Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57022 | 11 March 2024 16:19:00 | The following information was received from the Wisconsin Department of Health Services (the State) via email: On March 11, 2024, a contracted service provider was on-site to dispose of 6 sources housed in a Kevex Model 6700 Analyst. It is a 2000 Series Spectrometer, Serial Number A011E, Bench Number 5026. The Analyst (device), has been in the possession of the scrap facility for at least a decade but was never utilized. The device was identified in November 2023, as a device which contained radioactive material. At that point the State was notified, and plans were initiated to dispose of the material. The State was unable to determine who previously possessed the device, or to whom it was initially distributed. The device should have contained 3 Cd-109 pellets of 7 mCi each, and 3 Am-241 pellets of 7 mCi, each. The source serial number indicated on the labeling is 4047, Model 0202. The assay date was December 1, 1992. When the service provider disassembled the device to reach the source housing, no sources were present within the device. The service provider performed confirmatory surveys to ensure that no sources were present. Apparently, the sources were removed prior to the scrap yard receiving the device. Without knowing the provenance of the device, it is unclear whether the sources were ever properly disposed of, therefore, it is being reported as missing material. 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 57020 | 11 March 2024 12:13:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On March 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that an event at the facility resulted in molten metal being spewed out from the furnace. Some of the molten metal landed on the housing cover of a Berthold LB 300 gauge containing a 2.5 curie (original activity 3 years ago) source. The licensee was able to remove the cover and inspected the gauge. The licensee found that some of the molten metal had leaked on to the shutter operator for the gauge, preventing the shutter from closing. The RSO stated they were able to remove the gauge from the vessel and place in a storage area. The RSO stated the room has been locked and posted to prevent inadvertent entry. The RSO stated they had performed radiation surveys outside the storage room and readings obtained were less than 2 millirem per hour. The RSO stated no individual received any radiation exposure that would have exceeded any limit. The RSO stated they have contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10094 Texas NMED No.: TX240009 |
| ENS 57016 | 8 March 2024 13:02:00 | The following was received from the Illinois Emergency Management Agency (the Agency) via email: On March 7, 2024, the Agency was notified of equipment damage at Alton Steel in Alton, IL, that exposed two sealed radioactive sources. The licensee reported that molten steel flowed over Berthold Technologies source housings (source housing serial numbers 1197-10-21 and 601-05-12) and, despite trying to cool the steel, it damaged the source housings and exposed the sources. The Berthold Technologies sources are Co-60 and have an activity of 2.3 mCi each (source serial numbers 1200-10-21 and 600-05-12). The sources were removed from the housings by a licensed service provider and placed in secured storage. Leak tests are pending. The licensee determined there were no exposures to any personnel and that the incident does not pose a risk to any members of the public. Licensee surveys indicated no contamination, and radiation levels from these sources were comparable to those from an undamaged source. The Agency plans to conduct a reactionary inspection to verify the lack of contamination/exposure and accountability of licensed materials. This is a reportable event in accordance with 32 Ill. Adm. Code 340.1220(c)(2). Illinois Item No.: IL240008
(On 3/8/24), another email update was received in which Alton Steel's licensed contractor advised another portion of the source rod had been located and was actively being cut from the molten steel. A conference call was immediately scheduled and the following information noted: The incident had actually taken place on 2/22/24 with no notification to the Agency. It was stated that the licensee's authorized user removed the damaged sources using pliers and placed them in secured storage but did not follow their approved emergency procedures to cease work and rope off the area at 20 feet. The licensee contacted their consultant (R.M. Wester), and they were on-site the same day. R.M. Wester personnel surveyed the area and assumed there was no contamination because they were getting the expected radiation levels. At that time, the consultant recommended that the licensee contact the manufacturer (Berthold) to come out and further evaluate the sources and devices. The manufacturer was on-site on 3/7/24 and discovered that two source rods were damaged. The manufacturer's rep advised a call to the State was needed. He noted one source rod had been damaged to the point the internal Co-60/nickel wire was exposed. On the afternoon of 3/8/24, Alton Steel's licensed consultant surveyed the mold lid and found what they assumed to be the remaining portion of the source (exposure rate of 50 mR/hour). On 3/8/24, Alton Steel personnel used a torch to cut that portion of the source from the lid of the mold. This piece was also placed in secured storage. The lid was then surveyed by the consultant which he stated evidenced no further radioactive material. The two damaged sources, as well as the source rod fragment, are pending disposal. The Agency has requested that the lid and mold be held for surveys when Agency staff are on-site. Agency staff plan to be on-site 3/13/24 to further investigate. Leak tests from the consultant did not evidence removeable contamination in excess of 0.005 uCi. At this time, there is no indication of risk to workers or the public as all sources are in secured storage. The investigation is ongoing and updates will be provided as available. On Monday, 3/11/24, Agency staff conducted interviews with the Berthold service representative which conducted the service call. Information from that call indicated the licensee had cut through a source with a torch. At this point, Agency staff responded that morning to take surveys and interview Alton Steel staff. Survey readings were taken with a microR meter, which lacked the necessary sensitivity and were inconclusive due to (naturally occurring radioactive material) NORM and refractory material. Investigation findings indicate the licensee failed to follow emergency procedures, failed to follow operating procedures, failed to adhere to license conditions, received inadequate and incorrect training, improperly handled and manipulated sealed sources, failed to perform surveys, and failed to make timely notification to the Agency. The licensee's consultant also failed to notify the Agency, lacked sufficient knowledge of the sealed source and performed inadequate surveys. Additionally, it was discovered the licensee had used a 4 inch die grinder on one source, cut through another with an oxygen lance, had a practice of handling unshielded source assemblies and an inadequate radiation safety program. Agency staff arrived at the licensee's site again on 3/13/24 to perform additional surveys. Upon arrival, the licensee stated they had found yet another piece of the Co-60 rod source under the spray booth that washes down the cast billets. This was reportedly the area below where the source was first cut with a torch. The Agency confirmed the licensee was aware of the source when using the torch and did not perform surveys or alter operations. The second source which was found to be damaged had also been inadvertently withdrawn from its shielded housing when the molten steel overflowed atop the mold cap. However, the second source immediately fell into two pieces, apparently suffering damage within the housing. That source was reportedly burnt/melt and would not fit into the shield. A licensee gauge user then used a 4 inch angle grinder to smooth out the source so it would fit back into the shield. Agency staff investigated all areas accessible (some areas were inaccessible due to molten steel). A portable germanium spectrometer was employed to discern if elevated count rates were from NORM or Co-60 contamination. Preliminary findings indicate at least two areas adjacent to the vise (where grinding had occurred) had Co-60 contamination. Samples were collected for lab analysis and additional area surveys performed. The (Illinois Emergency Management Agency - Office of Homeland Security) IEMA-OHS lab reported on the afternoon of 3/13/24 that samples did evidence Co-60 contamination. The Agency covered the contaminated area and required it to be posted. Additional surveys will be taken once accessible, to include the wash-down water sedimentation areas. A full survey and remediation plan will be required by the end of the month. Decontamination efforts will be undertaken by a qualified contractor and the Agency will perform verification surveys to support release. Updates will be provided as they become available. Notified R3DO (Hills), IR MOC (Crouch), NMSS (Williams), NMSS Events (email) Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), Nuclear SSA (email), FEMA NWC (email), CWMD Watch Desk (email)
On 3/15/2024, the Agency dispatched seven inspectors to perform comprehensive surveys of the facility, characterize exposures, and determine if additional fragments of the source remained unaccounted for. Inspection findings indicate that there is Co-60 contamination within a single room (mold repair room) at Alton Steel. The licensee has secured the room and implemented contamination control procedures. Updated procedures and training were implemented on Friday, March 15, 2024. Extensive Agency surveys of the facility and personnel performed on 3/15/2024 indicate that the contamination is not being carried offsite; nor was there any indication of public exposures. There is no contamination of water. Contamination of the product (steel) has not been identified; nor is it likely to be a concern resulting from this incident. Due to improper handling of sources, it is likely a gauge user received an extremity dose in excess of regulatory limits. Time-motion study will be performed to refine dose estimates and substantiate. ONS-RAM is investigating additional, chronic internal exposures to Co-60 which have likely occurred over many years. ONS-RAM will return to the site on 3/20/2024 to evaluate the efficacy of contamination control measures, determine the timeline for remediation activities and perform additional sampling/surveys to better quantify exposures and determine the appropriateness of bioassays. This report will be updated as additional information becomes available. Notified R3DO (Hills), NMSS (Williams), NMSS Events (email), NMSS Regional Coordinator (Rivera-Capella) (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 56980 | 19 February 2024 18:44:00 | The following information was provided by the licensee via email: At 1045 EST, on 2/19/2024, during a maintenance activity, a loss of all reactor building ventilation occurred on Unit 2. With no flow past the ventilation radiation monitors, the radiation monitors were inoperable to support their ability to perform primary and secondary containment isolation functions or start the standby gas treatment system. Reactor building ventilation was restored within 15 minutes. Due to this inoperability, the radiation monitor system was in a condition that could have prevented fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector will be notified.
Upon further investigation, it was verified that the reactor building and the refueling floor radiation monitors are not needed to control the release of radiation for events described in chapter 14 of the updated Final Safety Analysis Report. For the analyzed loss of coolant accident (LOCA), the primary and secondary signals for this purpose were available and unaffected by this event. The radiation monitors provide a tertiary redundant method that is not credited within the station analysis. For all other analyzed accidents, the signal provided by the radiation monitors is not needed, as the secondary containment isolation function and start of the standby gas treatment system are not credited. Additionally, the fuel handling accident was not credible during the time of the event because no activities were in progress on the refueling floor. Therefore, the threshold for reporting the issue as an event or condition that could have prevented the fulfillment of a safety function was not met. The NRC Resident Inspector has been notified. Notified R1DO (Jackson) |
| ENS 56975 | 18 February 2024 16:02:00 | The following is a synopsis of information was provided by the licensee via email and phone call: A non-licensed supervisor had a confirmed positive during a random fitness for duty test. The supervisor's access to the plant has been terminated. |
| ENS 56976 | 18 February 2024 17:32:00 | The following information was provided by the licensee via email: On February 17, 2024, a Honeywell employee experienced a non-work-related medical condition that required off site medical support. The incident occurred at approximately 2140 CST in the Feed Materials Building at the Metropolis facility. Due to the nature of the employee's condition, the individual was transported to (Massac Memorial Hospital in Metropolis, IL). Honeywell health physics staff accompanied the injured employee, provided guidance to emergency room personnel, and controlled the facilities prior to decontamination. A whole-body survey of the employee and plant clothing was performed; the maximum amount of contamination present on the employee's coveralls was 65,500 disintegrations per minute (dpm) per 100 centimeters squared. All contaminated clothing was removed from the employee and an additional whole-body survey was performed; no contamination above background levels was detected. An emergency medical technician's (EMT) pants leg, boot, and the gurney wheels were found to be contaminated. The maximum amount of contamination present was 13,000 dpm per 100 centimeters squared. The EMT's pants leg, boot, and gurney were decontaminated to background levels. Following medical evaluation, hospital facilities were monitored and found to be free of contamination prior to release for unrestricted use. All contaminated materials from the hospital and injured employee were returned to the Metropolis facility. The NRC Fuel Facility Inspector has been notified." The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The contamination was reported as: uranium ore concentrate. The employee had fallen unconscious. They have been released from the hospital after recovering. |
| ENS 56974 | 17 February 2024 14:07:00 | The following information was provided by the licensee via email and phone call: At 0837 EST, on 02/17/2024, during a refueling outage at 0 percent power while performing local leak rate testing (LLRT) on the reactor core isolation cooling (RCIC) isolation valves, which is part of the containment boundary, it was determined that the Unit 1 primary containment leakage rate did not meet 10 CFR 50 Appendix J requirements specified in Technical Specification 5.5.12. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56979 | 19 February 2024 14:16:00 | The following was received from the the Virginia Office of Radiological Health, Radioactive Materials Program via email: At approximately 1743 EST, on 2/16/2024, the Virginia Office of Radiological Health was notified of an incident involving a portable nuclear gauge. At approximately 1600 EST, a Troxler gauge; Model 3430, containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be, was struck by a dump truck on a building construction site located in Chester, VA. The authorized user notified the radiation safety officer (RSO) who arrived on site and then he notified the Virginia Emergency Management's Operations Center at approximately 1630 EST. Per the RSO, the gauge was sitting on soil with the source in the retracted, shielded position when it was run over by a dump truck. The source remained in the shielded position, but the handle was bent slightly. He did not attempt to turn it on or extend the rod for any reason. He obtained survey readings of 2.5 mR/h at 12 inches and 0.1 mR/h at 3 feet from the gauge. The gauge was placed in its transportation box, secured in the back of a pickup truck, and transported back to the licensee's office for secure storage. The gauge will be sent to the manufacturer for assessment. The Radioactive Materials Program will follow up with an investigation. Virginia Report Number: VA240002 |
| ENS 56960 | 12 February 2024 14:30:00 | The following is a synopsis of information provided by the licensee via phone call: At about 0830 CST, 02/12/24, a Troxler Density Gauge was damaged by a bulldozer at a construction site in Kansas City, MO near the corner of 101st Street & Lister Road. The rod was broken off, but the sources were shielded and appeared to be intact and undamaged. Testing samples for leakage were taken and results are pending. Source information: Serial Number 77-18042,cesium (Cs-137), 8 mCi (0.306 GBq). Serial Number 78-13106, americium-beryllium (Am-241Be), 40 mCi (1.48 GBq). 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 56957 | 9 February 2024 15:07:00 | The following information was provided by the licensee via email: On 2/9/24 at 1322 EST, it was determined that the unit was in an unanalyzed condition. A review of DC feeder circuit protection schemes identified a circuit for the fuel pool cooling system is uncoordinated due to inadequate fuse sizing. This results in a concern that postulated fire damage in one area could cause a short circuit without adequate protection, leading to the unavailability of equipment credited for in 10 CFR 50 Appendix R, Fire Safe Shutdown. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). The postulated event affects the following fire zones: fire areas 6S and 6N (within the Unit 2 reactor building). Compensatory actions for affected fire areas have been implemented. An extent of condition review is being performed. The NRC Senior Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Fire watches have been established in the affected areas. These will be maintained until the protection scheme is revised.
The following updated information was provided by the licensee via email and phone call: On 03/08/24 at 1418, extent of condition reviews identified circuit(s) in the Units 2 and 3 Reactor Protection Systems (RPS) which are also uncoordinated due to improper fuse sizing. These circuits are not bounded by existing design and licensing documents for 10 CFR 50 Appendix R Fire Safe Shutdown and, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects the following fire areas: 32, 33, 38 and 39 (Units 2 and 3 Switchgear Rooms). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved. The NRC Senior Resident Inspector has been notified. Notified R1DO (Arner)
On March 13, 2024, at 1350 EDT, extent of condition reviews identified a circuit in the Unit 2 reactor protection system (RPS) which is also uncoordinated due to improper fuse sizing. This circuit is not bounded by existing design and licensing documents for 10 CFR 50, Appendix R, Fire Safe Shutdown, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects fire area 57 (Switchgear Corridor, common to Units 2 and 3). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved. Additionally, it was previously reported that fire area 6N contained a circuit which was not bounded by the Fire Safe Shutdown analysis; however, after further review it has been determined that compliance is maintained in this fire area and is therefore retracted from the scope of this report. The NRC Senior Resident Inspector has been notified. Notified R1DO (Jackson)
The following information was provided by the licensee via email: On 03/21/24 at 1211, extent of condition reviews identified an annunciator circuit for the Unit 3 emergency service water (ESW) and high pressure service water (HPSW) pump structure heating and ventilation panel that is also uncoordinated due to improper fuse sizing. This circuit is not bounded by existing design and licensing documents for 10 CFR 50 Appendix R Fire Safe Shutdown and, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects fire area 47 (Unit 3 pump structure for `B' ESW and `3A'-`3D' HPSW pumps) and the yard fire area (Manhole 026D). In order to restore immediate compliance, the cable has been de-energized to eliminate the possibility of the event of concern. This circuit will remain de-energized or other measures will be implemented until the condition is permanently resolved. The NRC Senior Resident Inspector has been notified. Notified R1DO (Ford) |
| ENS 56955 | 8 February 2024 18:32:00 | The following was received from the Colorado Department of Public Health and Environment via email: While conducting a six-month inspection of an Ohmart/Vega model SH-F2-45 fixed gauge, the shutter would not close. The fixed gauge contains a 375 mCi Cs-137 sealed source and is stuck in the open position. The licensee is following their emergency procedures, and the gauge is in a location that is not accessible by members of the public. The licensee has contacted the manufacturer to repair the gauge. Colorado Event Report ID No: CO 240002 |
| ENS 56954 | 8 February 2024 17:59:00 | The following information was provided by the licensee via email: A supervisor had a confirmed positive for alcohol during a random fitness for duty test. The supervisor's access to the plant has been terminated. |
| ENS 56927 | 17 January 2024 19:20:00 | The following is a synopsis of information provided by the licensee via email and phone call: On January 17th, at 1616 MST, the Reactor Supervisor violated Technical Specification (TS) 6.1.12.a. During an NRC exam, a trainee was operating the reactor under the supervision of the reactor supervisor. The doorbell rang, and the supervisor requested that the reactor be scrammed and the console power be turned off, which was accomplished. The supervisor then stepped out of the reactor room, but the key remained in the console, thus the reactor was unsecured. TS 6.1.12.a requires one reactor operator or reactor supervisor to be in the room when the reactor is not secured. |
| ENS 56892 | 15 December 2023 16:16:00 | The following is a synopsis of information provided by the licensee via phone call: On December 15, 2023, at 0652 EST, JAN X-ray Services received notification from the laboratory performing regularly scheduled analysis of their employee's thermoluminescent dosimeters (TLDs) that one of the units is indicating an employee received a dose of 5.729 rem. The limit is 5.0 rem. The worker is not normally involved in radiography. The licensee is investigating how the employee received the indicated dose.
The following retraction is a summary of information provided by the licensee via email: JAN X-Ray Services requested the event be retracted based on findings that indicated that the exposure was to whole-body monitoring badge and not the individual. Notified R3DO (Szwarc) and NMSS Event Notifications via email. |
| ENS 56891 | 15 December 2023 14:29:00 | The following was submitted by the California Radiation Control Program via email: Licensee reported the loss of a Troxler 4640-B # 1383, containing a sealed source of 8 mCi of Cs-137, on December 14, 2023, in the evening. Los Angeles (LA) County-Duty Officer took the initial call from the assistant radiation safety officer. The report was forwarded to LA County Radiation Management and the (State of California) Radiologic Health Branch-South. It was reported that the operator of the device drove only about one mile from the jobsite before realizing the gauge was not in his vehicle's enclosed camper-shell. The driver turned around to search for it and was unsuccessful. The LA County Sheriff's office was also contacted." 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 56958 | 9 February 2024 16:13:00 | The following is a synopsis of information that was provided by AMETEK Solidstate Controls Inc. via email: This component (07-020139-10) is a 13 micro-Farad AC oil filled capacitor. During operation in an inverter, oil may be visible on, around, or dripping from the capacitor or its mounting bracket or tray. If allowed sufficient time, enough oil will leak from the capacitor that it will short internally and fail. Time required for the failure could be greater than the recommended 10-year preventative maintenance cycle for this part. AMETEK Solidstate Controls has not been able to determine a definitive cause of the failure, but is working to do so. These capacitors are generally part of a larger capacitor bank. The failure would result in a reduction of output voltage that is directly proportional to the number of capacitors in the bank that fail. Any single capacitor failure would be less than a 3 volt decrease in output voltage. Users of these capacitors should visually inspect any equipment containing the capacitor part number stated above for evidence of an oil leak. A review of the output voltage for the parent equipment for any consistent decrease in voltage of 0-3V may serve as an indication of capacitor failure. The user should notify AMETEK Solidstate Controls if any oil is observed during inspection. Corrective actions should be established by May 2024. Affected plants are not listed. |
| ENS 56876 | 29 November 2023 11:45:00 | The following information was received from the Arizona Department of Health Services (the Department) via email: On November 29, 2023, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on 11/28/2023. A patient was prescribed a dose of 1.766 GBq, but was delivered 1.019 GBq. The dose delivered was 57.7 percent of the prescribed dose. The Department has requested additional information and continues to investigate the event." 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 56840 | 8 November 2023 05:59:00 | The following information was provided by the licensee via fax and phone call: An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility and felt inside the control room. A release of hazardous material has not occurred. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 11/08/2023 at 0337 MST, Urenco USA declared an Alert (EAL 5.1A) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 0559 EST (0359 MST). No radioactive release has occurred. A 5.2 magnitude earthquake occurred in western Texas with an epicenter 36.7 km west-southwest of Mentone, Texas. Plant personnel are conducting walkdowns of the site. The State and local authorities have been notified. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)
TERMINATION OF SEISMIC EVENT ALERT The following information was provided by the licensee via fax and phone call: The earthquake of 5.2 magnitude in western Texas was felt in the control room. No release of UF6 was detected. Building inspections have been completed with no damage identified. This event has been terminated at 0937 MST and has entered into the recovery process. The State and local authorities have been notified. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), NMSS (Brenneman), IRMOC (Grant), OPA (Burnell). The following additional information was obtained in accordance with Headquarters Operations Officers Report Guidance: US Geological Survey (USGS) updated the seismic event to 5.3 magnitude at 10:27 on 11/08/23. |
| ENS 56829 | 2 November 2023 16:41:00 | The following information was provided by the licensee via email: On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines. Investigation is ongoing to determine if the results are accurate. This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3). The NRC Resident Inspector has been notified by the licensee."
Follow-up investigation by an independent Health and Human Services laboratory confirmed that the blind specimen in question was analyzed correctly. The error is thought to have occurred during the preparation of the blind specimen, prior to delivery to the site. The NRC Resident Inspector has been notified by the licensee. Notified R3DO (Orlikowski) and FFD Group (email). |
| ENS 56827 | 1 November 2023 16:52:00 | The following information was provided by the licensee via email: On October 31 at 1856 CDT, Prairie Island Nuclear Generating Plant personnel identified a prohibited item (alcohol) in a kitchen area located within the protected area. An 'Extent of Condition' search was performed of all other protected area kitchen areas, no additional prohibited items were found. The NRC Resident has been notified. |
| ENS 56828 | 2 November 2023 11:03:00 | The following information was received from the Washington State Department of Health via email: At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM. The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged. Washington Incident Number: WA-23-029
The following information was received from the Washington State Department of Health via email: Attached is the final report for the reported medical event # WA-23-029. We are also reviewing the event closely and are available to provide further information if needed. Notified R4DO (Vossmar) and NMSS Events via email. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 56822 | 30 October 2023 17:06:00 | The following information was provided by the licensee via phone call and email: A non-licensed supervisory employee had a confirmed positive test during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56812 | 24 October 2023 19:58:00 | The following was received from the California Department of Public Health (CDPH) via email: On October 24, 2023, the Radiation Safety Officer (RSO) of Barnett Quality Control Services, contacted the California Department of Public Health (CDPH) regarding a moisture density gauge that was struck by a front loader at a construction site while the Cs-137 source was in the extended position. The gauge was a Troxler Model 3440, serial number 15052 (8 millicuries (nominal) Cs-137, 40 millicuries (nominal) Am:Be-241). The impact with the gauge resulted in the top section of the index rod breaking off. The source rod and the body of the gauge were intact (including the Am:Be-241 source). The RSO was contacted and responded to the scene of the incident. The RSO was able to place the Cs-137 source in the shielded position, but the section of the index rod that allowed the source rod to be locked in the shielded position was missing. The RSO was instructed by a CDPH inspector to secure the source with duct tape on the source handle and at the bottom opening to prevent the source from shifting from the shielded position. The RSO was also instructed to perform a radiation survey of the area of the incident after moving the gauge to ensure that the radioactive sources were not left behind. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health. There were no reports of contamination or exposure to personnel. California Incident (5010) Number: 102423 |
| ENS 56771 | 2 October 2023 16:43:00 | The following report was received from the Louisiana Department of Environmental Quality (the Department) via email: On October 2, 2023, Syngenta Crop Protection, LLC notified the Department that a nuclear level gauge shutter was broken. The shutter is stuck open at approximately 40 percent. The gauge manufacturer is Texas Nuclear, Model: 5182, serial number 149. The source is Cs-137 with 50 mCi activity, serial number: J34. BBP Sales has been contacted to come out to the facility to perform repairs on the nuclear gauge. Louisiana Event Report ID No.: LA20230012 |
| ENS 56768 | 30 September 2023 15:18:00 | The following was received from the Louisiana Department of Environmental Quality (the Department) via email: On September 30, 2023, Acuren Inspection, Inc. notified the Department that an industrial radiography camera failed to retract the source after an exposure. The industrial radiography camera was a Century 330 QSA Cobalt camera. The serial number of the camera is P30078. The radiation source is a Cobalt-60 with an activity strength of 52.2 curie. The source serial number is 59740G. The source was cranked back out the end of the source guide tube with a collimator. The facility where this event occurred is in St. Martin, Louisiana. Only the two man radiography crew was present at the site during the event, which occurred between 0300 (CDT) and 0350. A source retrieval was performed, resulting with the source in a shielded condition in the radiography camera. The individual performing the source retrieval received only 1 millirem. Louisiana Event Report ID No.: LA20230010 |
| ENS 56766 | 29 September 2023 14:55:00 | The following was received from the Illinois Emergency Management Agency (the Agency) via email: On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported. The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available. Illinois Item Number: IL230027 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.
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On September 29, 2023, the Agency was contacted by Rush University Medical Center (IL-01766-01) to advise of a Y-90 Therasphere under dose that occurred the day before. The prescribed dose was 200 Gy and the prescribed activity was 45.92 mCi. The administered dose was 153.1 Gy with an administered activity of 35.15 mCi. This is a 23.5 percent deviation (under dose). The administration was determined to be clinically effective with no adverse patient impact reported. The patient and the referring physician were notified within 24 hours. Agency inspectors performed a reactionary inspection on October 3, 2023. The infusion of the Y-90 TheraSpheres went as intended with no identifiable irregularities. Post-admin calculations were performed which calculated that the dose delivered was 35.15 mCi. At this time the (accredited medical practitioner) (AMP) determined the dose delivered was 23.5 percent less than the written directive resulting in a potential medical event. The RSO interviewed all staff involved in the procedure and performed PET/CT imaging of the waste container (with dose vial, administration tubing kit, connector, extension tubing, microcatheter, forceps, etc.). This image was processed, and 3D volume renderings were utilized to identify where hot spots were located within the waste materials. Images of the waste container showed the highest activity was located in the dose vial. No additional apparent issues were discovered by the RSO. During an interview with the AMP, they stated that they tilted the dose vial back and forth to 90 degrees and tapped the vial on a hard surface. After the inspectors reviewed the procedures and through further questioning, they realized that the AMP was not tapping the vial sharply enough against a hard surface. Agency investigation findings identified the root cause of this event as inadequate agitation of the dose vial. Inspectors determined that the tapping process was not performed firmly enough against a hard surface to release the microspheres from the septum of the dose vial. This likely resulted in an increased number of microspheres remaining on the septum of the dose vial, and not released into the solution for administration to the patient. The RSO stated that they had begun the process of revising the checklist utilized during Y-90 TheraSphere procedures to better describe the dose vial preparation which includes the agitation process. Pending no further developments, this matter is considered closed. Notified R3DO (Orth) and NMSS Events Notification (email). |
| ENS 56737 | 13 September 2023 16:47:00 | The following was reported by the Florida Bureau of Radiation Control (BRC) via email: (The branch administrator and vice president) of Ardaman & Associates, called the BRC at 1030 EDT to report a stolen moisture density gauge. Their technician was at a job site where he says there are two entrances, but not much security to check who comes and goes. Before doing his readings, he noticed a truck parked close by but did not make anything of it since there are other workers on site. After he was done he went to the trailer to get his reports and left the gauge outside. A few minutes later he says someone came to notify him they saw an individual from the truck take possession of the gauge and drive off the site. They called the police to report the stolen Troxler gauge, serial number 36530 model 3430. Police report number to follow." Florida Incident Number: FL23-143 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 56738 | 13 September 2023 17:02:00 | The following was reported by the California Department of Public Health, Radiologic Health Branch (RHB) via email: On 09/12/2023, RHB received a call from (the) Principal Engineer, and President of A3GEO, Inc., regarding the loss of their moisture density gauge. They stated that on 09/12/2023 at 1445 PDT, the radiation safety officer (RSO) of A3GEO parked his 2001 Dodge Dakota Pickup Truck, containing InstroTek Model 3500 Xplorer with serial number 503 moisture density gauge, at the corner of Ridge Road and Euclid Avenue in Berkeley, CA. The RSO went into the corner market, and as he was exiting the corner store, he saw a man driving away his truck. He tried to stop him by running behind the truck, but he was unable to stop him from driving off. He immediately reported the incident to the Berkeley Police Department. RHB advised the licensee to place an ad in a local Berkeley newspaper offering a reward for return of the stolen gauge. 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 56734 | 12 September 2023 16:27:00 | The following was reported by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted by IRISNDT, Inc. the morning of 9/12/23 to advise of a stuck radiography source and successful source retrieval that occurred the previous morning at the Phillips 66 Refinery in Wood River, IL. Reportedly, the guide tube came in contact with a hot pipe, partially melted, and prohibited the 46 Ci Ir-192 source from returning to the shielded position. The radiation safety officer reports no overexposures to workers or members of the public as a result of this incident (maximum 12 mrem occupational). The source was reportedly not damaged and the impacted guide tube has been taken out of service. Limited additional details are available at this time. Agency staff are conducting a reactionary inspection tomorrow, 9/13/23, to review dosimetry, gather incident details, perform a time-motion study and evaluate the adequacy of the licensee's actions. Illinois Incident Number: IL230025 |
| ENS 56736 | 13 September 2023 15:44:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On September 13, 2023, the Department was notified by Braskem Inc. that during routine testing, the shutter on two Vega model SH-F2 gauges failed to close. Shutters in the open position is the normal operating position. Both gauges contain 200 millicuries of Cesium-137. There is no risk of additional radiation exposure to members of the general public or radiation workers due to this event. Additional information has been requested of the licensee. Additional information will be provided in accordance with SA-300. Texas Incident Number: 10050 |
| ENS 56727 | 7 September 2023 23:35:00 | The following information was provided by the licensee via email: On September 7 at 1230 CDT, Arkansas Nuclear One personnel identified 5 bottles of vanilla extract in kitchen areas located inside the Protected Area. A total of 5 bottles were identified. The bottles ranged in sizes of 1 to 4 ounces. Ingredients were listed as vanilla extracts in water and alcohol. The percentage by volume of alcohol varied from 13 - 41 percent. This report satisfied the reporting criteria of 10 CFR 26.719. The NRC Resident Inspector has been notified. |
| ENS 56717 | 6 September 2023 11:01:00 | The following was received from the Colorado Department of Public Health and Environment via email: The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023. Colorado Event Report ID No.: CO230028 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 56772 | 2 October 2023 17:09:00 | The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email: On August 30, 2023, at approximately 0900 (CDT), an Ohmart Model SH-F1-0 level/density gauge experienced a shutter malfunction during a routine semiannual shutter test. The gauge was installed on the Reactor 3, West Production vessel within the Poly Process Unit. The gauge possesses a nominal 500 millicurie sealed source of Cs-137. The above gauge was undergoing a routine semiannual shutter test when the malfunction was observed. The gauge sealed source serial number is: 1560CO. The device serial number has not been provided by the licensee. The gauge containing source number 1560CO, is mounted on the Reactor 3, West Production Chamber vessel in the polyethylene unit. On the above date, the Radiation Safety Officer (RSO) for Union Carbide Corporation contacted BBP Sales (BBP), radioactive material license LA-10799-L01. BBP arrived on site on that day to repair the stuck shutter. After several unsuccessful attempts to break the shutter free, the licensee and the BBP service engineer decided the best course of action would be to order a rotor replacement kit and the BBP service engineer should return on site to replace it. BBP is currently awaiting delivery of the new rotor kit. On October 2, 2023, at 0824, Union Carbide RSO notified the LDEQ concerning this equipment malfunction. According to RSO, the gauge rotor bracket broke due to corrosion, which prevented the gauge shutter from closing fully. The gauge is under the licensee's control. There were no exposures to members of the public approaching regulatory limits. Currently, the shutter on the gauge remains in the open position as the gauge source is needed to operate process control equipment. The gauge cannot be locked out in its current state. No entry to the vessel will be conducted until the gauge is repaired by BBP. The licensee will continue to monitor the gauge until repaired. The licensee stated they will keep the LDEQ updated on the progress of repairs." Louisiana Event Report ID No.: LA230011 |
| ENS 56678 | 15 August 2023 11:35:00 | The following is a synopsis of information received from Maine Radiation Control Program via telephone: The licensee was in the process of shutting down the plant when it was discovered that 4 level gauges on one tank have stuck open shutters. The model and activity are not available at this time. Due to the location of the gauges, no exposures were recorded nor are any expected. This investigation for the stuck open shutters is on going. |
| ENS 56728 | 8 September 2023 10:27:00 | The following was received from the Texas Department of State Health Services (the Department) via phone and email: On August 10, 2023, the Department was notified by the licensee that during the August 9, 2023, inventory of the ExxonMobil (EM) Beaumont Polyethylene Plant (BPEP) Tritium (H-3) exit signs, 9 uninstalled signs previously stored in the (instrumentation and electrical) shop could not be located. After an investigation and questioning of the personnel with access to the signs it was determined the box of tritium exit signs was placed in the trash dumpster during cleanup of the (instrumentation and electrical) shop area. As of August 14, 2023, the signs are considered missing/lost. The general licensee stated there is no evidence the integrity of the signs was compromised during the cleanup and thus there was no radiation exposure to personnel. All other unused exit signs were moved to a secured storage location. The Department has requested additional information from the general licensee. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300. The signs contained a total of 234.9 Ci, H-3 when manufactured in 2016. Texas Incident Number: 10047 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 56668 | 8 August 2023 19:04:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On August 8, 2023, the Agency was notified by the licensee's service provider that the shutter on a Vega America SH-F2 nuclear gauge would not close. Open is the normal position for the gauge. The gauge contains a sixty millicurie (original activity) Cs-137 source. The source is mounted in an elevated location that prevents exposures to any personnel. The service provider stated the licensee had just completed maintenance in the vessel where the gauge was mounted and was opening the shutter when they began to feel resistance to movement. The licensee continued to open the shutter and as they reached the open position the screws holding the operating arm in place broke. The operating arm no longer operates the shutter. The licensee will contact a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 10044 |
| ENS 56666 | 8 August 2023 15:44:00 | The following is a summary of information provided by the licensee via telephone: During post procedure processing of a Y-90 treatment to a liver, it was realized that only 78.5 percent (0.77 Giga-Becquerel) of the prescribed dose (0.99 Giga-Becquerel), was delivered to the target organ. The remainder of the dose was still in the delivery vial. All of the administered dose was delivered to the target organ. The prescribing physician has been informed. A written report will be forwarded when complete. 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 56667 | 8 August 2023 17:03:00 | The following information was provided by the licensee via email: A licensed (non-active) individual failed to comply with fitness for duty testing policies. The individual's unescorted access was terminated. |
| ENS 56662 | 6 August 2023 18:38:00 | The following information was provided by the Arizona Department of Health Services (The Department) via email: The Department was notified by the licensee that on 8/4/2023, a person walked into their facility to report a box with a radioactive material label was sitting on top of a trash can outside of their facility with their name on it. The licensee determined that the box contained (1) Isoaid I-125 seed (0.150 mCi) that had been picked up by (Common Carrier) the day before (8/3) at 4:09pm. The licensee inspected the package and determined that the package was still sealed and intact. The Department has requested additional information and continues to investigate the event. Arizona Event No.: 23-014 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 56637 | 25 July 2023 16:06:00 | The following information was provided by the licensee via email: At 0924 (EDT) on July 25, 2023, it was discovered that both trains of control room air conditioning system were simultaneously inoperable due to an inoperable control room envelope boundary. The boundary was restored at 0925 (EDT) on July 25, 2023. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. There has been no impact to Unit 3 which remains at 100% power.
The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that the access hatch being open did not have an adverse impact upon the control room emergency ventilation system and the control room envelopes boundary's ability to perform their safety function including: Radiation dose to the occupants did not exceed the licensing basis, design basis accident calculated value. Protection of control room occupants from hazardous chemicals and smoke. Therefore, this condition is not reportable and NRC Event EN56637 is being retracted. The basis for this conclusion has been provided to the NRC Resident Inspector. Notified R1DO (Lally) |
| ENS 56642 | 26 July 2023 18:22:00 | The following information was provided by the Colorado Department of Health (the Department) via email: On July 19, 2023, Geotech Environmental Equipment, Inc. informed the Department that they rented a generally licensed Viken PB200i XRF device (SN: 1015) containing a 5 millicurie, cobalt-57 sealed source to Hi-Tech Environmental located in Brooklyn, New York on July 7, 2021. Geotech Environmental Equipment, Inc. stated that as of October 25, 2022, Hi-Tech Environmental stopped replying to emails, stopped paying their rental balance, and was not providing information for returning the device. Geotech Environmental Equipment also stated that as of June 26, 2023, they made the decision to report the XRF device as a transferred device on their 2023 general radioactive material license registration inventory. Based on the description of the event, the device was not transferred and as of July 19, 2023 the Department has determined that Geotech Environmental Equipment, Inc. lost the generally licensed Viken PB200i XRF device (SN: 1015). Colorado Event Report ID Number: CO230022 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 56640 | 25 July 2023 16:40:00 | The following information was provided by the New York Department of Health via email: Tesla reported that one of their Polonium-210 static eliminators is missing. The device is a NRD model P-2021-Z705, s/n A2ME848. The device was shipped to Tesla on 2/23/21. The device has been through more than six half-lives so the activity at this point should be below 0.1 millicurie. New York State Event Report Number: NY-23-07 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 56639 | 25 July 2023 16:23:00 | The following information was provided by the New York Department of Health via email: A patient at Sisters of Charity Hospital in Buffalo, RAM license 2911, was implanted with a Best Medical International model 2301, serial no. 56305C, I-125 localization seed (108.76 microcurie) on 6/23/23 for a surgical removal scheduled on 6/26/23. The seed was in the breast specimen when it arrived in pathology on 6/26/23 (Activity was 105.08 microcurie) and was supposedly removed, bagged, and stored in the proper storage area. Personnel from nuclear medicine retrieved the seeds from the pathology storage unit on 7/3/23 and filled out the log sheet and the chain of custody paperwork. While bringing the seeds to the nuclear medicine decay closet, a nuclear medical technician (NMT) noticed that one of the bags with seeds in it (they retrieved 4 seeds that day from pathology) had a seed that seemed thicker than the others. Upon further investigation, it was noted that there was a clip and not an I-125 seed in the one bag. NMT staff Immediately went and monitored all areas in pathology (floor, work areas, sharp containers, garbage of the remaining specimen and the patient slides). No activity was noted. Staff contacted the boiler house, and no radioactive waste has been discovered leaving the premises. The licensee believes that the seed possibly went down the drain in the pathology lab. As a precaution, the licensee plans to set up a dedicated area to survey the biohazard bag with the seed in it and the sink drain will be covered during dissection. This seed is considered lost with no reasonable probability of recapture. New York State Event Report Number: NY-23-06 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 56585 | 22 June 2023 13:50:00 | The following information was provided by the licensee via email: At 1035, on June 22, 2023, with Unit 2 in Mode 1 at 100% power, the reactor automatically tripped due to `A' train reactor trip breaker and `B' train reactor trip bypass breaker opening during testing. The trip was not complex, with all systems responding normally post-trip. MST-021 (Reactor Protection Logic Train `B' At Power) testing was in progress at the time of trip. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). As a result of the reactor trip, emergency feedwater actuated; therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56586 | 22 June 2023 14:01:00 | The following information was provided by the licensee via email: On the first floor of the Feed Materials Building at approximately 1530 CDT on 06/21/2023 while performing cylinder filling operations, a visual indicator of material was identified and operators initiated mitigating actions in accordance with site operating procedures. It was determined that a remotely operated valve closing mechanism at the number 4 fill spot failed to close a UF6 cylinder valve. The cylinder valve was then closed manually by operations personnel. Based on preliminary observations, the licensee does not believe that regulatory limits were exceeded. |
| ENS 56583 | 21 June 2023 15:28:00 | The following information was received from the Illinois Emergency Management Agency (Agency) via email: Agency staff responded to a radiation monitor trip at a scrap metal recycling facility (SIMS Metal Management in Chicago) on 6/20/23 and identified an activated component from a high energy therapy device. The component is estimated to contain less than 1 microcurie of Co-60 and had an exposure rate of 100 microrem/hour on contact. The device originated from Varian Medical Systems and was decommissioned and transported by Legacy Transportation Services. Legacy is an Illinois radioactive materials licensee (IL-02445-01) that receives decommissioned Varian (and other low/high energy) devices and sorts the equipment for recoverable materials versus scrap. Radioactive components are to be identified and returned to Varian. This piece reportedly circumvented their radiation screening process. The licensee was contacted by the Agency and their staff promptly recovered the piece today (6/21/23). An assessment of contamination was performed and none identified. This incident did not result in members of the public receiving exposures in excess of (Illinois) Part 340 limits. Pending appropriate enforcement action and the licensee's written report; this matter is considered closed. Root cause and the adequacy of corrective action will be assessed in the licensee's response. Illinois Item Number: IL230016 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 56555 | 5 June 2023 11:42:00 | The following was received by email from the Florida Department of Health, Bureau of Radiation Control (BRC): BRC received a call at 1045 EDT from the radiation safety officer of ECS Florida LLC. The caller stated that an Instrotek 3500 (#4012, AmBe K893/19, Cs137 BG1008) moisture density gauge was stolen from the back of a pickup truck on its way to a job site. The vehicle made several stops on the way and they do not know at which location it was stolen. Florida Incident Number: FL23-085 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 56510 | 8 May 2023 10:30:00 | The following information was provided by Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division), via email: The Division was notified of the incident at 7:38 AM on May 8, 2023, by email from the Utah Department of Environmental Quality's duty officer who was on call on Saturday May 6, 2023. Information received from the on-call duty officer: The Radiation Safety Officer reported a radioactive material (rubidium-82) release of an unknown amount due to a leaking generator. She said that Cardiac Molecular Imaging found liquid in the bottom of a well chamber of the infusion system. Proper decontamination procedures were followed, the liquid was placed in radioactive waste storage, a wipe test was done, and everything was cleaned up. She said this has happened before. There was no impact to patient treatment. The generator will be shipped back to the manufacturer for investigation. The incident has been contained and there is no immediate threat. This appears to be the exact same issue that we notified the NRC for the UT23-0002 and UT23-0003 incidents. The Division will investigate this matter and update the record upon completion of the investigation. Utah Event Report ID No.: UT23-0005 |
| ENS 56491 | 26 April 2023 16:30:00 | A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56489 | 26 April 2023 11:38:00 | The following information was provided by the licensee via email: Violation of Limiting Condition of Operation per Nuclear Science Center Reactor (NSCR) technical specifications (TS) 3.5.1. Report made in accordance with TS 6.7.2. At approximately 1300 (CDT), April 25, 2023, it was determined there was a Limiting Condition of Operation that required a remote display for a single Area Radiation Monitor (ARM) on the reactor bridge in the Emergency Support Center. That display had been inoperable for two weeks. The ARM was operable, and the displays in the reactor control room and on the reactor bridge at the ARM location were active. The remote display is located in a different building from the reactor confinement building. Upon discovery of the situation, the reactor was shut down. This notification to the (NRC) Headquarters Operations Officer is required by NSCR TS 6.7.2 within one working day. Corrective actions underway: The display of the ARM is being repaired and will be confirmed to be in operation prior to the restart of the NSCR, and for each successive start up. |