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ENS 5580123 March 2022 19:22:00The following was received from the Tennessee Division of Radiological Health via email: An in-line fixed gauge was discovered to have a stuck shutter. Licensee attempted to use penetrating lubricant without success. Licensee has contacted VEGA field technician to attempt to unstick the shutter. If technician is unsuccessful, the plan is to immediately replace the gauge. The following is the technical information on the gauge: Manufacturer: Ohmart/Vega Model: SHF1 Gauge SN: (Will be sent with 30-day report) Isotope: Cs-137, 20 mCi (1993) Source SN: 9274GG Source Holder Model: SHF1-45 Corrective actions will be updated with a report within 30 days. State Event Report ID Number: TN-22-020
ENS 5579822 March 2022 15:19:00The following information was provided by the California Department of Public Health (RHB) via email: On March 22, 2022, at approximately 0834 PDT, the ARSO/Field Operations Manager of Southern California Geotechnical contacted RHB Brea concerning the moisture/density gauge, CPN, MC-1DR, serial number MD 20400784, (Cs-137 0.370 GBq, Am-241, 1.85 GBq) that had been found missing along with the Authorized User since 3/18/2022 when he was last seen at a jobsite at 1740 Mountain Avenue, Norco, CA and did not report for work on Monday, March 21, 2022. (ARSO/Field Operations Manager) has contacted emergency contacts of the Authorized User and the employment agency he was hired through with no response at this time. (ARSO/Field Operations Manager) has also notified Orange County Sheriff and filed a missing person's/stolen property report, reference number 22-009329. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. (ARSO/Field Operations Manager) will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge and the Authorized User can be found. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been lost and it can not be determined what condition the sources are currently in." CA incident no.: 32222 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 557696 March 2022 00:55:00The following information was provided by the licensee: At 2115 CST on March 5, 2022 Byron Station Technical Support Center (TSC) emergency ventilation system supply fan belt failed. This failure affected the ability of the TSC ventilation system to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. All other capabilities of the TSC are unaffected by this condition. If an emergency was declared requiring TSC activation during this period, the TSC would be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, the Station Emergency Director would relocate the TSC staff to an alternate TSC location in accordance with applicable procedures. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the discovered condition affected the functionality of an emergency response facility. The licensee notified the NRC resident inspector.
ENS 557675 March 2022 10:21:00The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email and phone: On 3/4/2022, the Department was notified by the licensee's RSO that while performing six shutter checks on its fixed gauges it discovered that the shutter on a fixed gauge was not functioning properly . The fixed gauge was a Vega America Model SH-2, s/n 8906CM, containing 200 mCi of Cs-137. The licensee has contacted the manufacturer and has scheduled a repair of the shutter. The gauge is located approximately 12 feet off the floor on the side of a vessel and is not readily accessible by employees. On 3/5/2022, the Department On-call duty officer met with (licensee) to gain access to the gauge and perform a radiation survey. The radiation on the surface of the gauge measured 16 mR/hr and measured 6 mR/hr at 1 foot. The on-call duty officer verified that the gauge is inaccessible to employees and that radiation exposures to members of the public (non-radiation workers) would be minimal.
ENS 5579722 March 2022 12:33:00

The following information was provided by the licensee via phone and email: Agilent Technologies manufacturers ECDs (Electron Capture Detectors), containing 15 millicuries each, of Ni-63 for use in Gas Chromatographs (for generation of ionized atmospheres for chemical analysis). We have a number of ECDs in use at our facility as addressed below for customer support and R&D. We are required by our license to perform wipe (swipe) tests every six months. The ECD in question was last wiped in August. We were in the process of performing our most recent wipe test last month (February) when we discovered the ECD and its host GC were no longer in the lab they were being used in. (Source was determined to be missing on February 22, 2022 at 1000 EDT when it could not be found for the scheduled swipe test.) We discovered quickly that the individual chemist with ownership of the ECD retired in November of 2021 (last date the device was accounted for). Investigations to date have not been successful in recovering the ECD. Information pertinent to the incident to follow. I will also be submitting a letter to the appropriate address in one month if we are still unable to recover the ECD. ECD Model # G2397A ECD Serial Number # U25487 Activity: 15 millicurie Ni-63 Facility security: Access to building is limited to those issued electronic badges. Labs are further secured by electronic access only to necessary personnel. (Therefore the source is not suspected to have been stolen.)

  • * * UPDATE ON 4/21/2022 AT 1244 EDT FROM DAVID BENNETT TO BETHANY CECERE * * *

The following information was provided by the licensee via phone: The source is still lost. The licensee is submitting a written report to Region 1. Notified R1DO (Dentel), ILTAB, and NMSS Events Notification by 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 5574818 February 2022 08:35:00The following information was provided by the licensee via telephone and email: On 2/18/2022, McGuire Nuclear Station Unit 2 experienced a turbine runback to 55 percent power. Based on concerns with unit stability, the reactor was manually tripped at 0459 (EST). All Auxiliary Feedwater pumps started on low steam generator level as required. The reactor trip was uncomplicated with all systems responding normally post trip. A feedwater isolation occurred as designed. Unit 1 was not affected. Due to the Reactor Protection System actuation while critical, actuation of the Turbine Driven Auxiliary Feedwater Pump and Motor Driven Auxiliary Feedwater pumps along with the Feedwater Isolation, this event is being reported as a four hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an 8 hour nonemergency 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 The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: All control rods fully inserted. Decay heat is being removed via the condenser and normal feedwater. Unit 2 is in a normal shutdown electrical lineup.
ENS 5574918 February 2022 08:46:00The following is a summary of a report provided by Emerson Process Management: On December 13, 2021, Framatome discovered a non-conformance with TopWorx limit switch part number C7-13521-E0 and initiated a return to TopWorx. Emerson Process Management (TopWorx) discovered that, at certain orientations, the limit switch would indicate dual continuity (both open and closed). The anomaly appears to be due to an internal component (brass washer) rotated out of position during assembly. This potentially affects 129 limits switches. TopWorx notified Framatome of the issue. Contact Information: Steven Stoops, Quality Manager, TopWorx Emerson Automation Solutions, 3300 Fern Valley Road, Louisville, KY 40213 502 873 4606 Steven.Stoops@Emerson.com
ENS 5580023 March 2022 16:43:00The following information was provided by the licensee via email and phone: At 1625 (EST) on 2/13/2022, with Unit 2 in Mode 3 at 0 percent power and plant heat up to normal operating temperature in progress, an actuation of the Emergency Feedwater System (EFW) occurred. The reason for the EFW auto-start was lowering water level in the 2A and 2B Steam Generators due to failure of the 2A Main Feedwater Pump to respond as required to maintain Steam Generator water level as Steam Generator pressure increased during plant heat up. The 2A and 2B Motor Driven Emergency Feedwater (MDEFW) pumps automatically started as designed when the 'low steam generator level' signal was received for the 2A and 2B Steam Generators. Following further evaluation, it was determined that a valid EFW actuation occurred, therefore this event is being reported as a late 8-hour non-emergency notification of a valid actuation of the EFW system in accordance with 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 5571931 January 2022 16:05:00The following is a synopsis of an email received from the State of Florida: (RSO) called and reported that a Nuclear Moisture Density Gauge fell out of the back of his pickup truck while traveling/transporting the gauge from the office to a work site at SR 64 and Dam Rd. The gauge was padlocked in its case and chained on each side of the case to eyelets in the back of the truck using padlocks to secure the chains. Upon arrival at the worksite (Manatee County) the truck tailgate was open and the gauge was missing. The padlocks securing the chains were broken. (RSO) retraced his travel route two times to look for the missing gauge. The gauge was NOT found. (The RSO) reported the incident to both the Manatee County's and Sarasota County's Sheriffs Departments. Sarasota County Sheriff Dept. Case number 22-8695 was issued. Report identified the sources to be Cesium-137 (10 milliCuries) and Americium-241/Be (50 milliCuries). Florida Incident Number: FL22-012 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 5571831 January 2022 14:14:00

The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail: The Agency was notified early in the morning of 1/31/22 that an Illinois licensee (Lixi, Inc., IL-01339-01) operating in Anaheim, California under reciprocity had two radioactive gauges stolen from their rental car on the afternoon of January 30, 2022 (approximately 1600 PST). Local law enforcement have been notified and responded. The gauges were padlocked preventing the sources from being used and the keys were not stolen. The California program has been notified and is copied on this correspondence. The licensee appears to have reported the theft in a timely manner. The stolen devices were portable fluoroscopes containing approximately 1 Curie of Gd-153 each and were taken from the Staybridge Suites parking garage at 1050 W. Ball Rd. in Anaheim. The police report is 22-15907. The devices were model number TG41 source holders with serial numbers 3217 and 3218. They are marked with the model number 'TG41' and will display 'ON' when the source holder is rotated to expose the source. The radioactive material within the device is in the form of a powder, contained within a tungsten capsule approximately 7mm x 10mm. The source cannot be removed from the device without special tools which were not stolen. If it were somehow removed, it would appear as a stainless steel capsule and is engraved with the word 'Radioactive' and the words 'Gd153', 'C-381' and 'MDSN/LIXI'. Item Number: IL220003

  • * * UPDATE AT 1918 EST ON 01/31/22 FROM ROBERT GREGER TO THOMAS KENDZIA * * *

The following update was received from the California Department of Public Health via E-mail: On Sunday, January 30, 2022, (at 2247 PST), the Lixi, Inc. RSO reported to CAL OES (California Governor's Office of Emergency Services) the theft of two Gadolinium-153 sealed sources used in their Lixi pipe profilers, source S/N: 11/21 (943.15 mCi) and source S/N: 12/21 (926.46 mCi), source holders S/N 3217 and 3218). The users had been inspecting pipes at an Albertsons distribution center located in Brea, CA for two weeks. The theft was discovered on Sunday evening, where the locked and alarmed rental GMC Terrain SUV was parked in the hotel parking structure (address above). The employees stored the Lixi profilers with the Gd-153 source holders attached to the Lixi profiler detector system with the sources locked in the shielded position. There was no sign of forced entry, police speculated the thieves had an electronic bypass system of some kind since four cars were broken into. The value of each Lixi profiler is $50,000 to $75,000. Hotel security is reviewing garage camera footage and will update the PD (police department). The sources had Caution: Radioactive Materials labeling on them. A police report was made with the Anaheim Police Department (Number 22-15907). The licensee will submit a lost/reward ad in the local paper/website and gather additional information for the follow up investigation. CA 5010 Number: 013022 Notified R3DO (Orth), R4DO (Josey), and NMSS Events Notification, ILTAB, and CNSNS via email. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5571728 January 2022 19:08:00The following report was received from the California Department of Public Health (RHB) via email: On 1/28/2022, the licensee notified RHB of an incident in which an INC IR-100 (S/N 4314) radiography exposure device, containing 92 Ci of Ir-192 QSA Global source (S/N 57551M), prematurely actuated its safety latch plate when retracting the Ir-192 source to the fully shielded position resulting in the source assembly stop ball being on the wrong side of the safety latch plate. The source assembly was eventually returned to the fully shielded position by the RSO (radiation safety officer). The maximum dose recorded on the crews' pocket dosimeter was 7 mR. The incident occurred on 1/27/2022 at approximately 2100 PST at the MRC refinery in Martinez, CA. On 1/28/2022 licensee had taken the camera back to INC for evaluation. RHB will be investigating this incident further. California Event Number: 012822
ENS 5571628 January 2022 17:00:00The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail: At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon. Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. (Surveys of the delivery equipment indicated no microspheres were delivered to the patient.) To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident. The licensee is continuing their investigation into root cause. (Agency will review the investigation results.) Item Number: IL220002 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 556987 January 2022 16:29:00The following information was provided by the licensee via email: At 1223 CST on January 7, 2022, Callaway Plant was in Mode 1 at approximately 100 percent power when a turbine trip / reactor trip occurred. All safety systems responded as expected with the exception of an indication issue with the 'B' Feedwater Isolation Valve, which was confirmed closed. A valid Feedwater Isolation Signal and Auxiliary Feedwater Actuation Signal were also received as a result of the reactor trip. The plant is being maintained stable in Mode 3. All control rods fully inserted from the reactor trip signal, and decay heat is being removed via the Auxiliary Feedwater and Steam Dump Systems. The NRC Senior Resident Inspector was notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The plant is in a normal shutdown electrical lineup.
ENS 556967 January 2022 12:38:00The following information was obtained from the Arkansas Department of Health (Department) via email: On January 7, 2022, at 1000 (CST), the licensee reported the discovery (same day) of a damaged tritium exit sign. During preparations for removal of all tritium exit signs at the facility one was discovered to have been subjected to heat. The face of the exit sign was damaged, it is not known if any damage is below the face plate. The licensee is currently working with a consultant on the removal of the exit sign. The exit sign is identified as: Evenlite Model 201, Serial Number 1550F, containing 10.5 Curies of H-3. The Department will monitor the safe removal and disposal of the exit sign and will update this report. Arkansas State Event Report ID Number: AR-2022-01 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 556936 January 2022 20:51:00On January 6, 2022 at 1937 (EST), St Lucie Unit 2 commenced a reactor shutdown as required by Technical Specification 3.1.3.1 Action 'e', due to Control Element Assembly number 27 slipping from 133 inches to 120 inches withdrawn and unable to be recovered within the prescribed time limits. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Unit 2 entered 6 hour LCO to shutdown to mode 3 at 1539 EST as required by Technical Specification 3.1.3.1 Action 'e'. There was no impact on Unit 1.
ENS 556957 January 2022 11:06:00The following information was received by the State of Ohio via email: The licensee performs prostate seed implants on Tuesdays and Thursdays each week. End of day inventories are performed by two therapists. At the end of day inventory on 1/4/2022 the licensee had 53 unused seeds. The beginning of day inventory on 1/6/2022 the inventory was 52 seeds. No procedures were conducted between 1/4/22 and 1/6/22, and surveys did not locate the missing seed. The licensee is unable to account for the discrepancy in their inventory. Source/Radioactive Material: SEALED SOURCE BRACHYTHERAPY Manufacturer: BARD Brachytherapy Model Number: STM-1251 Radionuclide: I-125, 0.000393 Ci Ohio Item Number: OH220001 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 5566921 December 2021 15:01:00The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email: On Tuesday, December 21, 2021, Anbessaw Consulting, Inc. RSO ( ) reported the theft of a CPN MC-3 (#M320500859) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi). The theft occurred overnight between Monday and Tuesday 12/20-21/2021 at an authorized gauge user's apartment complex located at 642 Montgomery Circle, Claremont, CA 91711. The AU discovered that his truck was broken into at approximately 0430 PST Tuesday 12/21/21, the truck was parked in a non-covered space in the apartment complex parking area. The AU had returned to his apartment from a jobsite in Glendora at 2100 PST Monday and was scheduled to return to the jobsite early on Tuesday. The CPN nuclear gauge handle was locked to prevent operation, the gauge was locked in its transport case, and the transport case was locked inside the truck cab. Other equipment and personal items were also stolen from the truck. A police report was filed with the Claremont police department (DR# 2103145). The licensee also submitted a reward ad in the local Daily Breeze stolen section which will run from 12/23-29/2021. CA 5010 Number: 122121 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 556338 December 2021 15:25:00The following information from the state of Utah Division of Radiation Control (Division) was received by email: A licensee gauge operator lost/misplaced a Troxler portable nuclear density gauge model 3411 (SN 12109), (containing 8 mCi of Cs and 40 mCi of Am-Be). He claims he arrived at the licensee laboratory and signed his gauge out on the shipping log at 0615 (MST). He then took his gauge within the transportation case outside of the secured storage room and set it down on the floor inside the laboratory next to the storage room and proceeded to load additional equipment into his truck parked out back. He was outside loading this equipment and was having a conversation with another employee. The other employee said he had to leave and the gauge operator said he had to leave also and got in his truck and drove to his first project at 0630 (MST). At his first project site in Riverton, he then realized he had forgotten the gauge at the lab. At 0730 (MST) he left the project and drove back to the lab to discover that the gauge was not there on the floor at approximately 0830 (MST). He searched the lab, storage room, and questioned lab personal. The RSO was informed of this situation at 0850 (MST). The licensee has notified law enforcement of the missing gauge. The Division is waiting for additional information from the licensee. UT Event Report ID No.: UT-21-0007 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 556276 December 2021 18:14:00

On December 6, 2021, at 1125 hours Eastern Standard Time (EST), during planned maintenance activities, electrical power was lost to the 4160V emergency bus E-3. The power loss to emergency bus E-3 affected both Unit 1 and 2. Emergency Diesel Generator #3 received an automatic start signal but was under clearance for planned maintenance. Emergency bus E-3 was re-energized at 1315 EST hours via offsite power. The loss of power to E3 resulted in Unit 2 Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 3 (i.e., Reactor Water Cleanup), Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems), and Group 10 (i.e., air isolation to the drywell) isolations. The actuations of PCIVs were completed and the affected equipment responded as designed. Per design, no Unit 1 safety system group isolations or actuations occurred. Other Unit 2 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 2 and an automatic start signal to Emergency Diesel Generator #3. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. Except for the Emergency Diesel Generator, which is out of service for planned maintenance, all equipment has been returned to its normal alignment.

  • * * UPDATE FROM JJ STRNAD TO THOMAS KENDZIA AT 2028 EST ON DECEMBER 6, 2021 * * *

The loss of power to E3 resulted in Unit 1 Primary Containment Isolation System (PCIS) Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems). Other Unit 1 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 1. All Unit 1 equipment was returned to its normal alignment. The NRC Resident will be notified. Notified R2DO (Miller).

ENS 5570010 January 2022 17:47:00The following information was received from the Wisconsin Department of Health Services (DHS) via email: On January 10, 2022, DHS received a letter from the licensee stating that a generally licensed static eliminator device, originally shipped to them November 2, 2020, had been missing since November 2021. Activity data was not provided; however, DHS records indicate that all devices at this location contain 10 mCi of Po-210 upon receipt. The licensee did not answer the phone to confirm the written notification information. DHS will continue attempts to contact the licensee and a site inspection will be performed as soon as practical. Wisconsin Event Number: WI220001 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 5559822 November 2021 09:57:00The following was received from the Ohio Department of Health Bureau of Radiation Protection (ODH) via email: Cohen Brothers, scrap metal facility in Middletown, informed ODH on November 19, 2021, that they discovered two devices containing radioactive material at their facility. An ODH inspector responded and identified the devices as Industrial Dynamics Filtec 3-G devices, each containing a 100 mCi Am-241 sealed source. Dose rates on the devices were 30 microR/hr. No contamination was detected. The gauges are secured at Cohen Brothers pending proper disposal. ODH is working with Industrial Dynamics to determine the owner of the devices." The Filtec 3-G gauge serial numbers are 121015 and 121016. Ohio Item Number: OH2100010 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 555603 November 2021 18:05:00On 11/03/2021 Columbia Generating Station concluded the results for refueling outage 24 (R24) and 25 (R25) Local Leak Rate Testing as-found data was incorrect. At 1231 PDT on November 3rd, 2021 Columbia Generating Station determined the local leak rate tests (LLRT) for the X- 25B containment penetration did not meet Technical Specification requirements for LLRT acceptance criteria. The incorrect LLRT data identified for residual heat removal (RHR) B Suppression Pool Spray containment isolation valve (RHR-V-27B) was from the previous two refueling outages (R24 on 5/22/2019 & R25 on 6/512021) at which time primary containment was not required to be operable. The corrected leakage assigned to the X-25 penetration also resulted in total Type B and C leakage summation exceeding the maximum allowable leakage rate for the primary containment (1.0 La) for R24 and exceeding 0.6La in R25. The valve was flushed and retested satisfactory prior to entering the mode of applicability. 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 555552 November 2021 22:06:00

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email: The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. Utah Event Report ID Number: UT 210006

  • * * UPDATE FROM SPENCER WICKHAM TO THOMAS KENDZIA AT 1259 EDT ON 11/4/21 * * *

The following information was received via e-mail: At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information. Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi. The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed. Notified R4DO (KOZAL), NMSS Events Notification group (email), and ILTAB (email). THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5570921 January 2022 10:53:00The following is a summary of information received from the U.S. Navy, Naval Radiation Safety Committee via phone and email: 10 CFR 20.2201(b) requires that each licensee shall submit a written report within 30 days after learning of the following: Any lost, stolen, or missing licensed material becomes known to the licensee, licensed material in a quantity greater than 10 times the quantity specified in appendix C to part 20 that is still missing at 30 day. Naval Surface Warfare Center Crane Division (NSWC Crane), Crane, Indiana self-reported the loss of permitted radioactive material consisting of one Vapor Tracer 2 Hand Held Explosive Detector (HHED). The Vapor Tracer 2 HHED, contained one Ecker and Ziegler Isotope Products Laboratories Model NER-004 Nickel-63 (Ni-63) sealed source not exceeding 10 millicuries (370 Mega-Becquerel). Over the past years, NSWC Crane has recalled all the Vapor Tracer 2 HHED devices from all commands as the new, non-radioactive units are fielded for replacement. Vapor Tracer 2 HHED, S/N: 09-8347, which was issued to the USS John S. McCain (DDG 56), was misplaced during the recall process, sometime between March 2020 and January 2021. An administrative Judge Advocate General Manual (JAGMAN) investigation was performed on the lost Vapor Tracer 2 HHED and determined the device was lost during shipment from Defense Logistics Agency (DLA) San Joaquin in Tracy, California to NSWC Crane. On November 2, 2021 the Navy determined that radioactive material consisting of one Vapor Tracer 2 Hand Held Explosive Detector (HHED), was lost. The Vapor Tracer 2 HHED, contained one Ecker and Ziegler Isotope Products Laboratories Model NER-004 Nickel-63 (Ni-63) sealed source not exceeding 10 millicuries (370 Mega-Becquerel). The Radiation Safety Officer reported to the Navy master material license technical support center the loss of the licensed material on December 22, 2021. The HHED was being shipped by Defense Logistics Agency (DLA) from San Joaquin in Tracy, California to Nuclear Surface Warfare Center in Crane Indiana. Extensive research for the lost HHED did not locate the device. No exposure is known to have occurred. Exposure to individuals from radiation from the Vapor Tracer 2 is unlikely. The Ni-63 source, a weak beta emitter, does not pose an external exposure risk and is mounted as an internal component to the device. Under ordinary conditions of handling, storage, and use, the radioactive material contained in the device will not be released or inadvertently removed from the source housing. In addition, there are two radioactive material labels to warn personnel of the radioactive source that resides inside the device. One label is on the outside of the device and the other is on the detector housing on the inside of the instrument. The Navy notified the NRC Regional Inspector (Shaffer). 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 555532 November 2021 16:19:00The following information was received from the Arizona Department of Health Services (the Department) via email: On November 2, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, two IsoAid Advantage I-125 breast localization seeds were removed by surgery on October 29, 2021 and were verified to be included in the specimen. The specimen with the seeds was delivered to pathology on the afternoon of October 29, 2021. The seeds were not removed from the specimen until November 1, 2021 by pathology. At this time, pathology was only able to locate one of the I-125 seeds. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the one missing I-125 seed. (The missing I-125 seed was between 0.3 and 0.4 microcuries.) The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. Arizona Incident No: 21-008 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 5560223 November 2021 09:10:00This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation. At 0907 (EDT) on September 30, 2021, with Unit 1 in Mode 1, at 100 percent power, an actuation of the 1-1 emergency diesel generator (EDG) occurred during loss of voltage relay functional testing. The 1-1 EDG auto-start was due to human error during performance of the test procedure when the bus 1AE undervoltage signal was improperly defeated and a simulated undervoltage signal was applied. No actual undervoltage condition was present during this event. The 1-1 EDG automatically started as designed when the bus undervoltage signal was received. This was a complete actuation of an EDG to start and come to rated speed, and all affected systems functioned as expected in response to the actuation. Following the actuation, the relays were restored and the 1-1 EDG was shut down in accordance with plant procedures. This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A). The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, in accordance with 10 CFR 50.73(a)(1), this telephone notification is provided within 60 days after discovery of the event instead of submitting a written Licensee Event Report. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 555011 October 2021 08:38:00The following was received from the Virginia Radioactive Materials Program (VRMP) via email: On September 30, 2021 at 1530 EDT, the Virginia Radioactive Materials Program (VRMP) received a report via telephone from the licensee that a portable nuclear moisture/density gauge (Troxler Model 3430, serial number 25698, containing 8 millicuries of Cesium-137 and 40 millicuries of Americium-241/Beryllium) was damaged. It was hit by a compaction vehicle/machine at a temporary jobsite at approx. 1455 on 9/30/2021. The source rod was not out. The gauge housing was damaged but the source appeared to remain intact within the safe position. The licensee's survey of the gauge yielded readings of approx. 2.0 mR/hr at about 6 inches from the gauge. The readings were at or below background (0.02 mR/hr) along a 4 foot radius around the gauge. The gauge was transported to the licensee's office in its transport container. A survey was also performed on the ground and the reading was reported as background. The gauge will be tested for leakage and will be sent to the Troxler Electronics Laboratories for evaluation. The RSO indicated the gauge is not functional. The VRMP is working with the licensee to obtain additional information. This report will be updated once the licensee's investigation is complete. Event Report ID No.: VA210006
ENS 555542 November 2021 18:08:00The following information was received from Illinois Emergency Management Agency (Agency) via E-mail: The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today. The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021. The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time. Illinois Item Number: IL210035
ENS 5545712 September 2021 22:41:00

On September 12, 2021, at 1728 EDT, with Unit 1 in Mode 5 (Cold Shutdown) while performing inspections of the North Anna Power Station Unit 1 reactor vessel head flange area, a weld leak was identified on the reactor vessel flange leak-off line that connects to the flange between the inner and outer head o-rings. Entered TRM 3.4.6 Condition B for ASME Code Class 1,2, and 3 components. With known leakage past the inner head o-ring, this condition is reported since the fault in the tubing is considered pressure boundary (Reactor Coolant System) leakage. This event is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(A) for any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded. The NRC Resident has been notified.

  • * * RETRACTION ON 10/21/21 AT 1153 EDT FROM DENNIS BRIED TO BRIAN P. SMITH * * *

The condition identified in EN 55457, pursuant to 10 CFR 50.72 (b)(3)(ii)(A) has been evaluated, and has been determined not to be Reactor Coolant System (RCS) pressure boundary leakage. As such, the 8-hour report is being retracted, as it is not an event or condition that results in, 'the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.' The leakage was subsequently determined to be in a tubing connection downstream of the reactor vessel inner O-ring. Leakage past a seal or gasket is not considered to be pressure boundary leakage, as defined by Technical Specifications. The NRC Resident Inspector has been notified. Notified R2DO (Miller)

ENS 5545510 September 2021 14:45:00This is a four-hour notification, non-emergency for a notification of another government agency. This event is being reported under 10 CFR 50.72(b)(2)(xi) and 10 CFR 72.75(b)(2). At 1055 EDT on 9/10/21, an employee of a site contractor that was performing work under a contract and in possession of the immediate area where the work was being performed, was involved in a material handling accident in the owner controlled area at Three Mile Island. Londonderry Township EMS and Fire responded to render assistance to the individual. Upon arrival to the site, medical personnel declared the individual deceased. The fatality was work related and the individual was outside of the Radiological Controlled Area.
ENS 555593 November 2021 16:21:00The following information was received from the State of Texas via email: On November 3, 2021, a licensee reported a moisture density gauge was discovered missing on August 30, 2021. The licensee's attempts to locate the gauge were unsuccessful. The licensee last had eyes on the gauge during the previous inventory in January of 2021. The gauge is a Humbolt model 5001 serial 7442 containing 10 mCi of Cs-137 with serial 2376CZ and 40 mCi of Am-241 with serial 404-09. The empty transport container with locks on the latches was present at the licensee's storage location. The gauge may not be inside a transport container. The licensee was unsure if a lock was present on the source rod. The incident was reported to the local police department. More information will be provided per SA 300 as it is obtained. Texas incident no.: 9892 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 5542824 August 2021 15:06:00The following information was obtained from the Illinois Emergency Management Agency (Agency) via email: The licensee's radiation safety officer contacted the Agency to advise that a patient scheduled to receive Y-90 microsphere therapy (SirSpheres) for hepatocellular cancer on August 24, 2021, received only 77% of the dose prescribed in the written directive. This administration called for only 16.2 mCi of activity. The licensee's radiation safety officer is reviewing the delivery system as well as the specifics of the administration to determine root cause. The licensee suspects a clogged catheter but is currently investigating. No personnel or area contamination was reported. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. No untoward medical impact was expected to the patient. Agency inspectors will perform a reactionary inspection on Friday, August 27, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days. Illinois Item Number: IL210027 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 5542523 August 2021 23:20:00On August 22, 2021, Columbia Generating Station determined that no more than approximately eight (8) gallons of silicone oil was inadvertently released into a plant service water system due to a failed heat exchanger on a plant installed air compressor. The plant service water system returns water to a water basin that contains at a minimum 300,000 gallons of water. The water basin is connected to the Columbia River via a blowdown line. Although not confirmed, it is suspected that an unknown quantity of silicone oil may have been released to the Columbia River. A visual inspection of the basin did not identify any oil sheen or film, and there are no additional actions needed to mitigate this issue. It does not appear the oil release poses a threat to human health or the environment, however because there could have been a discharge of an unknown quantity of silicone oil into the Columbia River this matter is immediately reportable under RCW 90.56.280 to the US Coast Guard National Response Center and Washington State Department of Ecology. This condition is being reported pursuant to 10 CFR 50.72(b)(2)(xi) for news release or notification of other government agencies concerning an event related to the health and safety of the public or protection of the environment. Notifications to off-site agencies were performed at 1825 PDT on 8/23/2021. The NRC resident has been informed.
ENS 5542322 August 2021 12:10:00At 0529 EDT on August 22, 2021, HPCI ((High Pressure Coolant Injection System)) was declared inoperable due to receiving the HPCI Inverter Circuit Failure annunciator. The cause of the annunciator was a fuse failure. The cause of the fuse failure is unknown at this time and is under investigation. Concurrent with the HPCI fuse failure was a similar fuse failure within the Division 2 EDG ((emergency diesel generators)) Load Sequencer which renders the Division 2 EDGs inoperable. Relation to the HPCI issue is unknown and is part of the investigation. The RCIC ((Reactor Core Isolation Cooling System)) was verified operable per Tech Spec 3.5.1 E.1. In addition, offsite circuits were verified operable per Tech Spec 3.8.1.B. Division 1 EDGs remain operable. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability. There was no impact on the health and safety of the public or plant personnel. The Senior NRC Resident Inspector has been notified.
ENS 5542120 August 2021 16:00:00

At 0905 EDT, it was discovered both trains of Auxiliary Building Gas Treatment System (ABGTS) were simultaneously INOPERABLE due to the auxiliary building secondary containment enclosure (ABSCE) being inoperable; 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 has been notified. ABSCE and ABGTS were returned to operable.

  • * * RETRACTION ON 10/14/2021 AT 0756 EDT FROM TRACY SUDOKO TO THOMAS HERRITY * * *

This is a retraction of the 8-hour Immediate notification (EN55421) made to the NRC by Sequoyah Nuclear Plant on August 20, 2021. Sequoyah is retracting this event notification based on the following: Regulatory Guidance in NUREG-1022, Revision 3, 'Event Reporting Guidelines 10 CFR 50.72 and 50.73', Sections 2.8 'Retraction and Cancellation of Event Reporting', and 4.2.3 'ENS Notification Retraction'. On August 20, 2021 personnel found door A-118 open. This door is part of the ABSCE. During the initial investigation, it was found that other personnel had the door open using Precaution A of 0-TI-SXX-000-016.0 which allows material access through ABSCE doors if the door is closed within three minutes. It was found that A-118 door had been open for greater than three minutes. With this door open the ABSCE was beyond its capability for ABGTS fan to maintain the required pressure during an Aux. Building Isolation. Thus, the site declared the ABSCE and both Trains of ABGTS inoperable per LCO 3.7.12 Conditions A, B and E. With the ABSCE being a single train system, this caused a condition that "could have prevented the fulfillment of the safety function" which requires an Immediate Notification to the NRC within eight hours under 10 CFR 50.72 (b)(3)(v)(C) and 10 CFR 50.72 (b)(3)(v)(D). This Immediate Notification was reported on August 20, 2021 at 1600 EDT. It was later determined that at 'Time of Discovery', although Door A-118 was open, it was not obstructed, the door was open by normal means, was capable of being closed and was now attended. The time requirement per 0-TI-SXX-000-016.0 for closure of an open ABSCE door is within three minutes of notification. Although the individual found holding the door was unaware of the requirement of 0-TI-SXX-000-016.0 to close the door, communications were established and the Main Control Room (MCR), upon discovery of the 'Open Door', could have directed closure starting at the Time of Discovery if required. Since the MCR was aware the door was open, had communications established with personnel at the door, the door was capable of closure and not restricted, the three minute closure requirement of 0-TI-SXX-000-016.0 was met. Subsequently, the door was closed within approximately two minutes of notification to close. The closure of the door with these procedural measures met confirmed the integrity of the ABSCE and therefore Operability of ABGTS. Based on the above critical thinking, entry into LCO 3.7.12 Condition A, B, and E was retracted on August 22, 2021 at 2044 EDT. With the LCO conditions retracted and the above determination that at the Time of Discovery safety function was maintained, the Immediate Notification per 10 CFR 50.72 (b)(3)(v)(C) and 10 CFR 50.72 (b)(3)(v)(D) was not required. The issue of Past Operability remains for instances in time that the door did not have appropriate compensatory measures in place. Any further notification required for this event will be submitted as a Licensee Event Report. Notified R2DO (Miller)

ENS 5542020 August 2021 12:53:00A licensed operator failed a pre-access authorization test specified by the FFD testing program test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified.
ENS 5542924 August 2021 12:33:00The following was received from the Maryland Department of Environment Radiological Health Program via email: On August 17, 2021, at about 1215 EDT, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the Operations Manager of the Montgomery County Shady Grove Transfer Station and Recycling Center located at 16101 Frederick Rd, Derwood, Maryland 20855 that a "B17 Bomber", radioactive material was thrown into a scrap metal bin. The MDE/RHP responded the same day and investigated the "B17 Bomber", which was later identified as Sextant Bubble Type (with Altitude Averaging Device) AN-5851-1, Part number 3014-1-B and Serial Number AF-42-0676, Contract number AC-26968 and manufactured by Bendix Aviation Corporation navigation instrument which contain Radium - 226 source with estimated nominal activities of 2 microcuries. The Sextant Bubble Type navigation device was dropped by unidentified person(s) at an unknown date and time and was discovered by the Montgomery County Shady Grove Transfer Station and Recycling Center staff when screened for radiation on August 17, 2021. The device was isolated and stored at the temporary hazardous materials storage in the facility by the Operations Manager. The device was later transferred to the local radioactive waste management company, the RSO, Inc. for disposal on August 20, 2021. MDE/RHP will finalize a reactive investigation.
ENS 5542220 August 2021 17:59:00The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email: During the Agency's inspection on 8/12/2021, of licensee Applied Technical Services, license no. 1454, the representative stated that a technician lost the protective cover over the locking mechanism on a QSA 880D exposure device. The representative stated that the metal lanyard connecting the cover to the device housing snapped, and the cover fell between metal grating. The representative did not remember the date of this occurrence. The representative stated that no exposures to personnel or members of the public resulted from the lost cover. The Agency has followed up with Applied Technical Services for more information, with no more information at this time. The Agency is continuing to investigate. Device QSA 880-Delta, Ir-192 source, source activity and device serial number is not available at this time. Alabama Event 21-28
ENS 553985 August 2021 17:30:00A 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 553975 August 2021 11:39:00The following was received from the Texas Department of State Health Services (Agency) via email: On August 4, 2021, a consultant for the licensee reported to the Agency a stuck shutter on a VEGA SHLG-2 fixed gauge with a 5 Ci Cs-137 source. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located at the top of a ladder and does not pose an increased risk of exposure due to the malfunction. The licensee has contacted the manufacturer for repair. Texas incident number: I-9872
ENS 553963 August 2021 19:48:00At approximately 1539 CDT on 8/3/2021, the Dresden Station Main Control was notified of the inadvertent actuation of 17 full sounding emergency response sirens affected Dresden Station in Will County Illinois, while testing other sirens. Will County EMA inadvertently actuated the sirens on 8/3/2021 at 1440 CDT. This event is reportable per 10 CFR 50.72(b )(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-Hour Reporting requirement. The Dresden NRC Resident has been notified. See related Event Notification #55395.
ENS 553943 August 2021 13:18:00At 1026 EDT on 8/3/21, with Unit 1 in MODE 1 at 100 percent power, the reactor automatically tripped due to low reactor water level. The low reactor water level condition was due to a loss of both reactor feed pumps. The cause of the loss of feed pumps is under investigation. Additionally, the low reactor water level resulted in the automatic actuation of High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) systems, and Containment Isolation Valves (CIVs) in multiple systems. All safety systems responded normally. Operations responded and stabilized the plant. Reactor water level is being maintained via RCIC system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not affected. 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). It is also reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the HPCI and RCIC systems and CIVs. There was no impact on the health and safety of the public or plant. The Licensee notified the NRC Resident Inspector. The Unit will proceed to Mode 4 while the cause of the loss of feed pumps is under investigation.
ENS 5532323 June 2021 11:28:00The following report was received from the North Carolina (NC) Division of Health Service Regulation via email: A NC General Licensee reports the loss of 8 NRD Advanced Static Control devices. Each device contained Po-210 with an activity of 10 mCi, each. General License: TBD as at the time of this report our General License Coordinator is currently unavailable. The licensee reports that the devices may have been inadvertently disposed of and their search continues at this time. This report remains incomplete but shall be updated to complete and close the record. Advanced Static Control Device: Manufacturer: NRD Inc.; Model: P-2021-Z705; S/N's: A2MB768, A2MB770, A2MB771, A2MB775, A2MB777, A2MB731, A2MB736, A2MB738 Sources Information: Po-210 Activity .01 Ci each NC Item Number: NC210010 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 5531116 June 2021 23:41:00On June 16, 2021, at 1550 EDT, Palisades Nuclear Plant was operating in Mode 1 at 100% power. At that time, operations identified an acrid odor in the control room. Investigation revealed that the steam dump control relay had failed, rendering all four atmospheric steam dump valves inoperable. The loss of function of all four atmospheric steam dump valves is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. Troubleshooting and replacement of the relay are in progress. The plant remains stable in Mode 1 at 100% power. The NRC Resident Inspector has been notified. Unit 1 is in a 24 hour LCO for Tech Spec 3.7.4.b, atmospheric steam dump valve inoperability. The Unit is in a normal offsite power line-up.
ENS 5531217 June 2021 10:49:00The following was received from the California Department of Public Health via email: On June 16, 2021, the Radiologic Health Branch was notified of a reportable medical event that occurred on June 15, 2021 during a patients' liver metastases treatment with Y-90 Sirtex SIRSpheres. The AU's treatment plan called for treating the left lobe of the liver with 0.29-0.83 GBq of Y-90 SIRSpheres. The reason for the range was that if the liver became saturated, the treatment would be stopped at that point. During the treatment, periodic flushing cycles with contrast and flouroscopy were performed. At a mid-way point, the team discovered contrast material in the right liver lobe, indicating the microcather had moved from the left artery to the right artery. Upon discovery, the procedure was stopped, the microcatherter was removed and a new one was placed and the they began to infuse the left liver lobe again with the remaining Y-90 SIRSpheres without incident. Post treatment, a bremsstrahlung image of the two liver lobes indicated that both lobes had received Y-90 activity. The Radiation Oncologist estimated that the left lobe received less than the intended Y-90 activity. The right lobe received between 33%-67% of the Y-90 activity. The actual dose to either lobe has not been calculated, but based on dosimetry information in the package insert, the dose to the right lobe was > 0.5 Gy ( 50 rem). Treatment of the liver's right lobe was not intended during this procedure. On June 1, 2021, the patient had been treated with Y-90 SIRSpheres of the patient's right liver lobe. The patient was informed of the issue and there are no negative consequences expected for the patient. California Item Number: 061621 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 5530916 June 2021 10:14:00

The following was received from the Georgia Radioactive Materials Program (Agency) via email: Hurst Boiler Welding Company used (a common carrier) to ship a source changer back to QSA Global. It was shipped on May 19, 2021, and officially declared lost on 6/14/21. Hurst Boiler reported the loss to (the Agency) on 6/16/21. The licensee intended to ship a source changer back to QSA global via (a common carrier) on 5/19/2021. After approximately 14 days without a confirmation of receipt. The licensee contacted (the common carrier) on 6/14/21, who confirmed the source had been lost. The Radiation Safety Officer (RSO) then contacted (the Agency) on 6/16/21. When speaking with the RSO by phone, he stated the source changer contains an Ir-192 source (Serial # 9887G Model SC-800). The source activity when shipped (5/19/21) was 8.3 Ci and as of 6/16/21 it has decayed to 6.3 Ci. The most current leak test was performed on 8/31/21. The RSO was advised to provide a written report and submit all supporting documents as soon as possible. Georgia Incident #41

  • * * UPDATE ON 7/7/21 AT 1700 EDT FROM SHATAVIA WALKER TO BRIAN P. SMITH * * *

The source has been retrieved in North Carolina. The following e-mail was received from the North Carolina Department of Health and Human Services in regards to finding the lost source: (The common carrier) confirmed with our staff this morning that the shipment was located in Durham, NC. It had been delivered to an incorrect shipping warehouse. (The common carrier) will be picking it up from that location later today and getting it back on route to the vendor in Massachusetts. The error was discovered by reviewing video footage and noticing it being loaded to the truck bound for Durham. Notified R1DO (Lilliendahl), NMSS Events Notification (E-mail), and ILTAB (E-mail) THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5528531 May 2021 10:50:00A licensed operator had a confirmed positive 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 552396 May 2021 14:00:00On May 6, 2021 at 1223 (EDT), Unit 1 was manually tripped from 60 percent power due to degrading main condenser vacuum. Unit 1 was in the process of decreasing power due to increased secondary sodium levels identified earlier in the day. The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. All control rods fully inserted into the core following the reactor trip. This reactor protection actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). Auxiliary Feedwater pumps actuated as designed as a result of the reactor trip and provided makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater pumps is reportable per 10 CFR 50,72(b)(3)(iv)(A) for a valid actuation of an ESF (Engineered Safeguards Features) system. Decay heat is being removed by the condenser steam dump system. The electrical system is in normal lineup for shutdown conditions. There was no effect on Unit 2 operation. The NRC resident inspector has been notified.
ENS 552355 May 2021 13:22:00

A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified.

  • * * UPDATE ON 4/5/22 AT 1651 (EDT) FROM D.TOWNSEND TO T. HERRITY * * *

The initial event notification should have characterized the test type as a follow-up fitness-for-duty test, rather than a random test. R4DO (Dixon) and FFD Group via email.

ENS 5521526 April 2021 19:30:00A 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. The NRC Resident has been notified.