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ENS 5507118 January 2021 17:31:00On January 18, 2021 at 1600 hours (EDT), Holtec Decommissioning International (HDI) made an off-site notification to the Environmental Protection Agency's Enforcement and Compliance Assurance Division in accordance with Section B of the station's National Pollutant Discharge Elimination System (NPDES) Permit No. 0003557. The event was associated with an underground sewage water system holding tank. The specific details of the occurrence are as follows: On January 13, 2021 at 1000 hours (EDT) site personnel identified what appeared to be water bubbling up from an unidentified cover within the security protected area of the site. The water emanating from the cap had no visible color or solid material and no odor. The water estimated at 25 gallons per hour or less was flowing to a site storm drain connected to permitted outfall number 007. Initial indication was that the water was potable water as part of the station's fire protection system. Further investigation determined that a back-up in an underground sewage holding tank inlet was the source of the leakage. By 1400 hours (EDT) when bathrooms including toilets on site were shutdown and removed from service, efforts were underway to pump the tank and remove the blockage, and the bubbling from the cover had stopped. The licensee has notified the Massachusetts Environmental Protection Agency, the Massachusetts Emergency Management Agency and the NRC Resident Inspector.
ENS 5505330 December 2020 20:30:00On December 30, 2020 at 1550 CST, South Texas Project (STP) received a report that two Emergency Notification System sirens inadvertently actuated. The sirens were heard by residents in the area who contacted the Matagorda County Sheriff's office, which notified the Emergency Response Division at STP of the siren actuation at 1557 CST. Both sirens were initially restored, however siren #24 subsequently actuated again at 1735 CST. Siren #24 has been disconnected. Siren #27 remains available. Thirty-one of thirty-two sirens are available. This notification is being made under 10CFR50.72(b)(2)(xi) as an event where other government agencies were notified. The sirens are no longer alarming. A social media release is planned. The NRC Resident Inspector has been notified of the event. The licensee believes the sirens actuated due to significant rain in the area but will be investigating the cause of the inadvertent actuation.
ENS 5505130 December 2020 12:57:00The following information was received from the Texas Department of State Health Services (the Agency) via email: On December 30, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred at their facility. A patient was to receive a single fraction of 700 centigray from a high dose rate remote afterloader unit (HDR) but received a dose of 525 centigray. The patient was notified of the error and the RSO stated they were in the process of notifying the physician. The RSO stated that there would be no adverse effects to the patient from the error. The RSO was unsure of the manufacturer and model of the HDR unit and the activity of the iridium source that was used. Additional information was requested by the Agency. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9819
ENS 5505230 December 2020 12:57:00On December 29, 2020, Yale University received notification from their dosimetry vendor that one of their employee's badge indicated a whole body dose of 11,843 mRem for the October 2020 wear period. The employee works in the radiopharmaceutical area of the University. When the employee was interviewed, they admitted that they could not locate their whole body badge when swapping out the October badges for the November badges. The employee found their badge on November 17, 2020 in the fume hood where they believed it fell off their lab coat when cleaning the fume hood for maintenance. The employee's ring badges for the October wear period was 73 mR (left) and 63 mR (right). November ring badge readings were about the same with November whole body dose of zero. During the October/November timeframe, there were no abnormal surveys or area radiation monitor alarms. No other employee badge read abnormally high. Yale intends to perform an extensive investigation after the holidays, they believe the October badge was dosed while misplaced in the fume hood for the two-week period is was missing. The licensee will update this event, if required, once the investigation is complete.
ENS 5504118 December 2020 20:39:00The following information was obtained from California Department of Public Health Radiologic Health Branch Brea (RHB Brea) via email: On December 18, 2020, at approximately 1100 PST, (the) RSO ((Radiation Safety Officer)) of Sequoia Consultants, Inc., Radioactive Materials License #7597-30, contacted RHB Brea to report the theft of a moisture/density gauge: CPN, MC-3 Elite, serial #30582 (Cs-137 0.370 GBq, Am-241, 1.85 GBq). The gauge had been in a mobile storage unit at a temporary job site at approximate mile marker 20.07, Northbound State Route 99 (Golden State Highway) in Atwater, CA 95301. The storage unit had been broken into and the radioactive gauge was missing. The Authorized User who discovered the missing radioactive gauge at approximately 0830 on December 18, 2020 notified the RSO and then notified the Atwater Police Department, who directed him to contact the California Highway Patrol. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. The RSO will contact local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered. California 5010 number: 121820 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 5504017 December 2020 22:03:00On December 17, 2020 at 1539 EST, with Harris Nuclear Plant Unit 1 preparing for entry into Mode 4, the Reactor Coolant System was pressurized greater than 1000 psig for approximately 15 minutes with all three Cold Leg Injection Accumulator Discharge Valves closed. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Both Low Head and High Head Safety Injection Systems were operable at this time. This condition does not affect the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5503816 December 2020 12:19:00On December 16, 2020 at 0851 EST, with Harris Nuclear Plant Unit 1 in Mode 1 at 80 percent power, an automatic reactor trip occurred due to lockout of the main generator. The trip was not complex, with all systems responding normally post-trip. The initial assessment of this event indicates that there was a ground fault on the 'B' train of the non-safety electrical distribution system that caused the main generator lockout. Steam generator levels are being maintained by normal feedwater through the feedwater regulator bypass valves. Decay heat is being removed by using the condenser steam dump flow path. Due to the unplanned 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 condition does not affect the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. All rods inserted into the core during the trip. The electrical grid is stable and all safe shutdown equipment is available for service. No reliefs lifted during the transient.
ENS 5503716 December 2020 12:09:00A plant employee, after being selected for a random fitness-for-duty test, admitted to use of a controlled substance. The employee's unescorted access to the facility has been placed on hold pending an investigation. The NRC Resident Inspector has been notified.
ENS 5503917 December 2020 17:25:00The following information was received from the South Carolina Department of Health and Environmental Control via email: The South Carolina Department of Health and Environmental Control was notified on 12/16/20 that a piece of equipment was disabled or failed to function as designed when the equipment is required by regulation or license condition to prevent exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the consequences of an accident. The licensee reported that the electrical interlocks at the remote afterloader room entrance failed to function from 12/14/20 until 12/17/20. The source in the remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMed 232, Ir-192 source, with a reported activity of 8.5 Curies. The remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMedplus iX. As of 12/17/20, the licensee is reporting that the electrical interlocks at the remote afterloader room entrance is now operable and functioning as designed. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control. No overexposures were reported as a result of the failed interlocks.
ENS 550151 December 2020 09:55:00The following information was obtained from the State of Iowa via email: A maintenance technician at the 3M facility in Knoxville, Iowa discovered that a Thermo Fisher Scientific model SULP-77A fixed gauging device containing 661 milliCuries of Krypton-85 had a shutter that was stuck open and would not close. This discovery occurred when the production line was shutdown for routine maintenance. The RSO (Radiation Safety Officer) and backup RSO were notified and the gauge was isolated with caution tape to prevent personnel from getting close to the device. 3M maintenance personnel are authorized to perform shutter repair under the supervision of the RSO or backup RSO by Iowa radioactive materials license number 0042-1-63-FG. The licensee will provide a written follow-up report once repairs have been completed and the cause of the failure identified. The licensee had a service provider operating under reciprocity with Iowa onsite November 17, 2020 to troubleshoot and repair the gauge. The root cause of the stuck shutter was a broken shutter return spring. A new shutter operating cylinder with a new return spring was installed and the gauge shutter was tested and found to be operating correctly. To minimize the chance of future shutter closure failures, the shutter operating cylinders will be replaced for all beta gauges of the same model that are currently in use at the site. Cylinder replacement will occur during future planned maintenance activities. These failures are exceedingly rare. This is the first occurrence in more than 20 years of using these gauges. The site is considering implementing a preventative maintenance replacement of these cylinders every 10 years. Iowa report number: IA200004
ENS 5501130 November 2020 10:19:00The following information was received from ALLWEST Testing & Engineering, Inc. via email: On October 29, 2020, an ALLWEST employee (the authorized user) was testing the density of freshly placed asphalt on Painted Sky Street in the Spring Hollow Ranch subdivision in Nampa, Idaho using a CPN MC-1 portable nuclear densometer (SN 9216). At approximately 1115 Mountain Daylight time, the gauge was damaged by a Cat CCS9 combination roller under the direction of Nampa Paving. (The authorized user) was in the process of running a density test in AC mode when the roller backed up and impacted the gauge. The roller moved off of the gauge after impact. After impact, the handle was oriented at a 45-degree angle from the base of the gauge and the case was detached from the base. (The authorized user) moved away from the damaged gauge and cordoned off the area to prevent anyone from approaching the damaged gauge. (The authorized user) immediately contacted the Meridian office assistant RSO (radiation safety officer) who contacted the Corporate RS. (The assistant RSO) and another ALLWEST employee (the employee) responded to the accident and initiated ALLWEST's emergency protocol. (The assistant RSO) used a survey meter to obtain readings around the damaged gauge. The readings indicated the nuclear sources were not exposed and the shielding was intact. The handle was placed back in the case, and the handle, case and base were placed in the transport box. The transport box was then placed in an overpak barrel and transported back to the ALLWEST office. Additional readings were taken using the survey meter around the gauge at the ALLWEST office. All readings were consistent with the sources being in a shielded condition. (The assistant RSO) contacted lnstrotek and discussed the condition of the gauge and the readings obtained from the survey meter. lnstrotek representatives indicated it was acceptable to ship the damaged gauge to them for disposal in the transport box. As an additional precaution, (the assistant RSO) and (the employee) wrapped the damaged gauge in lead sheeting and placed the wrapped gauge in the transport box. The transport box with the damaged gauge was then shipped to lnstrotek for disposal. ALLWEST sent the personal dosimetry badges for (the authorized user), (the assistant RSO), and (the employee) to Landaeur for immediate evaluation. The radiation dosimetry report from Landauer indicated minimal exposure to all three individuals. The gauge contained 10 mCi Cs-137 source and a 50 mCi Am-241 source.
ENS 549303 October 2020 15:07:00During a scheduled refueling outage, a walkdown inside containment to investigate leakage revealed a pressure boundary leak upstream of 1RC-526B, HX-1B Steam Generator Channel Head Drain. This location would be considered part of the reactor coolant system as defined under 10 CFR 50.2. As such, this event is being reported pursuant to 10 CFR 50.72 (b)(3)(ii)(A). Unit 1 is currently in mode 4. Repairs for the condition are being determined. The NRC Resident Inspector has been notified. The leak rate was determined to be 0.138 gpm.
ENS 549272 October 2020 12:35:00At 0945 hours (EDT) on 10/02/2020, with Millstone Unit 3 in Mode 4, Operations discovered a door in the Secondary Containment boundary blocked open. Investigation determined the door was blocked open at 1842 (EDT) on 10/01/2020, rendering Secondary Containment inoperable. The door was closed at 1002 ((EDT) on 10/02/2020), restoring Secondary Containment to operable status. Since Secondary Containment was rendered inoperable, Dominion Energy is reporting this as a condition that could have prevented the fulfillment of the safety function to control the release of radioactive material and mitigate the consequences of an accident. This condition is being reported as an eight hour report pursuant to 10 CFR 50.72 (b)(3)(v)(C) and (D). There was no release of radioactivity to the public. The NRC Senior Resident Inspector has been notified. With the door blocked open, the plant was in a 24-hour shutdown action statement. The state of Connecticut and local towns were notified.
ENS 549282 October 2020 16:41:00The following information was received from the Commonwealth of Massachusetts via email: A shipment of radioactive material in the form of 5 packages, each containing 555 GBq of Americium/Beryllium, was delivered to QSA Global, Inc. at 0830 (EDT) on October 2, 2020, each of which exceeded regulatory package dose rate limits. All 5 packages exceeded the surface dose rate limit of 200 mrem/hour, the highest of which was 295 mrem/hour and the lowest 220 mrem/hour. Each package was labeled as Yellow III; TI 7. The transport index was also exceeded with a range of 13 mrem/hr at 1 meter for the lowest and 15 mrem/hr at 1 meter for the highest. It was reported that the final delivery carrier, (a common carrier), was notified of the event at 1430 (EDT) on October 2, 2020. The shipper, Weatherford International, LLC, at 7504 Benbrook Parkway, Benbrook, Texas, 76126, was also notified. The cause of the event is under investigation by the licensee. Further information from the Massachusetts Radiation Control Program will be forthcoming. The Commonwealth will be notifying NMED.
ENS 549293 October 2020 11:48:00At time 0815 (CDT) on 09/30/20, Main Steamline Radiation Monitor 2-RUK-2325/2327 (Main Steam Line 2-01/2-03 Radiation Monitor) was removed from service for planned maintenance. Compensatory measures were in place prior to removing the monitor from service to assure adequate monitoring capability available to implement the CPNPP (Comanche Peak Nuclear Power Plant) emergency plan in the unlikely event of challenges to the steam generator or fuel cladding. The N16 radiation monitor serves as a backup with alarm function and Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-01 and MSL 2-03. With this radiation monitor non-functional, compensatory measures in place and the monitor not restored to service within 72 hours, the condition is reportable as a loss of assessment capability per 10CFR50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity and there is negligible safety significance to the current condition with respect to the public health and safety perspective. Corrective actions are being pursued to complete maintenance and restore 2-RUK-2325/2327 to functional status. The NRC Resident Inspector has been notified.
ENS 5490216 September 2020 17:16:00The following information was obtained from the state of New York via facsimile: On September 9, 2020, the Department (New York State Department of Health) was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO (radiation safety officer) when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered. In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered. Ultimate disposition of the source is unknown and it is possible that the source may still be recovered. New York Event Report ID No.: NYDOH-20-04 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 549315 October 2020 13:51:00This 60-day telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of an emergency service water system component that does not normally run and which provides an ultimate heat sink. On August 6, 2020, at approximately 0128 CDT, the A3 Emergency Equipment Cooling Water (EECW) pump received an auto-start signal while performing Post-Maintenance Testing (PMT) on the 3C Core Spray pump. Normally, the involved EECW pump would be started prior to testing to prevent an auto-start; however, in this case the pump was not running prior to the test. When the 3C Core Spray pump breaker was closed while in the test position, an unanticipated actuation of the A3 EECW pump occurred. Work was stopped and the workers reported to the Control Room to evaluate the condition. Based on a review of this event, individuals involved were coached on understanding system response prior to performing work. The A3 EECW pump responded in accordance with the plant design. No other plant equipment was affected during this event. There were no safety consequences or impacts on the health and safety of the public. The event was entered into TVA's corrective action program for evaluation and resolution. Reference corrective action document CR 1628479. The NRC Resident Inspector has been notified of this event.
ENS 547428 June 2020 18:52:00At 1725 EDT on 6/8/2020, V.C. Summer Nuclear Station reported a transmission fluid spill to the South Carolina Department of Health and Environmental Control. The spill was the result of a hydraulic hose leak during equipment testing. This spill did not violate any NRC regulations or reporting criteria. 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 spill resulted in 1 - 2 ounces of transmission fluid being released into the Monticello Reservoir.
ENS 547406 June 2020 12:25:00At 0920 (EDT), with the unit in Mode 1 and 100 percent power, the reactor was manually tripped due to group 1 of control rod bank 'B' fully inserting into the core. All systems responded normally post trip. Operations has stabilized the plant in mode 3 at NOP/NOT (normal operating pressure and temperature). Decay heat removal is being accomplished via the steam dumps in the steam pressure mode to the main condenser. Emergency feedwater actuated due to low low steam generator level as expected. This event is being reported pursuant to 10CFR50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A) The senior NRC Resident Inspector has been notified. The plant response to the trip was uncomplicated. All safe shutdown equipment is available. There were no reliefs or safeties actuated during the transient. The licensee manually tripped eight days ago for the same condition. See EN #54731.
ENS 5471615 May 2020 13:25:00At 0947 (EDT) on 5/15/20, Salem reported to the New Jersey Department of Environmental Protection a sheen on the Delaware River. This discovery did not violate any NRC (Nuclear Regulatory Commission) regulations or reporting criteria. 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 licensee will be notifying the National Response Center and Lower Alloways Creek Township. The substance spilled was less than one pint of hydraulic oil.
ENS 5468530 April 2020 18:51:00The following information was received from the state of Nevada via email: The patient was undergoing radiation treatment using Ir-192 and the high dose rate remote afterloader (Varian VS 2000) in three fractions. There were no problems with fractions one and two. During the third fraction, the vaginal cylinder device was inserted into the patient by the doctor. Unknown to the doctor, the device penetrated through the body wall weakened by previous surgery (according to the doctor, (this is) not unknown following robotic hysterectomies). This penetration allowed the source to move about 4 cm past the treatment area. As a result, the treatment area only received 25 percent volume coverage instead of the planned 95 percent volume coverage. The device was a Varian Remote Afterloader, Model VS 2000, which contained 407 GBq of Ir-192. NMED Report No: NV200007 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 546891 May 2020 12:22:00

The following information was received from the state of California via email: On 4/30/2020, at approximately 1127 (PDT), the RSO (radiation safety officer) of RMA Group, RML Number 8055-19, contacted RHB (California Radiologic Health Branch) Brea concerning a moisture/density gauge, Troxler, model 3440, serial number 25671 (Cs-137, 0.3 GBq, Am-241, 1.50 GBq) that had been stolen from in front of a private apartment complex while the RMA employee was offloading his vehicle. The Troxler radioactive gauge was left on the sidewalk during offloading of the vehicle. (The RMA employee) forgot about the gauge he had left on the sidewalk as he then drove off to have his vehicle washed. When he returned from the carwash at approximately 1730 to 1800 on 4/28/2020, he realized that he had left the radioactive gauge in front of the apartment complex and that it was no longer there. The (RSA employee) finally reported the theft to the RMA RSO on 4/29/2020 at 1215, prior to reporting the theft to Los Angeles Police Department at the West Los Angeles office on 4/29/2020 at 1245. A copy of the theft report and the (employee's) statement has been sent to RHB Brea as part of this report. (The RMA RSO) will utilize local papers to attempt to retrieve the stolen gauge as well as notifying local servicing vendors of radioactive gauges to be alert of the serial number of the stolen gauge in case it turns up for any of their services. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10 CFR 20.220(a)(1)(i) since the radioactive gauge has been stolen with the source handle locked and the Type A transport container locked. California Report Number 5010-043020

  • * * UPDATE FROM DONALD OESTERLE TO DONALD NORWOOD AT 1516 EDT ON 5/4/2020 * * *

The gauge has been recovered intact. A formal closing report will be submitted later. Notified R4DO (Drake), and via E-mail: NMSS Events Notifications E-mail group, ILTAB, and CNSNA (Mexico). 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 5468024 April 2020 07:00:00At 0130 (EDT) on April 24, 2020, during the Beaver Valley Power Station, Unit 2 refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that one penetration could not be dispositioned as acceptable per ASME Code Section XI. Penetration 37 will require repair prior to returning the vessel head to service. The indication was not through wall and there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. The examinations were being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-4 to find potential flaws/indications before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 534446 June 2018 13:27:00Below is a summary of multiple emails received from the State: At 1530 hrs. MST on 6/5/18, the State was notified that a patient was undergoing high dose rate treatment (HDR) when the Nucletron HDR applicator malfunctioned. The treatment plan was to deliver the intended fraction using thirteen dwell points but the HDR applicator failed at dwell point 9 of 13. The vendor, Elekta, was notified and they repaired the applicator. The written directive was modified and the patient will be able to complete the treatment.
ENS 534466 June 2018 17:35:00The licensee's gauge operator was preparing to sample some work being done by a construction company when the company's road grader began backing into his sample area. The operator attempted to wave off the grader but he was in the grader operator's blind spot. The grader struck the gauge side and damaged the housing. The source rod was retracted so the sources were in their shielded position. The RSO (Radiation Safety Officer) was contacted and performed an area survey and a survey on the gauge. There were no abnormal readings. The gauge was swipe tested and the licensee has sent the swipe off for analysis. No overexposures were reported. The gauge was a Troxler model 3440 which contained a 9 mCi Cs-137 source and a 44 mCi Am-241 source. The gauge is currently in secure storage at the licensee's facility. Once the swipe tests are analyzed, the disposition of the gauge will be determined. The site of the incident was Ann Arbor, MI.
ENS 5468430 April 2020 15:37:00The following information was received from the state of Florida via email: The state of Kentucky Radiation Health (Branch) faxed a report of rejection of an UBC (used beverage can) bale from Logan Aluminum of KY, originating from Republic Services of Jacksonville, FL. The radiation measurement was 1200 cps (also reported as 0.7 mR/hr.) midway of the enclosed trailer. Background measured 121 cps. DOT-SP 10656 KY-FL-20-001 was issued. Per (an employee) of Republic Services, this load was comprised of household curbside waste, and 'people put whatever they want in there.' Only one bale was higher than background. The rest of load successfully resubmitted. Update: This bale was returned to Florida for investigation, whereupon (the Radiation Safety Officer at Republic Services) reached out to the (Headquarters Operations Officer at the Nuclear Regulatory Commission), who transferred him to the BRC (Florida Bureau of Radiation Control). Florida BRC will be conducting a follow-up investigation. Florida Incident Number: FL20-051
ENS 546539 April 2020 09:35:00On 4/8/20 at 0100 CDT, the University of Missouri-Columbia Research Reactor (MURR) was shut down due to a failure of the regulating blade drive mechanism to move the regulating blade during reactor operation. This email is a required notification per MURR Technical Specification (TS) 6.6.c.(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. Specifically, MURR was not in compliance with all Limiting Conditions for Operations (LCOs). MURR was not in compliance with two (2) LCOs: 1. TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation,' and 2. TS 3.2.f states, 'The reactor shall not be operated unless the following rod run-in functions are operable.' Specifically, the rod run-in function that occurs when the regulating blade position is less than or equal to 10 percent withdrawn was not operable as TS 3.2.f.8 requires. The regulating blade drive mechanism was repaired, post-maintenance operability testing was conducted on the regulating blade, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on 4/8/20. Currently, MURR is at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c.(3).
ENS 5467923 April 2020 10:57:00The following information was received from the Commonwealth of Pennsylvania via email: On April 5, 2020, a technician reported to the (licensee radiation safety officer) RSO that when a shutter handle on a Berthold LB8010 with 20 mCi Cs-137 was moved to the closed position, the radiation survey indicated reduced radiation, but not the expected level. The shutter was opened and closed again, and radiation levels were lower but not at normal closed position levels. The gauge has been removed from service and is secured onsite in Canton, PA, awaiting a shipping container for return to the manufacturer. The gauge will be returned for repair or replacement. No personnel overexposure has occurred. The Department (Pennsylvania Department of Environmental Protection) will perform a reactive inspection. More information will be provided upon receipt. Pennsylvania Report ID No.: PA200008
ENS 5459420 March 2020 17:47:00On March 20, 2020, at 1025 hours (CDT), Unit 2 MCC (motor control center) 28/29-5 failed to transfer to its alternate feed during surveillance testing. This would result in MCC 28/29-5 being de-energized in the event of a DBA LOCA (design basis accident loss of coolant accident) in which the Unit 1 Emergency Diesel Generator fails to energize Bus 29. Consequently, the LPCI (low pressure coolant injection) Injection Valve (MO 2-1001-29A/B) would not have power to open on the loop selected by LPCI Loop Select. This renders both divisions of the LPCI mode of Residual Heat Removal system inoperable. Technical Specification 3.5.1, Condition E had previously been entered during testing, requiring restoration of LPCI in 72 hours. No other ECCS (emergency core cooling) systems were inoperable at the time of the event. Troubleshooting and repairs are in progress. This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function. The plant is still in its 72-hr. LCO action statement. The licensee has notified the NRC Resident Inspector and the state of Illinois Emergency Management Agency.
ENS 5468630 April 2020 19:50:00The following information is summarized from the report received from the state of Nevada via email: A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled. During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose. At the time of the report, there were no acute ill-effects on the patient. NMED Report No.: NV200006 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 5467522 April 2020 10:43:00This 60-day optional telephone notification is being made in lieu of an LER (licensee event report) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). At approximately 1025 Eastern Standard Time (EST) on March 5, 2020, with Unit 1 shutdown in Mode 5 for refueling, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring and Post Accident Sampling isolation valves) occurred. The invalid actuation occurred when power was lost as a result of the Inboard Isolation Logic Fuse being removed per a planned clearance hang to support maintenance. The PCIVs functioned successfully and the actuation was complete. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation. This event did not result in any adverse impact to the health and safety of the public. The licensee has notified the NRC Resident Inspector.
ENS 5468328 April 2020 14:49:00The following information was obtained from the state of Tennessee via email: During a recent inventory at two different locations of Service King Collision Repair Centers, two static elimination devices were found to be missing. One location in Chattanooga, TN, lost the device during the transition of closing the repair center. Updated information will be included in a follow-up report. The information for the devices is below: Manufacturer Model Serial# Isotope Activity NRD, LLC P-2021 A2LV457 Po-210 10 mCi NRD, LLC P-2021 A2LU553 Po-210 10 mCi Tennessee Event Report ID No.: TN-20-076 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 5452614 February 2020 16:01:00

EN Revision Imported Date : 8/12/2020 AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3). The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program.

  • * * UPDATE ON 8/11/2020 AT 1715 EDT FROM SZYMON MUDREWICZ TO BETHANY CECERE * * *

Medical event no. 14-4085 was reported to the Massachusetts Radiation Control Program (hereafter, 'Agency') by Massachusetts General Hospital (hereafter, 'licensee') on 02/14/2020 involving administration of TheraSphere Y-90 microspheres to a patient for liver cancer treatment. The patient was scheduled to receive two doses on 02/13/2020 to the right lobe and segment 4 of the liver; 1.59 GBq and 0.29 GBq, respectively. Administration of both doses went accordingly and no unusual signs were observed by the authorized used conducting the administration. There were no problems with the flow of liquid through the microcatheter, no excessive pressure was needed to push the spheres, no leaks were observed, and there were no visual indicators that spheres were collecting at junctions in the tubing. The RADOS dosimeter, supplied with the delivery system, was reading 0.0 mR/hr at conclusion of each dose delivery indicating minimal residual activity inside the delivery system. After each dose the microcatheter and delivery system tubing are placed in a waste container - for storage to decay - where the dose is measured to calculate the activity of any residual microspheres that were not delivered. The calculations were performed the morning of 02/14/2020 and it was determined that only 0.512 GBq (33.7%) of the first dose was delivered to the target site, whereas as 0.273 GBq (95.9%) of the second was delivered to the target site. These calculations identified a possible occlusion in either the microcatheter or delivery set tubing and also identified a malfunctioning dosimeter. No physiological risk to patient health was identified. The Agency considers this event closed. Notified R1DO (Gray) and NMSS Events Notification (email) 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 545115 February 2020 09:31:00The following information was received from the state of Texas via email: The Methodist Hospital reported a source retraction failure during an intravascular Brachytherapy treatment performed on 2/4/2020. The intravascular brachytherapy system (Best Vascular Model A-1000 Serial #89670) contained a 1.3 GBq (35.2 mCi) Sr-90 source (AEA Model SICW.2 Serial #ZA925). The patient was treated as prescribed and the source was completely out of the patient. As it was retracting into the device, it didn't go into home position. The device was immediately placed in the emergency equipment box (shielding box) per manufacturer's instructions for response to this type of occurrence. There was no underexposure or overexposure to the patient. The manufacturer has been contacted to investigate and conduct repairs. Additional information in accordance with SA-300 will be provided. Texas Incident No.: 9739
ENS 5449929 January 2020 16:38:00The following is a summary of information obtained from the state of Texas via email: On January 28, 2020, the licensee notified the Agency (Texas Department of State Health Services), that it had discovered a load of soil containing Radium-228, collected during remediation/decommissioning activities for another licensee, had been taken to the municipal landfill in error. The soil was taken to the landfill on January 15, 2020, and was identified by the licensee on January 24, 2020. The error was identified while processing sample reports and other paperwork. A sample indicated the material had a concentration of 776 picoCuries of Radium-228 per gram. The Agency has confirmed the material does not pose a risk of becoming an uncontrolled contamination event, because it is in a cell at the landfill with clean soil covering it. The area has been cordoned off and the material does not pose a risk of exposure to any individual. The licensee has coordinated with the landfill to go onsite February 3, 2020, to take surveys and get information to develop a plan to recover the material so it can be properly disposed of. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: 9736
ENS 5449829 January 2020 15:28:00On January 9, 2020, a patient received Lu-177 treatment. The dose prescribed was 203.5 milliCuries. On January 28, 2020, the Authorized User was informed by the patient's physician that the patient was pregnant at the time of treatment. The Authorized User informed the patient. The initial dose to the fetus was calculated to be 143 milligray (14.3 rem). The licensee has hired a consultant to determine if the calculated dose is correct.
ENS 5448621 January 2020 19:03:00The following information was obtained from the state of Texas via email: On January 21, 2020, the licensee notified the Agency (Texas Department of State Health Services), that one of its company trucks with one of its moisture/density gauges had been stolen from its facility. The technician had pulled the truck into the licensee's yard (fenced area but gate open) and pulled up to the building. He turned off the truck, but left the keys in it, while he took a test sample inside the building. The licensee's video surveillance shows an individual walked into the yard and stole the truck which had a Troxler model 3440 moisture/density gauge in the bed. The gauge has a lock on the insertion rod. The gauge is inside its transport case which has a lock. The transport case is inside a metal box that is bolted in the bed of the pickup that also has a lock. However, the keys to these locks are on the same key ring as the truck ignition key. The licensee immediately notified the local police department who responded to the facility and is investigating. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Gauge info: Troxler 3440 SN: 27798 Sources: Am-241/Be: 40 mCi, SN: 479223; Cs-137: 8 mCi, SN: 750-9353 Texas Incident No. I-9734 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 5448317 January 2020 11:57:00The following information was received from the state of Alabama via facsimile: On January 16, 2020 at approximately 1445 CST, (the radiation safety officer (RSO)) of Alabama licensee East Alabama Medical Center notified the Alabama Office of Radiation Control (the Agency) that a patient apparently received more dose than prescribed during a treatment via HDR (high dose rate) afterloader on or around Thursday, 1/9/2020. (The RSO) stated that he noted the matter yesterday (1/15/20 at around 1530); he stated that the physician associated with the patient's case confirmed (the RSO's) concerns about the patient's dose. (The RSO) reported that the patient apparently received dose in 1 fraction that was to be administered over 2-3 fractions. The Agency has no further information on this matter as of the date of submission of this memo. Of note, East Alabama Medical Center is authorized to possess and use an Elekta Flexitron model 136149A02 HDR medical irradiator under Alabama license 105, with a maximum of 12 Ci of Ir-192. Alabama Event 20-01 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 5448417 January 2020 17:00:00The following information is summarized from an email received from the state of North Dakota: At approximately 2215 MST on 12/18/2019, while setting up for a radiography shot, the radiography team experienced a source disconnect. When the team realized a disconnect occurred, they established a 2 mR/hr. boundary and contacted the radiation safety officer (RSO). The RSO arrived on site and was able to retrieve the source back into the shielded position. No overexposures were reported. The licensee removed the camera from service and returned it to their facility in Bismarck, ND. The licensee determined that poor camera maintenance and personnel error contributed to the guide tube being only partially connected to the camera which led to the disconnect. The radiography crew was briefed on the cause of the event and the proper steps to maintain and inspect a camera prior to use. The camera was a SPEC 150, serial number 2592 , with a 66 Ci Ir-192 source, serial number AK 2405.
ENS 5443310 December 2019 11:04:00

At 0920 CST on December 10, 2019, Comanche Peak began a planned modification on the Unit 1 Plant Computer System. During this modification, the ability to perform emergency assessment in the Technical Support Center (TSC) and the Emergency Operations Facility (EOF) will be impacted. Since the ability to perform emergency assessment is not expected to be restored within 72 hours, this is reportable per 10CFR50.72(b)(3)(xiii) as an event that results in a loss of emergency assessment capability. During this modification, the Control Room will continue to have the ability to perform emergency assessment. If an Alert, Site Area Emergency, or General Emergency is declared during this modification, communicators dedicated to performing emergency assessment will be stationed in the Control Room, TSC, and EOF. The Plant Computer System modification is scheduled to be completed on December 22, 2019, and a follow-up ENS notification will be made once the Unit 1 Plant Computer System is declared functional. The NRC Resident Inspector has been informed.

  • * * UPDATE ON 1/24/20 AT 1034 EST FROM THOMAS BOWDEN TO RODNEY CLAGG * * *

Licensee provided an update to inform that as of 0853 CST on 1/24/20, the modification is complete and the emergency assessment capabilities of the TSC and EOF have been restored. Notified R4DO (Silva)

ENS 5439520 November 2019 09:28:00The following information was received from the state of Tennessee via email: Patient treated with Lutathera (Lu-177 dotatate) on November 14, 2019. It was determined during her infusion that the Foley catheter was leaking. After the leak was identified, proper decontamination procedures were performed. The patient was instructed upon discharge that there was a chance for potential skin injury. Licensee reported that the estimated skin dose was 7 Gray (Gy). On November 18, 2019, the patient informed her provider that there was skin irritation in the peri-gluteal and peri-labia areas. It was determined that this was skin injury consistent with radiation injury. A follow-up report will be submitted upon receipt of a written report from the licensee. Tennessee Event Report ID No.: TN-19-161 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 543777 November 2019 14:55:00The following information was obtained from the state of Texas via email: On November 7, 2019, the licensee's radiation safety officer (RSO) notified the Agency (Texas Department of State Health Services) that at approximately 2000 CST on November 6, 2019, one of their industrial radiography crews had been unable to retract a 113 Curie iridium-192 source (model 702, SN: TT2307) into a QSA 880 Delta exposure device (SN: D7727) at a temporary job site in Sonora, Texas. The RSO stated the drive cable had broken at the ball stop. Source retrieval was performed by authorized employees. The initial radiographers' and another of the licensee employee's self-reading pocket dosimeters read 13 and 14 mR. The two authorized source retrievers' self-reading pocket dosimeters had readings of approximately 300 mR. All dosimetry badges are being sent for immediate processing. There were no other persons in the area so there was no risk of exposure to any member of the public. The RSO and staff will examine the crank assembly and drive cable when it gets to their location on November 8, 2019. The RSO also plans to send the crank assembly/drive cable for evaluation by a third party service/repair company. The exposure device was tested multiple times using a different set of cranks following the retrieval and it operated properly. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No: 9723
ENS 543756 November 2019 21:07:00Below is a summary of a Part 21notification received from the vendor via facsimile: The vendor, via a testing facility, identified another batch of contaminated hydraulic snubber fluid. The fluid batch number is 16DLVS852, manufactured on 4/17/16 by Momentive Performance Materials, Leverkusen, Germany. Licensees that were supplied the contaminated fluid were identified as: Palisades, Pilgrim, Browns Ferry and Sequoyah. Previous batches were identified under the Part 21 process by Lake Engineering Co. as follows: Batch Number (followed by ADAMS Ascension Number) AD965 - ML070180491 and ML070300154 ZJS1518 - ML19077A096, ML19136A044 and ML19199A034 11KLVS145 - ML18211A302, ML18295A199, ML19008A043 and ML19071A112 14ELVS145 - ML17128A465, ML17212A628, ML17313A471, ML17355A139 and ML19121A155 For further information, please contact: Walter Paszul, PE General / Engineering Manager E-Mail: walter@fronekgrp.com Phone No: ( 603) 528-1931 Fax No: ( 603) 528-6381
ENS 5435426 October 2019 11:29:00While in use on a job site with the source extended, a Troxler Model 3430 moisture density gauge was damaged by a skid loader. The source was able to be retracted into the shielded area of the gauge but the shield cannot be closed due to damage to the bottom shield plate. The licensee has established a 15 foot radius boundary per their emergency procedure and will be obtaining a survey meter to verify radiation levels at the boundary. The licensee will be getting local assistance to secure the source for transportation back to their storage facility. A Troxler Model 3430 normally contains a 44 mCi Am-241/Be source and a 9 mCi Cs-137 source.
ENS 5433818 October 2019 10:45:00

EN Revision Text: INADVERTENT OPENING OF MAIN TURBINE BYPASS VALVES POTENTIONALLY AFFECTED SAFE SHUTDOWN CAPABILITY At 0207 (CDT), the Bypass Electro-Hydraulic Control (EHC) system was secured for planned maintenance. When the Bypass EHC pumps were secured, both of the Main Turbine Bypass Valves unexpectedly opened to approximately 4.5 percent. Plant parameters indicated no impact to Turbine Control Valve position, Reactor Pressure, Turbine First Stage Pressure, or Main Steam Line flows. There were no other abnormal indications noted. With the Turbine Bypass Valves partially open, there is a potential to affect instrumentation that trips on high Turbine First Stage Pressure. Therefore, this event is being reported as a potential loss of Safety Function. At 0256, the Bypass EHC system pumps were restored and the Turbine Bypass Valves Closed. No radiological releases have occurred due to this event from the unit. The licensee has notified the NRC Resident Inspector.

  • * * RETRACTION FROM THONG LE TO HOWIE CROUCH AT 1019 EST ON 11/19/19 * * *

This Event Notification was contingent on the Main Turbine Bypass Valves opening which resulted in the inoperability of Turbine First Stage Pressure monitoring instrumentation. A detailed review of system design and plant parameter trends has confirmed that the Main Turbine Bypass Valves remained closed for the duration of the event, permitting the instrumentation systems dependent on accurate Turbine First Stage Pressure to perform their respective design and licensing basis functions. Valve drift in the open direction was observed by position indication when hydraulic control pressure was removed. However, the valves were at an over-travel closed position prior to the event allowing the valves to settle at a position where an internal spring could provide closing force to the valve disc. Multiple plant parameter trends including Turbine First Stage Pressure, Reactor Pressure, Main Steam Line flows, and Main Turbine Bypass Valve discharge line temperatures indicate that the Main Turbine Bypass Valves remained closed for the duration of the event. The licensee has notified the NRC Resident Inspector. Notified R4DO (O'Keefe).

ENS 5433718 October 2019 02:28:00

At 1951 (EDT) on October 17, 2019, fretting indications on the reactor coolant system pressure boundary piping (pressurizer spray line) were identified. This condition does not appear to meet original construction code, ANSI B31.1, 1967 Edition thru summer 1971 Addenda. The condition will be resolved prior to plant startup. This event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. This condition will be corrected prior to the plant entering Mode 4.

  • * * RETRACTION ON 10/31/19 AT 1450 EDT FROM JIM SCHWER TO BETHANY CECERE * * *

An engineering evaluation has determined that the subject fretting is not considered a flaw, but instead is considered wear. Appendix F of Section III of the ASME Boiler and Pressure Vessel Code was applied and it was determined that the pressurizer spray line piping maintained its required design safety functions in the as-found condition. The wear has been repaired during the current refueling outage in accordance with the original construction code (ANSI B3l.l, 1967 Edition through summer 1971 Addenda) as well as Owner's Requirements. The NRC Resident Inspector has been notified. Notified R1DO (Young).

ENS 543167 October 2019 19:06:00

The following information was obtained from the state of Texas via email: On October 7, 2019, the licensee notified the Agency (Texas Department of State Health Services) that one of its Troxler model 3411-B moisture density gauges, containing 40 milliCuries of americium-241/beryllium and 8 milliCuries of cesium-137, had been secured inside the bed of a technician's pickup truck at a temporary job site when the truck was stolen. The technician had driven over to and gone into a port-a-can. There were other jobsite workers in the area. When the technician came back outside, the other workers told him his pickup was being driven away - they had not realized he was not driving it until they saw him. They attempted to follow the vehicle but were unsuccessful in locating it. The local police department was notified but have not yet arrived on the scene. The licensee reported that per the technician, insertion rod on the gauge was locked, the transport case was locked and was secured with two chains to the bed of the truck, and the tailgate was locked. The licensee stated it does not appear that an exposure could result to persons in unrestricted areas. The licensee and technician are attempting to collect information from persons who were in the area. More information will be provided as it is obtained in accordance with SA-300. Gauge: Troxler Model 3411-B, SN: 8489 Sources: Americium-241/Beryllium, 40 milliCuries, SN: 47-4872, Cesium-137, 8 milliCuries, SN: 40-5728 Texas Incident No.: 9719

  • * * UPDATED ON 10/8/19 AT 1214 EDT FROM KAREN BLANCHARD TO KERBY SCALES * * *

The following update was received from Texas Department of State Health Services via email: The licensee has notified the Agency that the vehicle and gauge were recovered by the local police at approximately 2230 CDT on October 7, 2019. The gauge was still fully secured in the vehicle as it had been when the vehicle was taken. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Keller), ILTAB, NMSS Events, and CSNS Mexico (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 5429526 September 2019 14:47:00

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE / DENSITY GAUGE The following information was received from the State of California via email: On September 26, 2019, the RSO (radiation safety officer) of Maurer Technical Services, (Maurer, CA RAM license 6163-30) a nuclear gauge service provider and authorized CPN/Instrotek dealer, contacted the Brea RAM/Radiologic Health Branch office to report the theft of one of their nuclear gauges that they had leased to G3 Quality, Inc. (G3). The gauge was a CPN Model MC-3, S/N M39028685 (10 mCi Cs-137 and (50 mCi) Am:Be-241). The gauge was stolen at the Hard Rock Hotel in Stateline, NV where the gauge operator was staying while working at a project in Lake Tahoe, CA. The gauge was locked to the bed of the vehicle (open bed), the alarm enabled, and left in the parking lot of the hotel on the evening of September 25, 2019 (around 2130 PDT). The gauge was discovered missing on the morning of September 26, 2019, with the handles broken off the transport case. The cab of the truck was also broken into with other items stolen, including a laptop and the front hood was broken into to defeat the vehicle alarm. A police report was taken (the specific law enforcement agency was not provided) and the loss was reported to the G3 office and then to (the Maurer RSO) who then contacted our (California Radiologic Health Branch) office. The incident is under investigation and corrective actions will be determined at a later date. CA 5010 No.: 092619

  • * * UPDATE AT 1334 EDT ON 10/4/19 FROM ANDREW TAYLOR TO JEFF HERRERA * * *

The following update was received from the California Department of Public Health via email: The gauge was recovered by Local Law Enforcement near Heavenly Village in South Lake Tahoe, CA and the gauge was returned to the license on September 27, 2019. Notified the R4DO(Proulx), NMSS Events, CNSNS (Mexico). 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 5429626 September 2019 18:11:00The following information was obtained from the State of Texas via email: On September 26, 2019, the licensee's radiation safety officer notified the Agency (Texas Department of State Health Services) that it had a shutter failure on one of its fixed nuclear gauges. The Ohmart SH-F1 gauge, containing 5 milliCuries of cesium-137 (SN: 2925 CG), is mounted on a vessel. The licensee had closed the shutter in order to do some work in the area. Upon completion of the work, the licensee was attempting to re-open the shutter when the screws holding the actuator to the shutter handle sheared. The shutter is in the fully closed position which was confirmed by survey. There were no exposures as result of this event. A service company has been scheduled to make repairs on September 27, 2019. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: 9714
ENS 5433216 October 2019 10:22:00This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system. On August 20, 2019, at approximately 1133 hours Central Daylight Time (CDT), Browns Ferry Nuclear Plant (BFN), Unit 2 experienced an unexpected loss of the 2A Reactor Protection System (RPS). This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of Standby Gas Treatment Trains A, B, and C and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected. Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid. The cause of the RPS MG Set trip was dirty potentiometer windings on an Over Voltage Relay. The dirt prevented the potentiometer's wiper from contacting its windings, resulting in erratic setpoint values. There were no safety consequences or impact to the health and safety of the public as a result of this event. This event was entered into the Corrective Action Program as Condition Reports 1542603, 1542608, and 1542569. The NRC Resident Inspector has been notified of this event.