|Entered date||Event description|
|ENS 54716||15 May 2020 13:25:00||At 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 54685||30 April 2020 18:51:00||The 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 54689||1 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
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 54680||24 April 2020 07:00:00||At 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 53444||6 June 2018 13:27:00||Below 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 53446||6 June 2018 17:35:00||The 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 54684||30 April 2020 15:37:00||The 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 54679||23 April 2020 10:57:00||The 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 54594||20 March 2020 17:47:00||On 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 54686||30 April 2020 19:50:00||The 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 54675||22 April 2020 10:43:00|
This 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 54683||28 April 2020 14:49:00||The 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 54526||14 February 2020 16:01:00||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.|
|ENS 54499||29 January 2020 16:38:00||The 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 54498||29 January 2020 15:28:00||On 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 54486||21 January 2020 19:03:00||The 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 54483||17 January 2020 11:57:00||The 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 54484||17 January 2020 17:00:00||The 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 54433||10 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.
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 54395||20 November 2019 09:28:00||The 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 54377||7 November 2019 14:55:00||The 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 54375||6 November 2019 21:07:00||Below 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: firstname.lastname@example.org Phone No: ( 603) 528-1931 Fax No: ( 603) 528-6381|
|ENS 54354||26 October 2019 11:29:00||While 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 54338||18 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.
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 54337||18 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.
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 54316||7 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
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 54295||26 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
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 54296||26 September 2019 18:11:00||The 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 54332||16 October 2019 10:22:00||This 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.|
|ENS 54199||5 August 2019 01:28:00||On August 4, 2019 at 1745 (EDT), Reactor Recirculation Pump (RRP) 11 tripped. The cause for the trip is under investigation. Following the RRP trip, the Average Power Range Monitors (APRMs) flow bias trips are inoperable due to reverse flow through RRP 11. The APRMs were restored to operable on August 4, 2019 at 1807, when the RRP 11 Discharge Blocking Valve was closed. This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(v)(A) which states: 'Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition.' The licensee has notified the NRC Resident Inspector.|
|ENS 54198||3 August 2019 23:33:00||At 1947 (EDT) on 8/3/19, with Hope Creek in Mode 1 at 37 percent power, the reactor was manually scrammed due to loss of condenser vacuum. All control rods fully inserted into the core. All safety systems responded as designed and expected. Reactor level was stabilized using Reactor Core Isolation Cooling (RCIC) and Reactor Feedwater Pumps. Currently reactor water level is being maintained by the feedwater system and decay heat is being removed by the main condenser using the main turbine bypass valves. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the manual actuation of RCIC, this event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50. 72(b )(3)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The plant is in its normal shutdown electrical lineup with all safe shutdown equipment available. The licensee will be notifying the state of Delaware, state of New Jersey and the Lower Alloway Creek township.|
|ENS 54197||3 August 2019 06:47:00|
EN Revision Text: AUTOMATIC REACTOR SCRAM ON LOW REACTOR WATER LEVEL At 0226 (CDT), an automatic scram on low reactor water level occurred due to a trip of the 'B' Reactor Feed pump. All control rods fully inserted. Reactor water level 2 was reached and the High Pressure Core Spray system, Reactor Core Isolation Cooling system, Division 3 diesel generator, Standby Gas Treatment Systems 'A' and 'B' and all shutdown safety related service water pumps started as expected. Reactor Core Isolation Cooling and High Pressure Core Spray injected as expected. All level 2 containment isolation signals occurred as expected and all level 2 containment valves closed as expected. Reactor water level is currently being controlled in band by condensate. Reactor pressure is being maintained by main turbine Bypass Valves. This event is being reported under 10 CFR 50.72(b)(2)(iv)(A), for ECCS discharge to RCS; 10 CFR 50.72(b)(2)(iv)(B), for RPS actuation, and 10 CFR 50.72(b)(3)(iv)(A), for specified system actuation. The NRC Senior Resident Inspector has been notified. No safety relief valves lifted during the transient. The plant is in a normal shutdown electrical lineup with all safety equipment available. The licensee notified the Illinois Emergency Management Agency per their communications protocol.
Following automatic initiation of the High Pressure Core Spray (HPCS) System as described above, the HPCS System was manually secured following station procedures after verification that additional RPV (reactor pressure vessel) injection was no longer required. Securing HPCS injection in this manner prevents automatic restart of the system in the event of a subsequent low RPV level condition, rendering it inoperable. As the HPCS system is considered a single train safety system, this meets the reportability requirements of 10 CFR 50.72(b)(3)(v)(D). This reportable condition was identified following review of post-scram actions. The HPCS system has been restored to a Standby lineup. The licensee will be notifying the NRC Resident Inspector. Notified R3DO (Pelke).
Following the scram, the Primary Containment to Secondary Containment and the Drywell to Primary Containment differential pressure limits were exceeded. Technical Specification (TS) Limiting Condition for Operation (LCO) 184.108.40.206, Primary Containment Pressure, and 220.127.116.11, Drywell Pressure, Actions A.1, B.1, and B.2 were entered. Primary Containment to Secondary Containment differential pressure and Drywell to Primary Containment differential pressure were restored to within the LCO limits at 1505 on 8/3/19 and the associated TS Actions were exited. This event is reportable under 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that could have prevented the fulfillment of the primary containment function due to being outside the initial conditions to ensure that drywell and containment pressures remain within design values during a loss of coolant accident. This event is also reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of the drywell and primary containment functions to control the release of radioactive material for the same reason. The licensee notified the NRC Resident Inspector. Notified R3DO (Pelke).
|ENS 54171||17 July 2019 15:35:00||The following information was received from the state of Maryland via email: On July 10, 2019, a health physics consultant contacted the Maryland Department of the Environment Radiological Health Program (MDE/RHP) concerning a discovery during a routine audit conducted on July 10, 2019 at a licensed medical facility. A review of incoming Department of Transportation wipe/survey listing reports at the licensed facility (St. Agnes Hospital in Baltimore, MD) indicated that two packages received on June 12, 2019 from the radiopharmacy had high wipe test values recorded at 400,000 dpm per 100 cm2. These values were documented for surface and contents of the packages. Both packages were labeled as White I and had no abnormal outer package surface exposure rate readings. The computer record contained a note stating that, 'dpm verified and Cardinal (Health) notified. Case stored for decay.' The technologists did not notify the Radiation Safety Officer or MDE/RHP. The cases were opened, the doses unpacked, and used. The computer record indicated good condition for each box. One box contained one syringe of Tc-99m Ceretec at 17.25 mCi. The other box contained one vial of Tc-99m sodium pertechnetate at 104.22 mCi, one syringe of Tc-99m macro aggregated albumin at 10.61 mCi, and one syringe Tc-99m Sestamibi at 30.41 mCi. A reactive inspection is planned (by the state of Maryland). Cardinal Health was the radiopharmaceutical provider. The delivery vehicle and the driver were both surveyed on June 12, 2019, with negative results. No other contaminations or any overexposures were identified when the hospital performed surveys of the facility.|
|ENS 54168||16 July 2019 17:34:00||At 1445 EDT, on 7/16/2019, during routine maintenance activities on the sanitary sewage system, a leak from an overflow line to a parking lot was discovered. The total amount leaked is estimated to be 20 gallons. Approximately 2 gallons reached gravel in an excavated section of the parking lot. A local sanitary contractor is currently responding to the site to clean the affected areas. The cause of the leak is under investigation. As a result of some of the sewage reaching gravel, environmental reports are being made to the Michigan Department of Environmental Quality (MDEQ), the Monroe County Health Department, and the local news media. Since these reports are in the process of being made, this is considered a News Release or Notification to Other Government Agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified.|
|ENS 54165||16 July 2019 13:34:00|
EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER MALFUNCTIONED The following information was obtained from the state of Georgia via email: The shutter on a saltcake density meter was identified as needing attention on the last inventory and Berthold was scheduled to come on the next outage to repair or replace as needed. The outage is scheduled for 7/31/19.
Today, (the licensee) identified that a saltcake pump near the gauge needs to be replaced and the gauge is listed on the pump's lockout sheet. When IM (instrument maintenance) attempted to lock out the meter as part of the established lock out, the shutter handle broke meaning the gauge cannot be locked out. (Lock out requires all energy sources affecting the pump to be locked out. The gauge is in the line ahead of the pump and about 6 feet away so does not really affect the pump.) Radiation survey at the pump showed 65 microRem/hr radiation. (500 microRem/hr at gauge surface and 134 microRem/hr at one foot)
Maintenance work at the pump will continue with a lock out variance to cite not being able to close the shutter and a proximity radiation work permit used. Berthold is still scheduled to come in 7/31/19 for gauge shutter repair. Source is Cesium-137, 20 mCi, model P-2623-100 in LB7440 holder, serial no. 2104-6-90.
The radioactive material was transferred to Berthold for disposal on 11/25/19. Notified R1DO (Henrion) and NMSS_EVENTS_NOTIFICATION (via e-mail).
|ENS 54163||15 July 2019 16:30:00||At 1335 EDT on 7/15/2019, during dredging activities in Fermi 2's General Service Water (GSW) intake canal, a hydraulic line on the dredging machine became disconnected and approximately one quart of hydraulic oil spilled into Lake Erie. The oil leak to navigable waters has been stopped. The oil was contained within a boom, cleanup activities commenced immediately, and cleanup was completed at 1500 EDT. The cause of the oil leak is under investigation. Environmental spill reports were made to local, state, and federal government agencies. This is considered a news release or notification to other government agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified. The State agencies notified were Michigan Department of Environmental Protection and the Michigan Pollution Emergency Alerting System. The licensee also notified the National Response Center.|
|ENS 54170||17 July 2019 15:11:00||The following information was received from the Commonwealth of Massachusetts via email: Two shipments of licensed material in the form of Iodine-125 saline, one with an activity of 1.75 Curies and the other, 1.25 Curies, were discovered not to be delivered by (a common carrier) to the licensee's authorized use site at 331 Treble Cove Road, Billerica, MA, on Friday, July 12, 2019. PerkinElmer leases authorized use space from another Massachusetts licensee, Lantheus Medical Imaging, Inc., at the same street address. PerkinElmer subsequently contacted Lantheus and (the common carrier) on 7/12/19 at approximately 1416 EDT to report the missing packages. On Monday, July 15, (the package) containing 1.25 curies of I-125 was delivered by (the common carrier) to the PerkinElmer shipping department. (The licensee) subsequently reported to (the common carrier) that one of the packages was delivered; however, the second package containing 1.75 curies of I-125 was not. On Tuesday, July 16, (the common carrier) contacted PerkinElmer to report that both packages were delivered and that the case was closed. On Wednesday, July 17, at 1054 EDT, (the common carrier) delivered the second package to the PerkinElmer shipping department and stated that it was just picked up from Lantheus a short time before. It had apparently been in Lantheus's possession since Monday, July 15. An investigation of the incident is underway.|
|ENS 54180||24 July 2019 09:34:00||The following information was obtained from the state of Ohio via email: (Manufacturing and Distribution) licensee received beta back-scatter on a device from customer for repair. Upon receipt, licensee conducted leak test and results indicated >185 Bq (0.005 microCi). Device contained 100 microCi Pm-147 source and is distributed under a general license. Upon investigation, licensee determined customer had used probe on wet surface, which clogged aperture, and customer attempted to clear aperture with sharp, pointed object which damaged source. At customer's request, licensee went to customer's location to survey area of use for contamination. No contamination was found. Ohio report no.: OH190012|
|ENS 54148||4 July 2019 12:36:00||A licensed supervisor had a confirmed positive for alcohol on a random fitness-for-duty test. The employee's access to the plant has been terminated. The licensee notified the NRC Senior Resident Inspector.|
|ENS 54181||24 July 2019 10:37:00||The following information is summarized from an email received from the state of Ohio: A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment. The patient and prescribing physician were notified. The State will be performing an investigation. Ohio report no.: OH190013 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 54116||13 June 2019 03:59:00||At 2127 EDT on June 12, 2019, during routine testing, the HPCI turbine experienced an overspeed trip and then subsequently restarted and ramped to the required speed. As a result, the response time of the system exceeded the 60-second acceptance criteria, thereby rendering the system inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) are operable. The safety significance of this event is minimal. Troubleshooting activities are in progress. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.|
|ENS 54102||5 June 2019 16:39:00|
EN Revision Text: PART 21 INTERIM NOTIFICATION - FAILURE OF A SIGNAL CONVERTER SUPPLIED TO COOPER NUCLEAR PLANT The following is a summary of the information received from Engine Systems, Inc. via facsimile: ESI was notified on April 6, 2019 that a signal converter (also called a signal conditioner) that sends the Reactor Core Isolation Cooling turbine speed to the turbine controller had failed. The converter is at the manufacturer's facility undergoing testing at this time and they have been unable to complete their evaluation within 60-days. The evaluation is expected to be completed by July 31, 2019. The converter was only supplied to Cooper Nuclear Plant.
The following is a synopsis of information received via facsimile: On June 5, 2019, Engine Systems, Inc. (ESI) issued an interim report regarding an identified deviation for which ESI was unable to complete an evaluation within the 60-day requirement. Per the interim report, ESI committed to complete the evaluation by July 31, 2019. The evaluation is now complete and the deviation is determined to be reportable in accordance with 10 CFR Part 21. ESI supplied the component which failed to comply or contained a defect. That part was a Signal Converter Transmitter, P/N SCT/4-20MA/4-20MA/24DC/-LIM-TA(DCM). This component was only supplied to Cooper Nuclear Station. The nature of the defect was that a power inverter transformer, internal to the signal converter transmitter, failed shorted. The transformer failure adversely affected other circuit board mounted components which prevented the device from functioning properly. The signal converter transmitter is a component of a turbine control panel. Within the panel, the transmitter is used to sense the customer's remote speed setpoint input signal and convert the signal which is transmitted to the turbine control. Since the signal converter transmits the customer's remote speed setpoint input to the turbine control, operability of the device is critical to operation of the RCIC turbine control system. Therefore, a failure of the signal converter would adversely affect the RCIC turbine control system and thus may affect the safe shutdown of the reactor. At Cooper Nuclear Station, the failed component has been removed and replaced with a spare transmitter from a different batch. No further action is necessary. For ESI, the previous design transformer (used in the failed transformer) was discontinued by the transformer manufacturer in 2016 which required the signal converter transmitter manufacturer to source a new transformer. The new transformer has the same functionality with a slightly different form factor which minimizes the potential for common cause failure with the original style transformer. Therefore, no additional actions are required since a different transformer is in current use. ESI has included a verification of the current transformer design in the commercial grade dedication package. The names and addresses of the individuals reporting this information are: John Kriesel Engineering Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804 Dan Roberts Quality Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804 Notified R4DO (Proulx) and the Part 21/50.55 Reactors E-mail group.
The following is a synopsis of information received via facsimile: Subsequent to the issue of the report on July 19, 2019, ESI became aware of another potential defect with the same device. As a result, ESI has amended the report to expand the extent of condition. ESI supplied the component which failed to comply or contained a defect. That part was a Signal Converter Transmitter, P/N SCT/4-20MA/4-20MA/24DC/-LIM-TA(DCM). This component was only supplied to Cooper Nuclear Station. The nature of the defect was that four circuit board mounted components (two transistors, a capacitor, and a diode) failed, causing the device to go to zero output. These prevented the device from functioning properly. Corrective actions for Cooper Nuclear: As stated above, no further action is necessary. Corrective actions for ESI for the subsequent failure: ESI has been unable to positively determine the root cause; however, correspondence with the signal converter manufacturer indicates this may be related to the previous style transformer. While no anomalies were detected with the transformer, the failed components are electrically connected to the transformer. Verification of the current style transformer is performed in the commercial grade dedication package. The names and addresses of the individuals reporting this information are: John Kriesel Engineering Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804 Dan Roberts Quality Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804 Notified R4DO (Kellar) and the Part 21/50.55 Reactors E-mail group.
|ENS 54100||4 June 2019 14:18:00||The following information was received from the state of Louisiana via email: On 06/03/2019, BCS (Blue Cube Solutions) detected a malfunction of an internal shutter of a gauge installed on a process. The gauge shutter would not function as designed by the manufacturer due to a rotor tip on an internal shutter. BCS called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. The source and device with will remain installed on the process until the repairs are completed. This is not a radiation exposure hazard and does not pose a health and safety situation for the BCS employees or the general public. This event is being reported to the NRC OP CENTER as required by Regulatory Requirement 10 CFR Part 30.50 (b)(2) & LAC 33:XV 340.B. The Level Gauge is an OHMART, Model SHF-1, S/N M 6989, loaded with an approximately 120 mCi Cs-137 source, Model # A-2102. Louisiana Report ID No.: LA-190008|
|ENS 54092||27 May 2019 11:53:00||On May 27, 2019 at 0940 EDT, a portable chemical toilet was found tipped over. Approximately one gallon of contents spilled to the gravel only and did not reach any waterways or storm drains. Cleanup efforts are in progress. A notification to the Michigan Department of Environmental Quality and local health department is required, as well as a press release. This event is being reported pursuant to 10 CFR 50.72(b)(2)(xi). The licensee has notified the NRC Resident Inspector.|
|ENS 54088||24 May 2019 17:43:00||The following information was obtained from the Commonwealth of Virginia via email: On May 24, 2019, the Radiation Safety Office for the licensee made a preliminary report of an incident which occurred earlier on that day. The technician extended the source rod while using a portable moisture density gauge but was unable to retract it. The technician placed the gauge, with source rod extended, in the bed of his truck and drove back to his office, approximately 15 miles. When he arrived at his office, the other technicians were able to retract the source. A radiation survey confirmed the source was secured in its shield. The Virginia Office of Radiological Health will perform a reactive inspection to investigate this incident. This notification will be updated with additional information determined during the inspection. Virginia Event Report ID: VA 19-001|
|ENS 54080||22 May 2019 17:49:00||The following information was obtained from the state of Oregon via email: (The licensee) was asked to perform density testing of the roadway at the intersection of US Hwy. 26 and SE Firwood in Sandy, Oregon. (The licensee's client), Fall Line Construction, is working for DEPCOM Power. At approximately 1115 (PDT), (the gauge user) was asked to move (his) vehicle by the construction workers onsite. (The user) moved the Nuclear Densometer to a place where (he) believed would be safe from equipment onsite. While (the user) was parking (approximately 400 feet away), (he) saw some construction workers waving down the bulldozer operator who had backed into (the) Nuclear Densometer. (The user) checked to see if the gauge had been damaged. The lead shield had not been damaged. The handle for the gauge had been bent. Due to this deformation, the (source) was stuck in the safe position. (The user) tested the gauge with (a) Geiger counter and there appeared to be no excessive radiation coming from the gauge. The gauge was loaded back into the transport box and returned to the permanent storage place. The gauge will be sent out for repair either today or tomorrow. The gauge is a Troxler model 3440, SN 26146, containing 9 mCi of Cs-137 and 44 mCi of Am-241:Be.|
|ENS 54084||24 May 2019 12:01:00|
The following information was obtained from the state of Iowa via email: The University of Iowa Radiation Safety Officer notified the Iowa Department of Public Health (IDPH) on May 23, 2019, of a possible medical event that had occurred at the University of Iowa Hospital on May 22, 2019. The event occurred during a therapeutic Yttrium-90 (Y-90) microsphere (TheraSphere) administration to the liver. The signed written directive from the authorized user was 1.37 GBq (37.03 milliCuries). During the administration, it appeared that the spheres were being administered without incident until the point at which the flow of spheres ceased. The interventional radiologist determined that stasis had been reached, which prevented the remainder of the prescribed dose from being administered and appeared to be the only explanation for what happened. Based on the final survey reading of the source vial and tubing in the waste container, the initial determined dose was 0.586 GBq (15.84 milliCuries) which is 42% of the written directive. The following morning, May 23, 2019, routine imaging of the patient indicated no Y-90 activity in the patient's liver or abdominal areas. A second whole-body scan to determine any migration of activity was also negative for Y-90. The University of Iowa Radiation Safety Staff initiated an investigation into the location of the remainder of activity that was not remaining in the dose vial by surveying the procedure room and patient's room which were background levels and verified correct imaging protocol for the patient. The dose vial was re-surveyed and was found to contain all the original activity and no Y-90 TheraSpheres. The licensee's preliminary probable cause is an occluded needle in the vial that could have prevented either the flow of saline into the source vial, or the flow of microspheres out of the vial to the patient. The authorized user, the interventional radiologist, and the patient have been informed of the issue with this administration. No direct harm to the patient has occurred because no radioactivity had been delivered to the patient. This is a preliminary report and IDPH will be conducting an investigation to provide additional updated information. Items to initially get resolved include but are not limited to the licensee's issue with how dosages are measured before and after the procedure, independently verifying that no dose had been delivered to the patient, examine the integrity of the tubing and needles used in the procedure, and communication with the manufacturer about the circumstances surrounding this event and if they or the NRC are aware of any similar events. NMED Report No.: IA190001
The following retraction was received from the Iowa Bureau of Radiological Health via email: The Iowa Department of Public Health requests to retract the NRC Event Notification No. 54084 (Item No. IA190001) that was transmitted to the NRC Operations Center on May 24, 2019. After conversations with the licensee's radiation safety officer and review of information provided by the licensee we have determined that no detectable amount of Y-90 TheraSpheres was administered to the patient, and therefore no dose was delivered. Based on a discussion with NRC Region III Office, we have determined that the circumstances surrounding this incident do not meet the reportable medical event described in 10 CFR 35.3045. Notified the R3DO (Daley), NMSS Events (via 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 54082||23 May 2019 16:55:00||The following information was obtained from the state of Florida via email: On May 22, 2019, (the licensee Radiation Safety Officer) notified the BRC (Florida Bureau of Radiation Control) of an overdose of radiation treatment to a female 60 year-old Caucasian patient. Patient was prescribed ten 340 cGy planning target volume (ptv) fractionated treatments: 2 per day for 5 days. Minimum dose of 340 cGy per fraction, mean dose value 625 cGy per fraction, actual dose administered 1167.3 cGy in single fraction. Source S/N: 24-01-7403-001-032119-13092-68. Licensee has notified the patient that an overdose did occur, and expects no harm to the patient due to this fraction of treatment. Patient has five more treatments. The machine used was a Varying GammaMed+, SN 641053, using a 7.385 Ci Iridium-192 GammaMed 232 source. Florida Incident number: FL19-071 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 54590||19 March 2020 16:56:00||The following information was summarized from the information received from the state of Colorado via email: In April 2018, the Colorado Department of Corrections - Territorial Facility identified that 19 tritium exit signs were missing. On 5/9/19, Territorial determined that the signs were lost. The exit signs contained 219 Ci of tritium in total. 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 54061||12 May 2019 04:51:00||On 5/11/19, Callaway Energy Center entered Mode 4 at 1217 (CDT). At 2305, the door from the Auxiliary Building to the RAM Storage building was found blocked open. This door is an Auxiliary Building pressure boundary for the Emergency Exhaust system. The Emergency Exhaust system is required in Modes 1,2,3,4, and during movement of irradiated fuel assemblies in the Fuel Building. The door was being blocked open with a large ramp. This rendered the Emergency Exhaust system not capable of performing its design safety function. LCO (Limiting Conditions for Operation) 3.7.13.B was entered, and preparations to move the ramp commenced. LCO 3.7.13.B is for two Emergency Exhaust trains being inoperable due to an inoperable auxiliary building boundary. The allowed outage time is 24 hrs. to restore the boundary to Operable. The door was closed and LCO 3.7.13.B was exited at 0111 on 5/12/19. This event is reportable per 10 CFR 50.72(b)(3)(v) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (C) control the release of radioactive material, or (D) mitigate the consequences of an accident. The NRC Senior Resident has been notified.|