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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 16:50:00The 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. 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 5494915 October 2020 17:29:00

EN Revision Text: AGREEMENT STATE REPORT - LOST GAUGES 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

EN Revision Text: AGREEMENT STATE REPORT - MISSING DENSITY GAUGE 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 Text: 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 16:38:00

In 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.
ENS 547669 July 2020 14:27:00The following was received from the California Radiologic Health Branch (RHB) via email: On 07/08/20, the licensee's ARSO ((Assistant Radiation Safety Officer)) contacted the RHB to report a stolen hydroprobe, CPN Model 503, S/N H330301362 containing 50 mCi of Am-241. The gauge belonged to Blue Ocean Organics, Inc. and was stolen on 07/03/20, out of a technician's truck parked overnight at a location in Visalia, CA. The ARSO stated that the hydroprobe was removed from the two chain lock in the back of the truck and placed in the cab of the truck overnight when it was stolen along with some other items. On 07/03/20, immediate notification was made to Tulare County Police Department (Deputy G. Canales A344, case # 20-055488). Licensee will be posting a reward for the safe return of the gauge. RHB will be following up with the investigation. The licensee will be cited for several items including failure to notify RHB per 10 CFR 20.2201(a). CA 5010 Number: 070820 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 5475222 June 2020 01:00:00At 2100 on June 21, 2020, a condition was discovered which will require corrective maintenance activities to be performed on the Technical Support Center (TSC) HVAC. The work will include repair of the Condensing Unit system. The estimated duration of repair is unknown at this time. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to the alternate facility. This is an eight-hour, non-emergency notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the discovered condition of the TSC affects the functionality of an emergency response facility. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 547364 June 2020 15:24:00The following was received from the California Department of Public Health Radiologic Health Branch via email: On 06/04/20 (PDT), California Office of Emergency Services (Cal OES) contacted the Radiologic Health Branch (RHB) to report a stolen moisture density gauge (CPN Model MC2, S/N 07226, containing 10 mCi of Cs-137 and 50 mCi of Am-241). The gauge belonged to Twining Inc. and was stolen out of a technician's truck while parked overnight at a Marriott hotel located at 2970 Lakeside Drive, Santa Clara, CA. The RSO ((Radiation Safety Officer)) was aware of the fact that the technician was working at a jobsite away from the permanent storage location. An immediate notification was made to Santa Clara Police Department (Report # T20001625). The RSO will be posting a reward for the safe return of the gauge. The RHB will be following up on this investigation. 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 547374 June 2020 16:57:00The following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email: At approximately 0700 (CDT) on 6/4/2020, the Agency was contacted by the Texas Radiation Control Program to advise that a rail car containing radioactive material had caught fire at the Belt Railway Co. of Chicago (BRC) located 6900 Central Ave., Bedford Park, IL. The Texas program had been contacted by the railway. IEMA staff contacted BRC and was informed that a lidded gondola (car WP-9241) transporting a load of UN2912 LSA-1 was found to be smoldering at approximately 0100 on 6/4/2020. The shipping manifest listed contents as 'solid oxides' with 4.13 mCi of Co-60, Cs-134, Cs-137, U-234, U-235 and U-238. BRC staff agitated the railcar and continued to observe until approximately 0300. At that time, flames had engulfed approximately 10 percent of the car and the Bedford Park Fire/Hazmat team arrived on scene. There is no indication of arson. The fire was monitored and the car separated from an adjacent car also containing LLRW ((Low Level Radioactive Waste)) (WP 9124). At approximately 0630, the fire burned itself out. At 0837, IEMA staff contacted the Response Management Team for the shipper and the General Manager for Alaron/Veolia to get shipping manifests (received 0920). Indications at that time were that the fire was rekindling and soil was added atop the fiberglass lid to help smother. Agency responders arrived on scene at approximately 1040. Bedford Park Fire/Hazmat was on scene as well as the railway's emergency response team. AreaRays had been deployed by the hazmat team and were reporting background exposure rates. Based on conversations with the shipper, the subject load contained un-irradiated zirconium fuel cladding and other debris enroute from Alaron Nuclear Services in PA to Waste Control Specialists in TX. The cladding at one point contained enriched fuel, so there is approximately 1.3 mCi of uranium present (predominately U-234 at a concentration of 41 pCi/gram and U-235 at 3 pCi/g. Load contains approximately 44g of SNM (Special Nuclear Material)). It is believed that the friction due to transport created pyrophoric zirconium dust which reacted with the surrounding building debris and combustible waste. This debris and combustible waste was also contaminated with radioactive material - approximately 0.8 mCi of Co-60, Cs-134 and Cs-137 each. At the time Agency staff arrived, the lid had been covered with soil and only a small amount of smoke was escaping. This was air sampled for any volatile radioactive contaminants by on site IEMA staff. Areas impacted by smoke, including adjacent cars, were wiped to check for surface contamination. On site measurements did not indicate any deviations from background and there is no indication that the radioactive material within the suspect load impacted personnel or the environment. Lab analyses will supplement this assessment. Impacted areas on the ground were surveyed and exposure rate measurements (reportedly maximally 400 microR/hour on contact with the railcar) documented for any first responder dose recreations. Modeling efforts are underway to provide bounding numbers on potential environmental impacts - albeit unexpected. Temperature of the car was recorded as approximately 400 degrees F and falling. Local Fire/Hazmat was still on scene and the shipper's radiological expertise was expected to arrive at approximately 1530. In the initial fire response, approximately 1000 gallons of water was added to the railcar. A hydrant was not accessible. The bulk of this water impacted the fiberglass cover and ran off. This drip line was assessed for contamination and none identified. The car was also moved approximately 2000 feet to distance it from the second car of LLRW. Both sites were evaluated by inspectors and no indications of radioactive contamination identified. Agency staff will continue to monitor the situation, especially if the shipper intends to uncover or repackage the shipment. The incident was reported to the National Response Center under Incident Report 1278842 by the Railway Police Department. Nuclear Regulatory Commission, IEPA and USEPA notified and briefed. This matter is also reportable to the Nuclear Regulatory Commission Ops Center for Emergencies under 32 Ill. Adm. Code 340.1220(c)(4). Item Number: IL200010
ENS 547353 June 2020 17:10:00A non-licensed employee supervisor had a confirmed positive for drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.
ENS 547332 June 2020 19:41:00On June 2, 2020, at 1905 Eastern Daylight Time (EDT), Brunswick Steam Electric Plant (BSEP) made a report to the Department of Transportation (DOT) concerning the identification during receipt inspection of removable contamination in excess of 49 CFR 173.443(a) limits on an empty Type 'A' transportation shipping cask received at BSEP. All smears taken on the cask rain cover, trailer bed, and tires were less than minimum detectable activity for removable contamination. This notification is being made as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 547343 June 2020 11:31:00The following was received from Paragon Energy Solutions via email: Pursuant to 10 CFR 21.21(d)(3)(i), Paragon Energy Solutions is providing initial notification of the identification of a defect. Duke Energy Harris Plant has identified instances where Size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by NLI. The auxiliary contacts have degraded prematurely and have failed to change state when the starter was energized which has affected indication and other controlling actions within the circuit. The identified starters have been installed for 3-5 years, operating in a continuous duty application. Formal notification will be submitted on or before 6/30/2020. For any questions or comments, please contact: Tracy Bolt, Chief Nuclear Officer Paragon Energy Solutions 817-284-0077 tbolt@paragones.com
ENS 5467822 April 2020 18:46:00A licensed operator had a confirmed positive for alcohol during a random fitness-for-duty test. The individual's unescorted access has been terminated.
ENS 5467622 April 2020 14:23:00The following was received from the state of Kentucky via fax: Kentucky Radiation Health Branch was notified on 4/22/20 by a representative from International Paper of a failure of a magnetic reed switch on their Honeywell gauging system. This switch senses when the mass measurement heads are separated and closes the shutter window on the radioactive source. There are two other means of determining whether the heads are out-of-alignment that also trigger the shutter window to close if indicated. Therefore, these additional layers of protection are adequate to protect against a radiation exposure if the heads are separated. International Paper has returned the system to service with the Honeywell recommendation to replace the switch as soon as the replacement part arrives. Per (the representative) of Honeywell, with the understanding that the failed component will be replaced, the customer can continue to keep the scanner under operation with the basis weight sensor.
ENS 5467722 April 2020 14:52:00At 1015 (EDT), on 04/22/2020, while Unit 2 was at approximately 0.4 percent power in MODE 2, reactor pressure was increased to 150 psig while HPCI was INOPERABLE due to not having been placed in standby. HPCI does not have a redundant system; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). ADS (Automatic Depressurization System) and low pressure ECCS (Emergency Core Cooling System) systems were OPERABLE during this time. HPCI was returned to OPERABLE status at 1109 hrs. on 04/22/2020. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5467421 April 2020 17:18:00The following is a summary of information received from Curtiss-Wright, Nuclear Division: Three RTL modules (thermocouple low level amplifiers) have been delivered to clients that may have included faulty resistors that could have remained undetected during functional testing and will eventually malfunction with time in service. MAY/MCY resistors are precision, low temperature coefficient, metal foil technology resistors used in circuits where stability with time and temperature is required. The RTL module uses this style of resistor to achieve its accuracy and variable temperature effects specifications. The symptoms exhibited by faulty resistors were open circuit or changes in value in response to physical or thermal stress. Faulty resistors were sent to the manufacturer for failure analysis. Cracks were discovered in the bond wires that connected the resistor leads to the resistor chip inside the resistor package. The failure rate of resistors manufactured in 2017 and 2018 was significantly greater than resistors manufactured in earlier years. A search of the build records during that time interval resulted in three units. These three modules contain 10 kilo-ohm resistors with date codes from 2017. There are two 10 kilo-ohm resistors in an RTL module, R8 and R17, on the main circuit board assembly. Configured for an RTD input, only R8 is active. R8 sets the 1 milli-ampere excitation current for the RTD element. R17 is used in a voltage offset circuit that is only used in thermocouple and low level amplifier configurations. If the module has been in service for any significant amount of time with no problems, 12 weeks or more, then it is probable that R8, the only suspect resistor in the default configuration, is not affected by this phenomenon. However, if the module has not seen significant service, then the module should be considered suspect. Additionally, if the module has been or could in the future be reconfigured to a low level amplifier or thermocouple application, then the same situation exists with R17, which is not used in the default configuration. Affected Plant - Part Number (Serial Numbers): Beaver Valley - NUS-A135PA-1/3 (s/n: 1800083) Indian Point 3 - NUS-A138PA-3/13/W (s/n: 1800334) Ginna - NUS-A138PA-1/4 (s/n: 1800666) Contact Scientech-I&C-Repair@curtisswright.com to return these modules for further testing and rework, if necessary. Should you have any questions regarding this matter, please contact: Shanen Onken Scientech Business Segment Manager Curtiss-Wright Nuclear Division sonken@curtisswright.com Tel 208-497-3410, Cell 208-821-4054
ENS 5466313 April 2020 19:33:00At 1550 EDT on 4/13/2020, with Millstone Power Station Unit 3 operating at approximately 82 percent reactor power, an automatic reactor trip occurred following a turbine trip due to low condenser vacuum caused by the trip of multiple circulating water pumps. Due to the loss of the circulating water pumps, decay heat removal was established by the steam generator atmospheric dump valves. All other systems responded as expected to the trip. Auxiliary feedwater actuated automatically as expected following the trip due to low-low levels in the steam generators. There was no risk to the public. There was no impact to Millstone Unit 2. The Senior Resident Inspector has been informed. This event is being reported as a four hour report under 10 CFR 50.72(b)(2)(iv)(B) as a condition that resulted in actuation of the reactor protection system while the reactor was critical, and as an eight hour report under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72(b)(3)(iv)(B) for actuation of the auxiliary feedwater system. The licensee also notified the state of Connecticut, the Connecticut Department of Energy and Environmental Protection, and the city of Waterford.
ENS 5465810 April 2020 14:30:00The following is a summary received from the state of Mississippi via phone: The licensee notified the state that during a routine check of an Ohmart gauge (s/n: 1169GK), the shutter would not close. The gauge contains a 10 mCi Cs-137 source (source holder: SHF-1). It is located over a chemical bin and the normal shutter position is open, so there is no additional exposure to employees. An authorized company is scheduled to remove and replace the gauge with an identical model.
ENS 5465910 April 2020 15:20:00The following is a summary received from the state of California via email: On 04/09/20, the California Office of Emergency Services (OES) contacted the Radiologic Health Branch (RHB) to report a notification made by a California licensee regarding a lost hydro probe. The gauge involved is a CPN Model 503DR, S/N H380104084 hydro probe containing 50 mCi of Am-241. The report stated that the field user placed the probe into its case without securing its latches and locks and drove off to the next field site. It is believed that the probe had fallen out of the truck somewhere on Crows Landing Road between Carpenter Road and Ehrlich Road. The RSO (Radiation Safety Officer) had notified the California Highway Patrol (CHP) and the local Fire Department of the incident. Repeated attempts made by the RSO, his staff and CHP to locate the gauge were unsuccessful. The RSO will be posting a reward on social media for the safe return of the gauge. The RHB will be following up on this investigation. 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 5466213 April 2020 12:21:00The following was received from the state of Georgia via email: An Iodine-125 seed (assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)) used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure. The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus (in a bag of solid waste) and transported to the (Pine Ridge Regional Landfill) by the waste disposal company's normal procedure on or around April 2, 2020. (The Radiation Safety Officer (RSO)) was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location. The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus. In (the RSO's) estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit. All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees. 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 5461426 March 2020 10:45:00

EN Revision Text: DEGRADED CONDITION On March 26, 2020, while McGuire Unit 2 was shut down for a scheduled refueling outage, the reactor vessel head penetrations were being examined in accordance with the in-service Inspection Program. Ultrasonic examinations identified a relevant indication in the Control Rod Drive Mechanism nozzle number 35 that did not meet the acceptance criteria under ASME, Section XI IWB-3600, 'Analytic Evaluation of Flaws.' Actions to address the relevant indication will be taken in accordance with the applicable codes, standards, and regulations. This event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). The relevant indication has no impact on the health and safety of the public or station employees. The NRC Resident Inspector has been notified.

  • * * RETRACTION ON 3/29/2020 AT 1700 EDT FROM TOM BERNARD TO BRIAN P. SMITH * * *

McGuire is retracting the eight hour non-emergency notification made on March 26, 2020, at 10:45 ET (EN#54614). A subsequent evaluation determined that the suspect indication identified during ultrasonic examination of Control Rod Drive Mechanism nozzle number 35 is not service induced nor representative of primary water stress corrosion cracking (PWSCC). The indication has been classified as "non-relevant" and is not reportable as a degraded condition. The senior NRC Resident Inspection has been notified. Notified R2DO (Miller).

ENS 5459923 March 2020 13:36:00On March 23, 2020, at 1013 EDT, with Harris Nuclear Plant Unit 1 in Mode 1, at 100 percent power, an unplanned actuation of the reactor protection system occurred. This resulted in an automatic reactor trip. The trip occurred during the restoration of the auto-stop turbine trip function during a planned maintenance evolution. All safety systems functioned as expected. Auxiliary Feedwater started as designed and was secured. Steam generator levels are being maintained by normal feedwater through the feedwater regulator bypass valves. Decay heat is being removed by using the condenser steam dump flow path. Due to the unplanned Reactor Protection System actuation while critical and the expected Auxiliary Feedwater actuation, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and 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 5459621 March 2020 23:46:00At 1644 EDT with Unit 1 in Mode 6 at 0 percent power, an actuation of the Unit 1 Bravo Train Emergency Diesel Generator system (EDG) occurred during Engineered Safety Feature Actuation System (ESFAS) testing. The reason for the EDG auto-start signal was a loss of voltage on the Bravo train safety related electrical bus due to the EDG output breaker opening. The EDG was already running at the time of the loss of voltage on the bus. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the EDG system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. There was no impact to Unit 2.
ENS 5459520 March 2020 18:30:00

The following was received from the state of Wisconsin's Radiation Protection Section (the Department) via email: On March 20, 2020, the (Wisconsin Radiation Protection Section) Department was notified by the licensee of a medical event which occurred the same day. The licensee was performing the first fraction of a vaginal cylinder treatment using a Varian VariSource iX high dose rate remote afterloader unit. Licensee staff had difficulty removing the cylinder post-treatment, and they determined that the cylinder had perforated the patient's tissue at some point following pre-treatment imaging. The licensee estimates the cylinder moved 3-4 cm from its original position. Dose reconstruction is ongoing, but is expected to exceed the 0.5 Sv threshold to the bowel. This is all the information available at this time. The Department will determine follow-up actions and provide additional information when available.

  • * * UPDATE ON 3/25/20 AT 1612 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *

The Department performed an investigation on March 25, 2020 to review this incident. For this fraction, the patient was prescribed a 6 Gy dose to the surface of the vaginal cylinder. Using CT imaging the licensee confirmed the proper placement of the cylinder prior to treatment. The licensee performed all pre-treatment checks, connected the patient to the HDR unit, and initiated treatment. Everything appeared to be as expected. However, following treatment it was very difficult for the authorized user to remove the cylinder; there appeared to be a vacuum suction seal. The licensee determined that the cylinder had been pulled an additional 3.5 cm into the patient, perforating the vaginal wall and protruding into the bowel space. The licensee believes that the bowel conformed to the shape of the cylinder during part or all of treatment, causing a much larger volume of the bowel to receive an elevated radiation dose as compared to the treatment plan. Based on the prescribed dose, the maximum unintended dose to the bowel is 6 Gy. The patient and referring physician were immediately informed of the event. The authorized user does not expect the patient to experience any radiological consequences from this event. Wisconsin Event Report ID No.: WI200010 Notified R3DO (Hanna) and NMSS Events Notification 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 5460123 March 2020 16:58:00The following was received from the Rhode Island Department of Health (RIDOH; the Department) via email: On March 4, 2020, the Department's staff at RIDOH, Radiation Control Program became aware of a medical event (ME) that occurred at the Rhode Island Hospital, Department of Radiation Oncology in Providence on March 3, 2020. The ME is reportable as per 10 CFR 35.3045(a)(1)(i)(A) and meets the criteria for an Abnormal Occurrence. On March 3, 2020, a patient underwent Gamma Knife treatment of a left vestibular schwannoma. At the conclusion of the treatment it was discovered that the location of the anterior screws securing the patient's head in the treatment position had moved. Before the patient was moved from the treatment table, the patient's position was observed by the radiation oncologist, neurosurgeon, and medical physicist. It is unknown at this time what contributed to the event and how the screws securing the patient in the treatment position had shifted from the initial position. Based on information provided by the patient and other participants associated with this event, a delivered dose was estimated using the GammaPlan Treatment Planning System. The estimated delivery to the target coverage area (volume of tissue receiving dose) was 44 percent. The estimated dose to the target was 4 Gy (400 rad). An unintended dose to a region of the left temporal lobe within the brain was estimated to be 13.6 Gy (1,360 rad). On the day of the incident, the attending neurosurgeon spoke directly with the patient informing the patient that the stereotactic frame had disengaged from his head at some point midway through the treatment and resulted in an unclear radiation dose to the tumor. The patient was informed of the estimated dose and told of the licensee's plan to obtain a follow-up brain MRI within 1-2 weeks after treatment and approximately 3 months after treatment. The licensee is taking a number of corrective actions, including having the radiation therapist ensure that the patient understands that any movement of their head within the headframe is not anticipated and should be communicated immediately. Event Report ID No: RI2020-01 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
ENS 545572 March 2020 22:31:00The licensee reported that a SPEC 150 Model G-60 (s/n: 1507) camera was lost when it fell overboard in the WD73-A area of the Gulf of Mexico. The device contained an 18 Ci iridium-192 source (s/n: 2604). The licensee stated that they will not attempt to retrieve the device. They will also notify the Louisiana Department of Environmental Quality. THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
ENS 5454727 February 2020 10:38:00

The following was received from the Veterans Health Administration via E-mail: Per 10 CFR 20.1906(d), Veterans Health Administration (VHA) National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received Thursday, February 27, 2020, at around 0710 EST by the North Florida/South Georgia Veterans Health System (Permit No.: 0912467-02) in Gainesville, Florida. This facility holds permit number 09-12467-02 under the VHA master materials license. The package was checked-in and surveyed upon receipt around 0710 EST. Wipe tests performed on the external surface of the entire package indicated a removable contamination level of around 560 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. Removable contamination level on the bottom surface of the package, indicated a removable contamination level of around 413 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. The package contained three unit doses consisting of a 6 mCi dose of Tc-99m Mebrofenin (calibrated for 1330), a 25 mCi dose of Tc-99m Sestamibi (calibrated for 0930), and a 1 mCi dose of Tc-99m Sulfur Colloid (calibrated for 0800). The dosage was shipped from Triad Isotopes, out of Jacksonville, Florida, who was also the delivery carrier. The facility Radiation Safety Officer immediately notified the delivery carrier by phone about the contaminated package around 0730 EST. The patient dosages inside the package were not impacted and were able to be used. As corrective actions, the packaging materials were bagged in plastic and set aside in a restricted area at the facility. VHA National Health Physics Program, who manages the master materials license, was notified of the incident around 0840 EST. In addition, the licensee is notifying their NRC Region III project manager (Parker) of the event by inclusion in this email. The external contamination was Tc-99m and the package will be held until the isotope has decayed prior to returning it to the pharmacy.

  • * * UPDATE FROM THE STATE OF FLORIDA, BUREAU OF RADIATION CONTROL TO DONALD NORWOOD AT 1725 EST ON 2/28/2020 * * *

The following is a synopsis of information received via E-mail: Reporting Organization: State of Florida Bureau of Radiation Control NRC Notified By: Matthew Senison Licensee: Jubilant DraxImage Radiopharmacies, Inc. City, State: Jacksonville, Florida License Number: 4587-5 Jubilant, Jacksonville received a call from the VHA in Gainesville, Florida about a delivery bag which had been delivered around 0710 EST that was contaminated on the outside. Jubilant, Jacksonville then notified their RSO who notified Jubilant's corporate RSO. Jubilant, Jacksonville personnel reviewed surveys and DOT documentation and found no removable contamination. They immediately pulled all six carts that are used in the pharmacy and wipe tested and surveyed each cart using a single channel analyzer and found only background. The driver is a third party (MDS) and had just returned. Jubilant, Jacksonville personnel surveyed and wipe tested the entire van and found it to also be at background. The Jubilant, Jacksonville RSO then called the VHA's RSO to relay that three patient doses were in the bag and no removable contamination had been found in the bag nor on the doses. VHA's RSO stated that she was notifying the NRC who would notify BRC. Since the NRC report shows the activity was Tc-99m, and neither party could find the source; at this point greater than five half-lives have passed, so there are no current plans to deploy investigators to either facility at this time. Florida Incident Number: FL20-023 (2) Notified R1DO (Ferdas), R3DO (Orth), and the NMSS Events Notification E-mail group.

ENS 5455128 February 2020 10:17:00The following was received from the Tennessee Division of Radiological Health via email: During a recent inventory at Blues City Brewery, the environmental health and safety manager discovered that two devices (Industrial Dynamics CI-2GV/3) were missing. Devices had been out of use for 1 - 2 years. Actual activity (of the Am-241 sources) are unknown at this point. The activity will be reported during the follow-up report. Incident Report No.: TN-20-038 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 5449424 January 2020 17:50:00The following summary was received from the Oregon Public Health Division via phone: The licensee reported that the handle of a fixed gauge used as a level indicator broke off. The device contains Cs-137 and the shutter is in the closed position. The device will not be used until it is repaired by an authorized party.
ENS 5448216 January 2020 14:47:00The following was received from the Texas Department of State Health Services (the Agency) via email: On January 16, 2020, the Agency was notified by a licensee of a source disconnect event. The licensee stated that on January 15, 2020, a crew using a QSA Spec-150 camera with 76 Curies of iridium-192 were unable to retract the source back into the camera. The source was recovered and returned to the shielded position. The licensee suspects that the source was not properly connected to the drive cable, allowing the source to be pushed inside the guide tube but unable to retract it. The licensee stated that the individuals that performed the recovery received 50 mR to 60 mR of exposure, and that no overexposures are suspected as a result of the event. Investigation is ongoing. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9732
ENS 5447814 January 2020 17:56:00

The following summary was initially reported by the Massachusetts Department of Public Health (DEP) and subsequently reported by the Tennessee Department of Environment and Conservation (DEC), both via phone: The MA DEP was notified by QSA Global, Inc. that a shipping container containing 12,400 Ci of Ir-192 did not arrive at their facility as expected. The original shipment had six (6) containers but only five (5) arrived at the Burlington, MA location. The last known location of the missing container was at the (Common Carrier) facility in Memphis, TN. QSA Global was in the process of notifying local law enforcement in Tennessee. Massachusetts DPH does not believe this event to be a theft or diversion. Additionally, TN DEC was notified by (the Common Carrier) of the missing container and that a search was in progress. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA IOCC, EPA Emergency Ops Center, FDA Emergency Ops Center (email), DHS Nuclear SSA (email), FEMA NWC (email), FEMA NRCC SASC (email), and DNDO-JAC (email).

  • * * UPDATE ON 1/15/2020 AT 1035 EST FROM SZYMON MUDREWICZ TO THOMAS KENDZIA * * *

The following was reported by the Massachusetts Department of Public Health (DEP) via phone and email: At 1015 EST this morning, MA DEP was notified (by QSA Global) that the package was located by (the Common Carrier) in Memphis, TN last evening. It has been delivered to Burlington this morning, not damaged, and is in the possession of the Licensee, QSA Global, in Burlington, MA. MA DEP will continue to investigate the event. Notified R1DO (Dentel), NMSS DDD (Williams), IRDM (Grant), ILTAB (Pearson), ILTAB (email), NMSS DAY (Rivera-Capella), INES (Milligan), NMSS Event Notification (email), NMSSDHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA IOCC, EPA Emergency Ops Center, FDA Emergency Ops Center (email), DHS Nuclear SSA (email), FEMA NWC (email), FEMA NRCC SASC (email), and DNDO-JAC (email). THIS MATERIAL EVENT CONTAINS A "CATEGORY 1" LEVEL OF RADIOACTIVE MATERIAL Category 1 sources, if not safely managed or securely protected would be likely to cause permanent injury to a person who handled them, or were otherwise in contact with them, for more than a few minutes. It would probably be fatal to be close to this amount of unshielded material for a period of a few minutes to an hour. These sources are typically used in practices such as radiothermal generators, irradiators and radiation teletherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5445727 December 2019 07:53:00

This is a synopsis of initial information received via phone: On December 27, 2019, at 0705 EST, while Unit 2 was at 100 percent (Mode 1), the 'A' Main Feedwater Pump tripped due to an unknown cause. The reactor was manually tripped and is currently at zero (0) percent power (Mode 3). Decay heat is being removed via Auxiliary Feedwater. The 'B' Feedwater pump is operable. There was no impact on Unit 3. The licensee notified the NRC Resident Inspector. Additionally, Connecticut Department of Environmental Protection, Waterford Dispatch, and East Lyme Emergency Management Division will be notified.

  • * * UPDATE ON 12/27/2019 AT 1330 EST FROM JASON PARIS TO CATY NOLAN * * *

This is an update to NRC Event Number 54457. At 0704 EST, on 12/27/2019, with Millstone Unit 2 operating at 100 percent power, operators inserted a manual reactor trip. The trip was initiated due to a trip of the 'A' Main Feedwater Pump. The Auxiliary Feedwater System (AFW) automatically actuated as required. All control and shutdown rods fully inserted. All safety systems responded as designed. No primary or secondary safety valves actuated during or after the transient. Unit 2 is currently stable at normal operating pressure and temperature in Mode 3, Hot Standby. Reactor Coolant System (RCS) temperature is being maintained by the steam dump system with all Reactor Coolant Pumps (RCPs) in service. Main Feedwater has been secured, and Auxiliary Feedwater is in service. The electrical system is in normal alignment. There was no impact on Unit 3. There was no impact to the health and safety of the public or plant personnel. Due to Reactor Protection System (RPS) actuation while critical, this event was reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B); and an eight hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the AFW system. The licensee will notify the NRC Resident Inspector of the update. Notified R1DO (Cherubini).