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| Entered date | Event description | |
|---|---|---|
| ENS 54156 | 10 July 2019 15:08:00 | The following report was received from the State of Tennessee via email: On July 8, 2019, technicians at Eastman Chemical were performing procedures that involved securing radioactive sources on the outside of a vessel. One source had rust and corrosion around the shutter mechanism. After 4 hours with lubricant on the mechanism, the shutter was still inoperable. Eastman Chemical contacted the VEGA technician and scheduled a repair appointment for 7/12/19. Manufacturer: VEGA Model #: SHF1B Serial #: (Will be included in follow-up report) Source Serial #: 7386 CP Isotope: Cs-137 (20 mCi) "A follow-up report will be submitted within 30 days. TN Tracking Number: TN-19-090 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| ENS 53971 | 3 April 2019 12:25:00 | The following was received from the Commonwealth of Massachusetts via e-mail: On 4/2/19, 1430 EDT, the licensee reported a medical event involving Nordion TheraSpheres (SS&D NR-0220-D-131-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-vial Y-90 62 mCi (13 mCi and 49 mCi vials) microsphere therapy treatment delivered to the patient's liver on 4/2/19 was stuck in the catheter causing delivery of approximately 37 mCi Y-90. This was discovered immediately after treatment. The administered dose to the treatment area differed from the prescribed dose by approximately 40 percent. The licensee stated that the primary cause was an equipment malfunction. The first vial of 13 mCi was delivered fully, but only 24 mCi of the second vial containing 49 mCi was actually administered to the patient. The prescribing physician, referring physician and patient have been notified. The licensee stated that there were no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment will be required. Corrective actions will include removal of the suspect equipment (catheter) and return of said equipment to the manufacturer for evaluation. A larger diameter catheter will be used during future therapy treatments. The licensee will submit a written report within 15 days of the discovery date. Agency on-site investigation is pending. This is a next day reportable medical event per regulations. Investigation ongoing. Agency considers this event docket to still 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 53640 | 3 October 2018 15:16:00 | At 1355 CDT on 10/3/18, the Nebraska Office of Radiological Health was notified by the Corporate Radiation Safety Officer (RSO) that a licensed moisture density gauge was run over by a large piece of construction equipment on a construction site in Omaha, NE. At the time of the notification to the State, the Corporate RSO did not know which of the licensee's gauges was involved in the incident, nor the device model number, isotope, or quantity. Staff from the Nebraska Office of Radiological Health were dispatched and are enroute to the event site to meet the licensee's Assistant RSO to assess the possible damage to the gauge and obtain further information. No injuries related to the event were reported to the State and no offsite emergency services support were requested.
Contamination swipes verified the source of the gauge to be intact. The gauge's source rod was broken during the event and the source had to be manually retracted into the shielded position. The gauge is currently at Terraco. The moisture density gauge is a Troxler Model 3440 (serial number: 30122). Notified R4DO (Farnholtz) and NMSS Event Notifications (email).
The following was received via email from the State of Nebraska: Nebraska Department of Health and Human Services, Office of Radiological Health was notified on October 3, 2018, by the Radiation Safety Officer (RSO) from Terracon, Inc (Nebraska license 01-58-01) that a portable nuclear moisture density gauge was damaged at a temporary job site. (The licensee authorized user) said that he arrived on the jobsite in Omaha, NE to perform moisture density measurements for Peter Kiewit Construction (general contractor) that was going to be pouring concrete later that afternoon by JR Barger & Sons Concrete Contractors (subcontractor). When (the licensee authorized user) arrived, he parked his vehicle near the work area and assessed the work area. He noticed that there were trucks and other heavy machinery working in the area. (The licensee authorized user) proceeded to take the Troxler portable nuclear moisture density gauge (model 3440, serial number 30122 containing 9 mCi of Cs-137 and 44 mCi of Am-241:Be) out of his vehicle and placed it on the ground where moisture density measurements were to be made. While performing a moisture density measurement with the Cs-137 source deployed from the protective housing, a skid loader backed up and hit the portable gauge. Fortunately, (the licensee authorized user) was able to dive out of the way with the back of the skid loader hitting the back of (the licensee authorized user's) arm. The extent of (the licensee authorized user's) injury is unknown. (The licensee authorized user) indicated he then proceeded to inform the skid loader to stop but said he continued without acknowledgement. (The licensee authorized user) was then able to get the attention of (the construction project supervisor) to inform him what just transpired. (The licensee authorized user) said that (the construction project supervisor) was not interested in stopping work for the damaged gauge and proceeded to tell (the licensee authorized user) (profanity) or we will call your boss . At this time, (the licensee authorized user) indicated that (an employee) picked up the damaged gauge and threw it to an area outside the work location. An assumption was made of the (the employee's) whole body dose of 571.1 millirem, assuming that he carried the gauge at one centimeter from the trunk of the body and that it took him one minute to move the gauge. (The licensee authorized user) said he then called (the Omaha RSO) and informed him of what just happened. (The Omaha RSO) then called the Corporate RSO. (The Omaha RSO) was then dispatched to the area with a survey meter and to assist (the licensee authorized user). (The Corporate RSO) informed (the Nebraska Department of Health and Human Services (DHHS), Office of Radiological Health Manager). (The Nebraska DHHS, Office of Radiological Health Manager) dispatched (personnel) to the scene. Meanwhile at the jobsite, (the licensee authorized user) maintained surveillance of the gauge and informed personnel to stay away from where the gauge was located. (The Omaha RSO) said that when he arrived, a radiation survey of the surveillance area and gauge was made. Radiation levels at the surveillance area was about 0.5 mR/hr and the gauge was 10 mR/hr, nearest to the extended Cs-137 source and the source was stuck into the ground to provide additional shielding. Calculations indicated that the exposure rate at the 15 foot exclusion boundary would have been 0.04 mR/hr. When Nebraska DHHS, Office of Radiological Health staff arrived, another confirmatory radiation survey of the gauge was completed with a result of 10.5 mR/hr. The gauge was also observed to have the source rod extended into the ground and part of the trigger mechanism was broken and sheared off. A wipe test was performed on the source rod with nip tongs and was reading the same as background. The portable gauge was then manipulated to place the Cs-137 source rod assembly back into the shielded position. After an unsuccessful attempt was made, the sliding spring lock was still open and was emitting 385 mR/hr on contact of the port hole. (The Omaha RSO) was able to clear off the excess mud and dirt on the port hole using the nip tongs and the sliding spring lock was shut. Another wipe test was completed and read at background. A radiation survey of the portable gauge confirmed that the Cs-137 source was in the shielded position and measured 20.8 mR/hr. (The Omaha RSO) placed the portable gauge back in the shipping container and duct tape was applied to prevent any movement of the source rod from the shielded position. A radiation survey of the transport case was performed with the portable gauge inside and the highest was 8.9 mR/hr on contact and 0.4 mR/hr at 3 feet. The listed TI (Transportation Index) of the package was labeled as 0.6 mR/hr. (The Omaha RSO) stated that he will contact InstroTek to either repair or dispose of the gauge upon their return to the Omaha office. An investigation is currently underway and the event is not closed. Notified R4DO (Farnholtz) and NMSS Event Notifications (email).
The State of Nebraska submitted the full report. The detailed information was previously provided via email. The item is still open pending a reconstruction of the dose received by the employee who picked up the damaged gauge. Incident Report No: NE180006 Notified R4DO (Gepford) and NMSS Event Notifications (email). |
| ENS 53639 | 3 October 2018 12:06:00 | The following was received via email from the State of California: On 09/28/18, (the Radiation Safety Officer) RSO initially contacted (Radiologic Health Branch) RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter). On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis. The licensee will submit a written report in accordance with 10 CFR 35.3945(d). California Report No. 5010-092818 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 53580 | 5 September 2018 12:53:00 | At approximately 0608 Pacific Daylight Time (PDT), the Control Room was notified of a SONGS SCE (San Onofre Nuclear Generating Station Southern California Edison) employee experiencing a non-work related medical emergency outside the protected area, inside the owner controlled area. SONGS fire brigade was dispatched. Camp Pendleton Fire ambulance was requested. At 0644 (PDT) Camp Pendleton Fire department in communication with a doctor determined the victim is deceased. This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) for a situation related to the health of on-site personnel for which a notification to other government agencies is planned. California Highway Patrol and Coroner notified and expect the California Occupational Safety and Health Administration (Cal-OSHA) will be notified. NRC Region IV was notified (approximately 0900 PDT) as SONGS does not have a NRC resident inspector. |
| ENS 53581 | 5 September 2018 14:39:00 | The following information was obtained from the State of New York via fax: Columbia University notified the New York State Department of Health (NYSDOH) on August 7, 2018 (regarding an August 2, 2018 event) of the detection of 592 Becquerel (0.016 microCurie) of removable radioactive material on a 10 milliCurie Ni-63 sealed source contained in a Shimadzu GC-8A II gas chromatography mass spectroscopy unit. The manufacturer and model number of the source were not available. The licensee immediately suspended the operation of the unit and placed the unit in storage. The source will be disposed of as radioactive waste and the equipment will be decontaminated prior to proper disposal by an authorized waste broker. New York Report Number NYDOH-18-02 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 49717 | 12 January 2014 06:44:00 | After achieving criticality a deviation between control rods was observed by plant personnel. When attempting to level the control rods, one rod could not insert to the level of the rest of the group. A manual reactor trip was initiated by the operating crew. All tripable control rods fully inserted into the core. The trip was uncomplicated and the licensee is investigating the cause of the control rod position deviation. The licensee has notified the NRC Resident Inspector.
Report was updated to indicate 8-hour reportable criteria for Valid Specified System Actuation (Reactor Protection System). The licensee will notify the NRC Resident Inspector. Notified the R4DO (Kellar). |
| ENS 49712 | 10 January 2014 13:27:00 | On January 10, 2014, Florida Power and Light reported to the Florida Department of Environmental Protection that the St. Lucie Nuclear Plant temporarily bypassed the normal storm collection outfall path at 17:45 EST on January 9, 2014. The bypassed flow of water was a result of severe rainfall at the station and a blockage in the normal outfall path. This non-emergency notification is being made pursuant to 10CFR50.72(b)(2)(xi) due to the notification of the Florida Department of Environmental Protection. The licensee originally made the offsite notification to the State of Florida agency associated with the emergency declaration and severe weather event on January 9, 2014 (see Event Notification 49707). The licensee has notified the NRC Resident Inspector. |
| ENS 48670 | 14 January 2013 08:44:00 | This is a non-emergency notification. At approximately 08:40 EST on January 14, 2013, radiation monitor RM-01TV-3547-1, Waste Processing Building Vent Stack 5A Wide Range Gas Monitor (WRGM) will be declared inoperable for pre-planned maintenance. MST-I0377, WPB Stack 5A Accident Monitor Channel Calibration will be performed. The maintenance activity is expected to complete January 15, 2013. This radiation monitor is necessary for accident assessment and is credited for Emergency Action Level (EAL) classification in the Harris Nuclear Plant Emergency Plan. Inability to classify an EAL due to an out of service monitor is considered a loss of accident assessment capability and is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2. This condition does not affect the health of safety of the public or the operation of the facility. The NRC Resident Inspectors have been notified. |
| ENS 48671 | 14 January 2013 14:53:00 | The following information was obtained from the Commonwealth of Pennsylvania Department of Environmental Protection via e-mail: On January 11, 2013 the licensee informed the Department's Southeastern Regional Office of the Medical Event. The event is reportable within 24 hours per 10CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified. On December 4, 2012 the patient received an iodine-125 prostate seed implant. The patient returned for the 30 day post-treatment follow-up CT scan on January 9, 2013. Upon review of the CT results on January 10, 2013, it was discovered that the prostate received approximately 60% of the intended dose. The D90 was determined to be 56 Gy out of a prescribed dose of 110 Gy. The potential cause of the event was noted as possible organ shift or incorrect depth placement of needles. The licensee plans to compensate for the undertreated area with follow-up external beam therapy. They will provide the Department a written report in 15 days. The Southeastern Regional Office plans to follow up with a reactive inspection. 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 48452 | 29 October 2012 19:18:00 | At 1855 EDT on 10/29/2012, the licensee declared a Notice of Unusual Event (NOUE) per criteria HU4 for high water level in the station intake structure of greater than 4.5 feet. At the time of the notification, water level in the intake structure was approximate 4.8 feet and slowly rising. The cause of the increased water level was due to storm surge associated with Hurricane Sandy. No other station impacts were reported at the time. The licensee continues to monitor the intake levels and ocean tides. The licensee has notified the NRC Resident Inspector and the State of New Jersey.
At 2044 EDT on 10/29/2012, the licensee escalated its emergency declaration to an Alert per criteria HA4 for high water level in the station intake structure of greater than 6.0 feet. At the time of the notification, water level in the intake structure was approximately 6.6 feet. The site also experienced a loss of offsite power event concurrent with the additional water level increase. Both emergency diesel generators started and are supplying power to the emergency electrical busses. Shutdown cooling and spent fuel pool cooling have been restored. Reactor pressure vessel level is steady at 584.7 inches. Intake levels continues to rise slowly and the licensee is monitoring. The licensee has notified the NRC Resident Inspector and the State of New Jersey. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, EPA EOC, and NuclearSSA via e-mail.
The licensee updated this report with an 8-hour non-emergency notification of emergency diesel generator auto-actuation due to the actual loss of off-site power event (which occurred at 2018 EDT on 10/29/2012). This event caused a valid RPS actuation with automatic containment isolations that resulted in a temporary loss of shut-down cooling to the reactor. Shutdown cooling was subsequently restored with power provided by the emergency diesel generators. The licensee has notified the NRC Resident Inspector. Notified R1DO (Caruso).
Termination of Alert. The Oyster Creek Station has terminated the Alert that was declared at 2044 (EDT) on 10/29/12 due to Intake Structure high water level greater than 6.0 ft. MSL (EAL HA4). Intake water level has returned to normal and is now below the Unusual Event EAL threshold (4.5 ft. MSL) and continues to lower. The licensee informed state and local agencies and the NRC Resident Inspector. Notified Region I IRC (Clifford), NRR (Evans), and IRD (Marshall). Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, EPA EOC, and NuclearSSA via e-mail. |
| ENS 47130 | 6 August 2011 10:45:00 | On August 6, 2011, Reactor Protection System (RPS) power supply 1B failed resulting in a partial loss of power to Primary Containment Isolation System (PCIS) groups and an invalid actuation of those PCIS groups. PCIS groups 1 and 2 received partial isolation signals with no subsequent system isolations, as designed. PCIS group 3, 6, and 8 received partial isolation signals with resulting system isolations, also as designed. The combination of loss of RPS 1B and PCIS group 6 isolation resulted in the isolation of the Drywell Floor Drain Sump and the Drywell Continuous Atmospheric Monitor for both particulate and gaseous activity. Thus, both means of automatic monitoring of Reactor Coolant System leakage became inoperable. Unit 1 entered Technical Specification Limiting Condition for Operation (LCO) 3.4.5.D (all required leakage detection systems inoperable) and immediately entered LCO 3.0.3 as required. At the time of occurrence, RPS 1A was being supplied from its alternate source for scheduled maintenance. Thus, the alternate source was not available to RPS 1B. Unit 1 entered LCO 3.0.3 at 0524 (CDT), 'Initiate actions within one hour to place the unit in MODE 2 within 10 hours; MODE 3 within 13 hours; and MODE 4 within 37 hours.' At 0617, Unit 1 began reducing reactor power to comply with LCO 3.0.3. This event requires a 4 hour report IAW 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.' The PCIS isolations which occurred at 0524 CDT are also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) 'Any event or condition that results in a valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B)(2), 'General Containment Isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs)), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' This event also requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A). The event time for the PCIS isolations is 0524 CDT. The NRC resident inspector has been notified. Service Request 412927 was initiated in the Corrective Action Program.
Browns Ferry restored power to the 1B Reactor Protection System power supply at 1208 CDT, reset all isolations and exited LCO 3.0.3. The licensee plans to return the unit to full power. The licensee notified the NRC Resident Inspector. Notified R2DO (Binoy Desai). |
| ENS 46616 | 15 February 2011 17:40:00 | On February 15, 2011, at about 0830 PST, approximately 65 gallons (calculated maximum of 98 gallons) of partially treated sewage spilled on the ground and into a concrete ditch at San Onofre Nuclear Generating Station (SONGS) at the Mesa area while cleaning up from the plant overflow on 2-11-11. The spill was contained, vacuumed up, and returned to the sewage treatment plant. At approximately 1140 PST, Southern California Edison notified the San Diego Regional Water Quality Control Board, and the San Diego County Department of Environmental Health was notified at 1220 PST. Unit 2 is operating at approximately 100% power and Unit 3 is in Mode 3 after a steam generator replacement and refueling outage. The licensee will notify the Resident Inspector. |
| ENS 45998 | 10 June 2010 10:37:00 | On June 10, 2010, at 0830 hours CDT, Byron Station removed part of the Technical Support Center (TSC) ventilation (I.e., OVV25C) filtration system from service to facilitate necessary maintenance on the makeup fan. This work is expected to last approximately 10 hours. This maintenance affects the ability of the TSC ventilation to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, then the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable site procedures. This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility because of the unavailability of the emergency filtration mode of the ventilation system. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector has been notified. * * * UPDATE FROM MIKE LINDEMANN TO PETE SNYDER AT 1542 EDT ON 6/10/10 * * * Maintenance has been completed and the TSC ventilation system was returned to service as of 1430 CDT. The licensee notified the NRC Resident Inspector. Notified R3DO (Phillips). |
| ENS 45869 | 23 April 2010 10:29:00 | An FPLE Seabrook employee experienced a medical emergency on site and was transported offsite for care. Subsequent notification was received from the hospital that the employee had passed away. OSHA (Occupational Safety and Health Administration) was notified at 0848 (EDT) on 4/23/2010, under 29 CFR 1904, of the fatality of an employee caused by an apparent heart attack while at work. The employee was entering into the Protected Area when she experienced the medical emergency, and as such the employee was not radiologically contaminated when transported offsite. The licensee notified the NRC Resident Inspector. |
| ENS 45865 | 21 April 2010 16:36:00 | The licensee reported that two cementing densometers were aboard the Deep Water Horizon Oil Rig when the oil rig caught fire on the evening of April 20, 2010. The oil rig is located in Federal waters in the Gulf of Mexico (Mississippi Canyon Block 252). At the time of the report, the oil rig was sinking in 4000 feet of water. The two gauges on the oil rig were as follows: 1. Device 10SD, Device S/N: V32785, Source S/N: DA071, Isotope Products Model No. A-3906, Isotope: Cs-137, Current Activity: 8.3 mCi 2. Device 10SD, Device S/N: W25980, Source S/N: XA923, Gammatron Model No. GTGHP, Isotope: Cs-137, Current Activity: 8.2 mCi When brought onto the oil rig, both devices were high integrity sources inside a tungsten cavity, and further contained in steel. The licensee had no information whether or not the sources were compromised as a result of oil rig fire and sinking. Based on the depth of the water where the oil rig is sinking, the licensee does not anticipate that the devices will be recoverable. The licensee notified the Region IV office of the incident. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore, it is being categorized as a less than Category 3 source 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 45864 | 21 April 2010 12:00:00 | Ohio Department of Health (ODH), Bureau of Radiation Protection (BPR) was notified of a possible overexposures to a member of the general public which occurred on 4/20/10 at the Ohio State University located in Columbus, Ohio. A patient received a temporary implant of Cs-137 and Ir-192 seeds on April 16-18, 2010. The patient's visitor (her fianc�) was instructed by the licensee that he could stay no longer than 2 hours with the patient in a twenty four hour period, and must stay behind the bedside shield during these visitations. On Tuesday, April 20, 2010, the licensee was informed by the Assistant Nurse Manager that the fianc� spent the night in the patient's room on two consecutive nights. In addition, the initial investigation by the licensee indicates that the visitor told the Assistant Nurse Manager that he slept in the same bed with the patient both nights. Nursing Management personnel are in the process of interviewing staff members that were involved directly with the care of the implant patient to verify that the fianc� was in the room overnight with the patient. A preliminary and conservative worst case dose estimate for the visitor is 6 Rad (6 cGy) whole body exposure, based on a 16-hour stay time (8 hours each night for two nights). ODH BRP will continue to collect information of this event and conduct an investigation. The licensee has initiated an internal investigation. Ohio Report OH100005
After investigation by the licensee and ODH the revised calculations indicate a dose estimate to the visitor to be 1.25 Rem. The licensee has instituted major procedural changes and conducted training for medical staff involved with brachytherapy treatments. |
| ENS 45870 | 23 April 2010 09:51:00 | The following report was received from the State via e-mail: At approximately 11 a.m. (EDT) on Monday, April 19, 2010, one of KeyTech's portable moisture density gauges (Troxler Model 4640B, Serial No. 2008, containing 9 mCi of Cs-137 and 44 mCi of Am-241) was struck by a steam-roller. The incident occurred at the intersection of Manchester Boulevard and Manchester Road in Manchester, NJ. On Wednesday, April 21, 2010, the licensee filed a report with the Manchester Police. The Manchester Police then contacted the Trenton Dispatch. At about 11 a.m., RMP (New Jersey Dept. of Environmental Protection Radioactive Materials Program) personnel were notified by Trenton Dispatch. The RMP contacted Manchester Police and it was learned that KeyTech reported that while the gauge was damaged the radioactive material remained intact within the device. KeyTech's RSO (Radiation Safety Officer) and administrator were contacted. The RSO stated that only the keyboard portion of the gauge was hit and that there was no damage to the radioactive material within the gauge. When the gauge was hit, the source rod was extended. The technician was able to retract the source rod into the safe position. The gauge was moved to a safe location and away from the public. RMP personnel went to KeyTech on Thursday, 4/22/10, to speak with the licensee and to conduct an investigation. The investigation concluded that the material was intact within the gauge and determined the licensee took appropriate actions to protect personnel and the public. New Jersey Report #C348104 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 45867 | 22 April 2010 15:17:00 | Unit 2 was in Hot Shutdown (Mode 4) for a Refueling Outage. At 0503 (CDT) on April 19, 2010, a valid Lo-Lo Steam Generator level condition occurred during restoration of feedwater system testing. The feedwater test was a planned activity and included isolation of feedwater to the steam generators. During performance of the test, steam generator levels decreased and the Lo-Lo level setpoint was reached on the 2D steam generator. This generated a reactor trip signal and auxiliary feedwater system start signal. Since the Unit was in Hot Shutdown, the reactor trip breakers were already open, and the auxiliary feedwater system was already removed from service when the steam generator water level unintentionally reached the Lo-Lo level setpoint. Additionally, the open steam generator blowdown isolation valves closed as expected at the Lo-Lo steam generator level setpoint. Steam generator level was promptly restored above the Lo-Lo steam generator setpoint. There was no impact on the reactor cooldown that was concurrently in progress as part of the preparation for refueling. Initial screening of the condition determined as not reportable in accordance with 10 CFR 50.72(b)(3)(iv), however, based upon further review it has been determined the condition is reportable. At the time of the event, both trains of shutdown cooling were in service and there were no challenges to offsite power. The licensee was not required to enter any Technical Specification LCO action statements as a result of the event, and the licensee is still investigating the cause of the decrease in steam generator level below the Lo-Lo level setpoint. The licensee has informed the NRC Resident Inspector. |
| ENS 45128 | 13 June 2009 09:19:00 | Planned maintenance activities are being performed today (June 13, 2009) on the Vogtle Nuclear Plant's Technical Support Center (TSC) power sources. This work activity is planned to be performed and completed expeditiously within approximately 3 days (78 hours). This maintenance activity is to perform a transformer replacement, perform preventative maintenance on several circuit breakers, perform preventative maintenance on the TSC HVAC unit, repair a leak on the Back-Up D/G (diesel generator) which provides a back-up power supply to the TSC HVAC, and other minor maintenance activities. If an emergency condition occurs that requires activation of the Technical Support Center during this work activity, contingency plans are in place to restore the TSC to fully functional status, with the time to restoration dependent on the stage of the work activity at the time the emergency occurs. Plans are to utilize the Shift Manager's Office in the Control Room as the Backup TSC for any declared emergency during the time the work activity is being performed. Procedure 91201-C, Activation and Operation of the Technical Support Center, provides instructions to direct TSC management to the Control Room to continue TSC activities if it is necessary to relocate from the primary TSC. At the beginning of the TSC outage, the ENN (Emergency Notification Network) and ERDS (Emergency Response Data System) will not be available until temporary power is being provided. This outage for the communications equipment will last from 2-4 hours, at which time they will be available. This event is reportable per 10 CFR 50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution. The licensee has notified the NRC Resident Inspector. The licensee provided notification of this issue prior to initiation of the maintenance per the licensee's 10 CFR 50.54(q) evaluation for the activity. The licensee intends to update this report when the temporary modification is completed such that the ERDS system is returned to service.
The licensee has returned the ERDS system to service using temporary power. Preventive maintenance still continues on the TSC. The licensee has notified the NRC Resident Inspector. Notified R2DO (McCoy).
The ventilation system has been returned to its normal power supply at 1121 on 6/19/2009. The licensee will notify the NRC Resident Inspector. Notified the R2DO (Bartley). |
| ENS 45059 | 12 May 2009 13:05:00 | The State of Florida provided the following via fax: (The licensee RSO) found 4 Troxler gauges missing from (a) storage facility (located in Winter Park, FL) on 12 May 2009. (The) gauge handles were locked, also a second lock to (the) structure and door was locked to storage room (when last checked by the licensee). (The) owner is contacting local police department and will offer an award. (The Florida Bureau of Radiation Protection) Orlando Inspection Office will investigate. The four Troxler gauges each contained 8 mCi Cs-137 and 40 mCi Am-241/Be sources. Three of the Troxler gauges were Model 3430 (S/N: 29922, 35106, and 35474), and the fourth Troxler gauge was a Model 3440 (S/N: 23037). Florida Incident Number FL09-042. 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. |
| ENS 44760 | 9 January 2009 16:19:00 | The State of Alabama was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 320 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the State of Alabama. The Wal-Mart representative informed the State Office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. Additionally, Wal-mart's report also relayed information regarding 21 damaged tritium exit signs that were used at several stores in the State of Alabama. The State of Alabama was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content where known. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 44759 | 8 January 2009 17:15:00 | The State of North Dakota was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 151 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the State of North Dakota. The Wal-Mart representative informed the State Office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The State of North Dakota was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content where known. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source. |
| ENS 44758 | 8 January 2009 14:52:00 | The State of Utah was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 71 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the State of Utah. The Wal-Mart representative informed the State Office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The State of Utah was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content where known. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 44755 | 6 January 2009 16:59:00 | The following information was provided by the State via e-mail: On 01/05/2009, an unlabeled, unmarked package containing 278 mCi of Rubidium-82 for cardiac PET studies was received at (the University of California at San Francisco) UCSF Receiving Department. The package was surveyed with radiation levels of 17 mR/hr at the surface and 0.5 mR/hr at 1 meter. A wipe of the package was negative. The container was not the usual one that UCSF has received for incoming shipments of Rubidium-82. The Receiving Department failed to contact the RSO's office, and instead contacted Nuclear Medicine to take custody of the package. Nuclear Medicine took custody of the package and exchanged the new Rubidium-82 generator for the old one. Nuclear Medicine alerted the RSO on 01/06/09, to the matter. The package insert indicated that the package was distributed by Bracco Diagnostics in Princeton, New Jersey. The UCSF Assistant RSO contacted personnel at Bracco Diagnostics and was subsequently referred to GE Healthcare in South Plainfield, NJ. Personnel at the GE Healthcare facility are investigating the matter and will report back to the assigned State of California inspector. State of California Report No. 1725-5010 |
| ENS 44752 | 5 January 2009 14:23:00 | A non-licensed contract employee was discovered to be in possession of an illegal substance inside the Unit 2 side of the common protected area following a for cause investigation. The contract employee was working in the construction of Unit 2. The contract employee's badge and access to the plant has been revoked. Contact the Headquarters Operations Officer for additional details. The licensee has notified both the Unit 1 and Unit 2 NRC Resident Inspectors. |
| ENS 44741 | 23 December 2008 14:30:00 | The State of Utah reported that one of their licensees, Chevron USA, Inc., reported a source disconnect on a custom made Ronan level density gauge at their refinery. The gauge was located in a dry storage tank with two pressure vessels inside. The source was inside the storage tank and was retrieved by a health physics contractor. The source is currently stored at the licensee's facility in a locked storage shed, surrounded by lead bricks. The licensee is awaiting the arrival of the Ronan representative on-site. There were no excessive exposures to either workers or the public. The source was 100 mCi of Cs-137 and is a Model SA-4.
The following information was submitted by the state by fax: Approximately 3:00 PM on December 22, 2008, Chris Crossman RSO from Chevron called to report that a Ronan Model SA-4 source holder containing a Cesium-137 source with approximately 100 mCi (s/n: 2231 CM) became unattached from a belt that the source holder was clamped to and fell to the ground and landed inside the storage silo it was mounted to. Upon discovery, the RSO was notified and the area was immediately cordoned off, and perimeter access was maintained. A service licensee was called to the facility to perform surveys of the area and retrieve the source. The source was sequestered and placed into a lead brick cave in a secured storage shed on the licensee's premises. Ronan Engineering, who built this custom device for Chevron, has been contacted and they indicated that they will be out sometime after the first of the year to re-install the source. On January 13, 2009, a reciprocity inspection and investigation by the Utah DRC was performed at the Chevron Refinery with a Ronan representative, (DELETED), and (DELETED) the Chevron instrument technician who initially reported the incident. The source holder is comprised of an 18 inch stainless steel rod with a clamp at one end. This clamp, the 'tape grabber,' clamps to the end of a guide belt. Over the clamp is a stainless steel threaded sleeve, held in place with a small tension screw. At the opposite end of the source rod is the Cs-137 source mounted inside the stainless steel rod. Over the source is a cylindrical collimator which can open to fine tune the exposure field. The source rod is mounted inside a dry 'guide tube' that is raised and lowered inside the tank, via an electronic pulley mechanism. The pulley also controls in tandem, at the same level as the source, a detector mounted on the outside of the tank, also in a dry guide tube. By using a dummy source holder for comparison, the source holder and clamp were briefly examined while inside the lead cave. The source holder was found intact and a previously done leak test indicated no leakage from the source. Closer scrutiny of the clamp end (the Tape Grabber) revealed that the set screw that holds the tape grabber together had partially loosened. Furthermore, small tension screw that holds the outer sleeve in place had worked itself loose and somehow sheared off. With the inner screw loose and the outer screw the weight of the source holder is all that was needed to pull the guide belt out of the clamp. Root Cause: Failure of equipment to perform as designed. Poor design and testing of design contributed to the failure of this device. Corrective Actions: The licensee called Rocky Mountain Health Physics (RMHP) who came out and relocated the source and source holder to a secure storage shed on the licensee's premises. The area where the source had fallen was roped off and all personnel in the immediate area were escorted away. RMHP wipe tested the source holder and there was no evidence of a leaking source. The licensee then called Ronan Engineering to report the failure of the device and Ronan indicated they would send a representative to the refinery in January 2009. Utah Incident Number: UT 08-0006 Notified the R4DO (Farnholtz) and FSME (Chang). |
| ENS 44573 | 17 October 2008 08:40:00 | The licensee's Radiation Safety Officer (RSO) reported that on 10/16/2008, at approximately 1500 EDT, a licensee truck transporting a Troxler 3400 Series moisture density gauge, flipped over in the Monitor-Merrimac Bridge Tunnel, near Newport News, VA. This series of Troxler gauge typically contains 8 mCi Cs-137 and 40 mCi Am/Be. The RSO indicated that it was reported that the handle on the case, in which the gauge was secured, was damaged in the accident. The RSO did not have any indications of elevated or abnormal radiation or contamination levels from the gauge after the accident. The driver of the truck was injured in the accident (broken arm). At the time of this report, the gauge was in the possession of the licensee, and the licensee is conducting follow-up surveys. Notified Virginia Radioactive Materials Program, DOT (NRC), DOE, and DHS.
The licensee RSO reported that follow-up surveys and visual inspection of the gauge found no abnormal radiation levels, and no apparent damage to the gauge itself. The licensee will send the gauge to the manufacturer (Troxler) for further evaluation and/or repair. Notified R1DO (T. Jackson), FSME EO (Einberg), NMSS EO (Regan), IRD Mgr (J. Grant). |
| ENS 44572 | 16 October 2008 15:40:00 | While performing an extent of condition review resulting from the unanalyzed condition related to certain fire conditions identified in Event Notification #44482, another situation was identified in which, under certain fire conditions, the ability to meet the performance criteria of the approved fire protection program may be challenged. Specifically, it was postulated under certain fire conditions affecting the relay room, the ability to maintain pressurizer level within the indicated range may be challenged due to spurious opening of pressurizer vent and reactor head vent valves. Compensatory actions to address the fire in the area of concern are in place. (1-hour Fire Watch). This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). NRC Resident has been notified. |
| ENS 44571 | 16 October 2008 12:38:00 | At 1030 (EDT) on 10/16/08, Emergency Planning personnel discovered that both ERDS (Emergency Response Data System) links (modems) were not functioning. The cause of the failure is unknown at this time and is being investigated by onsite technicians. The Emergency Notification System (ENS) was verified to be functioning properly. Loss of either ERDS link is considered a major loss of emergency communication capability and is reportable under 10 CFR 50.72(b)(3)(xiii). The licensee notified the NRC Resident Inspector. |
| ENS 44577 | 17 October 2008 15:35:00 | The state provided in the following information via e-mail: On 10/10/08, licensee's RSO notified DRH (Division of Radiological Health) of a Yttrium-90 SIR-Spheres medical event. The reportable event involved the administration of 54 mCi of SIR-Spheres for one patient with approximately 27 mCi instilled into both the right and left hepatic arteries. After instilling approximately 27 mCi of Yttrium-90 SIR Spheres based on radiation readings into the right hepatic artery, a smaller catheter for the left hepatic artery was used due to anatomy and to get to the segment feeding the tumor. While attempting to instill the Yttrium-90 SIR Spheres into the left hepatic artery over-pressurization caused the three (3) way valve in the containment box to give way and resulted in the release of a therapeutic dose of Yttrium-90 SIR Spheres into the delivery system containment box as per design. Due to the release of the second part of the dose into the containment box only approximately 50% of the dose was able to be administered. The procedure was terminated and the delivery box was bagged and held for decay-in-storage. Personnel in the room were monitored for contamination and the room was surveyed and released. The patient was released with no harmful effects foreseeable by the Radiation Oncologist. The patient and referring physician were notified of additional future treatment. Licensee suggested the incident may have been caused by the size of the catheter, a kink in the catheter, or a smaller syringe being used by the interventional radiologist putting increased pressure on the 3 way valve. As a result of the medical event the licensee's treatment team will review the delivery system setup before pressure is applied to ensure the flow of the SIR-Spheres will not be impeded within the catheter. License No.: MS-MBL-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 44578 | 17 October 2008 17:48:00 | The Commonwealth of Florida was notified on 10/17/2008 by the licensee's Medical Physicist regarding a dose of 3400 cGy (3400 rad) administered to unintended tissues during several breast cancer therapy treatments over the period of September 10 - 17, 2008. The apparent unintended dose was identified on 10/16/2008, when the patient reported to the licensee symptoms of erythma (skin reddening) to the breast not intended to be treated. Specifically, the patient was being treated for breast cancer with an Ir-192 High Dose Rate (HDR) Afterloader unit (source strength, manufacturer, and model unknown at the time of this report). When the erythema was reported by the patient, the Medical Physicist reviewed the records and determined that the HDR Afterloader was mis-programmed such that the source stopped 10 centimeters short of the intended tumor bed in the right breast. As a result, the entire dose intended for the tumor bed was administered to the left breast that was not intended to be treated. The Commonwealth of Florida did not currently have information regarding any potential long term effects for the patient due to this event. The Commonwealth of Florida will dispatch an inspector to the facility early next week to follow-up on this event. A written report of this event will be provide by the State at that time. 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 44027 | 4 March 2008 02:16:00 | On March 4, 2008, at 0100 CST, ten emergency notification system sirens in the Kewaunee Power Station Emergency Planning Zone (one in Kewaunee County, nine in Manitowoc County) were de-energized due to a planned power outage. The loss of power to these emergency notification sirens resulted in a lost population coverage of 51.2%. As a result, this event is being reported under 10 CFR 50.72(b)(3)(xiii) and guidance in NUREG-1022 as a major loss of off-site communications capability. The expected duration of the planned power outage is 2 hours. Kewaunee and Manitowoc County Emergency Management agencies have already established appropriate contingency measures for the planned loss of the emergency notification system. Contingency measures include route alerting and an available plane with loud speaker for the areas affected by the power outage. The State of Wisconsin and the Federal Emergency Management Agency were previously informed of this planned outage. The NRC Resident Inspector has been notified. |
| ENS 43847 | 17 December 2007 10:37:00 | At 0203 CST, the plant experienced a loss of the Safety Parameter Display System (SPDS) and other computer systems used for emergency assessment in the Control Room, Technical Support Center (TSC) and Emergency Operating Facility. This capability was fully restored at 0600 CST. The cause of the loss was an electrical fault in an intercom box in the TSC. The licensee will notify the NRC Resident Inspector. |
| ENS 43781 | 14 November 2007 15:15:00 | During Construction Activities for a new Security Training facility, an earth mover overturned resulting in a spill of diesel fuel, hydraulic fluid, and engine coolant. The magnitude of the spill is not positively known at this time, but is believed to be less than 50 gallons. The event occurred outside the Protected Area. No personnel were injured during the event. The New York State Department of Environment Conservation (NY DEC) has been notified per plant procedures (Avon Office DEC Spill #75111)." At the time of this report, the earth mover was still overturned and the licensee is taking actions to resolve. No media interest is anticipated as a result of this incident. The licensee notified the NRC Resident Inspector. |
| ENS 43716 | 11 October 2007 21:37:00 | A non-licensed employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details. |