ExxonMobil Baton Rouge Plastics Plant, notified LDEQ of equipment malfunctions. The licensee reported that two level/density gauges located at the ExxonMobil Baton Rouge Plastics Plant have shutters that cannot be closed. The two gauges are Ronan Model SA1-F37, device serial numbers, BDL012X and BDL011BX, respectively, installed on the reactor vessel on May 12, 2008. The gauges are installed in a vertical configuration on low pressure separator vessel, V201B within the B-Line unit. The gauges each contain one sealed source with 500 mCi of Cs-137, source serial numbers, 2577CN and 2555CN, respectively. The gauges were undergoing routine annual shutter tests when the malfunctions were observed. (The) Lead Instrumentation and Electronics Technician and Assistant RSO for the licensee, notified (the RSO) concerning the stuck gauge shutters at approximately 1000 CDT on September 7, 2022. The gauge shutters remain open, as the gauges are needed to operate process control equipment. The gauges cannot be locked out in their current state. As a result, no vessel entries will be conducted. The licensee will continue to monitor the gauges' status of repair and will keep the Department updated on the progress of the repairs. No exposures to radiation workers or members of the public above regulatory limits occurred. The licensee plans to meet with the vendor representative to discuss recommendations and a path forward. After repairs are completed, shutter tests and radiation surveys will be conducted according to regulatory requirements to ensure that the gauges operate according to design. The licensee shall notify the Department when corrective actions are completed. LA incident no.: LA20220007 |
| ENS 56097 | 8 September 2022 16:42:00 | The following was submitted by the MA Department of Public Health (Agency) by email: On 9/8/2022, 0930 EDT, (the) licensee reported potential medical event under license 60-0432 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 18 to 22.8 percent or more. A portion of the Y-90 0.5 GBq microsphere therapy treatment delivered to patient liver on 9/6/22 remained in the delivery system causing delivery of 0.386 GBq to 0.41 GBq Y-90 of the prescribed 0.5 GBq. The error was reported to the RSO the next morning. The licensee stated the cause, including possible clogged catheter, has not yet been determined. The prescribing physician has been notified. Notification of the referring physician and patient is pending. The licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment is expected due to this situation. Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation. The investigation is ongoing. The Agency considers this event docket to still be open. 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 56076 | 28 August 2022 15:41:00 | The following information was provided by the licensee via fax or email: On August 28, 2022 at 1348 EDT, DC Cook Unit 1 reactor automatically tripped due to a trip of the #13 Reactor Coolant Pump. This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. The DC Cook Resident NRC Inspector has been notified. Unit 1 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event. Unit 2 remains stable at 100% power / Mode 1. |
| ENS 56074 | 27 August 2022 21:51:00 | The following information was provided by the state of Florida via email: (The licensee's Radiation Safety Officer) (RSO) called at 1946 EDT to report a stolen Troxler Soil Moisture Density Gauge. The Pacifica technician found the chain and padlock were cut. The initial discovery was at approximately 0830 EDT, but was not reported to the RSO until later in the day. When asked why the incident was reported nearly 12 hours later, (the RSO) stated that the technician had a morning exam, and that he was afraid of losing his job. Additionally, since (the RSO) had not notified Law Enforcement at the time of his report, he was instructed to do so. Finally, (the RSO) was instructed to email this (Florida Bureau of Radiation Control) Duty Officer with the report number, along with his description of the event. Incident number: FL22-099 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 56071 | 26 August 2022 16:13:00 | The following information was provided by the Alabama Dept. of Public Health Office of Radiation Control via email: (The licensee's) Representative stated that a patient was prescribed 20 milliCuries of sodium pertechnetate (did not state for which type of scan); the patient received 30 milliCuries of sestamibi (intended for a cardiac stress dose). The representative stated that the nuclear medicine tech that administered the wrong dose is new and has been counseled. This nuclear medicine tech will also be subject to increased oversight into the near future. Representative did not state that the patient will experience any side effects, nor if the patient has been counseled. The misadministration appears to result in an EDE of 876.9 mrem; the highest organ/tissue dose appears to be to the gall bladder wall with a dose of estimated 3663 mrem. Alabama Incident 22-14
Cause and Corrective Actions (State's and licensees' actions): The tech that administered the wrong dose was still in her orientation/training period. The licensee stated that the tech was counseled and will be under increased monitoring during her orientation period. Close-out report Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification 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 56072 | 26 August 2022 17:52:00 | The following information was provided by the Maryland Department of Environment via email: On August 24, 2022, at about 1840 EDT the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone from the Emergency Response Department (ERD) staff that the ECS Mid-Atlantic, LLC, Troxler nuclear moisture/density gauge was run over and damaged by an excavator in the project jobsite at the Grosvenor-Strathmore Metro Station project. MDE/RHP inspector immediately called and contacted the RSO of the licensee and preliminary information about the accident and measures taken. The MDE/RHP inspection team responded on August 25, 2022 and August 26, 2022 went to the licensee office and conducted investigations. On the day of the accident, at about 1503 EDT the Technician moved the gauge to the side, on the curb beside the trench, and the excavator operator that moved the arm (bucket) down the trench hit the gauge. The source rod of the gauge was in its safe (parking) position and the top of the gauge was damaged. The Troxler gauge is Model 3440, with device serial number 31969 which contain Cesium - 137 sealed source with estimated nominal activities of 8 milliCuries, and Am-241:Be with estimated nominal activities of 44 milliCuries. The gauge was later locked and put into the transportation case and the technician took it to the ECS Mid-Atlantic. Surveys conducted at the surfaces of the gauge are normal; and leak test results are expected. The case has been reported to the Nuclear Material Events Database (NMED) on 8/26/2022. |
| ENS 56059 | 20 August 2022 02:11:00 | The following information was provided by the licensee via fax or email: At 2342 CDT on August 19, 2022, with Grand Gulf Nuclear Station in Mode 1 and at 40 percent power, the station initiated a normal shutdown to comply with its Technical Specifications (TS). The station entered Mode 3 at 0000 CDT August 20, 2022 to comply with (LCO) 3.5.1 Condition G Action G.1 due to the condition reported to NRC previously (EN 56058). This event is being reported under 10 CFR 50.72(b)(2)(i) as a shutdown required by the plant's technical specifications. The NRC Senior Resident Inspector was notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The plant is now in a 36-hour LCO to be in Mode 4 due to Low Low Set Valves inoperability per TS 3.6.1.6.
Grand Gulf Nuclear Station (GGNS) is performing this notification to retract event EN 56059 that was reported on August 20, 2022. Previously, GGNS notified the NRC that it had initiated a shutdown required by Technical Specifications to comply with Limiting Condition of Operation (LCO) 3.5.1 Condition G.1 due to the inoperability of four Automatic Depressurization System (ADS) valves. Following the shutdown, GGNS completed walkdowns and determined that the condition affected only one ADS valve. As a result, the shutdown to satisfy the required actions of TS LCO 3.5.1 Condition G.1 was not required. The NRC Resident Inspector has been notified of the retraction. R4DO (Kellar) was notified. |
| ENS 56056 | 19 August 2022 09:36:00 | The following information was provided by the State of South Carolina, Department of Health & Environmental Control (DHEC) via email: On August 18, 2022, at 0948 EDT, DHEC inspector Leland Cave received a call from Mitsubishi Polyester Films, LLC (S.C. Lic. No. 036) to report an incident that had occurred at the plant. The licensee stated that earlier that morning the thin window film was torn on one of their Thermo EGS Gauging, LLC beta gauges (1.25 Ci of Kr-85). The result of the tear was that the production line was stopped until the film could be replaced. The representative from Thermo was already onsite and needed verbal permission to begin the repair on the unit. The permission was given, and the reciprocity notification was sent in. The DHEC inspector called in the incident (to the NRC) at 0936 EDT on August 19, 2022, and is preparing to go to the licensee to review the cause of the incident.
The following information was submitted by the State of South Carolina, Department of Health & Environmental Control (DHEC) via email: The inspector called in the incident at 0936 EDT on August 19, 2022 and left to go to the licensee to review the cause of the incident. Upon the inspector's arrival, the Radiation Safety Officer (RSO), the representative from ThermoFisher, and other members of management sat down with him in a conference room to discuss the events that led to the call. The representative discussed with everyone about the gauging device and how it has a source side and a detector side. He stated that the detector side foil is an approximately six-inch circular piece of aluminum foil. He brought a piece that had torn before as well as the one that had been damaged the day before. He also brought an example of what the source side foil looks like and what it would look like when it would be damaged. The representative stated that the foil on the detector side ripped, and it shut down the machine as designed. The source was safe with no damage to any part. It was determined that this was not a reportable incident. They reviewed the specific unit and the RSO and representative best assessed that when the product is cut, it can leave a sharp edge on it that can lead to a tear. It is also possible for the product to bunch after it has been cut. The licensee and representative will continue to observe if this happens and potentially how often. Notified R1DO (Arner) and NMSS via email. |
| ENS 56023 | 30 July 2022 04:00:00 | The following information was provided by the licensee via email: At 2217 CDT on 7/29/22, cribhouse suction bay levels were reported less than 501.5 feet due to buildup of grass on bar racks. Ultimate Heat Sink (UHS) is INOPERABLE due to Surveillance Requirement 3.7.3.1 not met. ENTER Technical Specification (TS) 3.7.3 condition A (Required Action (RA) A.1 mode 3 in 12 hours, RA A.2 mode 4 in 36 hours). Dresden Lockmaster reports river level normal at 504.89 feet. Commenced trash rake operations to clear grass debris off of intake bar racks. At 0135 CDT on 7/30/22, cribhouse suction bay levels were reported at greater than 501.5 feet. Exit TS 3.7.3 condition A. Due to this INOPERABILITY, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(B). There was no impact on the health and safety of the public or plant personnel. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee notified the NRC Resident Inspector.
At 1116 CDT on 7/30/22, a repeat condition occurred where cribhouse suction bay levels were reported < 501.5 feet due to buildup of grass on bar racks. Entered TS 3.7.3 condition A (RA A.1 mode 3 in 12 hours, RA A.2 mode 4 in 36 hours). Actions are in-progress to clear grass debris off the intake bar racks. Due to this INOPERABILITY, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(B). At 1745 CDT on 7/30/22, cribhouse suction bay levels were reported at >501.5 feet. Exit TS 3.7.3 condition A. The station continues to monitor for intake grass buildup and taking appropriate actions to maintain UHS operability. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee notified the NRC Resident Inspector. Notified R3DO (Peterson). |
| ENS 56018 | 22 July 2022 16:27:00 | The following information is a synopsis provided by the licensee via email: An incident involving a Nuclear Gauge #26 (CPN MC1 DR serial# MD60503240) on a job site (#37: 1564-C) at about 1315 EDT on 07/22/22 in SE Washington, DC 20032. The gauge contained the following sealed sources: 370 MBq (10 mCi) Cs-137 01/17/96 and 1.85 GBq (50 mCi) Am-241/Be 03/27/96. The gauge was damaged by an excavator while it was under the control of an authorized user (AU). The AU went to their car about 50 feet away to grab some paperwork. The operator of the excavator did not see the gauge, and hit it hard enough to crack its plastic shell. The source rod and electronics were not damaged. The AU informed an ECS field supervisor about the incident immediately and cordoned off the 15 foot radius of an area around the damaged gauge. The back-up radiation safety officer (RSO), was contacted and came to the site to evaluate the damage. The gauge's plastic case was broken due to the impact, but the sources were in the shielded position. Several surveys were made using a survey meter (RADIATION Alert M4, calibrated on 12/22/21) at one meter distance, and the readings were found to be less than 0.4 mR/hr range. In addition to contacting the NRC Operations Center on 7/22/22, the Virginia Department of Health was informed at 1755 EDT the same day. All the pieces of the gauge were placed in a box and it was hauled back to the designated storage area in the Chantilly, VA office around 1700 EDT. After performing a leak test and once an all-clear report is received, the damaged gauge will be returned to the authorized distributor in the area, for them to repair it properly. All authorized users will be informed about the incident immediately, and this will be discussed in detail at our safety meetings to reiterate and stress the importance of maintaining physical control of gauges when the gauge is not otherwise secured using two independent physical locking systems to prevent unauthorized access or removal. |
| ENS 55964 | 25 June 2022 01:00:00 | The following information was provided by the licensee via email: At 2338 EDT, on June 24, 2022, with the unit in Mode 1 at 100 percent power, the reactor automatically scrammed due to an RPS actuation following a Main Turbine Trip. The cause of the turbine trip is not known at this time. The scram was not complex, with systems responding normally post-scram. Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at the normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred with no surveillances or activities in progress. Investigation into the cause of the Turbine Trip is in progress. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The low reactor water level caused an isolation of Primary Containment (Groups 4/13/15) as expected. The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified. |
| ENS 55868 | 29 April 2022 07:49:00 | The following information was provided by the licensee via email: At 0405 Eastern Daylight Time (EDT), with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to degrading condenser vacuum. The trip was not complex, with all systems responding normally post-trip. The Auxiliary Feedwater System started automatically as expected. Operations responded and stabilized the plant. Decay heat is being removed by the Main Steam System to the main condenser using the turbine bypass valves. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Auxiliary Feedwater System. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No Tech Spec limits were exceeded. Offsite power is available. The suspected cause for the loss of condenser vacuum is when performing the scheduled monthly swap of condenser vacuum pumps, a suction valve failed to shut. |
| ENS 55867 | 29 April 2022 07:04:00 | The following information was provided by the licensee via fax: On 4/28/2022, at 2338 EDT, Sequoyah received an unexpected alarm for seismological recording initiated. At 2341 EDT, unexpected alarm 1/2 Safe Shutdown Earthquake response spectra exceeded was received. The National Earthquake Information Center was contacted to confirm there was no seismic activity, and this was also confirmed on the U.S. Geological Survey website. The alarms were determined to be invalid, and they occurred due to a failure in the seismic monitoring system. This failure results in loss of ability to assess the Emergency Action Level for Initiating Condition HU2 `Seismic event greater than Operating Basis Earthquake (OBE) levels' per procedure EPIP-1, `Emergency Plan Classification Matrix.' If an actual seismic event had occurred, HU2 could not be assessed. However, compensatory measures have been implemented and include assessing OBE criteria based on alternative criteria contained in procedure AOP-N.05, `Earthquake,' which provides conservative guidance when seismic instruments are unavailable. This is an eight-hour, non-emergency notification for an event resulting in a major loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii). There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified." The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The faulty detector was removed from service, so the remaining detector provides conservative detection as the only source to make-up the logic for a seismological alarm. |
| ENS 55835 | 11 April 2022 17:20:00 | The following information was provided by the state of Colorado via email: Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed (the CO Department of Health) when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found. Isotope: Po-210 Manufacturer: NRD, LLC. Model: P-2021 Device: Static Eliminator Serial number: A2LT196 Activity: .01 Ci" CO Event Report ID No.: CO220009 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 55934 | 9 June 2022 16:18:00 | The following information was provided by the South Carolina Department of Health and Environmental Control via email: On June 8, 2022 inspectors (names redacted) went to Domtar Paper Company, LLC (SCRAM License Number 438) to perform a periodic re-inspection. During their inspection, they were presented with a copy of the inventory and their shutter check information. While reviewing the information, the inspectors saw that there were items on the checklist dated March 23, 2022, and March 30, 2022 that denoted the failed functionality of some of their gauge shutters. After discussion with radiation safety officer (RSO), it was determined that the shutters did, in fact, fail to operate as designed. There were other instances that were similar that the licensee stated that they will pull together and evaluate. At this time, the only information given by the licensee is the information below. The inspectors went to each of the source housings during the inspection and all shutters were all operational. The sources and housings are the following: Kay Ray source housing model 7064P Source model: 7700-5000 Serial number: 27007C Activity: 5 Curies Kay Ray source housing model 7064P Source model: 7700-5000 Serial number: 27007F Activity: 5 Curies
The following information was provided by the licensee via email: The licensee submitted a report on June 24, 2022. The Radiation Safety Officer, submitted an update to the report that was submitted on July 9, 2022. Upon further review, it was found that the gauges were stuck or inoperable on several other occasions. Gauge 27007C was listed as stuck on April 8, 2021, September 2, 2020, October 31, 2019, and April 16, 2019. Since the completion of the inspection, the licensee stated that they now understand the reporting requirements. Additionally, the licensee has a better understanding of what needs to be done in the event that the gauge is first reported as stuck. |
| ENS 55761 | 1 March 2022 18:45:00 | The following information was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the "Division") by email: The Division was notified at about 1515 MST, March 1, 2022, that a Bracco Rb-82 generator was not functioning as designed. The (Radiation Safety Officer (RSO)) was notified at 1353 MST by nuclear medicine personnel that a new Rb-82 Generator was received on Sunday, February 27, 2022. When the licensee pulled the first eluate and did the required QA (quality assurance review), the generator failed the tests. The nuclear medicine personnel tried to perform the QA again and the generator failed a second attempt. The manufacturer was contacted and the licensee's personnel worked all day on Monday, February 28, 2022 to try and determine what the issue was. No patients were treated using the generator. It was finally determined that the undercarriage of the generator was leaking, although all of the leakage was contained within the generator case. Utah Event Report ID No.: UT220001 |
| ENS 55743 | 16 February 2022 20:26:00 | The following information was provided by the Texas Department of State Health Services (the Agency) by email: On February 16, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews (at a temporary job site in Baytown, TX) were unable to retract an 89 Curie iridium - 192 source back into a QSA 880D exposure device. The radiographers were performing radiography when a pipe fell on the guide tube crimping it to the point that the source assemble could not pass through it. The radiographers isolated the area and contacted the company's RSO. A retrieval team went to the location and was able to recover the source within the hour of the start of the event. No member of the public received an exposure from the event. The radiographers did not exceed any exposure limits. The radiographer's dosimetry will be sent for processing. Texas Incident #: 9914 |
| ENS 55739 | 15 February 2022 15:22:00 | The following information was provided by the licensee via fax or email: While performing the pre-start checkout on 2022-02-15 (at approximately 0800 EST), the SRO (Senior Reactor Operator) performing the checkout discovered that the building exhaust fan was not operating. This fan is required to be operating during reactor operations, and it is typically left running all the time. Troubleshooting determined that the cause of the fan loss was power loss from a conduit being cut the previous day when a small area of the cement floor in the janitor closet was being removed for replacement of the janitor closet sink. The concrete work was performed between 1200 and 1453 EST, which was when the contractor signed in and out. The reactor was shut down at 1551 EST, so the reactor was operated for at least an hour without the fan operating. There were no safety implications for the reactor, the staff, or the public. |
| ENS 55760 | 1 March 2022 15:09:00 | The following information is a summary of information provided by the licensee ("the Company") via email: An x-ray fluorescence instrument (XRF) went missing while in the possession of a licensed Atlas ATC employee. The employee used the XRF in the course and scope of their duties on January 31, 2022. Following completion of their last assignment of the day, which was a lead inspection in New Haven, CT, the employee left the jobsite and went home where they kept the XRF overnight, secured in its case inside of their residence. The following morning on February 1, 2022, the employee packed the secured XRF with other equipment and materials they used for work into the trunk of their car. While traveling to the East Hartford, CT office, the employee had a flat tire. The employee's direct supervisor came to provide assistance and gave him shelter alongside the highway for approximately 60 minutes until a tow truck arrived. The employee accompanied the tow truck for tire repair. The XRF remained in the trunk of the vehicle. After arriving at the service station, the employee took the XRF out of the trunk and secured it in the back seat of the vehicle, where it remained the entire time that the vehicle was being serviced. The employee left the service center at approximately 1100 EST and drove to the East Hartford, CT office where the vehicle was parked for approximately 45 to 50 minutes. At approximately 1200 EST, the employee left the office to complete a job in Springfield, MA. That job did not require the use of the XRF. The employee arrived at the Springfield, MA project site around 1255 EST and parked approximately 1,000 feet from the actual work site address, which was in a residential neighborhood. The employee completed that job at approximately 1500 EST. After leaving the project site, the employee stopped at a gas station before arriving at the Company's West Springfield, MA office at 1400 EST. After leaving the office, the employee stopped at two restaurants (one in Springfield, MA and then one in East Windsor, CT). The employee then traveled back to the East Hartford, CT office. When they went to unload their equipment, they then noticed that the XRF was not in the back seat of the vehicle. The employee checked the entire vehicle for the XRF, but it could not be located. The Company's internal investigation has determined that the XRF was stolen out of the vehicle. There is video surveillance that confirms that the secured XRF was in the back seat of the vehicle when the employee left the service station, and the employee did not remove the XRF from the vehicle thereafter. There is no evidence that the employee willfully failed to maintain control of licensed material that was not in storage, either. Based on the investigation, the XRF was stolen somewhere between the employee's stop at the East Hartford, CT office and the time they left the restaurant in East Windsor, CT, which was around 1945 EST. The employee notified the East Hartford, CT office's Radiation Safety Officer (RSO), Branch Manager and Building Sciences Supervisor via text around 2120 EST. Extensive efforts on the part of the employee and licensee to locate the instrument were futile. The East Hartford, CT and Springfield, MA Police Departments were notified of the lost/stolen XRF. In furtherance of recovery efforts, the Company quickly put the appropriate regulatory authorities on notice that the XRF was missing. Immediately after the loss became known the next morning (February 2nd), the RSO contacted the CT Department of Energy and Environmental Protection Radiation Group to report that the licensed device was lost or stolen; they subsequently called the Massachusetts Department of Public Health Radiation Group as the XRF may have traveled to, but was not used in, Massachusetts. The RSO also called Protec (the company from where the XRF was originally purchased) as Protec's phone number is printed inside of the XRF case in the case of an emergency. The RSO felt that this notification was a necessary step to take, and in the event that the XRF is found and Protec is called, the Company will be notified immediately. After investigative efforts were unsuccessful in recovering the XRF, formal police reports were filed on February 4, 2022 with the Police Departments in East Hartford, CT (Case #2200003902) and Springfield, MA (Incident #22-1419-OF) regarding the theft. These cases are still open and the investigations are ongoing. The instrument is a Protec LPA-1 x-ray fluorescence instrument, serial number: 1331, 12 mCi Co-57 source s/n NA515. This event was also reported by the Commonwealth of Massachusetts as EN 55724. 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 55720 | 1 February 2022 11:42:00 | The following information was provided by the licensee via fax or email: At 1350 PST on 01/31/2022, Pacific Gas and Electric determined that a non-licensed employee supervisor violated Diablo Canyon FFD policy and had a confirmed positive on a direct observed test. The employee's access to the plant has been terminated and permanent denial has been entered into PADS. The NRC Senior Resident Inspector has been notified. |
| ENS 55703 | 13 January 2022 12:03:00 | The following information was provided by the licensee via fax: On 1/13/2022 at 0806 CST, Nebraska Public Power District was notified by Atchison County Missouri of a spurious actuation of (Cooper Nuclear Station) (CNS) Emergency Siren 2113 near Rockport, Missouri from approximately 0800 to 0805 CST. Nebraska Public Power District will issue a press release for this event. The CNS Emergency Alert System (EAS) was not activated. This condition is reportable under 10 CFR 50.72(b)(2)(xi) for any event or situation for which a news release is planned or notification to other government agencies has been or will be made which is related to heightened public or government concern. The NRC Senior Resident Inspector has been informed. |
| ENS 55686 | 4 January 2022 10:42:00 | The following information was provided by the licensee email: RCW 49.17.062 (1)(a) requires an employer report 'within 24 hours. that 10 or more of their employees at the workplace or worksite in this State have tested positive for the infectious or contagious disease that is the subject of the public health emergency, must report the positive tests to the department in a form prescribed by the department.' On 1/03/2022, at 1615 PST, the Framatome Horn Rapids Road human resources manager notified Washington State Division of Occupational Safety and Health that the Richland Fuel Fabrication site hit that threshold of 10 COVID-19 positive cases. These cases do not appear to be worker-to-worker transmissions of the virus. This notification is being made under the concurrent reporting requirement of 10CFR70 Appendix A concurrent reporting. |
| ENS 55634 | 9 December 2021 10:00:00 | On December 8, 2021 at approximately 0745 PST, an instrument technician was contaminated with uranyl nitrate solution while working on process instrumentation (calibrating a pressure transmitter in the Scrap Uranium Recovery Facility). The individual followed safety protocol by utilizing the emergency wash station and as a precaution was sent for medical evaluation (at Kadlec Regional Medical Center) due to skin exposure to nitric acid. Prior to leaving the site, Framatome Health and Safety Technicians decontaminated the individual to below release limits with the exception of their hands. The individual's hands were placed inside gloves which were secured to their wrists prior to being transported. The worker was transported to an offsite medical facility accompanied by plant health physics personnel. After being evaluated, the individual returned to Framatome where their hands were decontaminated to below release limits and returned to work. The process area where this work was being performed was cleaned and the equipment was secured. The event has been entered into the facility's corrective action system. Framatome is reporting this event consistent with the requirements of 10 CFR 70.50(b)(3). The licensee notified the Washington Department of Health and the NRC R2 Project Manager (Vukovinsky). |
| ENS 55630 | 8 December 2021 09:01:00 | The following was received from the Commonwealth of Pennsylvania by email: On December 6, 2021, a patient underwent a Y-90 TheraSphere treatment. There were no apparent issues during the treatment, but the four-sided equipment readings before and after treatment indicated that only 63% of the prescribed dosage got into the patient. The prescribed dose was 4.08 GBq and the calculated received dose was 2.57 GBq. Preliminarily the licensee believes there was a flow issue and the micro catheter caused some of the material to precipitate out. The licensee is currently investigating to determine if that is the cause. The patient and physician have been informed. No adverse effects to the patient are anticipated. PA Event Report ID No: PA210019 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 55639 | 9 December 2021 15:21:00 | A Medical Oncology employee discovered a radioactive source package when exiting the Medical Oncology suite around 1420 EST on Wednesday, 12/1/2021. She noticed the label 'Radiation' and proceeded to pick it up and bring it into the Radiation Oncology suite down the hallway on the same floor (2nd floor) of the building. Radiation Oncology Staff notified Chief Therapist and Physicist who promptly brought the source into the designated area, performed a survey and inspection to ensure no break in seals or radiation leakage and to document the receipt of the package. (The source was a 10 Ci Ir-192 source. On contact readings with the package were 4.2 mR/hr and one meter survey reading was 0.6 mR/hr.) Later that evening, the regional Smilow radiation oncology physicist notified the hospital radiation safety officer who started an investigation on Thursday, 12/2/2021, morning. (The common carrier's) tracking indicated that the package was delivered at 1404 EST on 12/1/2021, i.e., a few minutes prior to its discovery outside the Medical Oncology suite. The Medical Oncology secretary indicated that she had noticed a (common carrier) person in the hallway a few minutes prior to her finding the package outside the suite. The package was not delivered to the radiation therapy department at Greenwich Hospital as indicated by the shipper's declaration for dangerous goods and no signature/confirmation was obtained from the radiation therapy department for the delivery. Radiation exposure and potential risk to staff from this well shielded source over the incident encounter time would be negligible. The carrier has been notified of the incident, the fact that proper protocol was not followed in delivering the package and the fact that this is unacceptable. There was no measurable exposure to staff or patients. The incident is categorized as deviation from an already established and practiced radioactive material delivery procedure by (common carrier) staff. Radiation Oncology team had an in-service (training) to all concerned explaining this incident and as a reminder of procedures on delivery of radioactive material packages. We escalated this matter to the system (Yale New Haven Health System) (YNHHS) strategic resources who contacted the regional (common carrier) to obtain an explanation and corrective action from them. |
| ENS 55629 | 30 November 2021 10:24:00 | The following was received from the state of Florida by email: Received a call from Atlantic Drilling Supply Co. about a missing Troxler gauge (#21834) which has sent to his company for service. The gauge was shipped to the old address of the customer, NOVA Engineering in Tallahassee, FL vice the new address. The shipper cannot locate the gauge. Gauge was shipped 11/18/21 and scheduled for delivery 11/19/21. Gauge was reported missing to Atlantic drilling 11/29/21. As of 11/30/21, at 1035 EST, the shipper has found the Troxler gauge on their loading dock and will deliver it to the correct address. FL Incident number FL21-139 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 55671 | 23 December 2021 08:48:00 | The following was received from the state of Ohio by email: On December 16, 2021, the Ohio Department of Health was notified by Cardinal Health 414 LLC PET Manufacturing Services that one of their employees exceeded their extremity dose limits. On November 26, 2021 at 0440 EST, an employee of Cardinal Health was synthesizing Fluorine-18 FDG in a mini-cell. The employee heard a sound indicating the conical reservoir cap blew-off during synthesis and opened the door to the mini-cell. He contaminated his gloves, lab coat and pants, which he removed and replaced. He did not contaminate his skin, and the licensee stated surveys were conducted showing the floor was not contaminated as a result of this event. The Columbus PET Manufacturing RSO (MRSO) sent the employee's finger rings and TLD to Landauer for processing. The dosimetry is sent in biweekly. For the period of November 15 to November 28, the employee received 208 mRem total DDE to the chest, 58,330 mRem to the left hand, and 6,442 mRem to the right hand. On December 9, 2021 the MRSO notified the Corporate RSO of the event and removed the employee from radiation related work. Ohio Item Number: OH210011 |
| ENS 55596 | 20 November 2021 21:36:00 | The following was received by email from the Kansas Department of Health & Environment: At approximately 1300 CST on 19 November 2021, Kansas Radioactive Material Program received a call from a corporate safety officer for a local business, Advantage Metal Recycling. Advantage Metal Recycling is located in Kansas City, Kansas. The recycling yard, not a licensee, notified the department that they had a radiation detector alarm on their metal shredder. The corporate representative was calling from out of state and did not have all the information on the handheld survey meters but they had a 'Ludlum meter with a pancake probe that was off scale at 1000 microR/hr and a model 19 that was reading approximately 2000 microR/hr.' The surveys were estimated at 2-4 feet. At 1415 CST on 19 November, two members of the Kansas Radiation Control Program left Topeka, Kansas to respond to the site. They arrived at approximately 1509 CST. Surveys taken by 2401-P and 451P indicated the highest exposure rate reading of a large pile of shredded metal was 26.2 mR/hr. The Kansas staff also performed surveys of the machinery which shreds the metal and did not identify any elevated exposure rate readings. Because of this it is suspected the source was not punctured and there is not residual contamination of the yard or the machinery. Given the high exposure rate and identity of the source being unconfirmed at this time (Identifinder indicated Ra-226) it was determined to report this incident to the HOO. The scrap yard had an appropriately licensed contractor onsite remove the material on the evening of 19 November. The contractor entered Kansas via reciprocity and confirmed they removed the material and placed it in their secured facility. More information will follow as it becomes available. |
| ENS 55600 | 22 November 2021 15:14:00 | The following was received from the California Department of Public Health (CDPH) by email: On Saturday, November 20, 2021, at 0928 (PST), a CDPH-Radiologic Health Branch inspector was notified by e-mail that a medical event had occurred on Friday, November 19, 2021, at UCLA during a Y-90 liver cancer treatment. There were four liver segments being treated with four vials of Y-90 TheraSpheres. The prescribed dose for 'Segment 2' was 120 Gy, but the dose delivered was 74.9 Gy (or 62.42 percent of the prescribed dose). Segments 3, 6 and 8 were prescribed 120 Gy each and the doses delivered were 108.0 Gy, 110.9 Gy and 107.0 Gy (90 percent, 92.42 percent and 89.17 percent of the prescribed doses, respectively). Using the post treatment radiation surveys of the Nalgene waste container, a UCLA medical physicist determined that a medical event had occurred. The delivered dose to the organ differed by more than 20 percent from the prescribed dose. The authorized physician tried unsuccessfully to use a 2.0 Fr Truselect microcatheter for an hour to access the artery to segment 2, but it was extraordinarily small in caliber. He eventually chose to use a 1.7 Fr Echelon microcatheter for the treatment. Other treatment options were considered, but this particular tumor was in a location that was not amenable to ablation or chemoembolization. The patient will have a follow-up MRI scan in 3 months. A 15-day written report will be generated by the UCLA." CA 5010 Number: 112021 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 55594 | 19 November 2021 13:56:00 | The following was received by fax from the New York State Department of Health (NYSDOH): NYSDOH received a written report by mail of a leaking source. Suffolk Co. Public and Environmental Health Laboratory, (redacted), 725 Veterans Memorial Highway, Hauppauge, NY (NYSDOH Radioactive Materials License No. 1801) conducted routine leak testing on their two Agilent Technologies 8890 (03540A) GC (Gas Chromatograph) System (S/N US2106A027) ECO containing a 15 mCi (approx.) (Ni-63 source) G2397A (S/N U34601). Leak test samples were taken by the RSO on November 5th and sent to Agilent Technologies for analysis. The sample was processed on November 9th and preliminarily reported by Agilent to the Licensee on November 10th indicating that one of the ECO sources was leaking above the 0.005 uCi threshold. The Licensee RSO immediately obtained information from Agilent on the leaking source and copies of the preliminary reports. The Licensee provided NYSDOH with a written notification and report on November 10th by mail (received November 15th). The leaking quantity assessed at 45660 +/- 214 pCi. The GC unit was shut down and isolated. Agilent was notified (Radiation Safety Officer - RSO) to follow up on the leaking source and determine next steps. The system is less than one year old and still under service contract with Agilent. NYSDOH spoke with RSO upon receipt of this letter and GC/ECD was new as of March 2021. The defective detector (entire unit) has been isolated from service and Agilent is scheduled to arrive on 11/23/2021 to package and prepare unit for shipment. A radiological survey (contamination survey) was completed upon the isolation of the device showing radiation levels were consistent with background levels, indicating no fixed or removable contamination present. No further information on device or incident is available. NY State Event Report ID No. NY-21-04 |
| ENS 55527 | 16 October 2021 07:22:00 | (An) Unusual Event (was declared) due to a fire in the protected area not extinguished in less than 60 minutes. Main power transformer 3 faulted, the unit auto scrammed, all rods are in. The fire went out at 0622 CDT. (The licensee) is monitoring for re-flash. The unit automatically scrammed and all rods fully inserted. Decay heat removal is through the condenser. Unit 2 is unaffected and remains at 100 percent power. The licensee notified the NRC Resident Inspector and R3 Branch Chief (Riemer). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), and DHS Nuclear SSA (email).
The Unusual Event was terminated at 0709 CDT. Notified R3DO (Pelke), NRR EO (Felts), IR MOC (Kennedy), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), and DHS Nuclear SSA (email). |
| ENS 55528 | 16 October 2021 09:10:00 | On October 16, 2021 at 0428 CDT, an automatic scram was received on Unit 3 following a turbine trip. All Rods inserted to their full in position. All systems actuated and operated as expected. Unit 3 is being maintained in Mode 3, hot standby. This event is being reported pursuant to 10CFR 50.72(b)(2)(iv)(B), any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical. The NRC Resident Inspector has been notified. The event is related to Event Number 55527. |
| ENS 55522 | 14 October 2021 19:27:00 | At 1320 EDT, during a Traversing In-Core Probe (TIP) run for a scheduled Local Power Range Monitors (LPRM) calibration, it was reported to the Main Control Room that TIP A would not fully retract to the In-Shield position. With TIP A unable to fully retract to the In-Shield position the TIP A Ball Valve was declared Inoperable due to not being able to close and meet its safety function in that configuration. Furthermore the TIP A Shear Valve was previously declared Inoperable due to the Firing Fuses being removed. With the two valves Inoperable the penetration could not be isolated and Primary Containment boundary isolation could not be established. TIP A was subsequently manually hand cranked and placed back into its In-Shield position at 1333 EDT restoring TIP A Ball Valve Operable. This report is being made pursuant to 10CFR50.72(b)(3)(v)(C) based on control the release of radioactive material. The Senior NRC Resident Inspector has been notified.
The purpose of this notification is to retract a previous report made on October 14, 2021 (EN 55522). At 1320 EDT on October 14, 2021 while performing Traversing In-Core Probe (TIP) Machine Gain Adjustment in support of Local Power Range Monitor (LPRM) calibration, an unplanned inoperability of the TIP 'A' Primary Containment Isolation Valve (PCIV) was reported pursuant to 10CFR50.72(b)(3)(v)(C) by EN 55522. On October 14, it was reported to the Main Control Room that TIP 'A' would not fully retract to the In-Shield position. With TIP 'A' unable to fully retract to the In-Shield position, the TIP 'A' Ball Valve PCIV was declared Inoperable due to not being able to close and meet its safety function in that configuration. The TIP 'A' Shear Valve PCIV was previously declared inoperable due to firing fuses being removed. Further investigation determined that a "FAULT: MOVEMENT LIMITED" error was received. This TIP error condition did not present a primary containment isolation issue in the event of a primary containment isolation signal. The Automatic TIP Control Unit (ATCU) is designed to command the TIP drive mechanism to continuously retract a TIP probe to the in-shield position in the event of a containment isolation signal with this condition. In the event of a containment isolation signal, the TIP machine would withdraw the TIP detector back to the in-shield position and the TIP A ball valve PCIV would have closed to perform its safety function. Therefore, the inoperability of TIP 'A' ball valve reported under criterion 10CFR50.72(b)(3)(v)(C) was not met, and EN 55522 is hereby retracted. The NRC Resident Inspector has been notified. Notified R3DO (Peterson) |
| ENS 55601 | 22 November 2021 16:56:00 | The following is a synopsis of a telephonic report from the RSO at South Dakota State University: On about October 14, 2021, the University was contacted to collect two orphaned Ra-226 sources from a residence of a former employee. One source was within an Ionization Cell Model A-4149, the other was contained in a lead pig. Swipe surveys did not detect any leakage from the sources. Both sources are identical, 0.056 mCi Ra-226, Dated 09-66, Barber-Colman Company, Rockford, Illinois. There are no serial numbers to determine the original owner. The deceased employee also worked in the chemistry department at Southwest Minnesota State University. The Radiation Safety Officer has properly secured the items and is herby notifying the NRC of the possession of this licensed material, which is allowed by their license. 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 55521 | 14 October 2021 14:30:00 | On October 13, 2021, at 1420 MST, a Non-Licensed Supervisor's test results were confirmed positive for use of a controlled substance following a random Fitness For Duty test which resulted in determination that the individual violated the station's FFD Policy. The Non-Licensed Supervisor's unescorted access has been terminated in accordance with station procedures. The NRC Senior Resident Inspector has been notified. |
| ENS 55520 | 14 October 2021 13:19:00 | The following was received from the Pennsylvania Department of Environmental Protection (DEP/Department) by email: The Department received notification from a licensee on October 13, 2021, that a Troxler 3430 portable gauge (serial number 18794) was lost. The gauge typically contains 9 mCi of Cs-137 and 44 mCi of Am-241:Be. The authorized user completed his work at approximately 1800 EDT and prepared to secure the gauge in a case on the back of his truck by ensuring that the source rod was locked. He departed the site without properly securing the gauge in its storage case. When the authorized user approached the center of Loganton, a person alerted him that the tailgate on the truck was down. The authorized user realized that the gauge was missing and traveled back to the work site. He did not detect the gauge along the return to the work site and inquired if anyone had seen the gauge at the work site. He noted that there was traffic from employees leaving a nearby factory at the end of their shift. The employee contacted the licensee Radiation Safety Officer and informed him of the incident. The State Police Barracks at Lamar were also alerted. The licensee deployed an additional employee to search for the missing gauge. The search was hampered by poor visibility in the darkness. The source has not been recovered at this time. A press release is in the process of being drafted, and the licensee will be offering a monetary reward for the safe return of the gauge. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. PA Event Report ID No: PA210015
The following was received from the Pennsylvania Department of Environmental Protection (DEP) via email: The gauge was recovered on October 15, 2021, at a private residence unrelated to the licensee. An individual found it alongside Interstate 80, (a route not traveled by the employee who lost the gauge) took it home and contacted the Pennsylvania State Police. It is believed that the gauge was picked up from where the employee lost it and then discarded along this highway. The gauge was stored on the front porch of the residence where it was collected by the licensee, accompanied by the Pennsylvania State Police. The electronics were damaged, but leak testing revealed no radiological leakage. The gauge will be sent to a service provider for further evaluation and repair or replacement. Notified R1DO (BICKETT), ILTAB (via email) and NMSS Events Notification group (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 55458 | 13 September 2021 05:53:00 | At 0011 EDT, with Unit 2 in Mode 5 (Cold Shutdown), actuations of the 2B Diesel Generator (DG) and the 2B Motor Driven Auxiliary Feedwater (AFW) Pump occurred during Engineered Safety Features Actuation Periodic Testing while resetting the 2B DG Load Sequencer. The 2B DG was running unloaded following test actuation, and during realignment from the test, a blackout condition was experienced when the breaker opened supplying the 4160 Volt Essential Power System 2ETB from the Standby Auxiliary Power Transformer SATB. Sequencer actuation closed the emergency breaker to 2ETB and loaded the 2B Motor Driven AFW Pump onto the bus. Steam supply valves to the Turbine Driven AFW Pump were open from the previous test configuration. This event is being reported in accordance with 10CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 2B DG and the 2B Motor Driven AFW Pump. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55436 | 30 August 2021 01:50:00 | At 1804 CDT on 8/29/2021, Waterford 3 Steam Electric Station (WF3) experienced a Loss of Off Site Power event due to Hurricane Ida (See EN #55435). This event caused an automatic actuation of Emergency Diesel Generators Trains A and B. Both Emergency Diesel Generators started as designed and both are currently operating normally supplying power to their respective Class 1E Safety Busses. This automatic actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A). Prior to the loss of offsite power, WF3 was in progress of performing a plant cooldown in accordance with procedural guidance. As part of this cooldown and after entering Mode 4, all Safety Injection Tanks were isolated. As a result of losing offsite power, Reactor Coolant System Temperature increased above 350F which is above the temperature requirements for Mode 4. Safety Injection Tanks are required to be unisolated and OPERABLE in Mode 3. Therefore, with no Safety Injection Tanks OPERABLE, this constituted an event or condition that could have prevented the fulfillment of a safety function and the unit entered Technical Specification 3.0.3. The unit was in Technical Specification 3.0.3 for approximately 43 minutes from 1805 CDT until 1848 CDT when Mode 4 conditions were re-established. This event or condition that could have prevented the fulfillment of a Safety Function is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D). While continuing to perform the Reactor Coolant System Cooldown and prior to placing Shutdown Cooling Train in service, it became necessary to start one train of Emergency Feedwater. Emergency Feedwater Train A was manually started at 1847 CDT to feed the Steam Generators and was secured at 1947 CDT. Emergency Feedwater Train A started and operated normally during this period. This manual actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A). The licensee notified the NRC Resident Inspector.
The purpose of this notification is to revise Event Notification Report (EN) 55436 to include a partial retraction. On August 29, 2021, Waterford Steam Electric Station, Unit 3 (WF3) experienced a loss of offsite power (LOOP) event due to Hurricane Ida. Prior to the LOOP, WF3 had shutdown to Mode 3 (Hot Standby) in anticipation of the LOOP and was performing a plant cooldown in accordance with procedural guidance. When Mode 4 (Hot Shutdown) was achieved, all Safety Injection Tanks (SITs) were isolated as part of the plant cooldown. After the LOOP, Reactor Coolant System (RCS) temperature increased and the Core Exit Thermocouples (CETs) indicated that RCS temperature had exceeded 350 degrees F. Based on the CETs, this was above the temperature requirements for Mode 4 and, as such, WF3 declared entry into Mode 3. The SITs are required to be unisolated and Operable in Mode 3. Since no SITs were Operable at that time, it was determined that this constituted an event or condition that could have prevented the fulfillment of a safety function and included this as part of the EN 55436 report in accordance with 10 CFR 50.72(b)(3)(v)(D). An engineering evaluation has subsequently been performed to validate whether the RCS temperature excursion following the LOOP actually reached 350 degrees F. As defined in WF3 Technical Specification (TS) Table 1.2, Operational Mode temperatures are a function of RCS average temperature (Tavg), not just the indicated temperature of the CETs. Based on the calculated Tavg using validated temperatures, it was concluded that 350 degrees F was not reached. Thus, WF3 remained in Mode 4 following the LOOP and there was no event or condition that could have prevented the fulfillment of a safety function that was reportable pursuant to 10 CFR 50.72(b)(3)(v)(D). The remainder of EN 55436 remains correct and unchanged. The licensee notified the NRC Resident Inspector. Notified R4DO (Pick) |
| ENS 55393 | 3 August 2021 09:12:00 | The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email: Loyola University Medical Center (IL-01131-02), contacted the Agency on August 3, 2021, to advise that an administration of Y-90 resulted in an underdose exceeding 20 percent. The incident occurred yesterday, August 2, 2021. No untoward medical impact was expected to the patient. The licensee's Radiation Safety Officer contacted (the Agency) to advise that a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 71 percent of the dose prescribed in the written directive. The licensee's Radiation Safety Officer is reviewing the device today as well as the specifics of the administration to determine root cause. The licensee suspects a problem with a connector but is currently investigating. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. Agency inspectors will perform a reactionary inspection, tentatively within a week, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days. Illinois NMED report number: IL210023 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 55385 | 30 July 2021 00:16:00 | At 0922 PDT, on 07/28/21, the reactor building roof hatch was opened to support maintenance activities on the roof. Secondary containment differential pressure lowered and was recovered by the operating crew. Secondary containment differential pressure was maintained negative during the transient and was verified to have met technical specification requirements the whole time, however it was not identified at the time that the secondary containment was inoperable due to the roof hatch exceeding the allowable containment breech size and as such a TS 3.6.4.1.A entry was warranted. This report is being made pursuant to 10 CFR 50.72(a)(1)(ii) when it was identified that the secondary containment was inoperable while the roof hatch was open and a report should have been made under 10 CFR 50.72(b)(3)(v)(C) and (D) for loss of safety function. There were no radiological releases, system actuations, or isolations associated with this event. The licensee has notified the NRC Resident Inspector. |
| ENS 55364 | 20 July 2021 11:11:00 | At approximately 1310 EDT on July 19, 2021, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. The electric fire pump was without power as the result of a failure of an electrical feed from Duke Energy. The backup diesel fire pump remained fully operational and available to perform its safety function. Power was restored at approximately 1400 EDT on July 19, and the Deputy Fire Marshall was notified of system restoration. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)." The licensee will notify the North Carolina Radiation Protection Branch and NRC Region II. |
| ENS 55340 | 6 July 2021 14:44:00 | The following was received from the California Department of Public Health - Radiologic Health Branch (RHB): On 7/5/21, licensee contacted California Office of Emergency Services (Cal OES) to report a stolen moisture density gauge. The gauge stolen is a CPN Model MC-1, S/N MD 80304167 containing 10 mCi of Cs-137 and 50 mCi of Am-241. Gauge user's vehicle parked in Sacramento, CA, was broken into and the gauge that was stored inside a secured metal box bolted to the bed of the truck was stolen on 7/3/21. Licensee had immediately notified Sacramento County Sheriff's Department of the theft (Report # 21-2016910). RHB will be following up on this investigation. CA 5010 Number: 070521 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 55334 | 1 July 2021 20:17:00 | The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email: On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy. During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event. RHB will be following up on the medical event. CA 5010 Number: 070121 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 55333 | 30 June 2021 17:56:00 | The following report was received from the Texas Department of State Health Services (the Agency) via email: On June 30, 2021, the Agency was notified by one of its General License Acknowledgement holders that it had determined that a Vega model SHLD1 nuclear gauge, containing 50 milliCuries of cesium-137, was missing and suspected stolen. The gauge had been mounted at a facility (in Kosse, TX) that was closed in 2019. The gauge is thought to have been stolen at some point after the facility closed. Texas Incident Number: 9863 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 55631 | 8 December 2021 10:53:00 | The following was sent by the state of Colorado by email: Two Tritium (H-3) exit signs (6.2 Ci each) reported as lost on annual registration 12/07/2021. 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 55305 | 12 June 2021 23:57:00 | At time 2227 CDT on 06/12/21, Main Steam Line 2-01 Radiation Monitor 2-RE-2325 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-01 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-01. Corrective actions are being pursued to restore 2-RE-2325 to functional status. The NRC Resident Inspector has been notified. |
| ENS 55291 | 4 June 2021 16:47:00 | The following report from the state of Wisconsin was received by email: On June 4, 2021 the licensee reported to the Department (of Health Services) that a package containing 25 Curies of Cs-137 had been shipped from Wisconsin on April 16, 2021 and did not arrive at its destination in California. The last known location of the package was in Chicago, Illinois on April 22, 2021. The licensee is following up with the common carrier, but to date the package has not been located. WI Event Report ID No.: WI210004
The following report update from the state of Wisconsin was received by email: The package arrived at its destination on June 7, 2021. The package was completely intact, including seal, with no signs of damage. When the licensee who offered the package for shipment contacted the common carrier, the licensee was not provided with any details of problems during shipment. However, the package was located and promptly delivered. The Department considers this event closed. Notified R3DO (Hills), NMSS Events Notification (email), ILTAB (email) and CNSC Canada (email). 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 |