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 Entered dateEvent description
ENS 543167 October 2019 19:06:00

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

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

The following update was received from Texas Department of State Health Services via email: The licensee has notified the Agency that the vehicle and gauge were recovered by the local police at approximately 2230 CDT on October 7, 2019. The gauge was still fully secured in the vehicle as it had been when the vehicle was taken. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Keller), ILTAB, NMSS Events, and CSNS Mexico (email). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5429526 September 2019 14:47:00

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

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

The following update was received from the California Department of Public Health via email: The gauge was recovered by Local Law Enforcement near Heavenly Village in South Lake Tahoe, CA and the gauge was returned to the license on September 27, 2019. Notified the R4DO(Proulx), NMSS Events, CNSNS (Mexico). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5429626 September 2019 18:11:00The following information was obtained from the State of Texas via email: On September 26, 2019, the licensee's radiation safety officer notified the Agency (Texas Department of State Health Services) that it had a shutter failure on one of its fixed nuclear gauges. The Ohmart SH-F1 gauge, containing 5 milliCuries of cesium-137 (SN: 2925 CG), is mounted on a vessel. The licensee had closed the shutter in order to do some work in the area. Upon completion of the work, the licensee was attempting to re-open the shutter when the screws holding the actuator to the shutter handle sheared. The shutter is in the fully closed position which was confirmed by survey. There were no exposures as result of this event. A service company has been scheduled to make repairs on September 27, 2019. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: 9714
ENS 5433216 October 2019 10:22:00This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system. On August 20, 2019, at approximately 1133 hours Central Daylight Time (CDT), Browns Ferry Nuclear Plant (BFN), Unit 2 experienced an unexpected loss of the 2A Reactor Protection System (RPS). This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of Standby Gas Treatment Trains A, B, and C and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected. Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid. The cause of the RPS MG Set trip was dirty potentiometer windings on an Over Voltage Relay. The dirt prevented the potentiometer's wiper from contacting its windings, resulting in erratic setpoint values. There were no safety consequences or impact to the health and safety of the public as a result of this event. This event was entered into the Corrective Action Program as Condition Reports 1542603, 1542608, and 1542569. The NRC Resident Inspector has been notified of this event."
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 541995 August 2019 01:28:00On 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 541983 August 2019 23:33:00At 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 541973 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.

  • * * UPDATE FROM DAVID LIVINGSTON TO HOWIE CROUCH AT 0321 EDT ON 8/4/19 * * *

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).

  • * * UPDATE FROM JAMES FORMAN TO KERBY SCALES AT 1545 EDT ON 8/6/19 * * *

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) 3.6.1.4, Primary Containment Pressure, and 3.6.5.4, 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 5417117 July 2019 15:35:00The 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 5416816 July 2019 17:34:00At 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 5416516 July 2019 13:34:00

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."

ENS 5416315 July 2019 16:30:00At 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 5417017 July 2019 15:11:00The 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 5418024 July 2019 09:34:00The 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 5418124 July 2019 10:37:00The 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 5411613 June 2019 03:59:00At 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 541025 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.

  • * * UPDATE FROM DAN ROBERTS TO DONALD NORWOOD AT 1710 EDT ON 7/19/2019 * * *

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.

  • * * UPDATE FROM DAN ROBERTS TO DONALD NORWOOD AT 1643 EDT ON 10/11/2019 * * *

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 541004 June 2019 14:18:00The 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 5409227 May 2019 11:53:00On 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 5408824 May 2019 17:43:00The 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 5408022 May 2019 17:49:00The 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 5408424 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

  • * * RETRACTION AT 1641 EDT ON 5/30/19 FROM STUART JORDAN TO JEFF HERRERA * * *

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 5408223 May 2019 16:55:00The 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 5406112 May 2019 04:51:00On 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."
ENS 541473 July 2019 18:32:00This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Engineered Safety Feature actuation signal. On May 9, 2019, at Arkansas Nuclear One (ANO) Unit 1, while performing an Emergency Feedwater Initiation and Control (EFIC) Channel B monthly test, a test pushbutton was mispositioned, resulting in an inadvertent initiation of the Emergency Feedwater (EFW) System. In accordance with the Engineered Safeguards Actuation System (ESAS) Trip Test portion of the surveillance, the first technician placed EFIC Train B in the tripped condition. The second technician then went to the front of the control room to verify Remote Switch Matrix (RSM) indications. The first technician recalls thinking he was given the order to reset Train B EFW Bus 1 Trip. Therefore, the first technician performed the step using three-part communication, but there is uncertainty about what was said. Due to the amount of time the second technician spent in front of the control room, the first technician assumed Operations reset the RSM to complete the Train B reset. The second technician returned to the ESAS cabinet and directed the first technician to perform the reset of Train B EFW Bus 1 Trip. The first technician, expecting his next action to be the trip of Train B EFW Bus 2, placed Bus 2 in the tripped condition. This put both buses of Train B EFW in trip and caused the actuation of P-7A EFW Pump. This inadvertent actuation was caused by human error and was not a valid signal resulting from parameter inputs. The 1992 Statements of Consideration define an invalid signal to include human error. Therefore, this actuation is considered invalid. This event was entered into ANO's corrective action program for resolution. This event did not result in any adverse impact to the health and safety of the public. The plant responded as expected. In accordance with 10 CFR 50.73(a)(i) a telephone notification is being made in lieu of submitting a written Licensee Event Report. The licensee has notified the NRC Resident Inspector."
ENS 540423 May 2019 01:02:00

The Radiation Safety Officer (RSO) at International Isotopes, Inc. reported that at 2130 PDT on 5/2/19, while changing out the Cs-137 source on a research irradiator, they breached the source which resulted in widespread contamination and a possible uptake event. The irradiator is a JL Shepard Mark 168A and is located at the Harborview Research and Training Facility at the University of Washington in Seattle, WA. International Isotopes, Inc. is an NRC licensee working under reciprocity in the State of Washington (an agreement state). After discovery of the breach, the immediate area was isolated, the building was ordered evacuated, and the ventilation was secured. Indications are that the seven members of the source retrieval team were externally and potentially internally contaminated. The State of Washington was notified. The University of Washington RSO was sending response teams to the area. A local hazardous material team is on site.

The source was reported to be 2800 Ci.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE ON 05/03/2019 AT 1545 EDT FROM TRISTAN HAY TO JEFFREY WHITED * * *

The following update was received via E-mail from the Washington State Department of Health: University of Washington (UW) was having their research irradiator (Mark-1 SERIES / Cs-137) disposed of by International Isotopes (NRC License 11-27680-01MD). The Agreement state regulators were present to verify dose measurements and observe ALARA practices. During the source removal and transfer into the transport shielded cask, there was a breach of the sealed source and a small portion of the source was released into the working area. The working area was comprised of the irradiator unit, the shielded containment rig, the loading dock, a 100 feet radius around the loading dock, and the Harborview Research and Technology Center floors 1-3 and stair well. The source was encapsulated with International Isotopes' source housing capsule. A breach was identified during the precursor wipe survey performed prior to putting it into the source housing unit. Once contamination was identified, all personnel performed area contamination surveys and secured and taped off the work space area. All personnel who were present at some point during the transfer were notified of the potential contamination and were given special instructions to return to the Harborview Medical Center area for decontamination. Simultaneously the NRC, Washington Radiation Emergency Hotline, and the (National Materials Event Database) NMED were notified of the situation by International Isotopes immediately after the incident occurred. Seattle Fire and Seattle Hazmat units were dispatched to the scene to assess the situation and begin decontamination protocols. The International Isotope workers, UW RSO, FBI agent, and other present workers were decontaminated and placed in a contained area of the Harborview Medical Center Emergency Room. Bioassay samples were collected from urine and blood from the contaminated individuals. Additionally, employees from the State of Washington who responded to the event were surveyed, with the highest level of contamination being 300 cpm on the individual's shoes. Washington State Licensee: University of Washington Washington Agreement State License No. C001 Event Report ID No.: WA-19-015 Notified R4DO (Werner), IRD MOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE ON 05/04/2019 AT 2136 EDT FROM JOHN MILLER TO JEFFREY WHITED * * *

The following update is a synopsis of information received via E-mail from International Isotopes: In its E-mail, the licensee provided an initial incident report regarding the breached Cs-137 source incident that occurred during the removal of the source from the Research Irradiator at the Harborview Training and Research Building. The licensee provided a summary of planned work, a summary of the incident, a summary of the whole-body exposures received by International Isotopes and contractor employees, a summary of initial personnel skin contamination results, a summary of post-decontamination personnel skin contamination results, and a summary of recovery actions taken to date. According to its assessment, the licensee indicated that the highest whole-body exposure to any one individual was 55 mrem. The majority of surveys taken at the loading dock level indicated that surfaces were contaminated in the 50,000 - 300,000 cpm range. The summary of recovery actions taken to date are as follows: International Isotopes hired a contractor to perform decontamination and remediation of the affected areas. The Department of Energy, Region 8, Radiological Assistance Program team surveyed the building floors. International Isotopes employees surveyed the parking lot area where emergency response operations took place reducing the size of the controlled area, marking spots with identified levels. The loading dock area was further isolated from the building by covering outdoor louvers and double door between corridor and loading dock with heavy plastic. International Isotopes remains on-site to support the contractor and the University of Washington by performing assessment surveys and development of the decontamination and recovery plan. Notified R4DO (Werner), IRD MOC (Gott), NMSS (Kock), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE AT 1648 EDT ON 05/16/2019 FROM JOHN MILLER TO JEFF HERRERA * * *

This report provides an update to the May 2, 2019 incident involving the breached Cs-137 source. International Isotopes Inc. (INIS) performed dose estimates based on 24 hour urine samples collected from the INIS employees that were involved in the incident. There were seven INIS individuals involved, the INIS estimates are provided in the table below. Note that individuals 6 and 7 are not included in the LANL Report as their urine sample results were released later. These sample results have since been provided to LANL. Name; Time Between intake and sample (days); Concentration (pCi/L); Modeled Intake (uCi); Percent ALI; CED (mRem)

Individual 1: 1.625; 15,700; 2.284; 1.142 Percent; 57.1 Individual 2: 1.396; 6,100; 1.235; 0.618 Percent; 30.9 Individual 3: 1.698; 1,280; 0.186; 0.093 Percent; 4.7 Individual 4: 1.665; 8,540; 1.242; 0.621 Percent; 31.1 Individual 5: 1.697; 19,800; 2.880; 1.440 Percent; 72.0

Individual 6: 1.687; 5,540; 0.806; 0.403 Percent; 20.1 Individual 7: 1.437; 4,110; 0.624; 0.312 Percent; 15.6 Notified R4DO (Proulx), IRD MOC (Kennedy), NMSS (Rivera Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE ON 05/20/2019 AT 1050 FROM INTERNATIONAL ISOTOPES TO KENDZIA * * *

The following update is a synopsis of information received via E-mail from International Isotopes: International Isotopes provided a detailed update on internal and whole body doses, skin contamination and decontaminated results for the affected seven individuals. The highest internal dose was 57.1 mrem for individual 1, the highest whole body dose was 55 mrem for individual 7, and the highest dose to the skin from skin contamination was 36 mrem to individuals 3 and 4. Blood sampling of the individuals showed no changes due to radiation. Facility decontamination continues. International Isotope management is in the process of conducting a detailed investigation in order to determine the direct, contributing, and root causes of this event. Notified R4DO (Gepford) IRD MOC (Kennedy), and NMSS Events Notification via e-mail.

  • * * UPDATE ON 7/25/2019 AT 1228 EDT FROM TRISTAN HAY TO ANDREW WAUGH * * *

The following update is a synopsis of an email from the Washington State Department of Health: In this update the state of Washington provided detailed corrective actions taken and planned for this event and gave the status of current decontamination efforts. The update also states that one of the impacted employees was a University of Washington employee and not a contractor as previously stated. Notified R4DO (Taylor) IRD MOC (Gott), and NMSS Events Notification (email).

ENS 5402524 April 2019 13:55:00The following information was received from the state of New York via facsimile: The New York State Department of Health (NYSDOH) was notified by (the radiation safety officer) (RSO) of Pall Hauppauge (C1935) that they had an incident where the source did not retract completely leaving the source partially exposed for a period of time. According to the RSO, he was notified on April 23, 2019, at approx. (0900 hrs. EDT) of a fault at Vault 4, and arrived approximately 15 minutes later and found that the source had gotten stuck very slightly above the down (safe) position when the cycle ended. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action. The RSO contacted Nordion to discuss the situation and he was able to free the source and get it into the safe position without any issue. The RSO then checked the radiation levels in the irradiator and found that they were normal. There was no risk of personnel or public exposure at any time during this incident, nor was there any risk of contamination. The root cause for the source getting stuck has not been yet determined. The RSO will be working with Nordion to assess the equipment and decide the course of action. DOH will continue to monitor this incident. Pall Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator. NY Event Report ID No.: NY-19-06
ENS 5402223 April 2019 19:33:00The following information was received from the state of Washington via email: Swedish Medical Center notified the state of Washington that a lead pig, containing 50 mCi (1.86 GBq) of Y-90 Sir-Spheres, was picked up for lead recycling. When the recycling company (Stericycle) came to collect all the lead pigs, a tech let the company into the waste room to collect the pigs not knowing that one of the pigs contained the Y-90 material left over from a treatment on Friday the 19th of April 2019. On April 23rd, the RSO (radiation safety officer) was reviewing the lead disposal paperwork and realized the material was sent out with the other lead pigs and notified the State. The RSO called the recycling company and was told the pigs were still in a drum and had not been processed. They will be returning the drum to the medical center on April 24th, 2019 and the RSO will notify the State when it arrives. WA Event Report ID No.: WA-19-014 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 Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
ENS 5401722 April 2019 16:16:00A contract supervisor tested positive for drugs on a follow-up fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a random test administered the next day (see EN #54018). The licensee notified the NRC Resident Inspector.
ENS 5401822 April 2019 16:16:00

EN Revision Text: CONTRACT SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST A contract supervisor tested positive for drugs on a random fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a follow-up test administered the previous day (see EN #54017).

  • * * RETRACTION ON 4/30/2019 AT 1642 EDT FROM KELLI ROBERTS TO BRIAN LIN * * *

On April 16, 2019, an individual was selected for a follow-up drug test. The same individual was selected again on April 17, 2019 for a random drug test. The results for both tests were ruled by the Medical Review Officer (MRO) on the same day and ruled positive for the same drug on April 22, 2019. These FFD violations were reported to the NRC on April 22, 2019, as EN #54017 and EN #54018, respectively. As allowed by 10 CFR 26.185(o), the MRO further reviewed the quantitation of the drug in both tests and determined that no further drug use had occurred since the first positive test. Therefore, the MRO concluded that this should be considered one FFD violation, and EN #54018 is being retracted. No changes are needed to EN #54017. The NRC Resident Inspector has been notified of this retraction. Notified R2DO (Heisserer) and FFD Group (email).

ENS 5402323 April 2019 20:32:00The following information was excerpted from a report received from the state of California via email: (A) potential medical event occurred during an HDR (high dose rate) brachytherapy procedure in which the Tandem Ovoid (was) inserted into the patient. The patient was there to receive the 3rd dose of 8 Gy (for a total of 24 Gy) to the uterus. Instead, because all of the guide tubes were 132 cm instead of 120 cm in length, the entire 8 Gy of this last fraction was delivered to the vagina. They do not believe that the uterus received any of the prescribed 8 Gy, and all of it was delivered to non-target organ. The patient and her treating physician were informed, and she is going to return to the hospital for monitoring. Since this was the last of 3 fractions, the uterus has only received 16 Gy, not 24, while the unplanned dose to non-target organ was 8 Gy. A site visit will be conducted Monday, 4/29/2019, (by the California Department of Public Health, Radiologic Health Branch). CA 5010 Number: 042319 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 5401922 April 2019 17:38:00The following information was obtained from the state of Illinois via email: The RSO (radiation safety officer) at the University of Chicago (Hospital), called to report that the University received one lsoAid, Model IAl-125A, I-125 source for a seed localization procedure. It had an activity of 271 microCuries when implanted in the patient on Thursday, April 18, 2019. On Friday, the patient's tissue (containing the I-125 seed was excised) and sent to pathology for evaluation. During all steps, the individuals involved reported that they measured appropriate dose rates from the seed. The Pathology technician was using scissors on the patient's tissue and the seed popped out of the specimen and fell into the sink. The seed was recovered before it went down the drain. Surveys of the sink show no contamination or dose rate measurements. The radiation safety staff measured the recovered source with both a survey instrument and a gamma counter, and the source has no measureable dose rate. The patient was surveyed and it was determined that the source (was) not in the patient. A review of the SSDR (sealed source and device registry) sheet has determined that this source contains I-125 adsorbed on a silver rod which is further encased in the outer capsule. The outer capsule measures 3.0 mm x 0.5 mm and there are no visible signs that the source was cut. They plan to take the seed for an x-ray today to determine if the inner rod is missing and to see if there are obvious signs that the outer capsule was breached. UPDATE: The I-125 seed was found intact in the sink trap. The source that was initially believed to be the subject seed was from another patient and was a three-year-old prostate seed that had decayed to background. NMED Item Number: IL190012 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 5385029 January 2019 10:44:00The following incident occurred in federal waters on Chevron's St. Malo platform. On January 26, 2019, while retracting the source after a radiography shot, the radiographer determined that the source had become disconnected. The radiographer and assistant radiographer established a 2 mR boundary and contacted their radiation safety officer (RSO). The RSO dispatched a licensed source retriever to the platform. After arriving at the platform on January 27, 2019, the source retriever was able to place the source into a shielded container. The source and camera were transported back to the licensee facility located in Houma, LA. The camera and source will be inspected/repaired by the manufacturer prior to placing them back into service. The camera is a SPEC-150 camera, serial number 1717, containing a 33 Ci Ir-192 source, serial number ZI0603. The licensed retriever received 275 mR during the retrieval. The radiography and assistant radiography technicians received 24 mR and 41 mR exposure.
ENS 537652 December 2018 06:17:00

During the post-maintenance testing run of the Division III Emergency Diesel Generator (EDG), (a field operator) reported smoke coming from the diesel and an emergency shutdown was required. After the EDG was shutdown, significant damage (thrown rod) to the EDG was observed. Emergency Action Level HA 2.1 (an Alert) was declared at 0530 (EST). Currently, the plant is stable and operating at 100 percent power. All safety systems are available. The damage occurred approximately 20 minutes into the required 1 hour run. The licensee's emergency response organization has been activated. No offsite assistance was required or requested. There is a 14-day shutdown limiting condition for operation (LCO) in effect under technical specification 3.5.1 for the high pressure core spray system. Notified DHS Senior Watch Officer, FEMA Operations Center, DHS NICC Watch Officer, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email). The licensee has notified state and local authorities and the NRC Resident Inspector.

  • * * UPDATE ON 12/2/18 AT 0737 EST FROM TODD DAVIS TO HOWIE CROUCH * * *

The licensee terminated the Alert at 0731 EST on 12/2/18. The basis for termination was that the licensee has met all procedural requirements to terminate the emergency and on-shift personnel can operate the unit without further assistance. Notified R1DO (Burritt), NRR EO (Miller), IRD MOC (Gott), HQPAO (Couret), ERDS Activation Group, DHS Senior Watch Officer, FEMA Operations Center, DHS NICC Watch Officer, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email).

ENS 537111 November 2018 15:38:00On 11/01/2018, during the Beaver Valley Power Station Unit No. 2 (BVPS-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 27 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. The other 65 penetrations will be examined during the 2R20 (current) refueling outage. The plant is currently shutdown and in Undefined Mode. The reactor vessel head is not currently installed. Repairs are currently being planned and will be completed prior to startup. This is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A) since the as-found indications did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-4 to remain in-service without repair. The NRC Resident Inspector has been notified."
ENS 5368823 October 2018 04:17:00On October 22, 2018 at 2241 hrs. EDT, a loss of Control Room Envelope (CRE) was declared due to failing to meet the requirements of (surveillance requirement) SR 4.7.6.1h during 72-month surveillance testing. Measured in-leakage exceeded the SR acceptance value. Abnormal Operating Procedure 2588A, 'Mitigating Actions for Control Room Envelope Boundary Breach', have been implemented. The licensee has notified Connecticut Department of Environmental Protection, Connecticut dispatch, Waterford dispatch, and the NRC Resident Inspector of this event.
ENS 537765 December 2018 11:24:00This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a Primary Containment Isolation System (PCIS) Group 1 for Main Steam Isolation Valves (MSIVs), Group 3 for Reactor Water Cleanup (RWCU), Group 6 for Secondary Containment isolation, Group 7 for Reactor Water Sampling, Diesel Generator, Reactor Core Isolation Cooling (RCIC) System logic, and Residual Heat Removal (RHR) logic. Group 1, Group 6, Diesel Generator actuation, RCIC actuation and RHR actuation are within scope of 10 CFR 50.73(a)(2)(iv). Group 3 and Group 7 are not within scope as they affect only one system. Cooper Nuclear Station (CNS) was shut down in Mode 5 at the time of the event with the reactor cavity flooded. On October 13, 2018, at 0028 Central Daylight Time, CNS received full PCIS Groups 1, 3, and 6, and a half Group 7 on the Division 1 side. The MSIVs and RWCU isolation valves were already closed for maintenance. The Secondary Containment isolated. Control Room Emergency Filter and the Standby Gas Treatment Systems initiated. The inboard Reactor Water Sample valve isolated. Diesel Generator #1 started but was not required to connect to the critical bus. Reactor Core Isolation Cooling System logic actuated with no expected response due to being isolated for shutdown conditions. Division 1 RHR pump logic actuated. Division 1 RHR system was operating in shutdown cooling mode. The actuation caused the Division 1 RHR outboard injection and heat exchanger bypass valves to open. Shutdown cooling was unaffected and remained in service throughout the event. The plant systems responded as expected with no Emergency Core Cooling System injection. At the time of the event, an in-service inspection of welds inside the reactor vessel was taking place using a robot scanner that uses two vortex thrusters to hold the robot to the vessel wall. The robot inadvertently passed over an instrument penetration, drawing suction on the process leg, resulting in low reactor water level indications and the subsequent invalid Level 1 and 2 system actuations. Actual reactor vessel water level remained steady at cavity flooded conditions. The NRC Resident Inspector has been notified of this event."
ENS 5370831 October 2018 17:05:00The following information is summarized from information received from Fisher Valves via email: A customer ordered a replacement digital valve controller. When the original controller was purchased, documentation indicated that it was qualified under IEEE 323-1974. The DVC6000 series and the DVC6200 series are not qualified in accordance with IEEE 323, nor was there any intent to qualify these devices to this standard. The only customer that has requested Environmentally Qualified controllers is Seabrook Station. Fisher requests that the recipient of this FIN review it and take appropriate action in accordance with 10 CFR 21. If there are any technical questions, please contact: Jacob Clos Quality Manager Emerson Automation Solutions Fisher Controls International LLC 301 South First Avenue Marshalltown, IA 50158 Phone: (641) 754-2108 Jacob.Clos@Emerson.com
ENS 5356727 August 2018 13:11:00The following information was obtained from the state of Florida via email: Ardaman & Associates, Inc., reported to (the Florida Bureau of Radiation Control) a damaged Troxler Gauge at Lake Brantley High School, 991 Sand Lake Rd, Altamonte Springs, FL 32714. Gauge was backed into by heavy equipment. Sources were not extended at the time, and are not damaged. All radiation readings taken after damage were normal expected values. The gauge was immediately retrieved and removed from work site. Gauge is being transferred to Troxler Orlando Office for evaluation and determination for repair or replacement. The gauge contained an 8 mCi Cs-137 source and a 40 mCi AmBe-241 source. Florida Incident No. FL18-112
ENS 5370731 October 2018 15:57:00

The following information was obtained from the State of Tennessee via email: On 10/31/18, the Tennessee Division of Radiological Health was contacted via phone by Ludlum Measurements RSO regarding the loss of a licensed source. It appears the source was last seen on 8/10/18. The licensee realized the source was missing on 8/13/18. The licensee has been searching for the source from 8/13/18 to date. The whereabouts of the source are still unknown at this time. Isotope and activity: Am-241, 1.057911 microCi Manufacturer: Eckert and Ziegler Model and Source Serial #: 1637-72-2

A follow-up report will be submitted within 30 days. Tennessee State Event Report ID No.: TN-18-195 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 5351518 July 2018 19:27:00A contractor supervisor tested positive for alcohol during an access upgrade fitness-for-duty test. The employee's access to the facility has been suspended. The licensee has notified the NRC Resident Inspector.
ENS 5351317 July 2018 20:32:00The following information was obtained from the state of California via email: On July 16, 2018, the California Office of Emergency Services (OES) contacted RHB (California Radiation Health Branch) to report the recovery of a stolen moisture density gauge. The gauge recovery was reported to OES by the San Jose Police Department. The service truck containing the moisture density gauge was stolen from a private residence sometime over the weekend, and was found by the San Jose Police Department during patrol early on July 16, with the gauge still chained to the bed of the truck. The San Jose Police Department cut the chain and stored the gauge at the station. The moisture density gauge is a CPN Model MC-1DR-P, S/N MD60508312, containing 10 mCi of Cs-137 and 50 mCi of Am-241. The gauge was collected by RHB and put in RHB storage on July 16. RHB will be following up with the licensee concerning adherence to regulatory and license requirements. California report no.: 5010-071618
ENS 5350716 July 2018 21:24:00While performing measurements at a construction site in Big Rapids, MI, a Troxler Model 3430 was struck by a bulldozer while the source rod was extended. While attempting to retract the source, the 9 mCi Cs-137 source disconnected from the source rod. The RSO covered the source and established boundaries around the source. The licensee contacted the NRC Operations Center to get authorization to transport the source back to their storage facility. Notified R3DO (Reimer) and R3DNMS (McCraw) and placed them on a conference call with the licensee. The licensee was authorized to transport the source, in a sand-filled bucket, back to their facility. The Troxler serial number is 23659 and also contained a 44 mCi AmBe source. The AmBe source is in the shield.
ENS 534989 July 2018 18:23:00On July 9, 2018, at 1155 hours (EDT), while testing the TSC Ventilation System, an equipment malfunction occurred that resulted in an unplanned loss of TSC ventilation functionality/habitability for greater than seventy-five minutes. If an emergency had been declared requiring TSC activation during this period, the TSC would have been staffed and activated using existing emergency planning procedures. If relocation of the TSC had been necessary, the Emergency Coordinator would have relocated the TSC staff to an alternate location in accordance with applicable site procedures. The TSC ventilation system has been placed in an interim configuration that restored functionality and habitability. Additional maintenance is planned to promptly resolve the malfunctioning equipment. This 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 equipment malfunction affected the functionality of an emergency response facility. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The equipment malfunction (a failed solenoid valve) resulted in the loss of the ability to pressurize and filter the air in the TSC.
ENS 534906 July 2018 11:43:00

The following information was received from the State of California via email: (A Troxler) Moisture Density Gauge (Serial #18330) was stolen from a parked vehicle at a residence. An unknown subject cut a security cable then took the yellow box containing the device and associated equipment. The box was in the rear bed of a pickup truck. The police department has been notified and are enroute to investigate. The Troxler contained an 8 mCi AmBe-241 source and a 48 mCi Cs-137 source. California Report No.: 5010070618

  • * * UPDATE ON 7/10/18 AT 1024 EDT FROM KENNETH FUREY TO BETHANY CECERE * * *

The following was received by email from the State of California: The Troxler 3440, serial #18330 reported stolen on July 6, 2018 was recovered by the Rancho Cordova Police Department on July 7, 2018 at 2000 PDT after it was dumped in the Walmart parking lot in Rancho Cordova. (A representative) of Youngdahl Consulting took possession of the gauge. Notified R4DO (Pick), NMSS Events Notification, ILTAB, and CNSNS (Mexico) by 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 534916 July 2018 15:36:00At 1201 (CDT), Station Auxiliary Transformer 242-2 experienced a bushing failure, resulting in a loss of offsite power to Unit 2. The 2A and 2B Diesel Generators started and sequenced loads onto the Unit 2 ESF buses appropriately. All other buses normally powered from the Station Auxiliary Transformers automatically transferred to the Unit Auxiliary Transformers. ESF Bus 241 and 242 Undervoltage Relays actuated to start the Diesel Generators and the 2A Auxiliary Feedwater Pump started on the 2A Diesel Generator sequencer. ESF Battery Charger 212 tripped at the same time, which was an unexpected condition. DC Bus 212 was cross-tied with DC Bus 112. This notification is being made under 10 CFR 50.72(b)3(iv)(A) due to the actuation of both Unit 2 Diesel Generators and the 2A Auxiliary Feedwater Pump. The NRC Senior Resident Inspector has been notified. Currently, offsite power was restored via the Unit 1 Unit Auxiliary Transformer. Both Unit 2 Emergency Diesel Generators have been secured. DC Busses are still cross-tied. The licensee is currently in a 72-hour shutdown action statement for the loss of offsite power and a 7-day action statement for having the Unit 2 DC Bus cross-tied to Unit 1.
ENS 534885 July 2018 18:02:00

EN Revision Text: TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE EVENT The following information was obtained from the state of Texas via email: On July 5, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's (Stanley out of Tulsa, OK) consultant that an overexposure event may have occurred involving radiographers working in the state of Texas, under reciprocity, at a field site near Midland, Texas, but offered no actionable information. At 1620 hours (CDT), the consultant called back and stated that a crew was performing radiography in a pit using a 99.6 Curie iridium - 192 source. The individual who received the high exposure had been working in the dark room. He completed the task he was working on and exited the dark room and went straight to the pit. He picked up the collimator and started to move it while the source was still in the collimator. The other radiographers yelled at him and he dropped the source and left the pit. The consultant stated the calculations for the dose to the individual's hand provided by the licensee is 284 rem. The consultant stated the radiographer held the source for about 3 seconds and the dose calculation was based on no shielding. The consultant stated there is currently no apparent injury to the individual's hand. The consultant stated the licensee is contacting REAC/TS in Oak Ridge, Tennessee, for assistance. The licensee's radiation safety officer is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #9592

  • * * UPDATE FROM THE STATE OF OKLAHOMA TO HOWIE CROUCH ON 7/6/18 AT 1032 EDT * * *

The following information is excerpted from an email that was received from the state of Oklahoma: Oklahoma DEQ (Department of Environmental Quality) Radiation Management was contacted by the radiation safety officer (RSO) of Stanley Inspection, License No.: OK-32187-01, after hours on 7/5/2018. Stanley Inspection, a radiography company, was working in Midland, TX under reciprocity, and one of the radiographers potentially overexposed his hand. Stanley Inspection was instructed by Texas to do medical monitoring for the radiographer, including bloodwork and photographs of his overexposed extremity. Notified R4DO (Miller) and NMSS Events Notifications (email).

  • * * UPDATE FROM IRENE CASARES TO DONG PARK ON 7/19/18 AT 1158 EDT * * *

The following information was obtained from the state of Texas via email: Stanley Inspection Services reported that a radiation overexposure may have occurred involving radiographers working in Texas, under reciprocity, at a field site on 7/3/2018 near Midland, Texas. Reported to NRC as update on July 19, 2018. After complete investigation and reenactment of the incident the following information was obtained and being provided as an update of the incident. On July 3, 2018, a radiographer working a temporary field site project under reciprocity (OK licensee in TX) with another crew had an incident. The radiographer was working in the dark room and was developing film. He completed this task and exited the darkroom. This was the last shot of the day in which this crew was working. It was the last image for this shot in which four images are taken for this weld of a 36 inch pipe at a time of 6.5 minutes each image. They were about to end the workday. It was at dusk and his assistant went to the front of the vehicle to get a flashlight while a member of the other crew showed up. The time of day was between 9 and 10 pm. When this person showed up, the radiographer was exiting the darkroom. These two radiographers both walked down into the pit to retrieve the film, when they were walking to the film, the assistant arrived at the back of the truck, stating that the source was still out and at that time the survey meter being carried by the other crew member (RDS-30, Mirion technologies) was alarming. The person carrying the survey meter was about 2-3 feet behind the first radiographer. The first radiographer had already put his fingers (index and middle) and thumb on the collimator for estimated 3 seconds as he was checking to ensure it had not moved from the mark/film while imaging. He explained that he heard the alarms from the survey and dosimetry meters and they both ran out of the pit. It was reenacted on 16 July to confirm how he placed his fingers on the collimator and estimated the time. The Delta 880, sn D15456, camera was loaded with, QSA, A424-9, 66225G, Ir-192, at an activity of 101.5 curies. The calculated dose to the hand for 3 seconds with a collimator made of tungsten rated at 4 HVL was 25.54 rem for the extremity dose. The initial whole body dose was estimated to be unshielded at 109 mrem. The radiographer had been wearing an electronic dosimeter (Tracerco) which was acting as an alarming rate meter and dosimeter. The film badge was processed with results of 18 mrem. And the dosimetry was reported to have read 24 mrem by the radiographer for that day's work. The dosimeter was sent for verification/accuracy checks. The radiographer had his blood drawn as instructed by REAC/TS and the RSO photographed his fingers/hands for 3 weeks. The radiographer stated he had no abnormal redness, tingling or sensations in the tissue of the hand. The supporting documents and reenactment support an estimated dose of 25.54 rem to the extremity and approximately 20 mrem to the whole body. The company is completing its documentation of the incident and will be providing its detailed report with corrective actions, another update will be forthcoming. Notified R4DO (Young), INES (Milligan) and NMSS Events Notifications via email.

ENS 5347226 June 2018 04:26:00At time 0003 (CDT), Main Steamline Radiation Monitor 2-RE-2326 (Main Steam line 2-02) reading spiked and (was) declared non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 2-02 could neither be evaluated nor monitored. This unplanned 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. Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP 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 2-02. Corrective actions are being pursued to restore 2-RE-2326 to functional status. The NRC Resident Inspector has been notified."
ENS 5347025 June 2018 11:11:00The following information was obtained from the state of Ohio via email: An I-125 seed, approximately 127 microCi, was retrieved from a breast seed localization patient on 6/20/18. A gamma probe was used during surgery to verify it was present in the tissue sample. After surgery the sample was x-rayed and surveyed to verify the seed was still present in the sample; the tissue was placed in a formalin tray and locked in a cabinet. Pathology dissected the tissue on 6/21/18 and did not find the seed. The licensee believes the seed was loosely attached to the tissue and was thrown away with the rest of the materials after it was x-rayed. The licensee performed surveys and did not locate the source. Due to the low activity of the source, it is not expected that the public dose limit would be exceeded. Ohio NMED Report No.: OH180005 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