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ENS 554452 September 2021 15:30:00The following was received from the state of Oklahoma via e-mail: On Sept. 1, 2021 at approximately 1730 CST, (the State) was informed of an incident involving a nuclear gauge which fell from a truck and bent the source rod to the extent that it could not be operated. The source rod was in the shielded position at the time. (It is) believed this occurred sometime the previous day. We will provide more information as it becomes available.
ENS 5543931 August 2021 13:00:00

The following was received from the South Carolina Department of Health and Environmental Control (the Department) via e-mail: On August 31, 2021, the Department was notified by the licensee's RSO at approximately 1230 EDT that one of its trucks containing a portable density gauge had been stolen from the side of the road on Meeting Street in Charleston, SC. The gauge was a Troxler Model 3440 s/n 38444 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be. The licensee stated the police have been to the scene and took a police report. The truck is equipped with GPS and an active investigation is underway.

  • * * UPDATE ON 9/3/2021 AT 0730 EDT FROM ANDREW ROXBURGH TO HOWIE CROUCH * * *

The following information was received from the South Carolina Department of Health and Environmental Control via e-mail: On August 31, 2021 at 1555 EDT, officers apprehended the suspect that stole the licensee's truck containing Troxler Model 3440 s/n 38444. The gauge was recovered undamaged and a radiation surveys performed indicated that radiation readings were within the limits specified in the SSD (sealed source and device sheet) for this gauge. The Department's on-call duty officer performed an on-site investigation on September 1, 2021. Notified R1DO (Dimitriadis), NMSS Events Resource and ILTAB via email. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5544231 August 2021 17:53:00

The following was received from the State of Texas (the Agency) via e-mail: On August 31, 2021, the Agency was contacted by the licensee and informed that they could not retract a 70 Curie, iridium - 192 source into an INC IR100 exposure device. The licensee stated they were working at a fab shop and could not retract the source back into the camera. The licensee did not believe a disconnect had occurred. The licensee stated a 2 millirem barrier was in place. The licensee stated they did not have anyone on its license to retract the source and requested the Agency's assistance in location a qualified company to retrieve the source. The licensee stated it contacted the manufacturer and it stated they could not assist them. The Agency provided them with the contact information of another manufacturer. The licensee contacted the other manufacturer, but it did not offer immediate assistance. The licensee told the Agency that one of its radiographers had received the training for retracting sources but was never added to the license. The licensee was given the contact information for the Agency's licensing group to see if the individual could be added to the license for source retrieval. At 1515 (CDT) the licensee reported the licensing group was able to accept the radiographer's training and amended the license for the retrieval. The licensee stated the individual qualified to retrieve the source was leaving for the site to perform the retrieval. The licensee will contact the agency when the source is retrieved. Additional information has been requested. Additional information will be provided as it is received in accordance with SA - 300. Texas Incident No.: 9881

  • * * UPDATE ON 8/31/21 AT 2237 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *

The following was received from the State of Texas (the Agency) via e-mail: The licensee just reported the individual who will perform the recovery has just landed in Midland, Texas and will head to the site. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Josey) and NMSS via e-mail.

  • * * UPDATE ON 8/31/21 AT 2351 EDT FROM ARTHUR TUCKER TO BRIAN P. SMITH * * *

The following was received from the State of Texas (the Agency) via e-mail: On August 31, 2021 at 2040 CDT the licensee reported that the source had been recovered to the fully shielded position. The individual who performed the recovery received 190 millirem. The licensee stated the exposure device and associated equipment will returned to the storage location and examined. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Josey) and NMSS via e-mail.

  • * * UPDATE ON 9/2/21 AT 1548 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *

The following was received from the State of Texas (the Agency) via e-mail: On September 2, 2021, the licensee contacted the Agency to find out where to send the written report. During the conversation the licensee stated, 'just for your information it appears that the connector spring was malfunctioning as the spring did not engage until about halfway depressed. (The licensee) talked with INC corporate (Radiation Safety Officer) (RSO) and the source will be sent to INC for failure analysis.' The Agency asked if that meant that the spring had disconnected and they stated that it had. The Agency stated that the initial report did not reflect that. (The licensee) stated he knew that and that he had misunderstood what the radiographer had told him over the phone. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Josey) and NMSS via e-mail.

ENS 5544031 August 2021 16:00:00On August 4, 2021 a Licensed Reactor Operator violated the station's FFD policy. The employee's unescorted access to South Texas has been terminated. The event was determined to be reportable under 10 CFR 26.719(b)(2)(ii). The NRC Resident Inspector will be been notified.
ENS 5537723 July 2021 12:06:00At approximately 1040 CDT, July 23, 2021, the Minnesota State Duty Officer was notified by Xcel Energy Environmental Services of a fish kill in the Prairie Island Nuclear Generating Plant discharge canal. The fish kill resulted from a change in temperature due to the loss of power to the plant cooling tower pumps. The cause of the power loss is under investigation. This notification is being made as a four-hour, non-emergency notification 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.
ENS 5537222 July 2021 13:58:00

The following was received via an email from the Pennsylvania Bureau of Radiation: The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company (Radiation Safety Officer) (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received. Pennsylvania Event Report ID No.: PA210007

  • * * UPDATE ON 7/23/2021 AT 0738 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *

The following update was received via an email from the Pennsylvania Bureau of Radiation: QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated. Notified R1DO (Gray) and NMSS Events Notification via email.

ENS 5535715 July 2021 21:36:00

While preparing for the June 2021 Discharge Monitoring Report (DMR), Environmental was entering data per the lab results that were sent from Pace Analytical for the June DMRs. On June 1, 2021, a National Pollutant Discharge Eliminating System (NPDES) sample was collected at outfall 001A to test for copper, there is a NPDES permit condition to monitor for copper on a quarterly basis. The lab report was returned to Fermi Environmental on June 15, 2021. The results came back at 41.2 micrograms/liter. Fermi's NPDES permit maximum limit is 40 micrograms/liter for outfall 001A. Due to the June 1, 2021 sample exceeding the permit limit, a second sample was collected on June 21, 2021 as a verification sample and the copper results came back July 13, 2021. Those results came back at 5.9 micrograms/liter which is within the permit limit. Environmental was aware of the June 1, 2021 copper exceedance limit but failed to recognize the reporting requirement at the time of the discovery because it was thought that the exceedance would be reported through the DMR submittal. The June DMRs are due on July 20, 2021. At approximately 1740 EDT on July 15, 2021, a Fermi environmental engineer was preparing and reviewing the Discharge Monitoring Report and identified that a recent sample result for outfall 001A was outside of the NPDES permit limit for Copper. The Copper sample result was 41.2 micrograms/liter with a limit of 40 micrograms/liter. Subsequent discussions with Environmental personnel determined that this issue should be reported to the state of Michigan Department of Environment, Great Lakes and Energy (EGLE). A discussion is planned with EGLE on July 16, 2021. This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) based on the planned notification to EGLE. The licensee notified the NRC Resident Inspector.

  • * * UPDATE ON 07/22/2021 AT 2141 FROM MARGARET OFFERLE TO OSSY FONT * * *

The licensee initially reported the lab report was returned to Fermi Environmental on June 15, 2021. The date of receipt was June 16, 2021. The licensee will notify the NRC Resident Inspector. Notified R3DO (Pelke).

ENS 5535615 July 2021 16:19:00On July 14, 2021, a technician left a job site unknowingly leaving a Troxler gauge on the tailgate, which subsequently fell off. The project supervisor was informed of the incident at approximately 1445 EDT. A local business has still images of an individual in a truck picking up the gauge on the side of the road and driving off. Local law enforcement was called, and an investigation is underway. The Troxler gauge, model number 35/40, 25423, contained 8 mCi of Cs-137 (serial number 75-8257) and 40 mCi of Am-241:BE (serial number 47-21754). The Transport Index is 0.6. 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 5535214 July 2021 13:50:00The following was received from the Texas Department of State Health Services (the Agency) via e-mail: On July 14, 2021, the licensee notified the Agency that in the process of terminating their license for radioactive materials, the Agency discovered that its records indicated the licensee had at one time a Thermo Niton XL3p-800 device, containing 30 millicuries of americium- 241, which was not on the licensee's current inventory of devices and they learned it had not been on their inventory for years. The licensee stated to the best of their knowledge the analyzer was loaned to a former associated company several years ago and this company was then sold or dissolved. It appears the analyzer was not returned to the licensee. The individuals who were, or may have been involved, are no longer employed by the licensee so further information is not available at this time. An investigation is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: I-9868 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 5535112 July 2021 18:13:00The following was received from the state of California via e-mail: On Monday, July 12, 2021, (Radiation Health Branch) (RHB) Licensing Unit forwarded a July 9, 2021 email from (Radiation Safety Officer) (RSO) (redacted) (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver. RHB contacted the RSO (redacted) for additional information on July 12, 2021. The RSO (redacted) emailed a statement from the Authorized User (AU), Interventional Radiologist, (redacted), stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained. AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs. A written report will be provided to RHB within two weeks. CA Incident No.: 070921 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 5532122 June 2021 16:55:00At 1208 (EDT) on 6/22/2021, the high-energy line break door separating Auxiliary Feedwater Train Rooms 1 and 2 was not able to be latched following normal usage. The door was able to be closed, protecting Train 1 equipment from a break in Room 2. However, it is assumed a break in Room 1 would push the unlatched door open and allow high-energy fluids to enter Room 2. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The door was able to be latched at 1215 (EDT) on 6/22/2021 following repairs to the door latch interlocking mechanism. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). No other equipment was inoperable during this event. The NRC Resident Inspector has been notified.
ENS 5527324 May 2021 21:30:00

The following was received from the California Department of Public Health via e-mail: On May 24, 2021, (the licensee), contacted Los Angeles County Radiation Management regarding a CPN International MC3 (serial number not reported, containing nominally 10 millicuries Cs-137 and 50 millicuries Am:Be-241) moisture density gauge that had been stored in a gauge operators home that was involved in a house fire on May 23, 2021. The gauge was stored in the transport case. The gauge was found to have been melted and was unrecognizable. An inspector from the Los Angeles County was sent to the scene to perform radiation surveys and to evaluate the damage to the gauge and determine if the sealed sources were intact. The disposal of the source will be determined once the evaluation of the damage to the gauge has been completed. The California Department of Public Health will continue to investigate the incident. CA 5010 Number: 052421

  • * * UPDATE ON 5/26/2021 AT 2053 EDT FROM ROBERT GREGER TO JEFFREY WHITED * * *

The following was received from the California Department of Public Health via e-mail: The Cs-137 and Am:Be-241 sources were recovered the evening of May 24 by a member of the California radiation control program. The sources were taken to a licensed gauge service provider the next day, where wipes were taken of the sources for leak testing. The leak test results were received from the gauge manufacturer on May 26 showing that neither source was leaking. The serial number of the gauge was reported as M34125843. Notified R4DO (Gepford) and NMSS Event Notifications (email)

ENS 5527022 May 2021 13:03:00The following is a summary of a phone conversation with the State of Nebraska Radioactive Materials Program: On May 21, 2021, at 1600 (CDT), while performing a start up of the irradiator, the licensee noticed a fault on the control panel of the smoke detector. Troubleshooting revealed there was an issue with a circuit board in the fire system which was causing the fault. Replacement of the circuit board is in progress and is expected to be completed on May 25, 2021. The redundant heat and smoke detector in the vault does not provide an automatic shutdown of the irradiator in case of an emergency. Compensatory measures are in place which include stationing a fire watch.
ENS 5526921 May 2021 15:57:00The following is a summary of a phone conversation with the Licensee's Radiation Safety Officer (RSO): RLS (USA) Inc was informed that a package, which was shipped via a common carrier, was delivered to the wrong address. The package, which contained a sealed source of 297 millicuries of I-131, was dropped off at approximately 0930 (EDT) to Valassis Anderson Printing Plant. The package was labeled with the correct address, however the common carrier delivered it to the wrong location. Valassis Anderson Printing Plant informed the Licensee (RLS) at 1330 that they were in possession of the mis-delivered package at which time the Licensee immediately picked up the package and brought it to their facility. The package was missing for approximately 4.5 hours. Upon inspection, the package was not damaged. Wipes taken were at background levels. A surface survey reading indicated 17 mrem/hr and the transportation index was .5. The contents of the package are 1000 times the limit specified in appendix C to part 20. The RSO performed a worst case scenario: If a member of the public held on to the package for 4.5 hours that would yield a dose of approximately 76.5 millirem. The more likely scenario is that a member of the public was at 3 meters from the package for 4.5 hours which would yield a dose of 2.25 millirem. It is estimated that a member of the public could have received a dose greater then 2 millirem in 1 hours. However, there is no way to confirm this. The package originated from Jubilant Draximage, Canada. 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 5527122 May 2021 15:49:00The following was received from the Tennessee Division of Radiological Health via e-mail: During construction of a commercial business, a Troxler gauge was run over on May 21, 2021. The gauge is still in a shielded configuration and is being securely stored according to plans and procedures until the local field office can respond. The device information is listed below: Manufacturer: Troxler Model: 3440 Serial Number: 33760 Isotopes: Am-241 8 mCi Cs-137 40 mCi Activity Source Serial Number: Am-241 47-29413 Cs-137 750-8896 State Event Report ID Number: TN-21-058
ENS 552291 May 2021 15:39:00At 0755 EDT, on May 1, 2021, with Unit 2 in Mode 3 at 0 percent (not critical) power, the reactor trip breakers opened during heat-up activities. The trip was not complex, with all systems responding normally post-trip. At 1013 EDT, on May 1, 2021, with Unit 2 in Mode 3 at 0 percent power, an actuation of the Auxiliary Feedwater (AFW) System occurred. The loss of both main feedwater pump turbines caused an AFW auto-start. The 2A and 2B motor driven auxiliary feedwater (MDAFW) pumps automatically started as designed when the loss of both main feedwater pumps signal was received. The cause of the actuation is still being evaluated. Operations responded and stabilized the plant. Decay heat is being removed by the steam generators and discharging steam to the condenser. Unit 1 is not affected. Due to the Reactor Protection System (RPS) actuation while not critical and the actuation of the AFW system, this event is 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.
ENS 5522730 April 2021 17:30:00The following was received via e-mail from the Texas Department of Health Services: On April 30, 2021, Biomerics reported the loss of eleven static eliminators (NRD model P-2042-1000) Serial Numbers: A2LD792, A2LD794, A2LD795, A2LD799, A2LD803, A2JQ929, A2KT72, A2EZ959, A2EZ960, A2EZ961 and A2EZ962. Each device contained a 185 MBq (5 mCi) Po-210 source. The devices were received from NRD Advanced Static Control from April 5, 2006 to November 21, 2017. The company was supposed to ship used devices to NRD Advanced Static Control. Biomerics searched the areas where these parts were used and during the course of moving equipment, it is apparent that these devices were thrown away. More information will be provided as it is obtained in accordance with SA-300. Texas Event Number: 75751 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 5522530 April 2021 15:57:00The following is a summary from the Illinois Emergency Management Agency via e-mail: The Emergency Management Agency was contacted at approximately 1416 CDT on April 30, 2021, to report the loss of an industrial radiography camera containing 105 Ci of Ir-192. The device/source is believed to be in the possession of the common carrier and an active investigation is underway. There is no current indication of intentional theft or diversion. The Licensee called to report that the common carrier had dropped off a package on April 30, 2021, at 1040 CDT which was supposed to contain a Spec 150 camera (S/N 439) with a 105 Ci Ir-192 source (s/n CD2901). The cardboard overpack was damaged and the box was empty. The device/source had been overnighted from Spec Industries in St. Rose, LA to Romeoville, Illinois. The State is reaching out to the common carrier and notifying the Tennessee program officials since it is possible the package was lost at the Memphis hub. State Item Number: IL210012 Common Carrier Tracking Number: 166975368552 Notified: DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email). THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
ENS 5522830 April 2021 17:57:00The following was received via e-mail from the California Department of Public Health, Radiological Health Branch (RHB): On April 30, 2021, (The) ENGEO (Radiological Safety Officer) RSO contacted RHB to report a stolen moisture density gauge, a Troxler, Model 3440, S/N 26157 containing licensed material 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen from one of their storage locations (Extra Space Storage). The gauge was last in their physical possession on April 22, 2021, and was secured in the facility at approximate 1430 PDT. The facility is secured by a common gate with access granted with an access key code with security cameras that log entering and exiting the facility. The storage unit was secured by a keyed master lock, and the equipment was locked to the inside of the unit with a chain and secured with at least 1 master lock. Since April 22, 2021, (the) staff has visited the unit on a couple of occasions, however (the staff) was not concerned at the time when the equipment was not observed in the unit which is common as the equipment is used during the day on a regular basis and also due to the lock to the unit being intact (showing no signs of forced entry). On April 29, 2021, the individual who the equipment is assigned to, returned to pick up the gauge and noticed someone had removed it. It was determined that no one from their company removed the gauge from the storage unit after it was secured on April 22, 2021. (The) licensee was unable to view security footage due to privacy of other customers. (The) licensee was told by the manager that he reviewed all footage of their staff entering and leaving the facility between April 22 and April 29 and he observed the staff return the gauge to the unit on April 22, and leave without the gauge in his vehicle after he secured it in the storage unit. (The) licensee has conducted an internal investigation into the location of the gauge and determined that no one with their organization removed the gauge in question. This appears to be consistent with the reported observations of the facility manager's review of security footage. (The) licensee has notified Rohnert Park Police Department of the stolen gauge (police report #21-1838). A cash reward has been offered for the safe return of the gauge. RHB will be following up on this investigation. California Report Number: 043021 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 5522229 April 2021 17:39:00The following was received via e-mail from the Texas Department of State Health Services: The licensee reported that on April 28, 2021, a medical event involving a High Dose Rate (HDR) afterloader gynocological treatment, using a Varian VariSource iX device, with an iridium-192 sealed source of 6.93 curies, at the time of treatment, had occurred at is facility. The wrong length transfer tube was used which resulted in a dose of 600 centigray, the intended dose fraction, to an area, mostly skin, approximately 12 centimeters from the intended treatment site. The authorized user does not expect any harm to the patient. The patient has been informed. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: 9843 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 5519314 April 2021 13:15:00The following was received via e-mail from the State of Texas: On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive (potassium iodine, (KI)) KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9840 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 5519414 April 2021 17:44:00The following was received via e-mail from the Texas Department of State Health Services: On April 14, 2021, the licensee reported to the agency (Texas Department of State Health Services) that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300. Equipment information: QSA Delta 880 exposure device SN: D8849 96.7 curie iridium-192 source SN: 30413M Texas Incident no.: 9841
ENS 5519214 April 2021 13:15:00

The following information was received from the Washington State Department of Health: University of Washington broad scope license C001 reported a medical event. The event involves Y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded. 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.

  • * * UPDATE ON 04/28/2021 AT 1321 EDT FROM TRISTAN DAY TO BRIAN P. SMITH * * *

The following update is from the report received via e-mail from the Washington State Department of Health: On Friday April 9, 2021, a patient had been prescribed two dosages of yttrium-90 microspheres intended for two different liver treatment sites. One treatment dosage was a larger amount than the other, 35.9 mCi and 21.4 mCi. Both dosages were measured in the Nuclear Medicine CRC 15R dose calibrator prior to use. They were found to be the correctly prescribed amounts and the vials were labelled correctly. Both dosages were transported to the Interventional Radiology suite. When the authorized user (AU) called for the first dosage, the higher of the two activities (35.9 mCi), it was set up and administered, including the required radiation dose rate measurement taken prior to and during the dosing. When the AU called for the second dosage (21.4 mCi), he noticed that the radiation dose rate measurement of the second dosage was higher than it had read for the first administration, which was supposed to be the larger of the two dosages. Realizing that the smaller of the two dosages was mistakenly administered first, the physician stopped the treatment and did not administer the second dosage. It was then confirmed that the patient received the lower of the two dosages (21.4 mCi) to the treatment site that was supposed to receive the higher dosage (35.9 mCi). Nuclear Medicine informed the Environmental Health and Safety Department's (EHS) Medical Health Physicist (MHP), and the MHP subsequently informed the Radiation Safety Officer (RSO). Initially, there were questions regarding the need to evaluate this event as a possible Medical Event. There was uncertainty regarding applying the medical event criteria to both sites together or to each individual site. Additionally, the first treatment site was under-dosed and the AU subsequently had determined that the dose delivered was adequate for that site. After discussing the event with the MHP on Monday morning, April 12, 2021, the RSO requested a meeting with Department of Health (DOH) to discuss the event. The MHP and RSO discussed the event with DOH that afternoon, and DOH informed that it would depend if the written directive included both sites, or if there was a written directive for each site. On Tuesday, April 13, 2021, all the required information was obtained, and the MHP and RSO reviewed the dosage and dose calculations and determined that the medical event criteria was met. The dose delivered is less than prescribed, and will result in no harm to the patient and it is the intention of the physician to treat the second site at some future time. Washington Event Report Number: WA-21-006

ENS 552861 June 2021 14:40:00

The following was received from the state of Iowa via e-mail: The licensee reported a potential medical event involving a prostate seed implant therapy. The procedure was performed on April 7, 2021 and the post plan CT scan was conducted on May 27, 2021. The CT scan revealed that a number of seeds were implanted outside of the treatment site. The licensee called and emailed Iowa Department of Public Health (IDPH) Radioactive Materials (RAM) staff on Friday, May 28, 2021. RAM staff, who were out on extended memorial day holiday, did not receive the email or phone message until June 1, 2021 when returning to the office. RAM staff has reached out to the licensee for additional information. RAM staff is intending to conduct a reactive inspection of the licensee (the first week in June). The licensee will be providing the 15 day written report as required by rule. This event will be updated once the additional information requested from the licensee is received. Item Number: IA210002

  • * * UPDATE ON 06/04/2021 AT 1036 EDT FROM RANDAL DAHLIN TO JEFFREY WHITED * * *

The following was received from the Iowa Department of Public Health (IDPH) via e-mail: IDPH conducted an onsite investigation on June 3, 2021. This event is being updated based on that investigation. It appears that the iodine-125 seeds were implanted correctly on the day of the procedure, but due to swelling of the prostate and the 50 days until the post plan CT when the prostate swelling had reduced, the plan showed 16 seeds outside of the target volume. IDPH staff found no procedural problems with the licensees implant procedure. This possible event will be updated once again when the written report is received from the licensee. Notified R3DO (Dickson), NMSS EO (Sida) and NMSS Event Notifications (email).

  • * * RETRACTION ON 06/07/2021 AT 1527 EDT FROM RANDAL DAHLIN TO LLOYD DESOTELL * * *

The following was received from the Iowa Department of Public Health (IDPH) via e-mail: On June 1, 2021 Iowa reported a potential medical event at Spencer Municipal Hospital (License number 0164-1-21-M1) involving Iodine-125 prostate implant seeds. This potential medical event occurred on April 7, 2021 and was discovered by the licensee on May 27, 2021 during their post procedure review. This event was reported to the State on May 28, 2021 and Iowa Department of Public Health (IDPH) Radioactive Materials Program (RAM) staff became aware of the event on June 1, 2021 after the long Memorial Day weekend. IDPH RAM staff conducted a reactive inspection at Spencer Municipal Hospital on June 3, 2021 to interview staff involved in the prostate treatment therapy procedure. IDPH staff determined that all seventy-one Iodine-125 seeds were implanted in the correct location of the prostate based on the treatment pre-plan and that when the post procedure CT scan was evaluated it was determined that sixteen seeds had migrated outside of the target volume. Therefore, this does not meet the definition of a reportable medical event per Iowa Administrative Code 641-38.2(136C). IDPH program staff had a meeting with NRC Region III staff (Darren Piccirillo and Geoff Warren) via Microsoft Teams on Monday, June 7, 2021 to discuss this potential medical event. Region III staff agreed with IDPH that this seed migration is not a reportable medical event. Therefore Iowa is retracting event number 55286 (IA210002). Notified R3DO (Kunowski) and NMSS Event Notifications (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 552871 June 2021 17:46:00This 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 the 2A Reactor Protection System (RPS). On April 1, 2021, at 1302 (CDT), Browns Ferry Unit 2, 2A RPS (Motor Generator) MG set tripped causing a half scram. Unit 2 experienced an unexpected trip of the 2A RPS MG Set that resulted in automatic Primary Containment Isolation System (PCIS) Group 2, 3, 6, and 8 isolations and Trains A, B, and C Standby Gas Treatment (SGT) and Train A Control Room Emergency Ventilation (CREV) starts. At the time of the event, Unit 2 was in a refueling outage and the rods were already fully inserted. All 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. Based on the troubleshooting conducted, the cause was determined to be a loose wiring connection in the motor circuit. The lugs were replaced with ring lugs. Operations reset the 2A RPS Half Scram and PCIS in accordance with 2-AOI-99-1 on April 1, 2021, at 1324 CDT thus correcting the condition and returning RPS to service. 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 Report 1683358. The NRC Resident Inspector has been notified of this event.
ENS 5516230 March 2021 16:50:00The following is a summary of information received from Paragon Energy Solutions: North Anna Station has identified instances where Size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by NLI. The Mechanical Interlock exhibited binding that prevented the contactor to close when energized. The identified starters are utilized in an application of operating Motor Operated Valves. Date of Discovery: 3/29/2021 Formal notification will be submitted on or before 4/29/2021. Affected plants: North Anna Should you have any questions regarding this matter, please contact: Tracy Bolt Chief Nuclear Officer Paragon Energy Solutions 817-284-0077 tbolt@paragones.com
ENS 5522329 April 2021 19:52:00

The following is a summary of information received from Paragon Energy Solutions: On 3/29/2021, Dominion - North Anna Station has identified instances where size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by Nuclear Logistics LLC (NLI). The mechanical interlock exhibited binding that prevented the contactor from closing when energized. The identified failed starters are utilized in an application of operating Motor Operated Valves (MOV). This is an intermittent duty application. The issue was identified on Eaton Starter Model AN56DN*, AN56GN*, CN55DN*, CN55GN* style starters and contactors with supplied date codes T4514 (week 45 of year 2014) and T4215 (week 42 of year 2015). Paragon is in the process of identifying the date codes to provide the specific information to the identified plants. The following plants were supplied starters from September 2014 through October 2018: Beaver Valley, Columbia, Ergytech, Harris, Millstone, NEK KRSKO, North Anna, Prairie Island. The component design that exhibited the failure was revised by the original equipment manufacturer (Eaton) in October 2018. There have been no reported failures of the interlock mechanism in vintages manufactured before September 2014 or after October 2018. These recommendations are based on the specific application: The reversing starters and reversing contactors are typically wired in a configuration that will electrically lock out one of the contactors when the other one is being energized to prevent both contactors from being energized at the same time. Therefore, the mechanical interlock is not required to prevent both contactors from being closed at the same time when the electrical interlock configuration is being implemented. In this scenario, the mechanical interlocks are not required and can be removed. The motor control centers that contain the mechanical interlock should be monitored to ensure that there is no binding during operation. The evaluation being performed by Paragon is expected to be completed by May 29, 2021. Tracy Bolt Chief Nuclear Officer, CNO 817-284-0077 Paragon Energy Solutions, LLC 7410 Pebble Drive Ft. Worth, TX 76118

  • * * UPDATE ON 5/3/2021 AT 1559 FROM TRACY BOLT TO BRIAN LIN * * *

The following revision was received from Paragon Energy Solutions via email and corrects the identified date code and includes the size and serial number of the starter that failed: The issue was identified on supplied Size 1, 73262-025-00028 (Date Code: T4515 - 45th week of 2015) and Size 2, 73262-028-00001 (Date Code: T4215 - 42nd week of 2015). Notified R1DO (Young), R2DO (Miller), R3DO (Orlikowski), R4DO (Deese), NMSS Events Notification, and Part 21 Group via email.

  • * * UPDATE ON 5/28/2021 AT 1558 FROM TRACY BOLT TO KERBY SCALES * * *

The following update (Interim Report) was received from Paragon Energy Solutions via email: Paragon is submitting this Interim Report since this condition is currently under evaluation but will not be completed within 60 days. Paragon is in communication with EATON, the OEM for the starters/contactors to determine the extent of condition. The evaluation is expected to be completed by June 30, 2021. It was determined that Dominion - Millstone should not be included in the list of affected plants. Millstone will be removed from the list in the final revision of P21-03302021. Notified R1DO (Bower), R2DO (Miller), R3DO (Feliz-Adorno), R4DO (Gepford), NMSS Events Notification, and Part 21 Group via email.

  • * * UPDATE ON 6/29/2021 AT 1658 EDT FROM TRACY BOLT TO BETHANY CECERE * * *

The following is a synopsis of an update (completion of the evaluation) received from Paragon Energy Solutions via email: Paragon has identified the date codes of the supplied starters and contactors to provide the specific information to the identified plants. This information has been provided directly to the specific plant." (Millstone was removed from the list of plants.) The component design that exhibited the failure was revised by the original equipment manufacturer (EATON) in September of 2014. The failed units were from Date Codes T4215 and T4515 which are in the 42nd and 45th weeks of 2015. In September 2018 the drawing was revised again. In discussions with the OEM the revision of the drawing was due to a change in material type and was not a result of binding issues. This condition has not been identified on assemblies manufactured after September 2018. Due to the number of starters that have been installed and in service without issue, it is highly unlikely that there is a defect within all the supplied starters in the date range of September 2014 through September 2018. To date, Paragon has been unable to obtain any conclusive information from EATON regarding the potential cause of the binding issue. One of the failed starters along with samples of binding and non-binding interlocks have been provided to EATON for them to perform their own analysis on the potential causes of the binding issue. Until more information is gathered from the OEM (EATON) Paragon recommends the following: The reversing starters and reversing contactors are typically wired in a configuration that will electrically lock out one of the contactors when the other one is being energized to prevent both contactors from being energized at the same time. Therefore, the mechanical interlock is not required to prevent both contactors from being closed at the same time when the electrical interlock configuration is being implemented. In this scenario, the mechanical interlocks are not required and can be removed at the plant's discretion. Replacement mechanical interlocks may be ordered to replace the existing interlocks from the affected date code range if the plant application will not allow for removal. The motor control center cubicles or starter assemblies with date codes within the September 2014 through September 2018 range should be monitored to ensure that there is no binding during operation. It is possible that if the starter is found to bind during operation, the bound condition could be released by cycling the power to the starter. This action may release the bound condition and will allow the starter to operate. Notified R1DO (Lilliendahl), R2DO (Miller), R3DO (Stone), R4DO (Werner), NMSS Events Notification, and Part 21 Group via email.

ENS 5513713 March 2021 01:11:00On March 12, 2021, at 2102 (EST), Reactor Recirculation Pump (RRP) 13 tripped. The cause for the trip is under investigation. Following the RRP trip, the Average Power Ranger Monitors (APRMs) flow bias trips are inoperable due to reverse flow through RRP 13. The APRMs were restored to operable on March 12, 2021, at 2110 (EST) when the RRP 13 Discharge Blocking Valve was closed. This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(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 5522129 April 2021 13:59:00

The following was received via e-mail from the Rhode Island Dept. of Health, Radiation Control Agency: A licensee, Electric Boat Corporation, reported the inability to retract a 1.62 TBq (43.8 Ci) Co-60 source (QSA Global, Inc. Model A424-14, S/N 81346G) into the radiography exposure device (QSA Global, Inc. Model Sentry 330, S/N P30106) on March 7, 2021, at Electric Boat's Quonset Point Facility. At approximately 0120 (EDT), the (source) was (extended) without any issue. At the completion of the exposure, the radiographer attempted to retract the source into the exposure device, and attempted to re-expose the source to verify that the auto-locking mechanism on the Sentry 330 exposure device had engaged. At this time, the radiographer noted that the auto-lock did not engage and that dose rates indicated by his ND-2000A survey instrument at the reel (remote control) remained at approximately 10 mrem/hr. The radiographer then attempted to expose and retract the source to engage the locking mechanism 2 additional times without success. At approximately 0156 (EDT), the RSO ((Radiation Safety Officer)) was notified of the inability to retract a Cobalt-60 source into its exposure device. The RSO was able to observe the set up with an inspection mirror from the opposite side of the large part being inspected and determined that the guide tube had become disconnected from the collimator, exposing 10-12 feet of drive cable on the deck, and the source pigtail had become stuck in the collimator. After creating and briefing retrieval and contingency plans, source retrieval evolution began at 0640 (EDT). The RSO Delegate secured the source pigtail in the collimator with a 6 ft long remote handling tool to prevent the source from leaving the collimator prematurely while the RSO stepped out from behind the lead shield with another 6 ft long remote handling tool to move the guide tube from the deck back up to the collimator. While the RSO was straightening out the guide tube and drive cable, a radiography supervisor was slowly retracting the drive cable at the reel to remove the 10-12 ft of drive cable slack on the deck while the RSO communicated via radio. Once the drive cable slack was removed and the RSO guided the guide tube back up to the collimator and tension on the source pigtail was released, the RSO Delegate released control of the source and it was immediately retracted by the radiography supervisor into the exposure device. The source was confirmed to be secured in its device by survey, and the evolution was declared secure at 0649 (EDT). RI Radiation Control Agency has investigated the report by Electric Boat Corporation and has determined that this does not have generic implications for the security of sources in radiography equipment at Electric Boat Corporation. The incident is considered closed by RI Radiation Control Agency.

  • * * UPDATE ON 6/29/21 AT 1617 EDT FROM ALEXANDER HAMM TO BETHANY CECERE * * *

The following update was received via email from the Rhode Island Dept. of Health, Radiation Control Agency: Event Causes: 1) The first 1-3 male threads were rough, which lead to the female connection binding up prematurely. 2) The collimator connection was at or above the eye level of the radiographers, and obstructed from being able to perform a visual inspection of the connection. 3) Neither radiographer re-inspected nor verified the connection in the middle of the shift. Corrective Actions: By the licensee: 1) 2 collimators with male threads were identified as unsat and will be repaired or dispositioned for disposal by the RSO. 2) Thread protectors were procured and installed on equipment with exposed, male-threaded connections. 3) A Job Instruction Breakdown describing the connection and verification processes was developed. Notified R1DO (Lilliendahl) and NMSS Events Notification (by email).

ENS 5511223 February 2021 16:34:00

The following was received from the Massachusetts Radiation Control Program (the Agency) via email: The licensee (QSA Global, Inc., License No. 12-8361) reported at 1400 (EST), on February 23, 2021 that it discovered on same day (February 23, 2021) at 1200 (EST), that a package (Yellow-III, T.I. 1.5, Type B, UN 2916) containing one sealed source (Co-60, 62.6 Ci, SN 88647G) in a Sentry radiographic exposure device (SN P01017) was missing. The package was shipped by QSA Global, Inc. on January 29, 2021 for export to their customer Acuren Group, based in Canada. On February 23, 2021 at 1200 (EST), Acuren Group reported to QSA Global, Inc. that the package was not received. On February 23, 2021 at 1400 (EST), QSA Global, Inc. reported the event to the Massachusetts Radiation Control Program. The (common) carrier indicated that the package was at their Memphis facility on January 31, and that since then the location is unknown. The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. The four-hour reporting requirement of 105 CMR 120.077(B), missing shipment of Category 2 quantity of radioactive material, also applies. The Agency considers this event to be open.

  • * * UPDATE ON 03/03/2021 AT 1417 EST FROM ROBERT LOCKE TO THOMAS HERRITY * * *

The following was received from the Agency via email: Licensee reports that they were notified at 1645 (EST) on March 2, 2021 that the missing package had been located in the Memphis. The wooden crate containing the Type B Package was damaged, however, the Type B package itself was not damaged. The licensee is sending materials to (common carrier) in Memphis to repair the crate before continuing with export to the customer in Canada. Notified R1DO (BURKET), NMSS (RIVERA-CAPELLA), IR MOC (GOTT), and ILTAB (RICHARDSON) and via email NMSS EVENTS NOTIFICATION, INES NATIONAL OFFICER (MILLIGAN), AND CNSC (CANADA). Also notified DHS-SWO, FEMA-OC, USDA-OC, HHS-OC, DOE-OC, DHS CISA Central, and EPA-EOC and via email FDA- EOC, Nuclear SSA, FEMA-NWC, and CWMD-Watch Desk. THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 550999 February 2021 11:00:00At approximately 0800 on February 9, 2021, thirty-one (31) H.B. Robinson Nuclear Plant Offsite Emergency Notification sirens in Darlington County, SC were inadvertently actuated. The Darlington County Emergency Services and South Carolina Emergency Management Division were promptly notified. The actuation lasted for three (3) minutes at full volume. The cause of the actuation is under investigation at this time. Capability to notify the public was never degraded during the inadvertent actuation. All Emergency Notification sirens remain in service. This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi), Offsite Notification, as a four (4) hour report. The NRC Resident Inspector has been notified. A local news agency did report about the alarms sounding and reported that there was no concern at the site.
ENS 550989 February 2021 10:35:00On February 9, 2021, at 0153 CST, Cooper Nuclear Station experienced a spike in Secondary Containment differential pressure which exceeded the Technical Specifications Surveillance Requirements 3.6.4.1.1 limit of -0.25 inches of water gauge. Secondary Containment differential pressure oscillated coincident with barometric pressure oscillations. Three additional spikes occurred which exceed the Technical Specification limit. The duration of each spike was less than one minute. The last spike occurred at 0232 CST. Secondary Containment differential pressure has restored to Technical Specification limits and further investigation is ongoing. This unplanned Secondary Containment inoperability constitutes a condition reportable under 10CFR50.72(b)(3)(v)(C) and (D), "An event or condition that at the time of discovery could have prevented the fulfillment of the safety function of (Structures, Systems, and Components) SSCs that are needed to control the release of radioactive material and mitigate the consequences of an accident. The NRC Senior Resident Inspector has been informed.
ENS 5507419 January 2021 17:36:00The following is a summary of a call received from the licensee: The licensee reported a shutter stuck open on a DMC-19 gauge, s/n: 7759LX, with a 1,000 microCi AM-241 source. The shutter is currently closed and locked. There were no overexposures. Global Gauge was working on the shutter and is expected to conduct repairs on 01/20/2021.
ENS 551265 March 2021 16:20:00

The following is a summary of the report provided by the supplier: On January 6, 2021, Crane Nuclear, Inc (CNI) received an e-mail message from a customer identifying that the weld procedures Crane summitted for use on the customer's purchase order were unacceptable, as the procedure did not meet the requirements of ASME Code Section IX. CNI immediately began research and determined the customer to be correct. CNI is currently conducting research to determine where the affected weld procedures were used. The scope of supply is Code and safety related valve and valve parts supplied by CNI since 2009. Joyce Hammam Director, Safety and Quality (678) 451-2280 Crane Nuclear, Inc. 860 Remington Blvd Bolingbrook, IL 60440

  • * * RETRACTION ON 6/3/21 AT 1453 EDT FROM JOYCE HAMMAN TO JOANNA BRIDGE * * *

The following was received from the supplier: Update 6/3/21: Eleven procedures were identified by CNI as not having a supporting (Procedure Qualification Record) (PQR) for welding on greater than 1 inch base metal. Of those eleven, three have never been used. Those three procedures are being corrected to identify the procedure applies to base metal of up to 1 inch only. The remaining eight procedures have had a 1 inch coupon welded and tested. All coupons passed the penetrant test, the hardness tests, and macro testing, as required by table QW-453 of ASME Code Section IX. As a result, CNI is updating the affected procedures. This is a paperwork issue for Crane and not a Part 21 concern for the industry." Notified R1DO (Bicket), R2DO (Miller), R3DO (Dickson), R4DO (Groom) and PART 21/50.55 REACTORS (by email).

ENS 5409531 May 2019 14:27:00

The following is an excerpt of the Part 21 information received via email: Introl Positioners used by stations in G32 Terry Turbine control applicators have the potential to contain a latent defect. The defect is the result of internal corrosion which has been identified in Tl Operational Amplifiers Part No.TL084CN on the SL3EX Controller Boards of the turbine throttle valve positioner. It is believed the likely cause is associated with the ingress of solder flux into the IC Chip package on the controller board due to delamination caused by the soldering process during fabrication. The corrosion over time can result in intermittent open circuiting and high resistance in the aluminum metallization. Chlorine ionic contamination can also result in high leakage currents within the component circuitry. Failures may be manifested by a reduced valve position signal disproportional to the expected demand condition, no actuation signal (i.e. throttle valve remaining full open), or other anomalous unexpected behavior. There are three TL084CN chips on each SL3EX Controller Board within the positioner assembly. There have been two documented failures to date occurring in 2015 and 2019 in installed systems. Date determination was made: May 29, 2019 Affected sites: Farley, SONGS, Cooper, Almaraz Trillo Nuclear Power Plant (Spain), Clinton, Harris, Wolf Creek, Point Beach, Hatch, Watts Bar, Sequoyah. Stations are advised to work directly with Curtiss-Wright SAS via the technical contacts below. Randy F. Iantorno Project Manager, T: 585.596.3831, M: 585.596.9248, email riantorno@curtisswright.com or Justin Pierce 585.596.3866.

  • * * UPDATE FROM RANDY IANTORNO (CURTISS-WRIGHT) TO DONALD NORWOOD AT 1537 EDT ON 6/7/2019 * * *

The following is a synopsis of information received via E-mail: Shearon Harris Nuclear Plant experienced an overspeed trip of the Turbine Driven Auxiliary Feedwater Pump (TDAFW) on January 18, 2019 during routine system testing. Upon receipt of the initial start signal, the valve remained in the fully open position causing the TDAFW to trip on overspeed. Investigation into the overspeed trip revealed the positioner was not controlling the actuator properly in response to the governor command signal. This situation and subsequent troubleshooting led to replacement with the site spare positioner. Once installed, the system responded as expected and the suspect positioner was sent to Curtiss-Wright SAS (CW SAS) for evaluation. In a joint effort between CW SAS and Paragon Energy Solutions (PES), the positioner was tested and evaluated to determine the cause of the failure. Corrective action which has been, is being, or will be taken: - The three TI chips on the affected board have been successfully replaced at PES. The repaired positioner will be configured and returned to Shearon Harris. - The evaluation of suspect chips has been limited to those removed from the failed positioner, along with some supplied to PES by CW SAS. Work is ongoing in this area. - A complete list of potentially affected installations is listed in the PES Part 21 Report dated May 31, 2019. - Although this defect has the potential of preventing the Electronic Governor Speed Control System (EGSCS) from performing its intended safety function, it does not prevent the Terry Steam Turbine from operating. If the EGSCS fails, the turbine can be operated manually using the Trip and Throttle Valve (TTV) to control speed by regulating steam flow to the turbine. - Steps are being taken to develop a plan to replace chips on affected positioner boards. This is still in the preliminary stages and specific recommendations will follow. Notified R1DO (Carfang), R2DO (Rose), R3DO (Kozak), R4DO (Kellar), Part 21 Reactors E-mail group, and Part 21 Materials E-mail group.

  • * * 1058 EDT ON 7/11/2019, UPDATE FROM RANDY IANTORNO (CURTIS-WRIGHT) TO MICHAEL BLOODGOOD * * *

The following was received via e-mail. This is a follow up letter related to Curtiss-Wright SAS (CW SAS) Report no. 48 submitted on June 6, 2019 regarding the Introl positioner failure discovered at the Shearon Harris Nuclear Plant on January 18, 2019. As reported in the initial report, the failure has been isolated to internal corrosion discovered inside TL084N Operational Amplifier chips on the SL3EX Controller Board. The cause of the failure has yet to be determined; however CW SAS and Paragon Energy Solutions (PES) continue to investigate potential causes. CW SAS will continue working with affected sites to provide guidance on additional testing, along with developing solutions that include replacement of suspect chips on the Introl positioner control boards. To allow CW SAS to coordinate efforts on a site by site basis, this will be the final correspondence sent directly to the NRC on this matter. Notified R2DO (Ehrhardt), R3DO (McCraw), R4DO (Azua), Part 21 Reactors E-mail group, and Part 21 Materials E-mail group.

ENS 5406917 May 2019 03:35:00

EN Revision Text: REACTOR TRIP DUE TO SOURCE RANGE HI FLUX SIGNAL This is an 8-hour, non-emergency notification for a valid reactor trip signal with the reactor not critical, and a valid auxiliary feedwater system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A) - Valid System Actuation.

At 2303 (CDT) on May 16, 2019, the plant was administratively in mode 2 due to withdrawing control rods for startup following refuel. The reactor had not been declared critical. The P-6 permissive at 10E-10 Amps was met for one of two Intermediate Range detectors allowing for block of the Source Range high flux trip (1E5CPS). Prior to performing the block, the Source Range high flux trip setpoint was exceeded and a reactor trip received. All systems responded as expected. A feedwater isolation signal was received due to the reactor trip with feedwater temperature less than 564 degrees Fahrenheit. Auxiliary feedwater was started to maintain steam generator levels. The plant is being maintained stable in mode 3 with no complications. The NRC Resident Inspector was present during the startup and was notified of the reactor trip.

  • * * UPDATE FROM JONATHAN LAUF TO HOWIE CROUCH AT 1454 EDT ON 6/5/19 * * *

A correction is being made for the sixth sentence in the second paragraph above, which states, 'A Feedwater Isolation signal was received due to the reactor trip with feedwater temperature less than 564 degrees Fahrenheit.' Within this sentence, 'feedwater temperature' is to be replaced with 'reactor coolant system temperature.' The licensee has notified the NRC Senior Resident Inspector.

ENS 5406616 May 2019 00:54:00

The following is a summary of an e-mail received from the State of Florida: On May 15, 2019 at 2327 EDT, the Florida Division of Emergency Management, Radiation Control Duty Officer, contacted the NRC via e-mail to report that all westbound lanes of East Colonial Drive, in Orlando FL, were closed and the entrance and exit ramps to/from State Route 417 were closed. The State Trooper on scene reported that there was a potential release of an unknown quantity of medical grade radioactive material, Molybdenum-99. This material is used in the treatment of cancer. Orange County HAZMAT was dispatched to the scene and requested a call back for assistance. A state inspector was dispatched to the scene. The inspector found no damage to the radioactive material and no contamination. The material was housed in a lead lined box, surrounded by styrofoam, in a cardboard shipping container. There was one person reported with minor injuries due to the crash. Florida Report No.: 2019-2728 Notified DOT Crisis Management Center, DOE and DHS SWO.

  • * * UPDATE ON 6/6/2019 AT 1718 FROM STATE OF FLORIDA TO RODNEY CLAGG * * *

Vehicle accident occurred around 2215 EDT on the west bound side of East Colonial Drive at the south bound exit ramp of the 417 involving medical radioisotopes. Tradewind Enterprises Inc (Hillsboro, OR; 503-648-2823) courier vehicle was a small SUV with radioactive placards carrying three packages of Mo-99 in the back of the SUV. Contact cell phone numbers for Orange County Fire are 407-402-8532 and 407-383-9806. State of Florida inspector responded. The boxes did not leave the vehicle nor sustain any damage nor was there any leakage of radioactive material. Surveys of packages showed all within Tl (transportation index), swipes indicated no removable contamination. Custody of packages was taken by driver's supervisor. This incident is closed. Notified R1DO (Carfang) and the NMSS Events Notification E-mail group.

ENS 5407017 May 2019 08:06:00The following was received via e-mail: On May 14, 2019, at approximately 1620 (EDT) Kentucky Transportation Cabinet, (KY RML# 201-086-51) reported that a Humboldt 5001 EZ, serial number 3133 moisture density gauge had been severely damaged and partially buried by a bulldozer, at a road construction project in Madison County located near Richmond KY. The gauge contained 0.37 GigaBq (10 milliCi) Cesium-137 (serial number 8273GQ) and 1.48 GigaBq (40 milliCi) Americium-24:Beryllium (serial number NJ03357). The technician had been taking some readings, while waiting for more rock to be put in place and put the device in safety mode and set it on top of pile of Dense Graded Aggregate. He then walked over about 80 feet to talk to an operator when it was run over by a bulldozer. KY Radiation Health Branch personnel were on the scene at approximately 1800 (EDT) and determined that the top of the source rod had been broken off and the outer case of the gauge was cracked. There was no leakage detected and the survey of the broken case showed readings = 10mR/hr on contact indicating that the shielding had not been compromised. The area was taped off in a 30 foot circle surrounding the damaged device till it was recovered by the Fayette County HAZMAT Team and placed into a 55 gallon drum, sealed and removed to a storage facility. The Radiation Safety Office indicated that a final decision on the disposition of the gauge will be forthcoming, and that retraining of the employee would be a priority, to include emphasis on surveillance and situational awareness at jobsites. KY Event No.: KY190005
ENS 5406515 May 2019 11:11:00On May 14, 2019, at 1324 EDT the Radiation Safety Officer (RSO) was contacted by the Operation Manager and informed that a source located at a site in Muskegon MI could not be returned to the shielded position by the normal means. The technicians verified the boundary to ensure no unplanned exposure. The RSO called the site technician and went through the source retrieval procedure. The source was a SPEC model 150 camera with 89 Ci Ir-192 source. The RSO went to the site and was able to determine the location of the source and put temporary shielding on it. The RSO determined the source tubing was crimped and was able to straighten the tube. The source was retracted into the camera and locked by 1550 EDT. The crimped tubing was replaced with new tubing. The device was tested satisfactorily. There were no over exposures. The doses received during the radiography and retrieval process were: RSO 28 mR, Radiography 23 mR, and Assistant Radiography3 mR.
ENS 5403328 April 2019 14:57:00

The following was received from the state of Arizona via e-mail: The (Arizona Department of Health Services) received notification that an individual stole (three) industrial radiography cameras and threatened to use them. It is believed that the individual is a current or former worker at the licensee. The isotope is Iridium-192 for all three cameras and the approximate activity amounts are 30 Curies, 49 Curies, and 80 Curies. As of approximately 1120 (MDT), the individual was located, the material was secured, and the (Radiation Safety Office) is waiting to bring the material back to the storage location. The Department has requested additional information and continues to investigate the event. Arizona Incident No.: 19-009 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 Domestic Nuclear Detection Office Joint Analysis Center (email). THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

  • * * UPDATE ON 4/28/19 AT 1920 EDT FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following is a summary of a telephone call: The sources were safely recovered. They were found in the radiography cameras. It is widely believed that the suspect never removed the sources from the shielded cameras. The cameras have been returned to the storage facility. Notified R4RDO (Young), NMSS Events Notification (email), NMSS (Moore), ILTAB (e-mail), CNSNS Mexico (email), IR MOC (Kennedy), ILTAB (Smith), NMSS INES Coordinator (email), INES National Officer (email). 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 Domestic Nuclear Detection Office Joint Analysis Center (email).

ENS 540537 May 2019 13:57:00The following was received via e-mail: During a routine (Utah Division of Radiation Control) inspection on April 26, 2019, the licensee discovered that two planchet sources containing radioactive materials were missing from its secured laboratory. The sources were used to calibrate a wipe counting system that the licensee rarely used. One source contained 9.9 nanoCuries of strontium-90 (Sr-90) and the other source contained 17.81 nanoCuries of plutonium-239 (Pu-239). The activity of the Sr-90 source was well below the exempt quantity threshold. The inspector gave the licensee until May 3, 2019, to search for the sources and to let the inspector know the results of the search. On May 2, 2019, the licensee informed the Division that, after an exhaustive search, the licensee had failed to locate the sources. Following a review of the applicable rules by Division staff on May 6, 2019, the inspector verified with the licensee that the sources were still missing and informed the licensee of the incident notification requirements and the anticipated enforcement activities to be taken by the Division. Event Report No.: UT190001 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 5402725 April 2019 12:04:00At 0918 (EDT) on 4/25/19, with (Saint Lucie) Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a Turbine Trip. The reactor trip was uncomplicated with all systems responding normally. Operations is maintaining the plant stable in Mode 3. Decay heat removal is being accomplished by main feed water and the main condenser using the turbine steam bypass valves. Unit 2 is not affected and remains at 100% power. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B). The NRC Resident Inspector has been notified.
ENS 5402925 April 2019 17:42:00

The following was received from the state of Arizona via e-mail: The (Arizona Department of Health Services) received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. Arizona incident Number 19-008. 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.

  • * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following was received from the state of Arizona via e-mail: This correspondence is a follow-up to the notification sent (on 4/25/19) regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead (certified radiation technologist) in an (operating room) department of a hospital performing 6-7 fluoroscopic procedures per day. It is believed that the actual exposure was just to the badge and not to the person. Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).

ENS 5403026 April 2019 17:22:00The following was received from the state of Wisconsin via e-mail: On April 26, 2019, Wisconsin Department of Health Services (DHS) was notified that at the licensee's Kaukauna facility, a fixed gauge mounted to a coal chute had been damaged and failed with the shutter closed. The incident occurred on April 22, 2019. Maintenance staffs were repairing a valve located above an Ohmart/Vega Corporation Model SHLG-1 fixed gauge containing 5 mCi of Cs-137. The valve failed, rotated downward, and made contact with the shutter actuator handle which severed the handle from the device. The gauge was not in operation at the time of the incident and the shutter remained in the closed position, the licensee's (Radiation Safety Officer) (RSO) stated on the initial phone call that the shutter is now inoperable. The maintenance staff called the RSO on the day of the incident and he instructed them to cordon off the area and perform surveys of the device. The surveys indicated that the source was not impacted and the RSO later performed confirmatory surveys that yielded similar results. Wisconsin DHS intends to perform a reactive inspection when the licensee's service provider replaces the gauge; the date is still to be determined. Event Report No.: WI 190001
ENS 5399814 April 2019 03:21:00On April 14, 2019 at 0003 (EDT), Nine Mile Point Unit 1 experienced an automatic reactor scram during reactor startup. The cause of the automatic scram was due to high (Reactor Pressure Vessel) pressure following closure of the turbine stop valves. All control rods fully inserted and all plant systems responded per design following the scram. Following the automatic scram, the High Pressure Coolant Injection (HPCI) System automatically initiated as expected. At Nine Mile Point Unit 1, a HPCI System actuation signal on low Reactor Pressure Vessel (RPV) level is normally received following a reactor scram, due to level shrink. HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System. At 0004, RPV level was restored above the HPCI System low level actuation set point and the HPCI System initiation signal was reset. Pressure control was established on the Turbine Bypass Valves, the preferred system. No Electromatic Relief Valves actuated due to this scram. Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. The offsite grid is stable with no grid restrictions or warnings in effect. The unit is currently implementing post scram recovery procedures. The NRC Resident Inspector has been notified. The Licensee will notify the State of New York.
ENS 5399512 April 2019 11:24:00The following is a synopsis of an event received via email: On April 11, 2019, a trained technician was in the process of performing the biannual inventory/shutter check when the individual reported that Kay Ray Model #7050, Serial #1399, 250 mCi, Cs-137 gauge located on 5B DTU (Deslime Thickener U/Flow) in the Deslime basement had a frozen shutter mechanism and cannot be closed, rendering the shutter non-operable. The gauge won't be replaced until the first time the slurry pipeline goes down for repair. If the line goes down prior to that, the gauge will be replaced at that time. Similar events in the past have never had an exposure to any individuals. In the event of an emergency, the gauge will be removed and placed on a piece of lead and brought to storage.
ENS 5396026 March 2019 16:28:00The following is a summary of information received from the State of Nebraska: On March 26, 2019, the Nebraska Department of Radioactive Materials received a letter dated March 25, 2019, from the licensee (Flint Hills Resources) concerning the loss of two tritium exit signs, each with an activity of 17.51 Curies. Two H-3 exit signs were lost during recent construction of additional warehouse space on an existing building. One sign was over a personnel door on the wall demolished for the new space and one was on a personnel door proximal to the construction area. NE Item Number: NE190002 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 5395725 March 2019 17:53:00The following was received via e-mail: On March 25, 2019, the agency (Texas Department of State Health Services) reviewed a voicemail left on an investigator's office phone line in which a licensee reported a stuck shutter on a gauge. The gauge is a Thermo Fisher Scientific model 7062BP, with serial number S99G0101, containing a 100 millicurie Cesium-137 source with serial number 6551GQ. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located on a 6" line and no exposures are anticipated as a result of this malfunction. The manufacturer has been contacted and service will be scheduled. Updates will be sent in accordance with SA-300. Texas Incident: I-9668
ENS 5394116 March 2019 13:42:00At approximately 1100 CDT on March 15, 2019, Cooper Nuclear Station was notified by the National Weather Service that the Shubert radio transmission tower was not functioning due to evacuating their office in Omaha as a result of local flooding. This affects the tone alert radios used to notify the public in event of an emergency condition. Loss of function of this tower is reportable at 1100 CDT on March 16, 2019, when the tower could not be restored within 24 hours of the loss. This condition is reportable under 10 CFR 50.72(b)(3)(xiii). A backup notification method is available and will be utilized for notifications if needed. A return to service time for the Shubert tower is not currently available. The NRC Senior Resident Inspector has been informed.
ENS 5393715 March 2019 13:39:00On March 15, 2019 at 1300 EDT, Indian Point Unit 2 automatically tripped offline from mode 1 - 100% power operations. Reactor Operators verified the reactor trip and the plant is currently stable in mode 3. All automatic systems functioned as required. The auxiliary feedwater system actuated following the trip, as expected. All control rods fully inserted upon the trip, as expected. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72(b)(2)(iv)(B). The unit remains on offsite power in hot standby at normal operating temperature and pressure. Decay heat is being removed from the steam generators via the auxiliary feedwater system and the condensate steam dump valves. Unit 3 remains in mode 6 for a scheduled refueling outage. The licensee notified the NRC Resident Inspector, the local transmission company, and New York State Independent System Operator. The Indian Point Unit 2 automatic trip was caused by the trip of the main generator. The cause of the generator trip is unknown at this time.