Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56895 | 17 December 2023 21:31:00 | The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email: The IEMA-OHS Operations Center was contacted at 1712 CDT on December 17, 2023, by the radiation safety officer for Sterigenics to report a stuck source rack. The rack reportedly became stuck around 2300 on December 16, 2023, with approximately 10 percent of the sources above the pool level. The area was isolated with an additional restricted area established to maintain occupational exposures within limits. At this time, no public or occupational exposures above regulatory limits have been reported. This matter has a 24-hour reporting requirement under 32 Ill. Adm. Code 346.830 which was met by the licensee. IEMA-OHS inspectors will arrive at the facility on 12/18 to evaluate timelines for corrective action and the efficacy of safety systems. Staff will also evaluate the site and review staff dosimetry, potential impacts to source capsule integrity, any anticipated heat impacts, and plans for quality assurance of the impacted system(s). Source type: sealed source irradiator Radionuclide: Co-60 Activity: 24 MCi (888 PBq) Model no.: C-188 Illinois report no.: IL230036
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email: Agency staff arrived at the site on 12/18/23 and surveys indicate no public or occupational exposure levels above normal operation. The source rack is still stuck in the unshielded position. The Agency continues to monitor the situation and will update when additional information is available. Notified R3DO (Edwards), NMSS (via email).
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email: The Licensee reports 18 modules (3 rows), constituting 626,000 curies of Co-60, in the B/C cell remain stuck in the unshielded position due to product carts impeding travel of the rack. The sources are below the point of product cart impact. A second IEMA-OHS inspection was conducted to increase coordination on response activities and obtain additional data on the following: security requirements (all operational), radiation levels (700 microR/hour maximum reading), dosimetry procedures (transitioned to digital dosimetry which is read daily and employed at a 40 mrem/day investigational level), total occupational doses to date (20 mrem), exposure rate maps including access points used for radiation hardened cameras, personnel access, pool conductivity (within specifications), updated operations and emergency procedures (confirmed), on site staff and safety culture (satisfactory, additional manufacturer health physics staff brought in to assist), fire hazards (none at this time), status of deionizer (satisfactory), and mitigation planning. The Licensee is awaiting cameras and remote vehicles capable of withstanding radiation levels and manipulating product totes. The facility was confirmed to be in a safe and stable condition and ongoing response operations will be coordinated with IEMA-OHS. IEMA-OHS has now transitioned to weekly inspections until the incident is remedied. Updates will be provided as they become available. Notified R3DO (Stoedter), NMSS (via email).
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email: The source rack was successfully returned to the shielded position. Sterigenics staff employed engineered tooling to access the stuck rack through roof projections on the evening of 1/25/24. IEMA-OHS staff were on site to observe setup and operations throughout the week. A review of digital dosimetry in use for all phases of the operations indicates there were no occupational exposures in excess of regulatory limits. Full report and root cause analysis pending. This report will be updated. Notified R3DO (Orlikowski), NMSS (via email). |
| ENS 56614 | 9 July 2023 16:57:00 | The following information was provided by the licensee via email: At 1328 EDT on 07/09/2023, with Unit 3 in Mode 1 at 45 percent power, the reactor automatically tripped during power ascension testing due to low reactor coolant flow from decaying voltage to the reactor coolant pumps. The trip was not complex, with all safety-related systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam via steam generator power operated relief valves to the atmosphere, and startup feedwater is supplying the steam generators. Units 1, 2, and 4 are not affected. 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). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56569 | 11 June 2023 09:02:00 | The following information was provided by the licensee via email: At 0130 EDT on June 11, 2023, it was discovered that the Beaver Valley Power Station, Unit No. 2 auxiliary building door A-35-5A, credited for tornado missile protection of the primary component cooling water system, was open and unlatched. Upon discovery, the door was shut and latched. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(B). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56553 | 2 June 2023 13:17:00 | The following information was provided by the licensee via fax or email: An unscheduled shutdown of the reactor occurred on 6/2/23 at 0818 EDT due to an abnormal response of the Safety Power Level channel during the approach to power of 1 MW at 150 kW. The Reactor Operator observed a discrepancy in power indications by the Linear Power Level and Safety Power Level channels and took immediate actions required by procedure NRP-OP-105, Response to SCRAMS, Alarms, and Abnormal Conditions. The reactor was shut down and secured immediately. The Designated Senior Reactor Operator was immediately notified. The Safety Power Level channel is required to be operable per Technical Specification 3.3.b Table 3.3-1 while the reactor is being operated. During the startup checklist, the channel performed satisfactorily. The Safety Power Level channel is part of the reactor safety system and has two automatic shutdowns (SCRAMs) associated with it. Reactor power was correctly monitored by all other operable power monitoring channels which have redundant SCRAM capabilities. No SCRAM occurred or was needed due to the power level of the reactor. Following the reactor shutdown, the reactor staff investigated and determined that the high voltage power supply in the Safety Power channel was faulty. The power supply was replaced and a channel calibration of the Safety Power channel will be performed using procedure PS 1-05-03A:S1 to verify the channel is operable. Maintenance Log #0888 has been opened. There was no safety issue with this event. Procedures were followed during reactor operation, shutdown, and the investigation. This unscheduled shutdown is a reportable event per TS 6.7.1 based on the circumstances and as defined in the facility Technical Specification (TS 1.2.24.d) for reportable events from operation in violation of Limiting Conditions for Operation (LCO) established in TS. TS 1.2.24.d, does not allow for an exception for taking prompt remedial action. A report to the NRC is required within one working day and will be made by 1700 EDT by phone on 6/2/23, as required by TS 6.7.1. Also as required by TS 6.7.1, a written report to the NRC is due in 14 days (6/16/23). |
| ENS 56504 | 5 May 2023 15:39:00 | The following information was received from the New York State Department of Health (NYSDOH) via email: The New York State Department of Health conducted a routine inspection of lnficon, Inc. on May 5, 2023, and were made aware of Ni-63 (2.4 mCi) source that exceeded the 0.005 microcurie leak testing threshold and is considered leaking. Information on the source is below: Make: NRD, LLC Model: N1001 (SSDR: NY-0502-S-103-U) Serial Number: INF739 Date of Sample Collection: 4/27/2023 Leak Test Result: 1.82E-2 microcuries Analysis Report Date: 5/2/2023 In accordance with lnficon's license, this source was obtained for secondary manufacturing and assembly into Micro Argon Ionization Detector (MAID) cells. lnficon detected this leaking source immediately following assembly prior to distribution in accordance with all regulatory requirements and the conditions of their license. Once it was determined that this source was leaking, personnel were notified, and the device was immediately quarantined. lnficon conducted removable contamination surveys around the device in question, however, they do not believe that any personnel or equipment may have been contaminated from this leaking source. Wipe test results are pending to date. As this is the second leaking source reported by lnficon (See NY-23-01 notification for the first leaking source notification), lnficon has hired an external consultant to review and audit their assembly process. This audit has been scheduled and lnficon has agreed to submit the findings of this audit to New York State Department of Health. Following the results of these wipe tests, the facility plans to dispose of this source and equipment. New York State Department of Health is in continued discussion with lnficon regarding next steps for this event. No further information on the device, source or incident is available at this time. Any updates to this event will be provided as soon as feasible. This incident is tracked under Incident No. 1436 by NYSDOH. New York State report no.: NY-23-03 |
| ENS 56281 | 19 December 2022 13:12:00 | The following information was provided by the licensee via email: At 0735 EST on December 19, 2022, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness-for-Duty (FFD) testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56266 | 9 December 2022 00:19:00 | The following information was provided by the licensee via email: On 12/8/2022, Prairie Island Nuclear Generating Plant initiated a notification to the State of Minnesota due to a HVAC coolant leak reaching waters of the state. The estimated quantity is 5 gallons of NALCO LCS-60. The leak was due to a failed heat exchanger coil and has been isolated. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
The following information was provided by the licensee via email: At 0019 EST on 12/9/2022, the Prairie Island Nuclear Generating Plant (PINGP) made Event Notification 56266 notifying the NRC of an environmental report to the State of Minnesota due to an estimated 5 gallons of NALCO LCS-60 that leaked from a failed heat exchanger coil and reached the waters of the state. This event notification was made in accordance with 10 CFR 50.72(b)(2)(xi). During further review of NRC reporting guidance, PINGP has concluded that the reported quantity of NALCO LCS-60 that leaked during this event was below the reporting threshold outlined in NUREG 1022, Revision 3. The NRC Resident Inspector has been notified. Notified R3DO (Kozak) |
| ENS 56243 | 28 November 2022 15:34:00 | A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56232 | 18 November 2022 10:35:00 | The following information was provided by the licensee via email: SCOSHA (South Carolina Occupational Safety and Health Administration) was called due to CFFF (Columbia Fuel Fabrication Facility) an employee breaking their left ankle while descending stairs in the administration building. The employee was admitted to the hospital overnight and surgery was performed the morning of 11/18/2022. An in-patient hospitalization is required to be reported within 24 hours to SCOSHA. The event was reported on 11/18/2022 at 0838 EST through the online portal (SCOSHA-AR-2022-11-18-16433). |
| ENS 56240 | 25 November 2022 15:04:00 | The following information was received from the Georgia Radioactive Materials Program via email: We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the (redacted) prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in. Georgia incident no.: 61
The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email: Was source able to be retracted to safe position? Yes Manufacturer and Model number of HDR: Elekta's Flexitron Serial number: 00625 Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy) Root Cause: Equipment failure. Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly. Corrective Action: Recalibration. Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22. Notified: R1DO (Cahill). Notified 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 56280 | 19 December 2022 12:50:00 | The following information was provided by the licensee via email: This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) for an invalid actuation of a primary containment isolation signal affecting more than one system. On November 11, 2022, at 2333 hours EST, Peach Bottom experienced an unplanned loss of the #343 Off-Site Startup Source. Due to the temporary loss of power during automatic bus transfers, several systems experienced Primary Containment Isolation System (PCIS) Group II and Group III (GP II/III) isolation signals. Plant Systems impacted by isolation valve closure included: Reactor Water Clean Up (RWCU), Containment Atmospheric Control (CAC), Traversing In-Core Probe (TIP) Purge, Primary Containment Floor and Equipment Drains, and the Instrument Nitrogen system. All equipment responded as designed. Plant conditions which initiate PCIS GP II isolation signals are Reactor Vessel Low Water Level, High Drywell Pressure, RWCU system High Flow or RWCU Non-Regenerative Heat Exchanger High Outlet Temperature. The PCIS GP III actuations are initiated by the Reactor Vessel Low Water Level, Primary Containment High Pressure, Reactor Building Ventilation High Radiation or Refuel Floor Ventilation High Radiation. At the time of the event, none of these actual plant conditions existed; therefore, the actuation of the PCIS was invalid. The loss of the #343 Off-Site Startup Source was caused by a failed printed circuit card in the programable logic controller (PLC) for the 3435 breaker. There is no time-based maintenance strategy for PLC replacement. The PLC circuit card was replaced, and the breaker restored to full qualification and service. Preventive maintenance strategy will be enhanced to address the identified vulnerability. The licensee has notified the NRC Resident Inspector. |
| ENS 56218 | 10 November 2022 19:10:00 | The following information was received from the Arizona Department of Health Services (the Department) via email: On November 10, 2022, the Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed a dose of 150 Gy but was delivered 79.05 Gy, a percent dose delivered of 52.7 percent. The Department has requested additional information and continues to investigate the event. Arizona Incident No. 22-014 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 56214 | 9 November 2022 15:37:00 | A non-licensed supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56213 | 9 November 2022 13:00:00 | The following summary was received from the Colorado Department of Public Health and Environment via email: The Colorado Department of Public Health and Environment reported two exit signs (Model #700C-20), containing 7.99 curies of tritium each, lost by the licensee. The incident occurred November 8, 2022. CO Event Report ID No.: CO220037 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 56269 | 12 December 2022 11:05:00 | The following information was provided by the licensee via email: On October 13, 2022, during Refueling Outage 25, 2 bolts and 2 washers were discovered in the strainer basket upstream of the main steam stop valve in the steam line from the 'A' steam generator. It was determined that these bolts and washers were from the main steam isolation valve (MSIV) upstream of the stop valve. One bolt and one washer were also determined to be missing from the MSIV on the line from the 'B' steam generator. The MSIVs are a similar design as the Main Feedwater Isolation Valves (MFIVs). It appears that the torque values for these backseat bolts provided by the vendor weren't sufficient to prevent the bolts from coming loose. Wolf Creek Nuclear Operating Corporation personnel evaluated the condition and determined that the inadequate torque values provided by the vendor could have constituted a substantial safety hazard if left uncorrected. In particular, if bolts had come loose from the MFIVs, they could have traveled downstream to the steam generators and then challenged the integrity of steam generator tubes. The NRC Senior Resident Inspector has been notified. This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification will be provided within 30 days. |
| ENS 56157 | 11 October 2022 09:50:00 | The following information was provided by the licensee via phone call: At 1530 EDT on October 5, 2022, a Troxler gauge Model 3430, containing 8 mCi of Cs-137 and 40 mCi of Am 241, was damaged by a construction vehicle. The sources were in the test position at the time of the event. The unit's source rod was damaged, but the sources were not damaged. The gauge area was quarantined and a repair company was contacted. The repair company provided the licensee a lead lined container for the damaged gauge to be transported back to the vendor. There were no exposures and a leak test is in progress. The repair company took possession of the gauge. |
| ENS 56156 | 10 October 2022 14:18:00 | The following summary was received from the Minnesota Department of Health via email: A patient undergoing Lu-177 therapy was administered 110 mCi vice the prescribed 200 mCi. An investigation is in progress by the Minnesota Department of Health. 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. Minnesota Event ID: MN220005
The following information was received via email: The event date for this event was 09/28/2022. This event was discovered while investigating the event that occurred on 09/27/2022." (That event is recorded as EN56137.) Notified R3DO (Kunowski) and NMSS Events Notification email group. |
| ENS 56134 | 30 September 2022 16:51:00 | The following information was received from the state of Illinois (the Agency) via email: At approximately 1200 CDT on September 27, 2022, the Radiation Safety Officer for Illinois Institute of Technology (RML IL-01739-01), contacted the Agency to advise of a missing Cf-252 source, which has decayed to approximately 25 nanocuries. Reportedly, approximately 30 minutes earlier, radiation protection staff noticed the door to the source storage room was unlocked and the padlock found beneath a desk. An inventory of the room led to the discovery the Cf-252 source was missing. It is unclear if this involved intentional theft. The licensee states they will continue to search for the source until Monday and will then report the theft to public safety. Agency staff requested that appropriate context for the hazard be communicated to law enforcement as well, if reported. The Agency is awaiting additional information on source model/serial number. Illinois incident no.: IL220036 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 56118 | 19 September 2022 19:29:00 | The following information was provided by the licensee via email: At approximately 1520 CDT on September 19, 2022, Grand Gulf Nuclear Station (GGNS) requested transport for treatment of a non-responsive individual, a contract employee, to an offsite medical facility. The offsite medical facility notified GGNS at approximately 1630 CDT that the individual had been declared deceased. The fatality was not work-related, and the individual was outside of the Radiological Control Area. This is a four-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(xi) related to the notification of a government agency. The contractor's employee will be notifying the Occupational Safety and Health Administration. The NRC Senior Resident Inspector has been notified. |
| ENS 56073 | 27 August 2022 12:13:00 | The following information was provided by the licensee via email: At 0810 EDT on August 27, 2022, with Unit 2 at 27% power, the operating crew received an annunciator for a Turbine Trip Without Reactor Trip. At 0812 EDT, a report came in from the field of a fire in the north yard due to an "A" Main Transformer upper bushing failure. The station fire brigade was dispatched and offsite assistance was requested. However, at 0842 EDT the fire was put out, prior to needing the offsite assistance. No Emergency Action Level threshold was exceeded for this event. The switchyard is in a normal alignment for providing offsite power to Unit 2. At 1015 EDT, the Virginia Department of Emergency Management (VDEM) was notified of the event. Additionally, a notification to the Virginia Department of Environmental Quality will be made due to approximately 100 gallons of oil reaching the ground. As such, this issue is being reported per 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.' The NRC Resident Inspector was notified. |
| ENS 56054 | 18 August 2022 01:20:00 | The following information was provided by the licensee via email: At 2108 EDT on August 17, 2022 the Division 2 Mechanical Draft Cooling Tower (MDCT) fans were declared inoperable due to failure of the over speed fan brake inverter. The brakes prevent fan over speed from a design basis tornado. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The Division 2 EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) room cooler and Division 2 Control Center HVAC (CCHVAC) chiller. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. At the time of the event, Division I CCHVAC was inoperable for maintenance (but was running for a maintenance run) and the event caused an inoperability of Division 2 CCHVAC. This resulted in an inoperability of both divisions of CCHVAC. Failure of the Division 2 MDCT Fan brake inverter occurred due to a trip of the DC input breaker. The breaker was reset at 2128 EDT restoring Division 2 UHS Operability. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfilment of the safety function of structures or systems that are needed to mitigate the consequences of an accident based on a loss of a single train safety system and loss of both divisions of a safety system. The Senior NRC Resident Inspector has been notified
The following information was provided by the licensee via email: On 8/17/22 at 2108 EDT the Division 2 (Div. 2) mechanical draft cooling tower (MDCT) brake inverter input breaker tripped for an unknown cause. The result of the loss of power was the inoperability of the MDCT fan brakes which impacts the ultimate heat sink (UHS) (TS 3.7.2). The UHS cascades to the EECW (emergency equipment cooling water) (TS 3.7.2) which is a support system for Div. 2 CCHVAC (Control Cell) Chiller A/C system (TS 3.7.4). This resulted in the inoperability of the Div. 2 CCHVAC Chiller. The cause for the breaker to trip is an intermittent electrical transient. Immediate corrective action was to reset the breaker, and the long-term action is to implement a modification to mitigate susceptibility to voltage variations. Div. 1 has implemented this long-term mod and no unexpected trips have occurred to date. Div. 1 CCHVAC Chiller was previously inoperable from equipment issues which was repaired, and the unit was in service for a 24-hour confidence run. Although licensed personnel had not completed the administrative actions for documenting operability during the 24-hour confidence run to monitor parameters, the (post maintenance test) PMT related to the maintenance was already completed, which included a 4-hour run in accordance with surveillance 24.413.01, Div. 1 and Div. 2 Chilled Water Pump and Valve, to verify normal operation and motor current. These PMT's were completed prior to the identified inoperability of the Div. 2 UHS due to the tripped breaker on the brake power supply. At the time of the MDCT brake inverter trip, the Operations' Senior License and the Night Shift Manager were aligned that, although still operating as part of the 24-hour confidence run, the unit was in service and capable of performing its safety function, but the administrative tasks were not completed, the Limited Condition of Operation (LCO) sheet had not been cleared, and no log entries were made. Since the Div. 1 Chiller was, in fact, operable at the time of the trip of the breaker on the inverter, this would allow the use of Technical Specification (TS) 3.0.9 'Barriers'. Per Operations Department Expectation (ODE)-12 `LCOs' (standard guidance and expectations for preparing and implementing an LCO), Operations determined that the MDCT brakes are barriers to a tornado event and TS 3.0.9 could be utilized. By invoking TS 3.0.9, as long as all other supported systems in the other division are operable, Div. 2 supported systems relying upon the UHS can remain operable and the Automatic Depressurization System (ADS) and Reactor Core Isolation Cooling (RCIC) system can be used as backup to the High Pressure Coolant Injection (HPCI) system. Based on this information, there was no loss of safety function with CCHVAC A/C system or HPCI. Therefore, the NRC non-emergency 10CFR50.72(b)(3)(v)(D) report was not required and the NRC report 56054 can be retracted. The NRC Resident Inspector has been notified. Notified R3DO (Orlikowski) |
| ENS 56026 | 1 August 2022 16:03:00 | The following information was received from the Massachusetts Radiation Control Program via email: The licensee (QSA Global, Inc., License No. 12-8361) reported at 1359 EDT on August 1, 2022 that it discovered on same day (August 1, 2022) at 1303 EDT that two packages (Yellow-III, Type B(U)) containing 12 sealed sources (Ir-192; 1279.4 Ci total) were reported missing by the shipper, QSA Global. Package 1 was shipped on July 19, 2022 in two pieces and one of the pieces containing 4 Ir-192 sources (430.2 Ci) was reported missing. Package 2, also reported as missing, was shipped on July 20, 2022 containing 8 Ir-192 sources (849.2 Ci). Both packages were intended for export to Mexico. Package 1 was most recently scanned at common carrier facility in Memphis, TN on July 28. Package 2 was most recently scanned at the common carrier facility in Memphis on July 22. The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. The four-hour reporting requirement of 105 CMR 120.077(B), missing shipment of Category 2 quantity of radioactive material, also applies. The Agency considers this event to be open. Notified DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk via email.
The following was received from the Massachusetts Radiation Control Program via email: The Licensee reported at 1040 EDT on August 4, 2022 that the common carrier has confirmed all packages have been located and have arrived at their intended destination in Mexico. The Agency considers this event closed. Notified internal: R1RDO (Henrion), NMSS DAY (Rivera-Capella), IR MOC (Crouch), and ILTAB (MacDonald), and via email: INES (Smith), NMSS Events Notification, and ILTAB. Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, CWMD Watch Desk, and CNSNS Mexico.
The following was received from the Massachusetts Radiation Control Program via email: Reference: NMED Item 220346 and Massachusetts Event 20-5089. Original Agency Report to NMED 09/01/2022 Updates and Information noted in the NMED database as previously not reported by this Agency: Corrective Actions Information: No corrective action taken Source/Radioactive Material Information: Source 1 Model Number: A424-9 Source 2 Model Number: A424-9 Device/Associated Equipment Information: Device 1 Manufacturer: QSA Global, Inc. Device 1 Model Number: SC-360-4 Device 1 Serial Number: DU4021 Device 2 Manufacturer: QSA Global, Inc. Device 2 Model Number: SC-650L Device 2 Serial Number: 2145 Notified R1DO (Young) and NMSS Events Notifications via email. THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 56025 | 1 August 2022 15:44:00 | The following summary was received from the Tennessee Division of Radiological Health via email: At 1015 CDT, on 7/31/2022, a truck containing a density gauge was stolen. The gauge was secured and locked in a company work truck near the 4600 Block of Summer Avenue in Memphis, TN. A report has been filed with Memphis Police Department. The gauge is a Instrotek 3500 Xplorer, (SN: 4492) with 40 milliCuries of Am-241 (Source SN: K481/21) and 10 milliCuries of Cs-137 (Source SN: BG1480). Corrective actions or reports will be updated with a report within 30 days. TN incident no.: TN-22-056 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 56024 | 1 August 2022 12:10:00 | The following summary was provided by the licensee via email and phone: Two packages were tendered to a common carrier on July 1, 2022. One of two packages was lost during transport and handling. The last known status was at the common carrier's distribution facility in Memphis, TN on July 8, 2022. The lost package contains a liquid salt solution with an activity of 11.844 GBq (0.3201 Curies) of Thallium 201 (Tl-201). A written report shall be completed and submitted to the NRC pursuant to 10 CFR 20.2201(b). A search of the licensee's facility was not successful. An ongoing search is in progress at the Memphis facility. 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 55984 | 8 July 2022 17:38:00 | The following information was received from the Iowa Department of Public Health (IDPH) via email: At 1515 CDT, July 7, 2022, an NDC Technologies, Model 302 fixed gauge with (approximately) 80 mCi of Kr-85 had a shutter stick open when the line was turned off. The shutter was first identified as stuck open around 1600 when the Radiation Safety Officer was conducting their entrance radiation survey. Radiation safety perimeter was established. The service provider was called and arrived the morning of July 8, 2022. They were able to close the shutter but unable to conduct cause analysis. The gauge will be shipped back to vendor to safely analyze for cause. The IDPH will decide on a reactive inspection based on the cause of stuck shutter identified by the vendor. Licensee aware of 30 day written notification requirement. IA incident no.: IA220004 |
| ENS 55982 | 8 July 2022 12:19:00 | The following information was received from the Wisconsin Department of Health Services via email: On July 8, 2022, the State was contacted by a representative of the licensee to report a radiation event that had been identified on July 7. The licensee was performing routine checks on a fixed gauge device, and the individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. The device is believed to have been stuck open for approximately 13 hours. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized. The device is a Mahlo Model 11-200933, (serial number) SN: 11-011988. It contains an Eckert and Ziegler Pm-147 (Model) PHC.C1 source, SN:AH-4968. It has an assay date of April 15, 2016, 1000 mCi. It currently contains approximately 193 mCi. The licensee performed a dose reconstruction of any individual who would have been at the 8 foot boundary of the gauge, which indicates minimal exposure. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee. WI incident no.: WI220014 |
| ENS 55985 | 8 July 2022 17:06:00 | The following summary was received from the Colorado Department of Public Health and Environment via email: On June 6, 2022, the Colorado Department of Public Health and Environment reported one model 2040 exit sign containing an unknown amount of tritium lost by the licensee. The incident occurred between 2009-2010. CO incident no.: CO220022 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 55947 | 16 June 2022 10:19:00 | The following information was received from the Minnesota Department of Health (MDH) via email: We (MDH) received an initial report on 6/15/22 at 1515 CDT of a reportable medical event. The event occurred at the University of Minnesota, license number 1049, in Minneapolis on 6/14/22. The event involved a treatment with Y-90 SirSpheres where 2.2 GBq was ordered but a 5.1 GBq unit dose was delivered and administered. The licensee is working through dose calculations. No additional details are available at this time. Follow up information will be sent when it becomes available. 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.
The normal procedure for this therapy is to order a dose from the manufacturer a couple of weeks prior to the treatment so the radiopharmacy has the material on hand. The dosage ordered from the manufacturer is limited to few vial activities (want to make sure there will be enough for the therapy), and the actual dose to administer to the patient is drawn up by the pharmacy the day of the procedure. The pharmacy delivers the patient dose to the nuclear medicine department. Nuclear Medicine will check the activity compared to the shipping paper to make sure it is within range. They will also do the pre-measurements for determining the residual after the treatment. They will write the activity on the top of the Nalgene jar and bring it to interventional radiology. Interventional radiology will verify the dose on the lid and perform the administration. The residual is determined from the waste in the Nalgene jar per the standard microsphere procedure. The written directive is signed by the authorized user once the residual and actual dose given is determined. In the case on June 14, 2022, there was a communication error between the radiopharmacy (Jubilant) and the person ordering the dose. The pharmacy verified and the person who ordered the dose confirmed the dose was 5.6 GBq (the entire vial amount from the manufacturer). After drawing the dose, the activity in the vial the pharmacy sent was 5.1 GBq (they are not able to draw 100% of the material). Once received in nuclear medicine, the nuclear medicine technologist did their process, including comparing the dose in the vial with the shipping papers from the pharmacy (not the dose prescribed). The dose was brought to interventional radiology for the administration. The interventional radiologist did not see the activity on the Nalgene jar and was unaware that the activity was on the label. Without verifying the activity the interventional radiologist administered the dose. After the procedure the residual was calculated and it was determined that 5.1 GBq was administered (139 mCi prescribed and 137 mCi administered). The Authorized User signed the written directive after the procedure with the 139 mCi prescribed and 137 mCi administered activity. The prescribing physician (interventional radiologist) realized the error the next day when reading the post report. The State performed an on-site investigation and is pursuing enforcement actions. The event is still open. Minnesota will continue to keep NRC informed of the status of the investigation. Notified R3DO (Lafranzo) and NMSS (Rivera-Cappella) |
| ENS 55930 | 7 June 2022 21:50:00 | The following information was provided by the licensee via email: The plant is in a safe configuration. On June 3, 2022, isolated pressure fall (IPF) and isolated pressure rise (IPR) tests were completed satisfactory on manifold 1. A satisfactory Item Relied on For Safety (IROFS) surveillance was completed for manifold 1 and 1003 Autoclave was placed in service. On June 7, 2022 during the disconnect of 1003 Autoclave, an Operator noticed a white/yellowish film on the hex nut of the manifold and the upper portion of the cylinder valve. The Operator surveyed the film and found 4,000 to 6,000 dpm alpha and beta contamination. Prior to opening the door of 1003 Autoclave, the internal atmosphere was sampled for hydrogen fluoride (HF). No HF was detected by HF monitor. 1003 Autoclave has been taken out of service. Autoclave sampling manifold 1 has been isolated and IROFS 28 declared INOPERABLE. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No employee exposures occurred. The leakage was contained inside the autoclave.
The following was provided by the licensee via email: The IROFS28 boundary, components, associated accident sequences and manifold leak were evaluated by Urenco-USA (UUSA) engineering. The evaluation determined that the leakage from the manifold did not result in IROFS28 being inoperable. IROFS28 was determined to be operable during this event. Based on this reevaluation, UUSA is retracting event notification EN 55930. UUSA will be notifying Region II. Notified R2DO (Miller), and NMSS (Clark), NMSS Day (Rivera-Capella), NMSS Events (email). |
| ENS 55983 | 8 July 2022 15:39:00 | The following information was received from the Colorado Department of Public Health and Environment (the department) via email: The department was notified on June 6, 2022, that two SLX-60 Exit signs containing 7.62 Ci each of H-3 were lost in 2021. No additional information was provided. CO incident no.: CO220021 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 55919 | 31 May 2022 09:55:00 | The following information was provided by the Illinois Emergency Management Agency (IEMA, The Agency) via email: On 05/17/22, a shipment of scrap metal being hauled from Sallisaw, OK to Rogers, AR tripped a portal monitor at the receiving recycling company. It was returned to Oklahoma under DOT-SP AR-OK-22-007. The load was surveyed once returned to Oklahoma and a Thermo Measure Tech model 5201 fixed gauge containing 50 mCi of Cs-137 (s/n B4473) was identified. The gauge has since been isolated in a drum and secured in a shed at the Oklahoma recycling facility. Efforts to identify the owner resulted in a call from Oklahoma Department of Environmental Quality (OK DEQ) to the Illinois program on 5/27/22. IEMA staff were able to identify Mid America Dredging in Good Hope, IL as the owner. Mid America Dredging is registered with the Agency under #9223884 and last reported the gauge as present on 2/15/22. Agency staff requested the licensee confirm the gauge was on site and send pictures. Apparently, the `device' the registrant has been exercising control over since 2015 was the outer housing for the gauge which may have a secondary label according to the Sealed Source and Device (SSD) sheet. The licensee suspects the gauge was inadvertently disposed of or abandoned during work in Sallisaw, OK in or around 2015. IEMA will address noncompliance with the registrant. This device is generally licensed and registered under 32 Ill. Adm. Code 330.220(a)(4). Due to the activity involved, any loss, theft or diversion is immediately reportable under 32 Ill. Adm. Code 340.1210(a). The registrant did not report, nor was seemingly aware of the loss. OK DEQ notified the Headquarters Operations Officer on 5/18/22, and provided an update on 5/27/22. This NMED entry is made to document IEMA actions and track until the gauge is properly returned and/or disposed of. Updates will be provided as they become available. Reference Event Number 55900 for the initial notification from OK DEQ to the NRC. |
| ENS 55910 | 24 May 2022 06:49:00 | The following information was provided by the licensee via email: On May 24, 2022, at 0414 EDT, while rolling the Unit 1 main turbine during the Unit 1 Cycle 31 refueling outage, the Unit 1 main turbine experienced high vibrations and the main turbine was manually tripped with reactor power at 12 percent. Main turbine vibrations persisted and the reactor was manually tripped, Main Steam Stop Valves were closed, and main condenser vacuum was broken. 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. Both Motor Driven Auxiliary Feedwater Pumps started properly. Decay heat is being removed via Steam Generator Power Operated Relief Valves. 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. |
| ENS 55907 | 23 May 2022 11:23:00 | The following information was provided by the licensee via email: On May 23, 2022, at 0455 CST, Cooper Nuclear Station experienced a spike in Secondary Containment differential pressure which exceeded the Technical Specifications Surveillance Requirements 3.6.4.1.1 limit of -0.25 inches of water gauge. Secondary Containment differential pressure restored to Technical Specification limits within two minutes and further investigation is ongoing. This unplanned Secondary Containment inoperability constitutes a condition reportable under 10CFR50.72(b)(3)(v)(C) and (D). The NRC Senior Resident Inspector has been informed. |
| ENS 55906 | 22 May 2022 09:48:00 | The following information was provided by the licensee via email: At 0838 (MDT) on May 21, 2022, the diesel fuel day tank level transmitter for the B Central Utility Building (CUB) Standby Diesel Generator failed low. The failed level transmitter signaled the automatic start of the fuel oil transfer pump. When the transfer pump started, it pumped off-highway diesel fuel from the 8000 gallon bulk storage tank, located on the south side of the CUB, to the 150 gallon day tank which was already at its normal operating level of 70-90 percent. Since the level instrument had failed low, the transfer pump continued to run. Level in the day tank continued to rise and diesel fuel spilled from the day tank vent, located above and to the side of the CUB roof. The transfer pump continued to run for 23 minutes until an operator shut down the pump. This stopped the release. An estimated maximum of 240 gallons of diesel fuel was spilled. Most of the diesel fuel landed on the ground outside of the CUB in an area covered by gravel. There were no injured personnel and no radiation exposure as a result of this event. The plant is in a safe, stable condition. The B CUB Standby Diesel Generator does not perform a safety function. The transfer pump has been placed out of service. The area is currently being cleaned of diesel fuel. This event has been entered in Urenco USA's corrective action program as EV151632. This event was reported to the New Mexico Environment Department at 0643 MDT on May 22, 2022 and is being reported concurrently to the NRC. |
| ENS 55896 | 13 May 2022 17:47:00 | The following information was provided by the licensee via email: On 5/13/22 at 1111 CDT the station entered LCO 3.7.4 Condition B for Control Room Envelope being inoperable. This was due to results from an inspection in the Steam Jet Air Ejector room that identified steam leakage exceeding the leakage rate assumptions made in the Alternate Source Term (AST) dose analysis calculation. Therefore, this is being reported in accordance with 10CFR50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades plant safety and 10CFR50.72(b)(3)(v)(D) for any event or condition that at the time of discovery could have prevented fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. There is no impact to the health and safety of the public. NRC Resident has been notified. |
| ENS 55898 | 14 May 2022 17:33:00 | The following information was received from the Ohio Department of Health via email: Licensee reported a medical event that occurred on May 13, 2022. A patient experienced pain while undergoing a Y-90 TheraSphere treatment. The treatment was terminated with 65 percent of the prescribed dose administered. The referring physician and patient were informed. Additional information will be added when received from licensee in the 15-day event report. OH incident no.: OH220007 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 55897 | 13 May 2022 19:24:00 | The following information was provided by the licensee via fax or email: Two gamma monitors on filters associated with the waste water treatment system were discovered to be non-functional during their monthly calibration check. These gamma monitors are designated as an Item Relied on for Safety (IROFS) and are used to prevent gradual long term accumulations of uranium from exceeding a safe mass. The system has been shut down and will remain down until the required safety function is restored. This condition is being conservatively reported under the requirements of 10CFR70 Appendix A b(2) due to two Failed IROFS although Framatome believes that the performance requirements of 10CFR70.61 are still met. |
| ENS 55832 | 8 April 2022 14:10:00 | The following information was received from the Washington State Department of Health via email: The Radiation Protection Manager (RPM) for US Ecology (USE) notified the Washington State Department of Health (WDOH) on April 7, 2022, at 1440 PDT, of equipment which failed to function as designed in accordance with WAC 246-221-250 (2)(d). This was identified during an internal surveillance of the calibration program by the licensee. Specifically, the equipment is a Canberra Series 5 Extreme Low Background Alpha Beta Proportional counter (XLB). The spreadsheet used to calculate alpha efficiency to determine alpha activity from smears and air samples was off by 1 percent. The error for this matter will require USE to review all data from September 2021 through April 6, 2022. The preliminary cause was identified as a human performance error. An investigation is ongoing to determine the impact to health and safety. WDOH is planning a follow up investigation the week of May 9, 2022, to follow up for this matter. No media attention currently. WA incident no.: WMS-INC-22-01 |
| ENS 55816 | 1 April 2022 11:07:00 | The following information was received from the Louisiana Department of Environmental Quality (LDEQ) via email: On April 1, 2022, LDEQ received this event notification. The licensee was working at Bayer Crop Science, LP performing industrial radiography work on March 28, 2022. At approximately 1051 CDT, the RSO ((Radiation Safety Officer)) was notified of a source disconnect. The event involved a QSA 880 Delta, serial number 7511, source serial number 4806514. The source was an Ir-192 with an activity of 59 Ci. The drive cable end connector had broken off from the drive cable. The source was retrieved back into a shielded condition. The person performing the source retrieval received 460 mR exposure. The radiographer involved had his pocket ion chamber go off scale and his badge was sent in. The badge read 337 mR which was at the end of the working month. Louisiana Event Report ID No.: LA 20220004 |
| ENS 55815 | 1 April 2022 09:42:00 | The following information was received from the South Carolina Department of Health and Environmental Control via email: During a routine inspection of a licensee's specific license on 03/23/22, the South Carolina Department of Health and Environmental Control was informed that a generally licensed fixed gauging device (80 milliCurie, Kr-85, Mahlo Model 6270, serial number PH847) had a failed indicator and had been repaired by the manufacturer on 01/11/22. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry certificate. The licensee submitted a written notification of the event to the Department on 03/30/22. This event is still under investigation by the South Carolina Department of Health and Environmental Control. |
| ENS 55788 | 14 March 2022 18:30:00 | The following information was provided by the licensee via fax or email: At 1338 CDT on 3/14/2022, it was determined that a contract supervisor tested positive during a random fitness-for-duty test. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified. |
| ENS 55787 | 14 March 2022 15:48:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On March 14, 2022 the Agency received information from the gauge manufacturer that a call had come to their 24-hour number at approximately 1830 (CDT) on March 13, 2022 that Troxler moisture/density gauge (Model 3430: 8 milliCurie cesium-137, 40 milliCurie americium-241/beryllium) had been found in the parking lot of an apartment complex in San Antonio, Texas. The finder did not want to call the police so the manufacturer contacted them. The gauge was inside its unlocked transport case and the finder kept watch on it until the police arrived and took it between 2100 and 2200 (CDT). The gauge was placed in their impound. After receiving the information, the Agency contacted the police department but was only able to get limited information. Attempts to contact the police impound were unsuccessful. A radioactive materials inspector was dispatched but by the time he got there the gauge had been picked up by the owner licensee. The impound staff had called the manufacturer, provided the serial number, and the manufacturer contacted the licensee's corporate office who notified the San Antonio office. The Agency contacted the licensee, their radiation safety officer (RSO) is out of the office and the individual handling the incident is in the process of investigating until the RSO returns mid-week. The licensee confirmed that there were no locks on the case and the insertion rod did not have a lock when they retrieved it. More information will be provided as it is obtained in accordance with SA-300. Texas incident no.: I-9923
The following information was received via E-mail: On March 17, 2022, the licensee notified the Agency that its investigation had revealed that on February 14, 2022, one of its technicians had taken the gauge to their residence at the end of the workday and the gauge was stolen from the vehicle, which was parked at the technician's apartment complex, during the overnight hours. The technician stated that the transport case was secured with two chains in the bed of the pickup and that there was a lock on the insertion rod. The technician did not report the theft to the licensee's radiation safety officer (RSO) when he discovered it on February 15, 2022. The technician did make a statement to the RSO that day that the gauge was not in its storage location at their facility. The RSO presumed another technician had it out on a job. Since neither the technician nor any of the other technicians brought up to the RSO that the gauge was not there after that, the RSO did not follow up. Any additional information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Drake) and NMSS Events Notification E-mail group. 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 55811 | 31 March 2022 11:17:00 | The following information was received from the State of Oklahoma via email: Goodyear Tire and Rubber Co. has reported the loss of a 3M Model 703 Static Meter (S/N 411617). This device was possessed under Oklahoma GLD (generally licensed device) registration GLD0013. It was manufactured in 1977 and initially contained 250 mCi of tritium, which would have decayed to approximately 20 mCi today. Goodyear obtained the device in 2002 and used it for 2 or 3 years before placing it into storage. It was discovered missing earlier this month.
The following is a summary of the information received from the Oklahoma Department of Environmental Quality (DEQ) via email: The Oklahoma DEQ contacted the licensee Radiation Safety Officer (RSO) to verify the corrective actions established to ensure there is not a repeat event. The RSO described that they perform inventories on other devices and that the majority of their devices are attached to large machinery and are used in their everyday production process. The licensee also has onsite support provided by OnCare Digital Assets who help manage their equipment. Notified Cale Young (R4DO), and NMSS Events Notification and ILTAB 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 55861 | 27 April 2022 11:23:00 | The following information was provided by the licensee via email: The plant is in a safe configuration. NRC Region II re-exited an inspection on April 26, 2022 from an inspection which was conducted March 21st through the 24th. During this exit, an event was reclassified as a Non-Cited Violation for failure to report an event. As a result, UUSA (Urenco-USA) is reporting this event as a 24-hour Report per the NRC's inspection. On February 28, 2022, water was discovered on the floor of the Liquid Effluent Collection and Transfer System (LECTS) room. The water was leaking from the slab tanks berm into the non-Radiological Controlled Area floor. The area was conservatively and promptly roped off and signage was posted. Radiological readings in the area were taken and found to be less than background and the the spill was cleaned up that day. Historical issues are being reviewed and will be added to this notification per the NRC's position shared with UUSA. This issue has been entered in UUSA's corrective action program as EV 149668 and 149975.
The following update was provided by the licensee via email: As a result of this Event Notification, a review of Extent of Condition was performed. This Extent of Condition revealed nine historical examples of unplanned contamination events that resulted in expansions of Contaminated Areas that were not reported under 10 CFR 70.50(b)(1) as required by regulation. These conditions occurred on March 3, 2016 (EV 111023), April 14, 2016 (EV 1129221), August 4, 2016 (EV 113877), December 7, 2016 (EV 116283), February 23, 2017 (EV 117238), November 24, 2019 (EV 136211), November 29, 2021 (EV 148894), February 28, 2022 (EV 149668), and April 14, 2022 (EV 151253). These events have been investigated and corrected during the approximate time period in which they were identified. No contamination events are ongoing at UUSA at this time. The Licensee will notify the NRC Region 2 Inspector. Notified R2DO (Miller) and NMSS Events Notifications via e-mail. |
| ENS 55827 | 7 April 2022 15:15:00 | The following information was provided by Curtiss-Wright Nuclear Division via fax: The Tennessee Valley Authority (TVA) Browns Ferry Plant notified us (QualTech NP, Curtiss-Wright Nuclear Division) of two separate RCS/Dresser actuator failures which we had provided as safety related components. According to TVA, the first failure occurred on February 7, 2022, after being installed for approximately 167 days. The 2nd failure occurred on February 9, 2022, and was in service for approximately 24 hours when it failed. According to TVA in both cases the actuator's brake assembly wire harness shorted out to the frame, causing the on-board fuse to blow, disabling the actuator. The electrical short was caused by the wire harness laying against a sharp edge of the metal frame, which over time led to fraying of the wire insulation and subsequent bare wire to frame contact. Both units were returned to QualTech NP for evaluation and our findings confirmed TVA's assessment. The root cause of the issue is friction between the wires and the sharp metallic edge that over time cut through the insulation via vibration, which in turn shorted the power leads to the frame. This shorting effect was due to poor positioning and restraint of the wire harness/bundle by the manufacturer during assembly. It is not considered a design flaw, but a workmanship issue caused by the factory assembler. The corrective action taken with the two units was to install new brake assemblies and reposition the wire harness to prevent contact with the sharp edge. In addition, wire ties were added to restrain the wire's movement and keep it away from the sharp edge. As a follow up action, the associated dedication plan will be revised to inspect for this workmanship issue and correct as needed. Additional details are provided in the failure evaluation. QualTech NP has only sold this part to TVA (Browns Ferry) and could not find any additional failures of this type reported by the industry. Identification of the customer's orders and hardware involved are provided in the evaluation. Please phone (513) 528-7900 if you should have any questions. |
| ENS 55734 | 5 February 2022 18:54:00 | The following information was provided by the licensee via email: At approximately 1402 EST on 2/5/2022, with the Unit in Mode 1 at approximately 98 percent power, Operations was performing a valve lineup and inadvertently isolated a portion of the Reactor Coolant System (RCS) Letdown System, resulting in the system relief valve lifting and entry into the Makeup and Purification System Malfunction Abnormal Procedure due to loss of letdown. Pressurizer level increased and Technical Specification (TS) Limiting Condition for Operation (LCO) 3.4.9 CONDITION A was entered at 1414 EST due to Pressurizer level not below the limit of 228 inches, which has a REQUIRED ACTION to restore Pressurizer level within one hour. A rapid plant down power was initiated at approximately 1430 EST to reduce Pressurizer level. At 1514 EST on 2/5/2022, TS LCO 3.4.9 CONDITION B was entered, which has a REQUIRED ACTION to place the Unit in MODE 3 in 6 hours and in MODE 4 in 12 hours. As the Unit was continuing to down power, this represents initiation of a Technical Specification required shutdown, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). At approximately 1542 EST the down power was stopped at 15 percent power. Pressurizer level was restored to less than 228 inches at approximately 1603 EST, and TS LCO 3.4.9 was exited. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55732 | 4 February 2022 20:30:00 | The following information was provided by the licensee via email: At 1700 EST, on February 4, 2022 with the unit in Mode 1 at 58 percent power, the reactor automatically scrammed due to low Reactor water level due to a transient on the Feedwater System while preparing to shutdown for a refueling outage. 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 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 while in the process of removing the South Reactor Feed Pump from service. While reducing speed on the South, the North Reactor Feed Pump increased in speed and tripped on low suction. The plant was preparing to shut down for a refueling outage when the trip occurred. 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). Additionally, in preparation of plant shutdown, Primary Containment De-Inerting was in progress. The low Reactor water level caused an isolation of Primary Containment (Groups 4/13/15). 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 55730 | 4 February 2022 16:58:00 | The following information was received from the state of Arizona via email: The Department received a call from a construction project manager who stated that 110-116 tritium exit signs were stolen by a contractor and are being held at his residence in Flagstaff, Arizona. A police report has been filed with the Coconino Police Department. Additional information will be provided as it is received in accordance with SA-300. AZ report no.: 22-001 |
| ENS 55728 | 3 February 2022 16:49:00 | The following information was received from the state of Minnesota via email: The Minnesota Department of Health was notified by email on 02/02/2022 at 1652 CST of a shutter stuck in the open position on a generally licensed gauge. The gauge is an Endress+Hauser model FQG61, serial number S700290113F containing 2 milliCi of Cesium-137. The licensee isolated the area and has service for the gauge scheduled for Monday, 02/07/2022. MN report no.: MN220001 |
| ENS 55731 | 4 February 2022 17:23:00 | The following information was received from the state of Ohio via email: On 1/28/22 a verification of source inventory indicated a sealed source was missing. The source is an Sr-90 sealed source, activity of 0.32 milliCi, used in a Model 2210 irradiator. Subsequent surveys were performed in the area where the source should be and where it may have been handled, as well as a visual search of the entire facility was conducted and the source could not be located. A voicemail was left with the Ohio Department of Health (ODH) as a "heads up" of the ongoing investigation. A follow-up call was made to ODH on the morning of 1/31/22 to ensure that the message had been received. An investigation was conducted including interviews with personnel who have access to the locked cabinet the 2210 irradiator was stored in. The previous inventory check conducted on 7/20/2021 indicated the 2210 irradiator was stored in a secure cabinet. Access is limited to 3 employees only. The employee who indicated he most likely handled the irradiator last in the August 2021 timeframe could not remember if he removed the source holder and cap from the irradiator or not. There was also no communication to the Radiation Safety Officer to indicate movement of the source took place. It was also determined that a radioactive waste shipment was made on 12/6/2021 (Veolia Environmental Services/Alaron Nuclear Services). Alaron was called to determine if the shipment was still available. The shipment is still at the Alaron facility and the contents will be verified the week of 2/7/2022. There is a chance the source was included in the shipment since it is an old source with an assay date of approximately 2003. The employee who handled the source last also assisted in determining and gathering the older sources for disposal. To insure employee safety and find the missing source, surveys of all areas of the building were started utilizing a calibrated Bicron Microrem. Employees of all departments were asked to search their areas for the missing source and irradiator. Additional discussions and a meeting were conducted to further investigate what could have happened. The employee cannot be sure if he disassembled the irradiator or not. If the source holder and cap were removed, he would have placed it in a white plastic pig and applied a label with the serial number on it. The source capsule is received from our source supplier already in the holder and cap. We do not remove the actual source capsule from the holder and cap. Photos of the source holder and cap as well as the white plastic pig have been sent to Alaron for their reference when they inventory the waste shipment. Surveys of all bench tops and storage areas have been conducted and all are at their normal background levels. As of this writing, the source has not been located. OH report no.: OH220002 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 |