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 Entered dateEvent description
ENS 5537522 July 2021 20:28:00On July 20, 2021, at 1707 EDT, an apparent non-compliance with 10 CFR 50, Appendix R, section III.G.2 (separation of redundant fire safe shutdown equipment) was identified. This issue was initially categorized as not affecting train separation or the ability of the equipment to perform their Design Basis functions. The original concern was entered into the licensee's Corrective Action Program as CR1177199. Subsequently, on July 22, 2021, at 1751 EDT, a further review of the affected control circuits for the Unit 1 and Unit 2 Emergency Diesel Generator (EDG) output breakers and emergency bus feeder breakers identified a concern that breaker position interlocks routed to or through non-safety related components or spaces may affect the ability to provide emergency power on the affected unit due to impacts on the control power circuits during an Appendix R fire associated with a loss of offsite power. The following are the affected fire areas: - Unit 1 and Unit 2 Turbine Buildings - Unit 1 and Unit 2 Cable Spreading Rooms - Unit 1 and Unit 2 Normal (307) Switchgear Rooms This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60-day written report pursuant to 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as CR 1177399. The NRC Resident Inspector has been notified of this event.
ENS 5537322 July 2021 15:49:00The following was received from the Virginia Radioactive Materials Program (VRMP) via email: On July 22, 2021, at 0950 EDT, VRMP received a report via telephone from the Radiological Duty Officer of the Virginia Office of Radiological Health that a portable nuclear moisture/density gauge was damaged when hit by a car at a temporary jobsite. At 1000 EDT, the VRMP contacted the Radiation Safety Officer (RSO) of the licensee. The RSO stated that a Troxler density gauge (Model 4640-B, serial number 2266, containing 8 milliCuries of cesium-137) was hit by a car at a temporary jobsite. The gauge housing was damaged, but the source appeared to remain intact within the safe position. The licensee's survey of the gauge yielded readings of 0.02 mR/hr at about a foot distance from the gauge. The gauge was taken to the licensee's office in its transport container. A survey was also performed on the ground and the reading was reported as background. The gauge will be tested for leakage and after testing, it will be sent to the Troxler Electronics Laboratories for evaluation. The VRMP is working with the licensee to obtain additional information. This report will be updated once the licensee's investigation is complete and the information is received by the VRMP. According to the RSO, no public or personnel exposure occurred. Event Report ID No.: VA210004
ENS 5537021 July 2021 20:50:00At 1826 EDT on July 21, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a trip of the Main Turbine. Unit 1 reactor was operating at 100 percent reactor power with no evolutions in progress. The Control Room received indication of a Main Turbine trip with both divisions of RPS (Reactor Protection System) actuated and all control rods inserted. The Reactor Recirculation Pumps tripped on EOC-RPT (end of cycle recirculation pump trip). Reactor water level lowered to +8 inches causing Level 3 (+13 inches) isolations. No ECCS (Emergency Core Cooling Systems) or RCIC (Reactor Core Isolation Cooling system) actuations occurred. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water. The reactor is currently stable in Mode 3 with main condenser available. Investigation into the trip of the Main Turbine is in progress. The NRC Resident Inspector was notified. A voluntary notification to PEMA will be made. This event requires a 4 hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B).
ENS 5536620 July 2021 19:44:00The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone: The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs. The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.
ENS 5536821 July 2021 17:21:00The following was received from the California Department of Public Health via email: A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000. Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent). Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure. Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT (Certified Nuclear Medicine Technologist) on July 20, 2021. 5010 Number: 072121 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 5535415 July 2021 10:11:00The following was received from the Ohio Department of Health via email: A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD ((written directive)) prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad. Item Number: OH210006 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 5537422 July 2021 20:11:00The following was received from the California Radiologic Health Branch (RHB) via email: The licensee reported that on 7/13/2021, they received an externally contaminated package containing two unit doses of F-18 (110 minute T1/2 (half life)). The licensee's receipt survey found the outer surface removable contamination level to be 5,417,497 dpm per 100 sq cm. The inside of the package, including the F-18 vials, were not contaminated. The radiopharmacy courier was informed of the excessive contamination, and the radiopharmacy was contacted. The package radiation levels were acceptable. The package was received from Optimal Tracers (CA-RML 7975). RHB will investigate this matter further, including onsite at Optimal Tracers' facility. 5010 Number: 071921
ENS 5535515 July 2021 10:42:00The following was received from the Texas Department of State Health Services via email: On July 13, 2021, the licensee discovered a stuck shutter in the open position during a 6 month shutter test. This is the normal operating position and there is not expected to be any additional dose outside of normal operations to workers or public. The device was a Vega SH-F2B density/level gauge (serial number 3578CR), with a 200 mCi CS-137 source (serial number 3578CR). Texas incident number: I-9869
ENS 553489 July 2021 16:15:00The following was received from the Alabama Department of Public Health (the agency) via email: An agency representative received a call about 1400 CDT from the RSO (Radiation Safety Officer) of International Paper Company, license no. 222, in Pine Hill, Alabama. The RSO stated that a fixed gauge was discovered with its shutter stuck open about 1000 CDT on 7/9/2021. The RSO stated that the gauge is located on functioning process equipment; there are no health and safety issues. The RSO stated that the gauge will have shielding added, be removed, and placed in storage on the plant site, on Monday, 7/12/2021. The gauge is an Ohmart SH-L1-0 s/n M6846 with a cesium-137 source, 80 mCi on 8/1992. Alabama Event 21-22
ENS 5525915 May 2021 00:55:00At approximately 1300 CDT on 05/14/2021, a contract worker, who was using a scaffold ladder to access their work area on the iso-phase bus duct system for the main transformers at the Callaway plant, fell approximately 27 feet to the ground. An ambulance was dispatched to transport the individual to a local hospital. Union Electric (Ameren Missouri) subsequently learned that the event caused the individual to have a serious injury that required an overnight hospital stay. This event is reportable to OSHA per 29 CFR 1904.39(a)(2) by the contract worker's employer and is reportable to the Missouri Public Service Commission in accordance with Missouri regulation 20 CSR 4240-3.190(3)(A). This notification is being made to the NRC pursuant to 10 CFR 50.72(b)(2)(xi) due to other government notifications that will occur as a result of a situation related to the health and safety of onsite personnel. The NRC Senior Resident Inspector has been notified of this event. The individual was not working in a contamination area.
ENS 5526017 May 2021 08:55:00The following was received from the Ohio Department of Health via email: During removal of the Cs-137 source (20 mCi, Serial # 5450CN) and holder (Ohmart/Vega Model SHLM-B1-P) by the manufacturer (VEGA), it was discovered the shutter would not operate and was stuck open. INEOS is actively working with the manufacturer to develop a suitable path forward for removal of the source. In the meantime, a physical barrier is installed to prevent vessel entry. Ohio Reference No.: OH 2021-037
ENS 5522430 April 2021 07:38:00On 4/29/21 at 2354 (EDT), an alarm was received for U2 HPCI Inverter Power Failure. (It was) identified that the High Pressure Coolant Injection (HPCI) flow controller had lost power due to a failure of an inverter. Without the flow controller, HPCI would not auto start to mitigate the consequences of an accident; thus, HPCI was declared inoperable. All other emergency core cooling systems and reactor core isolation cooling (RCIC) system remain operable. HPCI is a single train system with no redundant equipment in the same system; therefore, this failure is reportable as an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident per 10CFR50.72(b)(3)(v)(d). The NRC Resident has been informed of this notification.
ENS 5536921 July 2021 17:36:00The following was received from the Illinois Emergency Management Agency (the Agency) via email: The RSO (Radiation Safety Officer) called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned. The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021. Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending. A reactionary inspection will be performed. Item Number: IL210020 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 5520722 April 2021 17:23:00

The following is a summary of a phone call from the state of Nevada: A plant manager for the HC Companies Inc. was performing a walkthrough when three NDC-102 thickness gauges were discovered. The manager was familiar with the gauges from a different site, but this site did not have any registered, nor does this site have a license for any material. The gauges, potentially only requiring a general license, were moved and the corporate safety group notified in order to secure them. When the safety group arrived, one of the gauges was missing (s/n: 2690; source: 150 mCi of Am-241). Item Number: NV210004

  • * * UPDATE ON 4/23/2021 AT 1720 EDT FROM COREY CREVELING TO THOMAS KENDZIA * * *

The state of Nevada sent a picture of the missing source via email: The picture confirms the the previous information and the date of the radiological strength was 1/92. Notified: R4DO (Azua) (email), NMSS Event Notifications (email), and ILTAB (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 551859 April 2021 16:08:00A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant had been terminated.
ENS 551869 April 2021 16:08:00The following was received from the Minnesota Department of Health via email: A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021. Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose (that varied by) greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days. The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state. 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 5514822 March 2021 13:16:00At 1005 EDT on 3/22/2021, the control room was notified of a personal medical event in the Radiologically Controlled Area. An ambulance entered Susquehanna plant property at 1019 and exited at 1028 to transport the individual to a local hospital. Ambulance did not enter the Protected Area. The individual was considered potentially contaminated since a complete frisk could not be performed prior to transport. Following transportation to a local hospital, Radiation Protection (RP) technicians confirmed the individual and ambulance were not contaminated. This event is reportable under 10CFR50.72(b)(3)(xii). An Event of Potential Public Interest (EPPI) was made to the Pennsylvania Emergency Management Agency (PEMA) due to an emergency vehicle accessing plant property. The NRC Resident Inspector was notified.
ENS 551213 March 2021 20:18:00The following is a summary of a report received from the California Department of Public Health (the Department) via email: The Department was notified that a Troxler model 3440, Serial Number 22188 (9 mCi. Cs-137, 44 mCi. Am:Be-241) had been lost when the operator left the worksite believing the gauge was in the bed of the truck. At approximately 1430 PST, the licensee reported the gauge had been located at the work site and returned. The licensee is investigating the event and the Department will review their findings. California Report ID: 5010-030321 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 5514922 March 2021 17:33:00

The following is a summary of a report received via phone: On February 25, 2021, the licensee did not receive a shipment of three Cs-137 Brachytherapy sources with an aggregate quantity of 42.9 mCi (activities: 8.8 mCi, 8.7 mCi, and 25.4 mCi). The licensee reached out to the common carrier, who stated that it was still at their Memphis, TN distribution center and delayed due to the ice storm. The licensee has contacted the common carrier a number of times, with the last one taking place on March 18, 2021. The common carrier states they are still looking for the shipment package.

  • * * UPDATE ON MARCH 29, 2021 AT 1908 EDT FROM TOM CLAWSON TO BRIAN P. SMITH * * *

The following update is a summary of a report received via phone: On March 29, 2021, the licensee notified the Headquarters Operations Officer that the common carrier had located the licensee's sources that had been lost and shipped them back to the licensee. The licensee has receipted the sources back into their inventory. The common carrier recovered the lost sources on March 23, 2021. Notified NMSS Events Notification (email), R4DO (Alexander), ILTAB (email), and R1DO (Janda). 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 5510617 February 2021 11:30:00A new, not qualified security officer self reported illegal drug use and resigned following a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC resident inspectors and R1 security inspector were notified.
ENS 551234 March 2021 12:06:00The following was received from Iowa Department of Public Health via email: On February 3, 2021, the University of Iowa received a package from (the common carrier) that was labeled as one of the standing orders of 1 millicurie P-32 dCTP for the Pathology Lab at UIHC ((University of Iowa Health Care)). The outer label was correct and the packing slip inside was correct, however the contents of the package was actually a prescription of Enbrel intended for an individual in Illinois. Further, the contents had obviously been repacked. It arrived in a large (common carrier) box, much bigger than required for the P-32 order or the Enbrel. Also, the top of the original package that held the P-32 had been torn off and affixed to the replacement box in an adhesive pouch. The licensee contacted both (the common carrier) and the pharmaceutical company that shipped the Enbrel. (The common carrier) returned to retrieve the Enbrel but haven't heard anything about the location of the original P-32 order. Perkin Elmer sent a replacement shipment of P-32 to the licensee. On February 10, 2021, (the common carrier) sent an email to the licensee notifying them that the original shipment of P-32 has not been located and they were closing the case. On March 4, 2021, the Iowa Department of Public Health contacted the University of Iowa Radiation Safety Officer (RSO) and was informed by the RSO that the original shipment of P-32 is still missing. The activity of the P-32 as of March 4, 2021 is approximately 244 microcuries. Item Number: IA210001 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 5506813 January 2021 15:04:00The following was received from the Alabama Department of Public Health via email: On 1/13/2021, registrant Pace Analytical Services reported that a 15 mCi Ni-63 source (model: 82397-65506; s/n: U25815) in an ECD ((electron capture detector)) device (Agilent 7890B; s/n: CN14453150) was reported to be leaking with a routine wipe test. The device was transferred to Pace Analytical in Ormond Beach, Florida on or around 10/29/2020. The registrant reported that the device is currently with Agilent awaiting disposal. Alabama Event: 21-02
ENS 5506512 January 2021 13:29:00

The following is a summary of a call received from the licensee: During routine maintenance, an inspector from Radiometric Services and Instruments found that the shutter for an AMC-19 gauge, s/n: 998110B, with a 100 microCi AM-241 source, would close slowly. This was not as expected. The inspector noted that the pneumatic system was over pressurized. The gauge is located on the Continuous Galvanizing Line and the shutter is open during normal operations. The shutter can still be closed and a Geiger counter can be used to verify. There was no exposure to personnel.

  • * * UPDATE ON 1/19/2021 AT 1731 EST FROM ROBIN BIRK TO JOANNA BRIDGE * * *

The following is a summary of a call and e-mail received from the licensee: While testing the shutter today we were experiencing some continuing problems with the shutter mechanism at our Continuous Galvanizing Line. During maintenance, we discovered some error codes in the RSI software that indicated possible additional shutter problems. There was no potential for employee exposures. RSI will be back at the plant to address on 1/20/21. Notified R3DO (Peterson) and NMSS Events (e-mail).

ENS 5506412 January 2021 12:24:00

The following was received from the Arkansas Department of Health (the Department) via email: The Department received notification on January 12, 2021, from licensee Mid-Continent Laboratories, Inc., that a Troxler gauge model 3411-B ((S/N: 4794; Activity: Am-241 (44 mCi); Cs-137(9 mCi))) had been stolen from a licensee while at his residence. Upon review of the event, the Authorized User checked the portable gauge out of its permanent storage location at approximately 0600 CST to travel to Colorado for work. Before leaving, the Authorized User returned to his place of residence. While at his residence the chains securing the gauge to the truck were cut and the portable gauge was stolen from the vehicle. This event has been reported to Law Enforcement, in addition, Arkansas Department of Health inspectors are currently working with the Tennessee Department of Environment and Conservation, Division of Radiological Health, to investigate and report. (West Memphis, AR is on the border with Tennessee). Arkansas Department of Health will be issuing a Press Release. The Arkansas Department of Health considers this investigation open pending receipt and review of any further information that may become available. Arkansas Event Report ID No.: AR-2021-001

  • * * UPDATE ON 01/13/2021 AT 1401 EST FROM CHRIS TALLEY TO OSSY FONT * * *

The following update was received from the Department via email: The Authorized User was allowed to store the gauge overnight in his vehicle at his place of residence. The theft occurred between 2130 CST, January 11, 2021 and 0730 CST, January 12, 2021. The Authorized User noticed the disappearance of the gauge while leaving his residence to go to work. Notified R4DO (O'Keefe) and NMSS Events Notification and ILTAB via email.

  • * * UPDATE ON 04/26/2021 AT 1030 EST FROM CHRIS TALLEY TO JOANNA BRIDGE * * *

The following update was received from the Department via email: The serial number for the missing gauge should be changed from 4794 to 7689. Law enforcement has received the updated information. In addition, the gauge is still missing and no other new information has been received. Arkansas has received the event report from the Licensee and still considers this event open due to the gauge having not been found. Notified R4DO (Azua) and NMSS Events Notification 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 5506713 January 2021 13:39:00The following was received from Massachusetts Radiation Control Program via email: The licensee reported by telephone on January 12, 2021 that it discovered on January 11, 2021 a radiopharmaceutical medical event involving the therapeutic administration of iodine-131 for treatment of thyroid cancer. The licensee reported that the administered dose was an underdose of greater than 20 percent and was a difference of greater than 50 rem to an organ, the thyroid, when compared with the prescribed dose, meeting the reporting requirements 105 CMR 120.594(A)(1)(a). One iodine-131 capsule instead of two iodine-131 capsules were administered. The prescribed total activity was 100 milliCuries and the administered total activity was 19.5 milliCuries. The second iodine-131 capsule that was not administered was accounted for and contained in its original glass vial. The licensee reported that the referring physician and the patient has been notified. The licensee reported that its staff had discussed the medical event and put into place competencies to prevent future recurrence and that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(A)(4). The Agency considers this event to be open. 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 5518912 April 2021 18:23:00The following synopsis was received from the Colorado Department of Public Health and Environment via email: During an inventory, a hotel manager discovered two exit signs were lost, each containing 7.62 Ci of tritium. 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 5500523 November 2020 14:36:00The following was received from the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on 11/23/2020 by the Radiation Safety Officer for Heuft USA, Inc. to advise that a package scheduled to arrive today at their Downers Grove, IL facility had not arrived. The carrier, (common carrier), could not immediately locate the package. The package contained (1) special form model AMC-25 sealed source containing approximately 45 mCi of Am-241. The source serial number is 1535AR. The source is contained in a 6"x6"x6" brown "U-Line" cardboard box. As it was an excepted package, it only bears UN2910 and does not have radioactive labels on the exterior. Should the package be opened, there is an aluminum 5"x5" round can filled with foam and a zip lock bag. The bag contains a shielded source holder with the Am-241 capsule therein. The bag and the can are reportedly labeled with a trefoil and the words "Radioactive Material". Unshielded, the source would yield an exposure rate of about 8 mR/hour at one foot. This is not an immediate hazard to workers or members of the public that locate the package. The package is assigned tracking number 349-162302-3 by (the common carrier). The package left their Kearny, NJ terminal on 11/19/2020. There is conflicting information on whether or not the package arrived at (the common carrier's) Akron, OH terminal. The package was bound for (the common carrier's) Bolingbrook, IL terminal but reportedly never arrived. The carrier is actively searching and Illinois staff are in contact. New Jersey program staff have been notified as well. This report will be updated as additional information becomes available. Illinois Item Number: IL200023 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 5496928 October 2020 16:50:00

The following is a summary of a call with the licensee: On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion. On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork. An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more. The patient was informed and no effects are expected. The licensee will notify the NRC Region 3 Office.

  • * * RETRACTION FROM EVAN BOOTE TO DONALD NORWOOD AT 1620 EST ON 12/2/2020 * * *

The following information was received via E-mail: Following review of the images and discussion of this case with surgery (personnel), the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip. Notified R3DO (Dickson) and NMSS Events Notification E-mail group. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 5496827 October 2020 21:43:00

At 1608 CDT on 10/27/2020, Wolf Creek Unit 1, operating at 100 percent rated thermal power in Mode-1, experienced a loss of the on-site wired corporate network. During actions to restore, it was discovered the ability to access the dose assessment software was compromised due to a security program. Access to the program was established after some time using Wi-Fi connectivity, but was not able to be accessed without network access. Actions are being taken to rectify. The NRC Resident Inspector has been notified. The licensee believes this was not a cyber-event and that the Emergency Response Data System was available, but couldn't verify. Should the Wi-Fi network access be lost, there's no capability to perform a dose assessment. Standalone laptops are being provided but have not been placed onsite yet. That should restore the ability to have dose assessment capability at all times.

  • * * UPDATE ON 10/27/2020 AT 2220 FROM JOHN WEBER TO OSSY FONT * * *

The licensee notified the NRC that the network has been restored to the Technical Support Center building and the emergency plan dose assessment group was capable of performing dose assessment. The licensee also noted that the group is able to perform dose assessment without the network, if needed. The network is still unavailable in the control room. The licensee confirmed that ERDS is available. The licensee will notify the NRC Resident Inspector. Notified R4DO (Pick).

ENS 5496727 October 2020 17:50:00The following was received from the Georgia Radioactive Materials Program (the Program) via email: The Y-90 event (occurred) on October 23, 2020. The AU ((Authorized User)) notified the Assistant RSO ((Radiation Safety Officer)) on October 26 and then subsequently notified our Program on October 27, 2020. The reason for the delay notifying the Program was both the Radiation Safety Officer (RSO) and Assistant Radiation Safety Officer (ARSO) were furloughed on Friday ((October 23)) and they did not check their emails until Monday. They used Monday to gather information before contacting the State Program. The patient was administered with 1.58 GBq using a 10 mL syringe. The reason for the 10 mL syringe was a small gauge catheter was used. The line was subsequently flushed 3 times with saline solution to ensure the Y-90 was pushed through. After the procedure, the catheter was removed and surveyed along with the vial to determine residual activity. It was calculated that there was more residual (activity) than expected. Though it is has not been clearly determined the cause of the excess residual (activity), it is thought to be either not enough saline was used to push the Y-90 through or it got stuck in the catheter. The ARSO and the Authorized User will discuss the cause of the event, best way to prevent occurrence, and (perform) patient follow-up. The licensee will follow-up with a report within 15 days. In the interim, the licensee is required to submit a copy of the written directive, Y-90 procedure and checklist, and the rational why they used a small catheter gauge. The actual dose delivered was 1.039 GBq (65.5 percent). Georgia Incident No: 31 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 5496221 October 2020 10:14:00A carpenter working in a clean area (not a radiological controlled area) injured his hand and required medical treatment. The nature of the hand injury requires reporting to the State of Washington Department of Labor and Industry. This concurrent report is being made in compliance with 10 CFR 70 Appendix A criteria c) which requires the reporting of any event or situation, related to health and safety for which notification to other government agencies has been or will be made. The licensee also notified the NRC Region 2 office.
ENS 5494915 October 2020 17:29:00

The following was received from the state of Tennessee via email: General licensee, Blues City Brewery, reported the loss of 3 gauges after contractor work that involved the movement of the gauges. Blues City reported the loss. It is possible that the gauges could have made it into the local scrap metal stream. From the scrap metal facility, the load that might have included the gauges went to a shredding facility in Alabama. The State of Alabama Radiation Control has been notified in case gauges are discovered at the shredding facility. The gauge is below: Manufacturer Model SN Isotope Activity Industrial Dynamics CI-2GV/3 44 Am-241 300 mCi Industrial Dynamics CI-2GV/3 46 Am-241 300 mCi Industrial Dynamics FT-100 33 Am-241 100 mCi TN event number: TN-20-152

  • * * UPDATE ON 11/12/2020 AT 2014 EST FROM ROBERT SIMS TO BRIAN P. SMITH * * *

The following update was a summary of an email report received from the state of Mississippi concerning information pertaining to the lost gauges: On October 19, 2020, the Tennessee Division of Radiological Health contacted the Mississippi Division of Radiological Health and the Alabama Department of Public Health Radiation Control concerning three lost gauges from the Blues City Brewery facility. The facility believes the gauges were lost in the July-August timeframe during construction on some of their lines. Blues City Brewery told the contractor to take the gauges to a storage area, but the contractor moved the wrong parts allegedly to the scrap yard. The scrap metal/gauges are believed to have been brokered by an unknown entity and allegedly sent to Iskiwitz Metals at 604 Marble Ave, Memphis, TN 38107. The Tennessee Division of Radiological Health sent someone to look for the gauges and survey for them, but they only found the detector for part of one of the devices. From Iskiwitz, the metal was believed to be sent to a shredder in TN and a scrap yard in Mississippi named Martin Brothers Scrap Metal located at 690 Belmont Rd, Sardis, MS 38666, then allegedly to a smelter in Alabama. Soil samples were taken at the scrap yard in Mississippi, however, readings show only background radiation. The gauges have not been found. Mississippi Division of Radiological Health considers the event closed. Mississippi Event Number: MS-200004 Notified R1DO (Carfang), R4DO (Dixon), NMSS Events Notification (Email), ILTAB (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 5494815 October 2020 14:31:00

The following was received from the Colorado Department of Public Health and Environment (CDPHE) via email: (A Troxler 3440 (SN 23106) containing not more than 333 MBq (9 mCi) of cesium-137 and 1.63 GBq (44 mCi) of americium-241:beryllium; or 2.44 MBq (66 microCi) of californium-252) was reported missing after a licensee was unable to account for it during a routine inventory check. The material was noticed missing at approximately 1000 MDT on Wednesday, October 14, 2020. The event was reported to the CDPHE at approximately 1700 on October 14, 2020. No signs of a burglary at the facility are present. The last entry for the gauge in the utilization log is August 19, 2020. The licensee suspects that a former employee stole the gauge, the employee to last check-out the gauge was terminated on bad terms. The licensee is in the process of reporting the theft to the local police.

  • * * UPDATE ON 11/16/10 AT 1513 EST FROM DEREK BAILEY TO THOMAS KENDZIA * * *

The following was received from the Colorado Department of Public Health and Environment (CDPHE) via email: Following a police investigation the nuclear gauge was anonymously returned to the owner. On November 16, 2020, the missing nuclear density gauge was found chained to the fence at the Olsson office. It was discovered at 1015 MDT Olsson examined the gauge and found it to be in the proper original packaging with no apparent damage to the gauge's packaging, components, or sources of radiation. It was determined that the gauge was returned at approximately 2330 MDT November 15, 2020. Notified the R4DO (Taylor), NMSS Events Notification (email), and ILTAB (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 5494613 October 2020 14:49:00The following is a summary from a phone call with the licensee: A patient at the Indiana University Health Methodist Hospital was prescribed 46.7 mCi of Y-90 Theraspheres to segments 5 and 8 of the liver, but received 54 percent (25.2 mCi) of the prescribed dose. The remaining 46 percent (21.5 mCi) was trapped in the catheter or the line. The patient and the physician were notified and a follow-up treatment has been scheduled for next week. 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 5495015 October 2020 17:17:00The following was received from the state of Tennessee via email: Energy Solutions experienced a fire in the gas furnace 'Drum Drying Operation' of the Liquid Volume Reduction Facility (LVRF) building, which is a sub building off of the Incinerator building located at the 1560 Bear Creek Road, (Oak Ridge, TN) facility. The drums being processed contained Energy Solutions secondary waste with the following listed source term associated with the containers: C-14 (0.5 mCi), Co-60 (2.2 mCi), Cs-137 (0.96 mCi), Fe-55 (2 mCi), H-3 (4 Ci), and Tc-99 (98 mCi). Estimated 0.03 mrem dose to the public as a result of the event. TN event number: TN-20-155
ENS 5494714 October 2020 14:28:00The following was received from Illinois Emergency Management Agency (the Agency) via email: During the afternoon of October 13, 2020, the Agency received a call from the RSO ((Radiation Safety Officer)) at Rush Oak Park Hospital, Inc. (IL-01676-01) to notify the Agency of a potential 24-hr notification requirement from an event which occurred at 0830 CDT, Friday, October 9, 2020. According to the RSO, a Nuclear Medicine Technologist (NMT) was administering a 27 mCi dose of Tc-99m to a patient when the vein "collapsed" which created pressure and sprayed a small quantity of Tc-99m back into the technicians face and eyes. The technician soon thereafter went to the E.R. ((emergency room)) and had her eyes rinsed out. At 1000 the same morning, the RSO met the NMT in the E.R. and took a near contact measurement of her face utilizing a Ludlum model 26 which identified a maximum 6,050 cpm on her forehead. The RSO stated that he could not identify any contamination elsewhere or within the wash water at the E.R. Having no other information, the RSO calculated that in consideration of an approximately 0.23 percent efficiency of the instrument, approximately 1.2 microCi of Tc-99m was on the skin of the NMT. The RSO also stated that he did a few worst case scenario calculations but didn't come close to reportable levels. The Agency concurs with the licensee's determinations. Furthermore, the patient was given most of the dose and still had a normal scan. No contamination was identified on the patient. The used syringe measured 1 mCi remaining following treatment and the accident. The RSO explained that he didn't think it was reportable but following a closer look at 32 IAC 340.1220(c)(3) thought he had better complete his due diligence and give us a call. Inspection and Enforcement supervisor to follow up with the licensee. The incident will be entered into NMED ((Nuclear Material Events Database)) and reported to the Headquarters Operations Officer within 24 hours of notification, as required. The licensee will be advised of the requirement to submit a written report within 30 days in accordance with 32 IAC 340.1230. Item Number: IL200019
ENS 5486629 August 2020 16:14:00

The following was received from the Texas Department of State Health Services (the Agency) via email: The licensee notified the Agency at approximately 1315 CDT that one of its company pickups had been stolen and a Troxler model 3440 moisture/density gauge (SN: 37337) was secured in the bed of the truck. The gauge contains 40 milliCurie americium-241 and 8 milliCurie cesium-137 sources. The technician had a late testing and then went to his residence from the job site due to a serious water leak that was occurring there. After fixing the leak, it was late and he fell asleep and did not return the gauge to the licensee's facility. He last saw the vehicle/gauge at approximately 0100. At approximately 0900, he discovered the vehicle, with the gauge, had been stolen. The set of keys to the locks securing the gauge and the insertion rod were in the cab of the truck. Local police were notified. Police will notify the local pawn shops and the licensee will search local buy/sell/trade internet sites for the gauge and other equipment. More information will be provided as it is obtained in accordance with SA-300. Texas Incident # I-9790

  • * * UPDATE ON 08/29/20 AT 2018 EDT FROM KAREN BLANCHARD TO OSSY FONT * * *

The following update was received from the Texas Department of State Health Services via email: The licensee's Radiation Safety Officer notified the Agency at approximately 1847 CDT that he has possession of the gauge and it was back at their facility. He had been called by the San Antonio Fire Department HAZMAT at approximately 1800 that they had been called to a location where the gauge was - the gauge was sitting on the edge of a street next to the curb. The latches on the transport case were unlocked but the gauge and all other equipment were present. The chains and locks that secured the gauge in the bed of the truck were also present. There was no damage to the transport container or the gauge. Technicians put the device through its normal testing procedures and it is fully operational. Any further information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Kellar), and NMSS Events Notification, ILTAB, and CNSNS (Mexico) 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 5486528 August 2020 18:58:00

EN Revision Imported Date : 9/1/2020 AGREEMENT STATE REPORT - LOST SHIPMENT OF TRITIUM EXIT SIGNS The following was received from the Texas Department of State Health Services (the Agency) via email: On August 28, 2020, the Agency was contacted by an individual to notify it that they had shipped seven Forever Lite tritium exit signs to a manufacturer in May of 2020 and they have been informed by the transportation company that they do not know where the signs are. The signs are Forever Lite signs, each containing 7.03 curies (original activity) of tritium, manufactured in May 2011. The package was last scanned in Fort Worth, Texas, in May of 2020. The shipper stated that they were told on May 19, 2020 it was to be delivered in Canada. The next update when they followed up they were advised the package was lost and they were trying to locate the shipment and opened a claim. The location where the signs were lost is unknown at this time; therefore, the Agency is making this report for your information. The Agency has requested additional information and clarifications from the shipper. Additional information will be provided as it is received. Texas Incident #: I - 9789 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

  • * * UPDATE ON AUGUST 31, 2020 AT 1126 EDT FROM ART TUCKER TO BRIAN LIN * * *

The following was received from the Texas Department of State Health Services (the Agency) via email: After reviewing documents provided by the licensee, the Agency contacted the licensee and confirmed that eight signs were lost and not seven as previously reported. The transportation company's radiation safety officer (RSO) was contacted by the Agency and the RSO stated they do not store the tracking records of shipments in their computer system for very long, therefore they would not be able to review the tracking information for this shipment. The Agency will provide additional information as it is received in accordance with SA-300. Notified R4DO (Deese), NMSS Events Notification, ILTAB, CNSC (Canada), and CNSNS (Mexico) via email.

ENS 5486428 August 2020 16:38:00In accordance with 10 CFR 52.99(c)(2), as described in NEI 08-01, 'Industry Guideline for the ITAAC Closure Process Under 10 CFR Part 52,' Vogtle Units 3 and 4 Construction is making this notification to the NRC for determining that Inspections, Tests, Analyses and Acceptance Criteria (ITAAC) 2.5.02.07a (Index No. 534) and ITAAC 2.5.02.07e (Index No. 538) for both units require additional actions to restore their completed status. The ITAAC Closure Notifications for ITAAC 534 were submitted on March 31, 2017 (Unit 3 ML17093A286, Unit 4 ML17093A535). The ITAAC Closure Notifications for ITAAC 538 were submitted on November 30, 2016 (Unit 3 ML16351A350, Unit 4 ML16351A334). On August 26, 2020, it was determined that a design change, issued for several Protection and Safety Monitoring System (PMS) isolation barrier assemblies (ISBs), materially altered the basis for determining that the ITAAC 534 and ITAAC 538 Acceptance Criteria were met. The modified ISBs will require testing per IEEE 384-1981, Standard Criteria for Independence of Class 1E Equipment and Circuits, to demonstrate that the Acceptance Criteria is met. System function is not required while the plant is under construction. ITAAC Post Closure Notifications in accordance with 10 CFR 52.99(c)(2) will be submitted following completion of corrective actions. The 10 CFR 52.99(c)(4) All ITAAC Complete Notification has not been submitted for VEGP ((Vogtle Electric Generating Plant)) 3 and 4. The resident inspector has been notified.
ENS 5482610 August 2020 14:38:00

At 1258 CDT on August 10, 2020, Duane Arnold Energy Center declared an Unusual Event due to a loss of offsite power due to high winds. The event at the single unit plant resulted in an automatic scram from 82 percent power (Mode-1) to zero percent power (Mode-3). They are headed to Mode-4. There is damage on site, but the Reactor Building is intact. All rods inserted and cooling is being addressed via Reactor Core Isolation Cooling (RCIC) for level control and Safety Relief Valves are removing decay heat to the torus. Both Standby Diesel Generator are running. The licensee notified the NRC Resident Inspector, the Iowa Department of Emergency Management, and the Linn County and Benton County Emergency Management agencies. Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE ON 08/10/2020 AT 1554 EDT FROM CURTIS HANSEN TO OSSY FONT * * *

This report is being made under CFR 50.72 (b)(2)(iv)(B) for an automatic reactor scram due to loss of offsite power due to high winds. In addition, this report is being made under CFR 50.72 (b)(3)(iv)(A) and (B) due to PCIS ((Primary Containment Isolation System)) Groups 1, 2, 3, 4 and 5 (activating) due to loss of offsite power. All isolations went to completion. RCIC injecting for level control. All rods fully inserted during the scram. The plant electrical line up is both SBDGs (Standby Diesel Generators) are running. Decay heat is being removed via SRVs (Safety Relief Valves) to the torus. Progress towards shutdown cooling. NRC Senior Resident (Inspector) notified at 1448. Notified R3DO (Pelke).

ENS 548237 August 2020 16:59:00The following was received from the Tennessee Division of Radiological Health via email: On August 6, 2020, World Testing radiographers were radiographing at Matrix Drilling in Lewisburg, Tennessee. They were radiographing pipes and one of the pipes (weighing approximately 1000 pounds) rolled onto the guide tube, denting it. They could not crank the source back in. They called the RSO ((Radiation Safety Officer)). The guide tube was curled and making it more difficult to get the source back into the camera. They pulled on the crank to straighten out the guide tube and with enough pressure they were able to get the source past the dent and back into the exposure device. They placed lead on the collimator for additional shielding while working with it. The camera was a Sentinel, Model 880D, Serial number D-1120. The (Ir-192) source serial number was 96522G, with an activity of 44Ci. The source was exposed for approximately 4 hours. All personnel involved were wearing dosimetry. There were no overexposures. Tennessee Event Report ID No.: TN-20-114
ENS 548091 August 2020 09:51:00The following is a summary of information received from the licensee's Radiation Safety Officer (RSO) via phone: While two radiographers where shooting pipe welds in Saint Albans, WV with a 100 Ci Ir-192 radiography camera, a separate pipe rolled off and crimped the guide tube with the source in the collimator. They extended the work area to 1 mR/h and called a retrieval team. The team arrived 1.5 hours later with lead bags, which were placed on the collimator, reducing the dose rate to 1 mR/h at the source. They cut some of the crimped metal in order to retract the source. The camera was returned to the licensee's South Point, Ohio storage unit. The guide tube will be cut and replaced. The dose to the radiographer and radiographer assistant was 30 mrem and 19 mrem, respectively. The dose to the retrieval team RSO and RSO assistant was 30 mrem and 22 mrem, respectively.
ENS 5479923 July 2020 12:47:00The following was received from the Florida Bureau of Radiation Control (BRC) via email: (The licensee) called the BRC at around 0945 EDT to report that a package (containing 53.91 mCi of I-125) of Brachytherapy seeds was lost by (the common carrier). The package left the manufacturing facility, then the local facility, was picked up by (the common carrier) at 1706 on July 20, 2020, but was lost somewhere before Tampa. IsoAid checked the delivery status on July 21, 2020, but it was not scanned. Route intended to be Tampa to Memphis to New York to South Africa. There are 100 seeds loaded in 7 magazines, 6 magazines contain 15 seeds each, and a 7th magazine contains 10 seeds. These seven magazines are contained in a white leaded pig. The pig was packaged in a white box, 9" x 7" x 5" weighing about 4lbs. The package was labeled as Radioactive White - I, UN2915. Florida Incident Number: FL20-085 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 5479621 July 2020 12:42:00At 0851 EDT on July 21, 2020, a Technical Specification required shutdown was initiated at Robinson Unit 2. Technical Specification LCO 3.0.3 was entered due to LCO 3.1.7 not being met as a result of indication loss on Control Rod positions with more than one position indication inoperable for a group. LCO 3.0.3 was entered at 0752 EDT to initiate action within 1 hour to place the unit in MODE 3 within 7 hours. Since a Technical Specification required shutdown was initiated, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). Technical Specification LCO 3.0.3 was exited at 1003 EDT on July 21, 2020. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. Shutdown was initiated and power was reduced approximately 3 percent. Reactor power was back to 98.5 percent at the time of notification.
ENS 5479822 July 2020 17:59:00The following was received form the California Radiologic Health Branch (RHB) via email: On 7/17/2020, licensee's RSO ((Radiation Safety Officer)) contacted RHB to report an incident in which a portable nuclear gauge (Humboldt 5001EZ SN: 2919, 11 mCi Cs137, 44 mCi Am241:Be) was damaged by a construction truck at approximately 2330 PDT on 7/16/2020. The RSO secured the gauge after notification by the gauge technician and transported the gauge to the licensee's permanent storage location. The RSO determined and confirmed to RHB that the source rod was able to be retracted into the shielded position after the incident. The RSO performed a radiation survey and reported readings of 0.099 mR/hr at 1 meter. RHB will be following up with this investigation. California 5010 Number: 071720
ENS 5478617 July 2020 09:49:00The following was received from the Florida Bureau of Radiation Control (BRC) via email: On July 16, 2020, a 54 year old man was mistakenly provided two doses of Tc-99 Sestamibi for heart stress test. Two doses were administered with a total activity of 41.6 mCi, estimated dose of 7.49 R, to the intestinal wall. The RSO ((Radiation Safety Officer)) reports that standard verification process for patient identification prior to dosage was not followed. Patient and patient's cardiologist have both been notified, no effects of the mis-dose are expected. The RSO will provide additional info in the 15 day letter to BRC. Licensing and Technology will be tasked to investigate. Florida Incident Number FL20-081 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 5477915 July 2020 10:22:00The following is a summary from the South Carolina Department of Public Health received via phone: At 0945 EDT on 07/15/2020, the licensee's Radiation Safety Officer (RSO) notified the State that two Troxler moisture density gauges (model 3430P, serial #'s 72756 and 75041), each containing 8 mCi of Cs-137 and 40 mCi of Am-241, were stolen from their Ballentine, SC storage facility. The devices had not been used in a few days, so it is unknown when they were stolen. The RSO reports that the job box containing the travel cases were taken, but the locks were not cut. Additionally, the roll up gate was closed but not secured. The RSO believes it could be an inside job. The RSO was in the process of calling the police. 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 5478416 July 2020 10:48:00The following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email: At approximately 1530 CDT on July 14, 2020, the Agency was contacted by the RSO ((Radiation Safety Officer)) /owner of Construction & Geotechnical Material Testing (IL-02179-01) regarding a Troxler 3440 gauge (s/n: 24805; containing 8 mCi of Cs-137 and 40 mCi of Am-241) that was run over and crushed by an operator running a roller on a construction site at 1514 Main Street in Lombard. The RSO reported that operations had stopped and that he needed guidance to get the source rod out. At 1550 CDT, the Agency contacted the licensee for details and to provide guidance. The gauge user was uninjured but the gauge was run over and destroyed. At the time of the incident it was confirmed that the source rod was extended into the ground and a measurement was in process. The gauge user immediately notified personnel in the area and cordoned off the area. The gauge user then notified his RSO, who then notified Troxler (their emergency contact) and IEMA as per their emergency procedures. The RSO immediately went to the scene. He stated that he verified the security of the scene. He did not believe that the source rod was bent. The RSO stated that he was headed back to his office for a survey meter. Agency inspectors reviewed concerns regarding exposure from the Cs-137 source and the possibility of a leaking source with the RSO. Procedures were reviewed for surveys of the area once the gauge was removed to ensure the Cs-137 source had not become dislodged and that the source was not leaking. The Agency offered to dispatch inspectors to assist; however, the licensee had the gauge manufacturer engaged and able to respond. The gauge manufacturer responded to the scene at approximately 1700 CDT and confirmed the source rod was unbent and able to be shielded. Both the Am-241 and the Cs-137 sources were confirmed as present and intact. The gauge was safely repackaged into the Troxler case by Troxler personnel and the TI (Transport Index) confirmed as 0.3. This information was confirmed with pictures sent to the Agency. Troxler personnel performed surveys of the area to confirm the source was removed and that there was no contamination/leakage. Both sources (Cs-137 and Am-241) were placed into the Troxler transport container without incident. Both Troxler and the licensee performed surveys of the site prior to departing and after packaging the damaged source. At 1830, the licensee confirmed background readings at the site and the gauge was transported back to Troxler. The gauge will be leak tested and then shipped to Troxler in North Carolina for disposal. This matter will remain open pending receipt of leak tests, additional gauge information, documentation of disposal, and required written reports. Illinois Item Number: IL200011
ENS 5477814 July 2020 23:51:00The following was received from the California Department of Public Health via email: A Troxler moisture density gauge (model 3430, serial # 31716) was reported stolen Monday morning at approximately 0600 PDT from the bed of an employee's vehicle while the vehicle was parked for 1-2 hours outside the employee's residence in Moreno Valley, CA. The gauge contains approximately 0.3 GBq (8 mCi) of Cs-137 and 1.50 GBq (40 mCi) of Am-241. The gauge was reportedly picked up earlier that morning at the licensee's office in Rancho Cucamonga, and left appropriately chained/locked in the back of the vehicle at the employee's residence before leaving for a work location. The theft was reported to the Moreno Valley Police Department (police report #MV201950058 taken by Officer Flores). A reward will be advertised for the return of the gauge. California 5010 NUMBER: 071420 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 547657 July 2020 14:38:00The following is a summary of a phone call received from the licensee: A technician was at a job site taking measurements with a Troxler 3430 density gauge (S/N: 23216). The gauge contains an 8 mCi Cs-137 source and a 40 mCi Am-Be source. While the source rod was extended into the ground, the technician, along with others, attempted to get the attention of the driver of a pickup truck backing up into the work area. They were unsuccessful, and the truck backed into the gauge, bending the rod, preventing it from being retracted. The technician attempted to straighten the rod, but was unsuccessful. Then the rod was bent in the other direction and the Cs-137 source became dislodged. It was placed in a plastic container and the area was cordoned off. The Radiation Safety Officer (RSO) was en route, and with guidance from the service company, will place the source in a bucket and fill it with sand, survey the area for any contamination, return the source to the facility for a leak test, and store the gauge. The RSO will determine how to dispose of the source and gauge once the leak test results are received. The technician was wearing dosimetry and it will be sent in for analysis. It is not expected that there was much additional exposure received.