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ENS 5580629 March 2022 09:34:00

The following information was received from the state of New York (NYSDOH) via fax: Four transmission/reference/calibration sources were shipped out in two separate shipments via (a common carrier) to Eckert & Ziegler on 3/17/2022 under two-day shipping and have been listed as 'delayed' since 3/18/2022. Upon contacting (the common carrier), an incident (No. C-61803614) was opened to attempt to locate the sources as (the common carrier) was unable to locate the two shipments. The licensee formally reported the sources as missing to NYSDOH on 3/28/2022. The Gd-153 source, (1.27 mCi as of 3/17/22), is deemed a reportable quantity under 20.2201 (a)(1)(ii), as greater than 10 times the Appendix C to Part 20 value (10 microCi), but less than 1000 times. The three other sources (Cobalt-57) fall below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201. The licensee is continuing to contact (the common carrier) regarding these sources and keeping NYSDOH updated on the status. NYS is consistently monitoring this situation under Incident No. 1389: Device Manufacturer: Eckart & Zeigler Device Model: TBD Device S/N: S5-864 Source Manufacturer: Eckart & Zeigler Source Model: TBD Source S/N: S5-864 Isotope: Gd-153 Activity: 1.27 millicuries on 3/17/2022 (10 mCi assayed on 4/1/2020)

  • * * UPDATE ON 04/21/22 AT 1216 EDT FROM DANIEL SAMSON TO TOM HERRITY * * *

The following information was received from the state of New York (NYSDOH) via fax: Updated Event description: The previously reported Gd-153 source (1.27 mCi on 3/17/22) was recovered on Friday, April 1, 2022. The Gd-153 source was successfully delivered to the intended recipient (Eckert & Ziegler) without any signs of tampering, opening, or modification. All sources in question were accounted for by the NY state medical licensee and Eckert & Ziegler. This event is attributed to a logistical error in transporting these packages by the common courier. As previously reported, the Gd-153 source was deemed a reportable quantity under 20.2201(a)(1)(ii) (1.27 mCi as of 3/17/22), as greater than 10 times the Appendix C to Part 20 Value, but less than 1000 times (10 micro-Ci). The 3 other sources (Cobalt-57) fell below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201. All other Cobalt-57 sources were also recovered without any signs of tampering, opening, or modification, and were all accounted for by the NY state medical licensee and Eckert & Ziegler on 4/1/2022. NYS opened Incident No.1389 to track this event. As of today, Incident No.1389 has been closed. Device Manufacturer: Eckert & Ziegler Device Model: HEGL-0133 Device S/N: S5-864 Source Manufacturer: Eckert & Ziegler Source Model: HEGL-0133 Source S/N: S5-864 Isotope: Gd-153 Activity: 1.27 milliCuries on 3/17/2022 (10 mCi assayed on 4/1/2020) Event Report ID No.: Update to NYDOH - 22-02 Notified R1DO (Dentel), NMSS Events Notification, ILTAB, CNSC (Canada) 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 557779 March 2022 09:55:00The following information was received from the state of New York via email: A portable XRF (x-ray fluorescence) device containing a 6 millicurie Cobalt-57 source was unintentionally left by an authorized user on a public bus in the Castle Hill neighborhood of the Bronx in New York City. Specific device information is below. The licensee contacted the MTA Police as well as Viken, the device manufacturer. The licensee was able to search the buses at the end of the day on January 26, 2022, but the device was not located at that time. According to the licensee an individual found the case with the device and contacted Viken. The representative at Viken was then able to get the individual in contact with the licensee. As of 1710 EST on January 27, 2022, the device is back in the licensee's possession and is in working order. Device Manufacturer: Viken Device Model: Pb200i Device S/N: 2219 Source Manufacturer: Isotope Products Laboratory Source Model: Model 3901 Series Source S/N: R4-672 Isotope: Cobalt-57 Activity: 6 millicuries NY incident no. NYDOH- 22-01 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 5563810 December 2021 03:54:00At 0049 EST, on December 10, 2021, with Unit 2 in Mode 1 at 73 percent power, the reactor automatically tripped due to an unknown condition. The trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being maintained by discharge steam to the main condenser using the turbine bypass valves. Units 1 and 3 are not affected. The cause of the trip is under investigation. 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 to 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 plant is in its normal shutdown electrical lineup maintaining normal operating pressure and temperature.
ENS 5561227 November 2021 13:16:00At 0519 EST on November 27, 2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Emergency AC Electrical Power System occurred. The reason for the Emergency AC Electrical Power System auto-start was a lockout of the CT-2 transformer; causing a temporary loss of AC power to the main feeder bus. The Keowee Hydroelectric Units 1 and 2 automatically started as designed when a main feeder bus undervoltage signal was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Emergency AC Electrical Power System. Additionally, the temporary loss of AC power resulted in a loss of Decay Heat Removal (DHR) that was restored upon power restoration to the main feeder bus. Therefore, this condition is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v) for an event or condition that could have prevented fulfillment of a safety function. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The loss of the CT-2 transformer is under investigation. Main feeder bus power was restored within a minute so no plant heat up occurred as a result of the loss of the decay heat removal system.
ENS 5557010 November 2021 18:38:00

At 1515 EST on 11/10/21, approximately 89 gallons of PCB oil is unaccounted for from the Substation 'N' Transformer, located in the Owner Controlled Area. Transformer nameplate oil capacity is 569 gallons. Prior to removal of the original Substation 'N' Transformer, approximately 475 gallons of 10-CA-OIL (PCB Oil) was evacuated and stored by HEPACO (a licensee vendor). Approximately 5 gallons of oil is inaccessible to evacuate and remains in the original transformer. Below the transformer was evidence of oil leakage to the ground. The leakage appears to have been occurring over time, not as a result of a catastrophic failure. This condition is reportable to the Virginia Department of Environmental Quality (VA DEQ). The VA DEQ was notified of this condition at 1815 on 11/10/21. Cleanup activities are on-going. This event is reportable in accordance with 10CFR50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.' The licensee will be notifying the Louisa County administrator and has notified the NRC Resident Inspector.

  • * * UPDATE FROM MARC HOFMANN TO DONALD NORWOOD AT 1309 EST ON 11/12/2021 * * *

Initial, unofficial, field testing performed by HEPACO indicated the oil released to the ground was PCB-Contaminated Oil. The official test results from the lab indicated that the oil is in fact not classified as PCB-Contaminated Oil. Therefore, this update is being made to EN55570 to clarify that the oil released to the environment was not PCB-Contaminated Oil. The licensee notified the NRC Resident Inspector and the VA DEQ of this update. Notified R2DO (Miller).

ENS 555679 November 2021 13:33:00At 1040 hours EST, November 9, 2021, the site reported a violation of the station National Pollutant Discharge Elimination System permit. The 24-hour environmental report addressed an unauthorized discharge of 7,245 gallons of non-radiological water that was pumped into a storm drain to de-water an on-site electrical vault located outside of the protected area. This discharge occurred from 0800 to 1230 hours on November 8, 2021. Sampling and analysis of the vault water is in progress to assess for the presence of pollutants. 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 notified the U.S. Environmental Protection Agency and the Commonwealth of Massachusetts Department of Environmental Protection.
ENS 555139 October 2021 07:27:00At 0300 EDT, with Unit 3 in Mode 3 at 0 percent power, an actuation of the Auxiliary Feedwater System occurred when steam generator water level rose to 80 percent causing a Feedwater Isolation signal, which tripped the last remaining Steam Generator Feed Pump during plant cooldown. The Auxiliary Feedwater System automatically started as designed when the feedwater isolation signal was received. This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified. The cause of the high steam generator level is under investigation.
ENS 555064 October 2021 19:59:00At 1433 CDT, on October 4, 2021, Arkansas Nuclear One, Unit 2 (ANO-2) completed the analysis related to an indication revealed on head penetration 46 during Reactor Vessel Closure Head inspections. It was determined the indication is not acceptable under ASME code requirements. The indication displays characteristics consistent with primary water stress corrosion cracking. No leak path signal was identified during ultrasonic testing. The plant was in cold shutdown at 0 percent power and in Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. This condition has no impact to the health and safety of the public. This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier. This is the only indication that is currently present, however, if additional indications are found, they will also be repaired prior to the plant startup. The NRC Senior Resident Inspector has been notified.
ENS 5548423 September 2021 18:46:00During planned testing of the Unit 1 HPCI (high pressure coolant injection) system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable. HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done. The licensee has notified the NRC Resident Inspector.
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 5545913 September 2021 23:47:00On September 13, 2021, at 1822 EDT, an apparent non-compliance with 10 CFR 50, Appendix R, section III.G.2 (separation of redundant fire safe shutdown equipment) was identified. Specifically, it was determined that some Emergency Diesel Generator (EDG) cables may be susceptible to a hot short/spurious operation to the close circuit. A spurious closure of the emergency bus normal supply breakers after the EDG is powering the bus could result in non-synchronous paralleling, EDG overloading, or EDG output breaker tripping due to faulted power cable from normal supply breaker. The spurious closure of the normal supply breakers is not currently addressed in the Appendix R Report or previous Multiple Spurious Operations (MSO) analysis. This condition is associated with the Appendix R safe-shutdown function of the Emergency Power System. The Emergency Power System is considered operable but not fully qualified for its safety-related design function. The following fire areas are impacted: 1) Fire Area 13, Unit 1 Normal Switchgear Room 2) Fire Area 46, Unit 1 Cable Tray Room 3) Fire Area 3, Unit 1 Emergency Switchgear and Relay Room 4) Fire Area 2, Unit 2 Cable Vault and Tunnel Until this condition is analyzed, Surry has implemented mitigating actions in the above fire areas. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60-day written report pursuant to 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as CR (condition report) 1180502. The NRC Resident Inspector has been notified of this event. Mitigating actions include posting fire watches in the affected areas.
ENS 5546613 September 2021 14:53:00The following information was received from the state of Oklahoma via email: We (Oklahoma Department of Environmental Quality) have been informed that earlier today a Troxler Model 3440 gauge was struck by a truck in Oklahoma City. The gauge belonged to CEC Corp. (OK-31047-01). Surveys of the gauge indicated that the shielding was intact. (The State) will provide more information as it becomes available. Troxler Model 3440 gauges contain 40 mCi Am241:Be and 8 mCi Cs-137 sources.
ENS 5546013 September 2021 17:00:00The following information was received from the state of Oklahoma via email: On August 30, 2021, (one) of Thunderhead Testing's portable density gauge operators was on a construction site near Vian, Oklahoma. At approximately 1530 CDT, after completing a density/moisture measurement, one of the contractor's employees struck the gauge with a pickup truck. The gauge operator claims he was instructed by the superintendent to do the density measurements in front of the job superintendent's truck. When the operator had completed the density measurements and retracted the probe safely back into home position in the gauge, he turned around to pack up the gauge to move to the next location. As he turned to open the transport case, the job superintendent moved his truck to go to the next location and ran over the gauge. The superintendent stopped and the technician immediately secured the area and notified his RSO (radiation safety officer). The RSO stated that the survey meter measurements indicated a radiation level at the gauge of 0.02 mR/hr indicating no breach of the source capsules and no leakage. The operator photographed the gauge/incident area and then placed the gauge and gauge pieces into the case, properly secured it per standard transportation protocol and then transported it back to the storage location in Bixby, Oklahoma. Upon arrival at the lab in Bixby, the operator conducted a leak test and then shipped the completed test via expedited, next-day delivery to InstroTek (NC) for analysis. The leak test report (was provided to the NRC). With the leak test results indicating the integrity of the sources had not been compromised, arrangements were made with InstroTek to ship the gauge to InstroTek's facility in NC for proper disposal. The gauge was a Troxler Model 3430, serial number 16349, and contains 40 mCi Am241:Be and 8 mCi Cs-137. Oklahoma Department of Environmental Quality is initiating a reactive inspection and is waiting for further details including date and time.
ENS 5541418 August 2021 11:21:00The following information was received from the state of Texas (the Agency) via email: On August 18, 2021, the Agency was notified by the licensee that a Troxler model 3430 moisture density gauge was stolen from the back of an employee's truck. The employee's truck was parked at their apartment overnight. The licensee stated that the apartment complex security camera system showed the theft occurred at about 0149 CDT on August 18, 2021. The gauge contains a 40 milliCurie Americium - 241 source and an 8 milliCurie Cesium - 137 source. The licensee stated the gauge was locked using chains in the back of the pickup truck. The licensee reported local law enforcement has been notified of the theft. The Agency requested additional information from the licensee. Additional information will be provided in accordance with SA-300. TX Incident #: 9877 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 5541719 August 2021 07:19:00

The following information was obtained from the state of Iowa via email: On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan. The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241. NMED Number: IA210003

  • * * UPDATE ON 9/2/21 AT 1522 EDT FROM RANDAL DAHLIN TO JOANNA BRIDGE * * *

The following information was obtained from the state of Iowa via email: The SenTek service technician arrived onsite late afternoon on August 18, 2021 and determined that the bolts holding the shutter had sheared and needed to be replaced. All other shutter bolts were inspected and found to be satisfactory. As a corrective action, the licensee is implementing an annual preventative maintenance check to inspect and replace the bolts on all shutters. The licensee's intent is to replace these fixed gauging devices with x-ray tube devices. The State considers this event closed. Notified: R3DO (Riemer) and NMSS Events Notification via e-mail.

ENS 5541318 August 2021 01:07:00

At 0024 EDT on 8/18/21, an unusual event was declared (EAL HU 4.1) due to receipt of multiple fire alarms and halon discharge in the cable tunnel. At 0036, the fire brigade verified no signs of fire. Unit 1 remained at 100 percent power and stable. The area is currently being ventilated. Unit 2 was not affected by this event. The licensee has notified State and local authorities and the NRC Resident Inspector. R1 Public Affairs (Screnci) was notified. Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE FROM ROBERT KLINDWORTH TO HOWIE CROUCH AT 0414 EDT ON 8/18/21 * * *

At 0401 EDT, Beaver Valley terminated their notification of unusual event. The basis for termination was that there was no indication of fire. The licensee will be notifying the NRC Resident Inspector and has notified State and local authorities. Notified R1DO (Jackson), IRD MOC (Gott), NRR EO (Felts), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

ENS 5540613 August 2021 16:44:00The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email: Loyola University Medical Center contacted the Agency this afternoon to report a medical underdose of Lu-177 that occurred today, August 13, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient. (The) Radiation Safety Officer for the licensee contacted the Agency at approximately 1500 CDT on August 13, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 14 percent of the dose prescribed (28 mCi) in the written directive. The underdosing was intentionally aborted by the authorized user after the patient advised they had received the planned chemotherapy injection the day before, rather than after the radiopharmaceutical administration per procedure. The licensee is investigating root cause. The licensee is calculating organ dose to the kidney, but preliminary estimates are 67 rad. If the dose falls beneath 50 rad, the incident may be retracted. Notification to the patient and the referring physician has been completed. Agency inspectors are awaiting additional information but plan a reactive inspection within 10 days. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated as additional information becomes available. Illinois NMED Report No.: IL210024 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 553912 August 2021 14:23:00

The following information was received from the state of Nevada via email: Authorized user brought a portable nuclear gauge (PNG) up to Reno, Nevada (their license is based out of Las Vegas) to use on job today, August 2, 2021, and stayed the night of August 1, 2021, at the Atlantis, parked in the South East Corner lot. When he went out at 0800 PDT he noticed that the gauge was missing and the chains had been cut. He reported the missing gauge to the (Radiation Safety Officer) RSO and looked around the parking lot, drove the perimeter of the lot and a few blocks around the hotel and did not find the gauge. They notified Reno PD of the stolen gauge and (was notified they) would respond by 0915 PDT (no report number available yet). Atlantis is checking their parking lot security cameras to see if they caught anything on the camera to get a line on the device and fix the time line. Nevada NMED report number: NV210010

  • * * UPDATE FROM COREY CREVELING TO HOWIE CROUCH AT 1923 EDT ON 8/2/21 * * *

The following update was received via email: The PNG is from Terracon Consultants, Inc. Sacramento, California office covered by California RML CA 8064-34, and it entered the State of Nevada without reciprocity authorization or shipping papers of any kind. Updated the reciprocity pull down and the license number. Added the police report number (21-13940). Atlantis Hotel-Casino will provide anything found in their search of security camera footage to Reno Police Department. Notified R4DO (Gepford) and NMSS 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 553922 August 2021 17:01:00The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email: Children's Hospital of Chicago Medical Center (IL-01165-01), contacted the Agency on 8/2/21 to advise that a pediatric administration of Y-90 resulted in an underdose exceeding 20%. The incident occurred today, August 2, 2021. No untoward medical impact was expected to the patient. The licensee's radiation safety officer designee contacted (the Agency) to advise that a pediatric patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 75 percent of the dose prescribed in the written directive. A Therasphere representative was on site for the administration and did not note stasis. The licensee suspects a kink in the delivery catheter but is currently imaging the RAM waste and tubing to confirm. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. The patient's father was advised. It is unclear at this point if the referring physician has been notified. Agency inspectors will perform a reactionary inspection tomorrow, August 3, 2021, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days. Illinois NMED report number: IL210022 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 5539031 July 2021 21:37:00At 1646 (CDT) on 7/31/21, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to control board indications of a Unit 1 'B' Main Feed Pump trip. After the reactor trip, one of the Condenser Steam Dump valves cycled to intermediate and remained stuck. The Condenser Steam Dump Valve was isolated locally using manual isolation valves. The 'B' Feed Regulating Bypass Valve did not control in automatic and was taken to manual to control the level in 'B' Steam Generator. The Auxiliary Feedwater System automatically actuated as designed when the valid actuation signal was received. Operations stabilized the plant in Mode 3. Decay heat is being removed by atmospheric dump valves due to condenser unavailability. Unit 2 is unaffected. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified. During the transient, all control rods inserted into the core. There is no known primary to secondary leakage. During the transient, no relief valves or safeties lifted. The plant is currently maintaining normal operating temperature and pressure with all safety equipment available. The plant is in its normal shutdown electrical lineup.
ENS 5538830 July 2021 15:43:00

The following is a summary of a phone call with the licensee: On 7/30/2021 while at the jobsite in Moca, Puerto Rico, the licensee's InstroTek MC-3 Elite gauge was run over by a paving roller while in the safety drum. The gauge plastic casing was damaged and the source rod was broken. The sources were in the shielded position at the time of the incident. The InstroTek gauge serial number is 31331 and contains nominally 10 mCi of Cs-137 and 50 mCi of AmBe. The damaged gauge was placed in its storage container and returned to the licensee's Cabo Rojo facility for a swipe test. After the incident, the gauge read 0.2 to 0.3 mR/hr at 1 meter with a survey meter. No overexposures were reported.

  • * * RETRACTION ON 8/3/21 AT 1320 EDT FROM ALFONSO BOSQUE TO KERBY SCALES * * *

The following retraction is a summary of a phone call with the licensee: The Radiation Safety Officer inspected the gauge and verified that the gauge maintained its safety function. The source was secured and a leak test verified no leakage. Notified R1DO (Eve) and NMSS Event Notification via email.

ENS 5541920 August 2021 10:05:00The following information was received from the state of North Carolina via email: A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate. An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated. Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures. NMED Report No.: NC210014 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 5538630 July 2021 13:47:00

The following information was received from NMED for the Georgia Radioactive Materials Program: This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason. Georgia Incident Number: 45

  • * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *

The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital: The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study. The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward. Notified R1DO (SCHROEDER) and NMSS Events Notification group. 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 552957 June 2021 18:31:00At 1527 (Central Standard Time) Unit 2 Reactor tripped caused by a turbine trip due to a fault and fire on Unit 2 Main Transformer #1. All Aux Feedwater Pumps started due to steam generator Lo-Lo levels. Unit 2 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007B. The Emergency Response Guideline Network has been exited. Decay heat is being rejected to the Main Condenser via the steam dump valves. Fire was extinguished at 1546 without offsite assistance. No major injuries reported and no personnel transported offsite for medical attention. Cause of the fault and fire are under investigation. NRC Resident Inspector has been notified. All rods inserted into the core during the trip. There were no relief valves or safety valves lifted during the transient. The plant is stable in its normal shutdown electrical lineup via the auxiliary transformer with all safety equipment available. Unit 1 was not affected by the transient.
ENS 5579923 March 2022 07:56:00The following information was obtained from the state of New Jersey Radioactive Materials Program (NJ RMP) via email: On 2/17/2022, staff (at NJ RMP) was notified via police report that two XRF devices were stolen from the licensee's location in March of 2021. This notification resulted from an investigation initiated by NJ RMP staff to obtain unpaid licensing fees in January 2022. While doing so, staff found that the RSO died in March of 2021 and the licensed storage location was for sale. Staff were able to make contact with the estate lawyer to attempt to locate the devices. On 2/17/2022, the estate lawyer forwarded staff a police report filed on 3/9/2021 reporting the stolen devices and other items. No follow up to find the stolen items was done by the police or family members. No further investigation is expected. The license was revoked on 2/23/2022. Device 1 was manufactured by RMD Instruments, Inc., model LPA-1, serial number 1183, containing 12 mCi of Co-57. Device 2 was manufactured by Viken Detection, model Pb200i, serial number 2537, containing 5 mCi of Co-57. NJ Investigation number: 448354-INV220001 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 5510920 February 2021 22:00:00At 1830 (EST) on 02/20/21, Turkey Point Nuclear Station Security identified three distressed individuals, potentially drowning, in the bay just offshore of the Owner Controlled Area. The licensee contacted the U.S. Coast Guard and local sheriffs department for assistance. At 1852 all 3 individuals were reported as safe and onshore. This event is being reported pursuant to 10 CFR 50.72(b )(2)(xi). The NRC Resident Inspector has been notified.
ENS 5510819 February 2021 17:02:00The following information was obtained from the state of California, Department of Public Health - Radiologic Health Branch (RHB) via email: On 2/16/21, the licensee contacted RHB to report that a contamination incident occurred during cutting of a source rod of a moisture density gauge. The gauge involved is a Troxler Model 3440, S/N 17263, originally containing 8 mCi of Cs-137 and 40 mCi of Am-241. The source serial number is 50-6634 and the 'IAEA Certificate of Competent Authority Special Form Radioactive Materials' that was provided by the licensee identifies the source as QSA Global Models XN30/0, XN 30/1, or 30XN/2, and states that the sources are single encapsulated. On 2/13/21, the licensee was attempting to replace a source rod on a customer's nuclear gauge. After removing the source rod tip, licensee surveys of the area detected contamination. Wipes of the rod and work area were counted using a Ludlum 3030, S/N 222793, calibrated 10/12/20, and indicated low levels of beta contamination (approximately 25 nCi total) apparently due to a leaking source. It is not believed the cutting of the source rod breached the Cs-137 source. The contamination was confined to a small portion of a countertop, a vise, a hack saw blade and the floor directly below the work area. The contaminated area was wiped with damp rags and contaminated items and rags were collected into plastic bags and then placed into a 5-gallon bucket. The source and the piece of the source rod cut off were placed into a large lead container. The area was subsequently surveyed again, and no radioactivity was detected. No contamination was detected on clothes or shoes. California Report ID: 5010-021621
ENS 5508629 January 2021 02:43:00This is an eight-hour, non-emergency notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the Technical Support Center (TSC) Supply Fan belt had failed which affects the functionality of an emergency response facility. Corrective maintenance activities are being performed on January 29, 2021 to the TSC HVAC (heating, ventilation, and air conditioning system). The work includes replacing the failed belt and restarting the TSC Supply Fan. The work duration is approximately 12 hours. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency. 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 Illinois Emergency Management Agency.
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.