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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
--------------------
Alabama Radiation Control - Auburn AL
Report Date 12/14/2021 17:34:00
Event Date 12/14/2021 0:00:00
EN Revision Imported Date: 5/5/2022
EN Revision Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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
The State closed out this incident on May 4, 2022. The source, originally 15 mCi on 10/1999, is ascertained to have been incinerated by MedSharp Disposal on 12/6/2021. Remnants of incineration were transported to a Waste Management class 1 landfill in Campbelton, Florida. Chase Environmental Group was contracted to survey and characterize contamination of the incinerator. Contamination attributable to niclel-63 was found inside the incinerator, estimated activity 6 to 13 microcuries. It is believed that the majority, if not all remaining, of source activity is in the landfill. Chase Environmental reported that remaining material would not result in an average member of the critical group receiving over 0.016 mrem/year, and that it is highly unlikely that a member of the public would receive over 10 mrem/year from nickel-63 present in air emissions. The incinerator was free-released for use. The Alabama Office of Radiation Control issued a violation of severity category IV to Veterinary Diagnostic Lab.
NMED item number 210541.
Notified R1DO (Lally) and NMSS_Events_Notification and ILTAB via e-mail.
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Brunswick - Southport NC
Report Date 03/09/2022 23:20:00
Event Date 03/09/2022 20:13:00
EN Revision Imported Date: 5/5/2022
EN Revision Text: HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE
The following information was provided by the licensee:
"At 2013 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated conditions was not met. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) are operable.
"There was no impact on the health and safety of the public or plant personnel. Investigation is in-progress to determine the cause.
"Unit 1 is not affected by this event. Unit 1 is in a refueling outage.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 20:13 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated flow and pressure was not met. Subsequent to this, it was determined that the required response time was overly conservative for assuring the safety function of the system could be fulfilled. The required response time was revised. The operability determination for this event has been updated indicating that system operability was never lost for this event. There was not a condition that could have prevented the system from fulfilling the safety function.
"The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
--------------------
WA Office of Radiation Protection - St. Bellevue WA
Report Date 03/31/2022 20:48:00
Event Date 03/31/2022 0:00:00
EN Revision Imported Date: 5/3/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:
"The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago.
"Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill."
WA incident no.: WA-022-006
The following update was received from the state of Washington via email:
"Based on their [licensee] corrective actions we [the state of Washington] have closed the incident. The lost source will most likely not be findable due to it making it into the landfill already and still being in its shielded container. "
Notified R4DO (Warnick) and ILTAB, NMSS Events Notification and CNSC 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
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Utah Division of Radiation Control - Clive UT
Report Date 04/22/2022 16:10:00
Event Date 04/18/2022 7:30:00
EN Revision Imported Date: 5/17/2022
EN Revision Text: AGREEMENT STATE REPORT - GROUNDWATER CONTAINING URANIUM IDENTIFIED DURING EXCAVATION
The following was received from the Utah Department of Environmental Quality via email:
"On April 18, 2022, Licensee personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The excavations for sumps extended into the groundwater and were not included on the conditionally approved plans. The smell triggered an investigation where groundwater samples were collected for both chemical and radiological analysis. One sample indicated a concentration of 12,000 pCi/L of uranium (preliminary findings). The presence of uranium in the groundwater was unanticipated. Subsequently, the Division of Waste Management and Radiation Control has communicated to the licensee to characterize the nature and extent of the contamination. The Division is waiting for additional information from the licensee."
Event Report ID No.: UT220003
The following update was received from the Utah Department of Environmental Quality (the agency) via email:
"On April 18, 2022, [Licensee] personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The [Licensee] did not anticipate encountering groundwater at the depth of excavation. Upon encountering the groundwater and observing a hydrocarbon odor, the Licensee collected groundwater samples for both organic and radiological analysis. The preliminary screening of one sample indicated a potentially high concentration of uranium. The preliminary result of the analysis was reported to the agency with the intent to conduct additional confirmatory work. The Licensee contends that the initial high concentrations were in error due to improper analytical methodology. These results were presented to the agency prior to confirmation. Results of further investigation by the Licensee indicate that the contaminant was thorium, not uranium, and that all radionuclides were below detection limits.
"The agency collected confirmatory samples for analysis and is awaiting results of both organic and radiological analysis.
"The Licensee is preparing an investigation plan to fully characterize the nature and extent of the contamination."
Event Report ID No.: UT220003 (updated)
Notified R4DO (Gepford) and NMSS Events Notification (email).
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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 04/25/2022 11:31:00
Event Date 03/11/2022 0:00:00
EN Revision Imported Date: 4/27/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE LOST IN TRANSIT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"GE Healthcare in Arlington Heights, IL shipped a Type A package containing one (1) 10mL vial of Indium-111 liquid within a standard 6mm lead shielded container on 3/4/22 to Cardinal Health in Sioux Falls, SD. The outer package is a corrugate box, measuring (L)16.1 x (W)16.1 x (H)16.5cm. The last viable scan was 3/7/22 at the [common carrier] hub under tracking number 270485520236. At the time of shipment, the package contained 3.201 mCi, but is decayed at the time of writing this report to 0.58 mCi. The package was expected to arrive 3/7/22. After no available status updates, [common carrier] dangerous goods advised GE Healthcare to consider the package lost in transit. The licensee reported the matter timely. The licensee advised there were no available updates as of 4/11/22. There have been no available updates since this date and this package is considered lost in transit. The activity is now less than 1.0 microcurie and does not represent a significant public hazard. This matter is considered closed.
"The package has now decayed beneath the NRC reportable quantity and does not represent a significant radiation hazard. No indication of intentional theft or diversion and the contents would not be useful to illicit intent."
Illinois Event Number: IL220010
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
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WA Office of Radiation Protection - Everett WA
Report Date 04/26/2022 18:35:00
Event Date 04/26/2022 13:23:00
EN Revision Imported Date: 4/27/2022
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following is a summary of an e-mail received from the Washington Office of Radiation Protection:
At 1323 PDT, Washington State received a report of two leaking electron capture detectors (ECD). The detectors failed leak testing and were removed from service. The licensee is working with the vendor on additional corrective actions. There was no spread of contamination and no overexposure.
The ECD contain Ni-63 sources (model number G2397A and G1223A / serial number U37921 and F5004) with an activity levels of 0.0144 microCuries and 0.009 microCuries.
Incident Number: WA-22-011
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Louisiana Energy Services - Eunice NM
Report Date 04/27/2022 11:23:00
Event Date 02/28/2022 7:35:00
EN Revision Imported Date: 5/18/2022
EN Revision Text: UNPLANNED CONTAMINATION EVENT
The following information was provided by the licensee via email:
"The plant is in a safe configuration. NRC Region II re-exited an inspection on April 26, 2022 from an inspection which was conducted March 21st through the 24th. During this exit, an event was reclassified as a Non-Cited Violation for failure to report an event. As a result, UUSA [Urenco-USA] is reporting this event as a 24-hour Report per the NRC's inspection.
"On February 28, 2022, water was discovered on the floor of the Liquid Effluent Collection and Transfer System (LECTS) room. The water was leaking from the slab tanks berm into the non-Radiological Controlled Area floor. The area was conservatively and promptly roped off and signage was posted. Radiological readings in the area were taken and found to be less than background and the the spill was cleaned up that day.
"Historical issues are being reviewed and will be added to this notification per the NRC's position shared with UUSA.
"This issue has been entered in UUSA's corrective action program as EV 149668 and 149975."
* * * UPDATE ON 5/17/22 AT 1305 EDT FROM BARRY LOVE TO BRIAN PARKS * * *
The following update was provided by the licensee via email:
"As a result of this Event Notification, a review of Extent of Condition was performed.
"This Extent of Condition revealed nine historical examples of unplanned contamination events that resulted in expansions of Contaminated Areas that were not reported under 10 CFR 70.50(b)(1) as required by regulation.
"These conditions occurred on March 3, 2016 (EV 111023), April 14, 2016 (EV 1129221), August 4, 2016 (EV 113877), December 7, 2016 (EV 116283), February 23, 2017 (EV 117238), November 24, 2019 (EV 136211), November 29, 2021 (EV 148894), February 28, 2022 (EV 149668), and April 14, 2022 (EV 151253).
"These events have been investigated and corrected during the approximate time period in which they were identified. No contamination events are ongoing at UUSA at this time."
The Licensee will notify the NRC Region 2 Inspector.
Notified R2DO (Miller) and NMSS Events Notifications via e-mail.
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Colorado Dept of Health - Colorado Springs CO
Report Date 04/27/2022 13:19:00
Event Date 04/27/2022 10:48:00
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail:
The licensee reported a damaged Troxler 3430 portable moisture density gauge (SN:24886) containing Am-241/Be (SN:4721079) and Cs-137 (SN:757025) sources. The gauge fell out of the back of a truck onto an interstate highway while in transit. Pieces of the gauge are on the interstate as a result of vehicles running over the gauge and the licensee is attempting to retrieve them. The licensee intends to contact the police to help cordon off the affected area to support retrieval of the remaining pieces and conduct surveys. A search is ongoing and some of the pieces of the gauge have not been accounted for.
CO Incident Number: CO220013
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
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NJ Rad Prot And Rel Prevention Pgm - Harmony NJ
Report Date 04/27/2022 13:26:00
Event Date 04/27/2022 8:39:00
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following is a summary of information received from the New Jersey Department Environmental Protection (NJDEP) by e-mail:
On 4/27/2022, North State Materials notified NJDEP that an asphalt roller bumped a density gauge (Troxler model 4640-B, serial #77923 with a Cs-137 source up to 9 milliCuries) at a jobsite in Harmony, New Jersey. The incident was caused by heavy equipment operator error. The operator intended to move the roller backwards, but instead moved forward. The damage was limited to the faceplate and the plastic on one corner of the gauge. The licensee surveyed the gauge to confirm the source was properly shielded prior to transporting it to the licensee's storage location in Philipsburg, NJ. A sealed source leak test is pending.
NJ Incident Number: NJ-22-0003
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Texas Dept of State Health Services - Houston TX
Report Date 04/27/2022 17:10:00
Event Date 04/27/2022 9:15:00
EN Revision Imported Date: 4/28/2022
EN Revision Text: AGREEMENT STATE REPORT - TELETHERAPY DEVICE FAILED IN SHIELDED POSITION
The following information was received from the Texas Department of State Health Services (the Agency) via e-mail:
"On April 27, 2022, the Agency received a notification from the licensee that the drive mechanism on their Theratronics T708C teletherapy device failed in the shielded position. The device contains 5,042 Curies of Co-60. The licensee stated that while starting a procedure at around 0915 hours CDT on April 27, 2022, the technician found that the source would not move out from the shield. There were no exposures as a result of this event. The licensee contacted a service company and scheduled a repair. An investigation is ongoing."
TX Incident Number: I-9926
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Texas Dept of State Health Services - Freeport TX
Report Date 04/28/2022 17:23:00
Event Date 04/28/2022 12:00:00
AGREEMENT STATE REPORT - SHUTTER MALFUNCTION
The following report was received via e-mail from the Texas Department of State Health Services (the Agency):
"On April 28, 2022, the licensee notified the Agency that the shutter handle on one of its Ohmart Vega model SH-F2 gauges, containing a 200 milliCurie cesium-137 source, had malfunctioned. A service company was preparing the gauge for removal and had opened and closed the shutter. The shutter closed completely (verified by survey), but they could not lock the shutter handle. A repair kit will be ordered and upon receipt the service company will make the repair and complete the removal. The gauge is in an area of the plant that is no longer operational in a location that is inaccessible without scaffolding. The scaffolding being used at the time of this event will be removed until time for repair.
"There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: I-9927
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Sequoyah - Soddy-Daisy TN
Report Date 04/29/2022 0:19:00
Event Date 04/28/2022 23:55:00
EN Revision Imported Date: 5/3/2022
EN Revision Text: NOTICE OF UNUSUAL EVENT
The following is a summary of information provided by the licensee via telephone:
On 04/28/22, at 2355 EDT, with both Sequoyah Unit 1 and 2 in Mode-1, 100 percent, a Notice of Unusual Event was declared due to receiving two seismic alarms and security feeling ground movement. Additionally, security in a tower heard an explosion. Both units remain in Mode-1, 100 percent and they are investigating the validity of the seismic alarms before proceeding with the Abnormal Operating Procedure required shutdown.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email).
The following is a summary of information provided by the licensee via telephone:
On 4/29/22, at 0406 EDT, Sequoyah Unit 1 and Unit 2 terminated the Notice of Unusual Event. The Civil Engineers determined that the alarms were due to a failed seismic indicator channel. Through interviews, only one security officer felt ground movement for a couple of seconds and heard a faint rumbling sound.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified.
Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Gott) via email.
Additionally, notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email).
The following information was provided by the licensee via email:
"SQN [Sequoyah Nuclear Plant] is retracting the previous NOUE [Notice of Unusual Event] declaration made on 4/28/22 at 2355 [EDT] based on Emergency Action Level HU2 for a seismic event greater than Operating Basis Earthquake levels. Following the declaration of the NOUE, the station reviewed all available indications and determined that a seismic event had not occurred. The instrumentation failure was documented under Event Notification #55867."
Notified R2DO (Miller), and IR MOC (Gott), NRR EO (Miller) via email.
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Wisconsin Radiation Protection - Oshkosh WI
Report Date 04/29/2022 10:07:00
Event Date 06/21/2021 0:00:00
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DISCREPENCY WITH WRITTEN DIRECTIVE
The following summary was received from the Wisconsin Department of Public Health (the Department) via email:
On April 28, 2022, during an inspection, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on June 21, 2021. A patient's procedure planned for two vials and an activity of 2.81 GBq, which were administered. The written directive erroneously only accounted for one vial and a prescribed activity of 1.94 GBq; therefore, the administered activity was 138.4 percent of the activity specified on the written directive. The administered activity was within 2 percent of the planned activity.
Wisconsin Event Report ID No.: WI220010
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.
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Alabama Radiation Control - Mobile AL
Report Date 04/29/2022 17:58:00
Event Date 04/27/2022 0:00:00
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION
The following information was received from the Alabama Office of Radiation Control (the Department) via E-mail:
"The Department received a phone call and e-mail on 4/28/2022 from the licensee regarding two patients that apparently received the wrong radiopharmaceuticals on 4/27/2022. The patients' doses appeared to have been inadvertently switched.
"Patient: 1 (male) "Ordered dose: 10.0 mCi Fluciclovine (Axumin) F-18 "Given: 10.64 mCi FDG F-18
"Patient: 2 (female) "Ordered dose: 10.0 mCi FDG F-18 "Given: 12.62 mCi Fluciclovine (Axumin) F-18
"It appears that at least one patient received an effective dose over 500 mrem.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Event: 22-07
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.
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Illinois Emergency Mgmt. Agency - Burr Ridge IL
Report Date 05/03/2022 12:07:00
Event Date 05/02/2022 0:00:00
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted at 0830 CDT on 5/3/22 to advise that a radiography crew had a 55 Ci Ir-192 source disconnect from the drive cable while working at a site in Bradley, Illinois over the evening. The crew contacted their RSO and the source was successfully retrieved and placed into a shielded position. As the work was done after hours, there are reportedly no concerns over public exposures. Three MISTRAS staff recorded maximum exposures of 65 mrem on their [direct reading dosimeters] DRDs from the operation and have overnighted dosimetry for processing."
Illinois Event Number: IL220013
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North Anna - Richmond VA
Report Date 05/03/2022 14:48:00
Event Date 05/03/2022 8:19:00
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"A non-licensed Dominion Energy 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 licensee notified the NRC Resident Inspector."
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Marathon Pipe Line LLC - Indianapolis IN
Report Date 05/03/2022 15:24:00
Event Date 05/02/2022 9:30:00
NON-AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the licensee via email:
"
Marathon Pipe Line LLC and the Manufacturer, VEGA Americas, Inc., evaluated a [fixed gauge] device [OHMART/Vega Corporation Model SR-1A, S/N M5965. Cs-137 80 mCi ] on 05/02/22 to verify the operation of the shutter mechanism. "
During the evaluation of the device the VEGA FS Technician confirmed that the shutter mechanism would not close.
"
The cause is internal mechanism failure of the shutter device. "
The shutter is in the Open position and won't close.
"
The Open position is the normal operating position. "
There was and is no radiation exposure concern for Marathon Pipe Line LLC employees, contractors, visitors or the general public. "
Vega Americas, Inc. has been contacted for a path forward to order and install a replacement device as well as develop a plan and assist in the safe removal, isolation and disposal of this gauge."
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Vogtle - Waynesboro GA
Report Date 05/03/2022 18:44:00
Event Date 05/03/2022 15:41:00
MANUAL REACTOR TRIP AND AUTOMATIC ACTUATION OF AUXILIARY FEEDWATER SYSTEM
The following information was provided by the licensee via email:
"At 1541 EDT on May 3, 2022, with Unit 1 in Mode 1 at 100 power, the reactor was manually tripped due to the loss of one of the main feed pumps. The trip was not complex, with all systems responding normally post-trip. No equipment was inoperable prior to the event that contributed to the event or adversely impacted plant response to the scram.
"Operations responded and stabilized the plant. Decay heat is being removed by Auxiliary Feedwater through the steam dumps to the condenser. Unit 2 is not affected.
"An automatic actuation of the Auxiliary Feedwater System (AFW) also occurred. The AFW auto-start is an expected response from the reactor trip.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
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California Radiation Control Prgm - La Jolla CA
Report Date 05/04/2022 19:31:00
Event Date 05/03/2022 0:00:00
AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEEDS
The following was received from the California Department of Public Health Radiologic, Health Branch via email:
"The Radiation Safety Officer for UCSD [(University of California, San Diego)] contacted the Radiologic Health Branch regarding the loss of I-125 sealed sources. He also reported the loss to the CA State Warning Center (control no. 22-2532).
"A medical physicist at the Moore's Cancer Center at UCSD received a box that contained 4 packs of I-125 sealed sources instead of his expectation of 3 packs. The medical physicist removed 3 packs and set the packing box outside for recycling, believing it was empty. The cardboard box was taken away by environmental services staff and has possibly been taken to the on-campus recycling center. The pack contains approximately 6-7 I-125 medical brachytherapy seeds with combined activity of 2.3 millicuries. The seeds are sealed in a shielded, sterile pack. The expected exposure level is close to background radiation level outside of the shielded pack. UCSD sent health physicists to the recycling center to search for the missing package."
5010 Number: 050322
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
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California Radiation Control Prgm - Valencia CA
Report Date 05/04/2022 20:47:00
Event Date 05/04/2022 0:00:00
AGREEMENT STATE REPORT - LOST GD-153 LINE SOURCES
The following was received from the California Department of Public Health, Radiologic Health Branch via email:
"On May 4, 2022, the Radiation Safety Officer for Eckert & Ziegler Isotope Products, Inc. (EZIP) contacted Los Angeles County Radiation Management regarding two missing sources. Pennsylvania licensee Abington Jefferson Health, located in North Wales, PA, shipped a package on October 21, 2021, and [the common carrier] tracking information indicated the package was delivered to EZIP with no receipt signature on October 22, 2021. Abington Jefferson Health contacted EZIP on November 10, 2021, requesting a receipt for confirmation of the returned sources. The sources were two gadolinium-153 line sources, with approximately 13 millicuries (mCi) each (greater than 1000 times the Appendix C value of 10 microCi). EZIP did not have a record of receipt of the package, and a search of the EZIP facility did not find the sources.
"The notification to Los Angeles County Radiation Management by EZIP was delayed due to confusion by EZIP regarding whether the package had been returned to Abington Jefferson Health by [the common carrier]."
5010 Number: 050422
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
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Palo Verde - Wintersburg AZ
Report Date 05/05/2022 4:30:00
Event Date 05/04/2022 19:55:00
VALID ACTUATION OF UNIT 2 AND UNIT 3 EMERGENCY DIESEL GENERATORS AND UNIT 3 AUXILIARY FEEDWATER PUMP
The following information was provided by the licensee via email:
"At 1955 on May 4, 2022, a start-up transformer de-energized, resulting in a loss of power to the Unit 2 Train A 4.16 kV Class 1E Bus and the Unit 3 Train B 4.16 kV Class 1E Bus. The Unit 2 Train A Emergency Diesel Generator (EDG) and Unit 3 Train B EDG automatically started and energized their respective 4.16 kV Class 1E Buses.
"As a result of the Loss of Power on the Unit 3 Train B 4.16 kV Class 1E Bus, the B Auxiliary Feedwater Pump automatically started, as expected. The B Auxiliary Feedwater Pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The B Auxiliary Feedwater Pump did not supply feedwater to the steam generators.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems and an auxiliary feedwater system."
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PA Bureau of Radiation Protection - Williamsport PA
Report Date 05/05/2022 8:13:00
Event Date 05/03/2022 0:00:00
AGREEMENT STATE REPORT - MALFUNCTIONING SHUTTER
The following was received from the state of Pennsylvania [the Department] via email:
"On May 4, 2022, the licensee informed the Department of an equipment malfunction. The licensee reported that on May 3, 2022 a QSA Global Model 880 containing a 37 Curie source of Iridium-192 malfunctioned. The camera's serial number is D15520 and the source serial number is 36110M. During the course of radiographic operations, the automatic lock slide that secures the source failed to completely close. While the source was completely retracted, secured, and verified using a survey meter, the camera was not fully functioning as intended. The licensee contacted with QSA Global, who suspect a spring malfunction. The camera was sent back to QSA for evaluation and repair. There were no overexposures because of this event."
PA Event Report No: PA220015
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Texas Dept of State Health Services - Dallas TX
Report Date 05/05/2022 8:14:00
Event Date 05/04/2022 12:00:00
AGREEMENT STATE REPORT - GAUGE STRUCK AND DAMAGED BY BULLDOZER
The following was received from the Texas Department of State Health Services [the Agency] via email:
"On May 4, 2022, the licensee's radiation safety officer contacted the Agency and reported one of it's Humboldt 5001EZ gauges containing an 8 millicurie cs-137 source and a 40 mCi am-241 source had been struck by a bulldozer at a temporary field site. The gauge was damaged, and the licensee stated their engineer was going to the site to inspect and recover the gauge. The RSO contacted the Agency later that day and stated the source was in the shielded position and readings on contact with the transport case was 5 millirem an hour and 2 millirem an hour at three feet. The licensee transported the gauge back to it's facility. The licensee contacted it's service provider who will dispose of the gauge. No significant exposures were received as a result of this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number I-9930
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Kansas Dept of Health & Environment - Springfield MO
Report Date 05/05/2022 13:41:00
Event Date 05/05/2022 9:45:00
EN Revision Imported Date: 5/13/2022
EN Revision Text: AGREEMENT STATE REPORT - TRANSPORTATION EVENT
The following was received from the State of Kansas Department of Health and Environment via email:
"At approximately 0945 CDT on May 5, 2022, the Kansas Department of Health and Environment (KDHE) was notified of a Cardinal Health carrier involved in an incident where the vehicle was swept off the road due to flooding. The nearest intersection to the site of the incident is E 520th Ave and S 240th Ave in Pittsburgh, KS, near the Missouri border. The vehicle was transporting unit doses of Tc-99m [total activity unknown at this time] from its Springfield, Missouri facility to locations in Kansas. The vehicle [type unknown at this time] is currently sitting in approximately 3 to 3.5 feet of water. KDHE was informed that the driver had to exit the vehicle through the window, which remains open. KDHE was informed that the driver left the area and the vehicle is currently unattended. The weather forecast includes additional rain and potential flooding for the rest of the day into the evening and a towing company is unable to assist until the water recedes. It is unknown at this time when the vehicle will be able to be retrieved."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Container information: Syringes containing Tc-99m individually contained in pigs Pigs contained in nylon bag No placarding of vehicle Containers labeled with RADIOACTIVE WHITE-I (less than 0.5 mrem/hr on surface) Vehicle also likely contained empty used Tc-99m syringes
Notified: DHS, FEMA, USDA, HHS, DOE, CISA, EPA, DOT, KS All Hazard Notification System Notified via email: FDA, DHS, FEMA National Watch Center, FEMA NRCC SASC,CWMD Watch Desk
"The Cardinal Health RSO was able to access the vehicle on Friday (5/6/2022) afternoon and removed the radioactive material which was then returned to the pharmacy. The RSO also performed surveys and wipes and found them to be below action levels.
The contents of the vehicle was confirmed as follows: "There were two containers of doses containing a total of 121 doses and about 200 mCi of Tc-99m, calibrated for between 0700 and 1300 CDT on Thursday (5/5/2022)."
Notified R3DO (Skokowski), R3DO (Stoedter), R4DO (Gaddy), IR (Kennedy), NMSS Events Notification email group.
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Utah Division of Radiation Control - Provo UT
Report Date 05/05/2022 15:00:00
Event Date 05/04/2022 13:00:00
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION
The following was received from the Utah Department of Environmental Quality (the Division) via email:
"At approximately 1030 MDT, the [Radiation Safety Officer] for the licensee notified the Division that a patient had been administered an isotope to perform a PET scan. The technician double checked with the ordering physician and found that the order was supposed to have been for a CT scan, not a PET scan. The order received showed it was a PET scan. An investigation is being conducted to see how the order was changed.
"The patient was administered about 10.6 mCi of FDG when a CT scan was to be performed. Therefore, the dose was greater than 20 percent of the prescribed dose. The order received by the radiology department showed that a PET scan had been ordered. The TEDE to the patient was less than 5 rem and the highest organ dose (to the bladder wall), was less than 50 rem. The patient was administered the FDG at about 1300 EDT on May 4, 2022. The FDG was allowed to decay and the patient was later given a CT exam.
"At this time, this is all the information that the Division has, an investigation will be conducted, and an update will be provided at a later date."
Event Report ID No.: UT220004
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.
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CTL Engineering, Inc - Morgantown WV
Report Date 05/05/2022 21:55:00
Event Date 05/05/2022 0:00:00
NON-AGREEMENT STATE REPORT - STOLEN GAUGE
The following is a synopsis of information received via telephone:
A portable nuclear density gauge was stolen from the bed of a pickup truck parked at a hotel in Hurricane Creek, WV. The chain securing the gauge had been cut. The licensee notified the Putnam County sheriff's office who indicated other thefts had occurred in the area. The licensee indicated that the theft occurred within a day of discovery.
Gauge Information: Make: Troxler Model number: 3430 Sources (nominal): 8 mCi of Cs-137 and 40 mCi of Am-241:Be. Serial number: 65490
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
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New York State Dept. of Health - Herkimer NY
Report Date 05/06/2022 10:11:00
Event Date 05/05/2022 0:00:00
EN Revision Imported Date: 5/11/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following was received from the state of New York, Bureau of Environmental Radiation Protection (BERP): "A portable XRF device containing a 6 millicurie Cobalt-57 source was shipped via [common carrier] to Viken on April 13, 2022. Viken (device manufacturer) was contacted on or around May 4, 2022, and indicated they never received the package. Specific device information is below. Based on tracking information, the package arrived in Syracuse but there are no records of it leaving. BERP is monitoring this situation under Incident No. 1396.
"Device Manufacturer: Viken; Device Model: Pb200i; Device S/N: 2599; Source Manufacturer: Isotope Products Laboratory; Source Model: Model 3901 Series; Source S/N: TBD; Isotope: Cobalt-57"
NEW YORK EVENT REPORT ID NO. NYDOH - 22-03
The following was received via fax from the state of New York, Bureau of Environmental Radiation Protection (BERP):
"On Friday, May 6, 2022, BERP was notified via electronic mail that the device was located in New Hartford, NY [common carrier] Package Center. A representative from the Herkimer District Office went to the Center and picked up the device on Monday. The package appears intact with no damage."
Notified R1DO (Ferdas), NMSS Events Notification, ILTAB, and CSNC (Canada)
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
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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 05/06/2022 16:36:00
Event Date 05/05/2022 0:00:00
AGREEMENT STATE REPORT - LOST RADIOPHARMACEUTICAL PACKAGE
The following was received from the Illinois Emergency Management Agency (the agency) via email:
"The Agency was contacted on 5/5/22, by GE Healthcare to advise that a radiopharmaceutical package was damaged in transit and reported as lost at the carrier's facility. GE Healthcare reports the 6 inch x 6 inch package (UN2915, Type A Package, Yellow II, TI 0.1) was shipped from Arlington Heights, IL to Richland, MS on 5/3/22. The package contained a lead shielded container with 1.956 mCi of In-111 (activity at the time of shipment on 5/3/22). The package reportedly arrived in one piece at the [common carrier's] Memphis hub on 5/3/22. On 5/5/22, the carrier advised the licensee that they had found the damaged package at their Memphis hub with its inner contents missing. Dangerous Goods is currently working with the shipper and conducting a search of the facility. The package now contains approximately 1.2 mCi [of In-111].
"There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent.
"This matter has a 30-day reporting requirement to the US NRC. Updates will be provided as they become available."
Item Number: IL220015
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
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Texas Dept of State Health Services - Houston TX
Report Date 05/06/2022 17:08:00
Event Date 05/06/2022 0:00:00
AGREEMENT STATE REPORT - THREE MEDICAL EVENTS - UNDERDOSES
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: I-9931
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.
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MA Radiation Control Program - Tewksbury MA
Report Date 05/06/2022 17:21:00
Event Date 05/06/2022 12:00:00
AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following was received from the Massachusetts Radiation Control Program (the "Agency") via email:
"On 05/06/2022, at 1340 EDT, the Agency received a call from RSO [Radiation Safety Officer] at Thermo Scientific Portable Analytical Instrument, Inc. (the `licensee') reporting a leaking sealed source. The 20-year-old source/device (Thermo Scientific Portable Analytical Instruments, Inc.; Model XLi 969; Device s/n 5243; Source s/n EG-8804) is currently containing 0.12 mCi of Fe-55 (original activity was 20 mCi on 04/07/2002). The RSO received the leak test report on 05/06/2022 and he noticed that the source is leaking as 0.0058 microcuries of removal activity which is in excess of regulatory limits (0.005 microcuries). This device was sent to the licensee for decommissioning and was received from the licensee's customer on 04/21/2022. The source was removed from the device as part of decommissioning. There was no external contamination spread outside of the device or surrounding work area surfaces. The source will be secured and properly disposed of in accordance with the regulations."
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Oconee - Seneca SC
Report Date 05/07/2022 4:37:00
Event Date 05/06/2022 23:10:00
AUTOMATIC ACTUATION OF EMERGENCY FEEDWATER
The following information was provided by the licensee via fax:
"At 2310 EDT on May 6, 2022, with Unit 3 in Mode 3, an actuation of the Emergency Feedwater (EFW) System occurred while entering a planned refueling outage. The reason for the EFW auto-start was a loss of all Main Feedwater (MFDW) Pumps which occurred when the 3A MFDW Pump tripped on steam generator (SG) overfill protection due to high level in the 3B SG. The high level in the 3B SG occurred when a Startup Feedwater Control Valve (3FDW-44) malfunctioned, resulting in excessive feedwater flow to the 3B SG. Investigation and repairs are in progress. Units 1 and 2 were not affected.
"This event is being reported as an 8-hr non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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PA Bureau of Radiation Protection - Philadelphia PA
Report Date 05/07/2022 9:54:00
Event Date 05/04/2022 0:00:00
AGREEMENT STATE REPORT - UNDERDOSE
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (Department) via fax:
"On May 6, 2022, the University of Pennsylvania informed the Department of an underdose incident on May 4, 2022, involving yttrium-90 (Y90) SIR-Spheres. A patient underwent a Y90 SIR-Sphere treatment and the catheter placement changed during a SIR-Spheres administration and the Authorized User intentionally stopped the administration as continuing could have resulted in harm to the patient. The administered activity was 67 percent of the prescribed activity (15.1 mCi vs 22.51 mCi). The Department will perform a reactive inspection and is currently in contact with the University of Pennsylvania. The event will be updated this as soon as more information is provided. It is reportable as per 10 CFR 35.3045(a)(1)(i)."
Pennsylvania Report Number: PA220017
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.
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New Mexico Rad Control Program - Carlsbed NM
Report Date 05/09/2022 12:36:00
Event Date 04/11/2022 0:00:00
AGREEMENT STATE REPORT - INDUSTRIAL RADIOGRAPHY EQUIPMENT FAILURE
The following is a summary received from the New Mexico Environmental Protection Division (the agency) via phone:
On 05/09/22, at 0934 MDT, the agency was notified of an industrial radiography event that occurred on 04/11/22. The licensee reported a mechanical equipment failure and that no exposure occurred. The agency is en route to follow-up and gather additional details on the event.
The agency also notified R4 (Erickson).
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Quad Cities - Cordova IL
Report Date 05/10/2022 23:42:00
Event Date 05/10/2022 13:59:00
EN Revision Imported Date: 5/12/2022
EN Revision Text: BOTH TRAINS OF LOW PRESSURE COOLANT INJECTION (LPCI) INOP
The following information was provided by the licensee via fax:
"At 1359 CDT on May 10, 2022, the 1B LPCI Loop Upstream Injection valve (1-1001-28B) was found to have a motor operated torque switch issue and inadequate lubrication. This issue called into question the ability of the valve to close when required.
"At 1746 CDT on May 10, 2022, both trains of Unit 1 LPCI were made simultaneously inoperable. TS 3.6.1.3 Condition A required de-activation of 1B LPCI Loop Downstream Injection valve (1-1001-29B) which was completed at 1746 CDT. Because of the de-activation of the 1B LPCI Loop downstream injection valve and LPCI Loop select logic, both trains of LPCI were made inoperable. Due to this inoperability, the system was in a condition that could have prevented the 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). Unit 1 HPCI and both loops of Core Spray are operable. After further engineering review, it was determined that 1B LPCI Loop Upstream injection valve condition was minor in nature and would not have affected the ability of the valve to close when required.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone call and email:
The last sentence in the second paragraph, "After further engineering review, it was determined that 1B LPCI Loop Upstream injection valve condition was minor in nature and would not have affected the ability of the valve to close when required," has been deleted. The licensee is continuing to follow up on the issue and believes that sentence to be unclear and premature.
Notified R3DO (Skokowski).
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California Radiation Control Prgm - Duarte CA
Report Date 05/10/2022 23:57:00
Event Date 05/10/2022 0:00:00
AGREEMENT STATE REPORT - UNDERDOSE MEDICAL EVENT
The following information was received via e-mail:
"The City of Hope Radiation Safety Officer contacted LA County Radiation Management (LA County) on May 10, 2022 to report a Medical Event that occurred on the same day at City of Hope in Duarte, CA. The patient was underdosed during a Selective Internal Radiation Therapy (SIRT) treatment for liver cancer that involved the administration of SIR-Spheres yttrium-90 (Y-90) resin microspheres. The prescribed dose to the patient was 10 mCi, but the dose delivered to the patient was only 6.42 mCi due to a leakage caused by a loose tubing connection.
"City of Hope will conduct an investigation to gain a better understanding of the details of the event."
California 5010 Number: 051022
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.
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Millstone - Waterford CT
Report Date 05/11/2022 18:12:00
Event Date 05/10/2022 21:21:00
FITNESS FOR DUTY REPORT
The following information was provided by the licensee via email:
"A licensed operator had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.
"The licensee notified the NRC Resident Inspector."
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Fermi - Newport MI
Report Date 05/11/2022 22:25:00
Event Date 05/11/2022 18:14:00
HIGH PRESSURE COOLANT INJECTION INOPERABLE
The following information was provided by the licensee via email:
"During performance of High Pressure Coolant Injection (HPCI) Pump and Valve Operability surveillance in accordance with procedure 24.202.01, the turbine tripped without operator action. The plant was operating in Mode 1 at 10 percent power with the HPCI turbine running in a test mode at 5100 gpm with all surveillance criteria met. The surveillance was near completion at the point where the HPCI turbine is manually tripped. Before the manual trip was performed, the HPCI turbine tripped without operator action.
"Prior to performance of the surveillance, HPCI was provisionally operable with only satisfactory completion of Post Maintenance Testing (PMT) surveillance remaining to declare HPCI operable. HPCI surveillance testing was performed at low reactor pressure (165 psig) in Mode 2 satisfactorily. Investigation into the cause of this trip is in progress. HPCI has been declared inoperable from the time of release of the surveillance. Reactor Coolant Isolation Cooling (RCIC) was verified to be operable prior to and after the surveillance in accordance with Technical Specifications 3.5.1 condition E.1.
"This report is being made pursuant to 10 CFR 50.72(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 NRC Resident Inspector has been notified."
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SC Dept of Health & Env Control - Charleston SC
Report Date 05/13/2022 13:46:00
Event Date 04/13/2022 14:00:00
AGREEMENT STATE REPORT - TRITIUM IN EXCESS OF LICENSE LIMIT
The following information was received from the South Carolina Department of Health and Environmental Control [The Department] via e-mail:
"On April 13, 2022, at approximately 1400 EDT, the Department was notified by the licensee that it possibly received two samples that contained Tritium (H-3) that if logged in would have exceeded the license possession limit. The licensee receives samples from various customers for analysis to determine the amount of radioactivity that may be present in the sample. The two samples (drums) contained 50 pounds of concrete cores. These samples were believed to contain 1.57 E4 milliCuries of Tritium. Due to the potential elevated level of Tritium in the samples, the drums were never unpacked, were re-sealed, and returned to the client. The client submitted information indicated that each sample (drum) contained approximately 346 microCuries/gram of Tritium. The licensee calculated that the activity of each sample contained 7.85 Curies of Tritium and totaled 15.7 Curies for both samples. The licensee has submitted the required 30-day written report on May 12, 2022."
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Monticello - Monticello MN
Report Date 05/13/2022 17:47:00
Event Date 05/13/2022 11:11:00
CONTROL ROOM ENVELOPE INOPERABLE
The following information was provided by the licensee via email:
"On 5/13/22 at 1111 CDT the station entered LCO 3.7.4 Condition B for Control Room Envelope being inoperable. This was due to results from an inspection in the Steam Jet Air Ejector room that identified steam leakage exceeding the leakage rate assumptions made in the Alternate Source Term (AST) dose analysis calculation. Therefore, this is being reported in accordance with 10CFR50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades plant safety and 10CFR50.72(b)(3)(v)(D) for any event or condition that at the time of discovery could have prevented fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"There is no impact to the health and safety of the public. NRC Resident has been notified."
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Framatome ANP Richland - Richland WA
Report Date 05/13/2022 19:24:00
Event Date 05/12/2022 19:10:00
GAMMA MONITORS NON-FUNCTIONAL
The following information was provided by the licensee via fax or email:
"Two gamma monitors on filters associated with the waste water treatment system were discovered to be non-functional during their monthly calibration check. These gamma monitors are designated as an Item Relied on for Safety (IROFS) and are used to prevent gradual long term accumulations of uranium from exceeding a safe mass.
"The system has been shut down and will remain down until the required safety function is restored.
"This condition is being conservatively reported under the requirements of 10CFR70 Appendix A b(2) due to two Failed IROFS although Framatome believes that the performance requirements of 10CFR70.61 are still met."
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Ohio Bureau of Radiation Protection - Cincinnati OH
Report Date 05/14/2022 17:33:00
Event Date 05/13/2022 0:00:00
AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE
The following information was received from the Ohio Department of Health via email:
"Licensee reported a medical event that occurred on May 13, 2022. A patient experienced pain while undergoing a Y-90 TheraSphere treatment. The treatment was terminated with 65 percent of the prescribed dose administered. The referring physician and patient were informed. Additional information will be added when received from licensee in the 15-day event report."
OH incident no.: OH220007
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.
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Peach Bottom - Philadelphia PA
Report Date 05/16/2022 19:51:00
Event Date 05/16/2022 15:52:00
AUTOMATIC SCRAM DUE TO ELECTRICAL TRANSIENTS
The following information was provided by the licensee via fax:
"Unit 2 experienced multiple electrical transients resulting in a Group I Primary Containment Isolation Signal (PCIS) isolation and subsequent unit reactor scram. Low reactor water level during the automatic scram caused PCIS Group II and III isolation signals. Following the PCIS Group I isolation, all main steam lines isolated. All control rods inserted and all systems operated as designed."
The following additional information was obtained from the licensee via phone in accordance with Headquarters Operations Officers Report Guidance:
Peach Bottom Unit 2 automatically scrammed from 100 percent power due to an electrical transient and subsequent PCIS Group I isolation (Main Steam Isolation Valve closure). Unit 2 lost main feedwater due to the PCIS Group I isolation, however, all other systems responded as expected following the scram. High Pressure Coolant Injection is maintaining pressure control while Condensate Pumps are maintaining inventory. The unit is currently stable and in Mode 3. Peach Bottom Unit 3's Adjustable Speed Drives were impacted by the electrical transients and the unit reduced power to 98 percent power.
The NRC Resident Inspector was notified.
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OK Deq Rad Management - Sallisaw OK
Report Date 05/18/2022 14:41:00
Event Date 05/17/2022 0:00:00
EN Revision Imported Date: 6/1/2022
EN Revision Text: AGREEMENT STATE REPORT - DISCOVERED FIXED GAUGE
The following information was received from the Oklahoma Department of Environmental Quality (DEQ) via email:
"On 5/17/2022, the state of Arkansas notified Oklahoma DEQ's Radiation Management Section that a DOT [(Department of Transportation)] Special Permit 10656 had been issued for a trailer that originated in Sallisaw, Oklahoma. The load was surveyed at the scrap metal facility in Arkansas and sent back to Oklahoma. It arrived back to Sallisaw today and was surveyed by the owner of the salvage yard. The owner of the salvage yard found a Thermo Measure Tech Model 5201 fixed gauge containing 50 mCi of Cs-137, serial number R4473. The source housing appears to be intact. When the gauge was removed from the trailer no additional radiation was measured on the trailer. The facility owner was instructed to isolate and secure the gauge. The owner stated that he would place it in a drum and lock it in a concrete shed."
DOT Approval Number: AR-OK-22-007
The following information was provided by the DEQ via email:
"The manufacturer of the gauge provided [DEQ] with the name of the company that purchased the gauge; they are still a valid company based out of New Jersey. [DEQ] has contacted them and are waiting for a response.
"[DEQ] searched NMED [(Nuclear Material Events Database)] but did not find any reported loss or theft of this gauge.
"Source: CM-3539; Serial: B4473 [(different than previously reported)]; Model: 5201; Isotope: Cs-137; Activity: 50; Units: mCi; Tag Activity: 50; Tag Assay: 10/16/2003; Capsule: 696984; Customer: EXCAVATING MATERIALS & EQUIPMENT; Order: 275976; PO#: DG-111505; License #: L03524; Ship date: 2/9/2006"
Notified R4DO (Pick) and NMSS Events Notification via email.
The following information was provided by the DEQ via email:
"Using the manufacturer-provided information, we found that the gauge had been transferred to Illinois. The Illinois Agreement State program found that it had been sold to Mid America Dredging in Good Hope, IL. The state of Illinois is following up with their registrant and presumably will report on events. Oklahoma DEQ will assist as needed."
Notified R3DO (Lafranzo), R4DO (Pick), and NMSS Events Notification via email.
Reference Event Number 55919 for Agreement State report for Illinois.
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Pharmalogic Puerto Rico - San Juan PR
Report Date 05/19/2022 10:45:00
Event Date 05/19/2022 2:00:00
NON-AGREEMENT STATE REPORT - TECHNETIUM-99M SPILL
The following is a synopsis of information provided by the licensee via phone call:
At approximately 0200 on May 19, 2022, a spill of approximately 3 curies of Tc-99m occurred in the compounding room at the Pharmalogic Puerto Rico facility in San Juan, PR. The spill was contained to the compounding room (a restricted area). One worker received a skin contamination that did not require medical attention.
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Nuclear Fuel Services Inc. - Erwin TN
Report Date 05/19/2022 11:45:00
Event Date 05/18/2022 14:50:00
CRITICALITY ACCIDENT ALARM SYSTEM SPEAKERS DISABLED
The following information was provided by the licensee via email:
"On May 18, 2022, at approximately 1450 (EDT), an electrical switch for the Criticality Accident Alarm System (CAAS) legacy speakers was noted to be out of its normal position. A functional redundant speaker system is installed in the main processing plant and laboratory. As a consequence of the switch being out of position, in the highly unlikely event that the CAAS had actuated, the alarm would not have been annunciated in areas outside of the main processing area and laboratory where there are no redundant speakers. Compliance was restored at approximately 1500 (EDT) when the switch was placed back in its normal position. The system was subsequently tested and confirmed to be operational. The most recent audibility test of the speaker system had been performed on May 13, 2022, at approximately 1100 (EDT). The licensee notified the NRC Resident Inspector on May 18, 2022, at approximately 1625 (EDT). There were no actual nuclear safety consequences. The potential consequence was that, in the event of a nuclear criticality accident, evacuation could have been delayed for those personnel outside of the main processing area where redundant speakers have not been installed."
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North Dakota Department of Health - Drayton ND
Report Date 05/19/2022 16:13:00
Event Date 05/18/2022 0:00:00
AGREEMENT STATE REPORT - SHUTTER FAILURE
The following is a synopsis of an email received from the state of North Dakota:
On 5/18/2022, the licensee reported to the North Dakota Department of Environmental Quality an equipment failure of a nuclear device sealed source shutter manufactured by Berthold Technologies. The seal source is model SSC-100, containing 20 millicuries of Cs-137. The source holder is Berthold Technologies model LB 300 IRL Type I. The manufacturer was contacted by the licensee to come on site and evaluate the device.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The source is in a safe location and there was no exposure to personnel.
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PA Dept of Environmental Protection - Philadelphia PA
Report Date 05/20/2022 9:21:00
Event Date 05/18/2022 0:00:00
EN Revision Imported Date: 5/26/2022
EN Revision Text: AGREEMENT STATE REPORT - TARGET TISSUE MISSED
The following was received from the Pennsylvania Department of Environmental Protection (the Department) via email:
"On May 19, 2022, the licensee informed the Department of an incident involving Cobalt 60 in a Leksell (R) Gamma Knife Perfexion. It is reportable as per 10 CFR 35.3045(a)(1).
"On May 18, 2022, a patient underwent treatment of four lesions in the brain. Upon review of the treatment, the physicist noticed that all four lesions were missed by approximately 0.5 centimeters and healthy brain tissue was treated. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.
"The Department will perform a reactive inspection. More information will be provided as received."
Event Report ID No: PA220018
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 updated was received from the Department via email:
"The patient had MRIs and CT Scans. Those images were fused by the neurosurgeon and radiation oncologist. Upon completion of the treatment, they discovered that although the targets were moved with the second image fusion, the shots and contours were not. This resulted in the treatment being 0.5 cm off for all 4 targets. Prescribed dose was 20 to 21 Gy, delivered dose to target tissue was 8 to 15 Gy, maximum dose to healthy tissue is estimated to range from 21.82 to 27.09 Gy. More information is expected once the licensee completes their investigation."
Notified R1DO (Eve) and NMSS Events Notification via email.
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LaSalle - Marseilles IL
Report Date 05/20/2022 17:39:00
Event Date 05/20/2022 9:05:00
BOTH TRAINS OF CONTROL ROOM AREA FILTRATION SYSTEM AND AREA VENTILATION AIR CONDITIONING SYSTEM INOPERABLE
The following information was provided by the licensee via email:
"At 0905 CST on 05/20/2022, it was discovered both trains of Control Room Area Filtration and Area Ventilation Air Conditioning Systems were simultaneously INOPERABLE. Due to this INOPERABILITY, the system was in a condition that could have prevented the 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 has been notified."
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Louisiana Energy Services - Eunice NM
Report Date 05/22/2022 9:48:00
Event Date 05/21/2022 8:38:00
DIESEL FUEL SPILL
The following information was provided by the licensee via email:
"At 0838 [MDT] on May 21, 2022, the diesel fuel day tank level transmitter for the B Central Utility Building (CUB) Standby Diesel Generator failed low. The failed level transmitter signaled the automatic start of the fuel oil transfer pump. When the transfer pump started, it pumped off-highway diesel fuel from the 8000 gallon bulk storage tank, located on the south side of the CUB, to the 150 gallon day tank which was already at its normal operating level of 70-90 percent. Since the level instrument had failed low, the transfer pump continued to run. Level in the day tank continued to rise and diesel fuel spilled from the day tank vent, located above and to the side of the CUB roof. The transfer pump continued to run for 23 minutes until an operator shut down the pump. This stopped the release. An estimated maximum of 240 gallons of diesel fuel was spilled. Most of the diesel fuel landed on the ground outside of the CUB in an area covered by gravel. There were no injured personnel and no radiation exposure as a result of this event.
"The plant is in a safe, stable condition. The B CUB Standby Diesel Generator does not perform a safety function. The transfer pump has been placed out of service. The area is currently being cleaned of diesel fuel. This event has been entered in Urenco USA's corrective action program as EV151632.
"This event was reported to the New Mexico Environment Department at 0643 MDT on May 22, 2022 and is being reported concurrently to the NRC."
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Cooper - Brownville NE
Report Date 05/23/2022 11:23:00
Event Date 05/23/2022 4:55:00
EN Revision Imported Date: 5/24/2022
EN Revision Text: SECONDARY CONTAINMENT PRESSURE EXCEEDED TECHNICAL SPECIFICATION REQUIREMENT
The following information was provided by the licensee via email:
"On May 23, 2022, at 0455 CST, Cooper Nuclear Station experienced a spike in Secondary Containment differential pressure which exceeded the Technical Specifications Surveillance Requirements 3.6.4.1.1 limit of -0.25 inches of water gauge. Secondary Containment differential pressure restored to Technical Specification limits within two minutes and further investigation is ongoing. This unplanned Secondary Containment inoperability constitutes a condition reportable under 10CFR50.72(b)(3)(v)(C) and (D).
"The NRC Senior Resident Inspector has been informed."
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LaSalle - Marseilles IL
Report Date 05/23/2022 19:15:00
Event Date 05/23/2022 12:56:00
BOTH TRAINS OF CONTROL ROOM AREA VENTILATION AIR CONDITIONING SYSTEM INOPERABLE
The following information was provided by the licensee via fax:
"At 1256 CST on 05/23/2022, it was discovered both trains of Control Room Area Ventilation Air Conditioning Systems were simultaneously INOPERABLE. Due to this INOPERABILITY, the system was in a condition that could have prevented the 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 has been notified."
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Susquehanna - Allentown PA
Report Date 05/23/2022 21:01:00
Event Date 05/23/2022 17:16:00
AUTOMATIC REACTOR SCRAM The following information was provided by the licensee via email:
"At 1716 hours EDT on May 23, 2022, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed.
"Unit 1 reactor was being operated at approximately 100 percent [Rated Thermal Power] RTP. The Control Room received indication that both divisions of [Reactor Protection System] RPS actuated from [Reactor Pressure Vessel] RPV high pressure signals and all control rods fully inserted. The Main Turbine bypass valves opened automatically to control reactor pressure. Reactor water level lowered to -42 inches causing Level 3 and Level 2 isolations. [High Pressure Coolant Injection] HPCI [Emergency Core Cooling System] ECCS actuation occurred as designed at -38 inches and injected to the Reactor Vessel. No other ECCS system actuations occurred. [Reactor Core Isolation Cooling] RCIC automatically initiated as designed at -30 inches. The Operations crew subsequently maintained reactor water level at the normal operating band using Feedwater pumps.
"The reactor is currently stable in Mode 3. An investigation is in progress into the cause of the Automatic SCRAM.
"The NRC Senior Resident Inspector was notified. A voluntary notification to [Pennsylvania Emergency Management Agency] PEMA will be made.
"This event requires a 4 hour ENS notification in accordance with 10 CFR 50.72(b)(2)(iv)(A) & 10 CFR 50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(iv)(A)."
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Cook - Bridgman MI
Report Date 05/24/2022 6:49:00
Event Date 05/24/2022 4:14:00
EN Revision Imported Date: 5/25/2022
EN Revision Text: MANUAL REACTOR TRIP FOLLOWING MANUAL TURBINE TRIP FROM HIGH VIBRATIONS ON MAIN TURBINE
The following information was provided by the licensee via email:
"On May 24, 2022, at 0414 EDT, while rolling the Unit 1 main turbine during the Unit 1 Cycle 31 refueling outage, the Unit 1 main turbine experienced high vibrations and the main turbine was manually tripped with reactor power at 12 percent. Main turbine vibrations persisted and the reactor was manually tripped, Main Steam Stop Valves were closed, and main condenser vacuum was broken.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. The DC Cook Resident NRC Inspector has been notified.
"Unit 1 is being supplied by offsite power. All control rods fully inserted. Both Motor Driven Auxiliary Feedwater Pumps started properly. Decay heat is being removed via Steam Generator Power Operated Relief Valves. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event."
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Westinghouse Electric Company - Hopkins SC
Report Date 05/24/2022 9:02:00
Event Date 05/23/2022 9:25:00
EN Revision Imported Date: 5/25/2022
EN Revision Text: PROCEDURAL NONCOMPLIANCE WITH ADMINISTRATIVE ITEMS RELIED ON FOR SAFETY (IROFS)
The following additional information was obtained from the licensee by phone and email:
"Administrative IROFS WT-165 and WT-166 require independent operators to sample and verify the V-1170 uranium concentration is below an administrative limit prior to discharge to the V-1160 tank. These IROFS were correctly performed on May 18, 2022, for both the V-1170A and V-1170B tanks. In between the 18th and the 23rd, the warm caustic filter was water washed with the process solution sent to the V-1170 tanks.
"At 0422 EDT on May 23, 2022, the contents of V-1170A and V-1170B tanks were pumped to the T-1160B tank without the tank uranium concentration being updated following the warm caustic filter wash.
"At 0925 EDT on May 23, 2022, an evaluation into the reportability of the event was initiated when a Uranium Recovery and Recycling Services (URRS) team manager contacted Criticality Engineering to report the transfer without the test results required by procedure. After reviewing updated tank test results, performing calculations to determine risk, and discussing actions taken by the operators, IROFS WT-165 and WT-166 were considered failed and IROFS WT-171, WT-172, WT-175 and WT-176 were considered degraded.
"Per CSE-15C-S1-G3, the remaining safety margin was 1.000E-2, which was below the required 1.000E-4.
"The result is reportable per 10 CFR Part 70 Appendix A (b)(2), 'Loss or degradation of items relied on for safety that results in failure to meet the performance requirements of 10 CFR 70.61.'
"Following the event, the contents of V-1170A and T-1160B were tested and historical tank level indication data was reviewed with results well within the IROFS limits. There was no safety impact as a result of the failed IROFS."
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Illinois Emergency Mgmt. Agency - Seneca IL
Report Date 05/24/2022 13:09:00
Event Date 05/22/2022 19:00:00
EN Revision Imported Date: 6/2/2022
EN Revision Text: EXTERNAL FIRE
The following information was provided by the Illinois Emergency Management Agency (Agency) via email:
"The Agency was contacted on the morning of May 24, 2022, to advise that a fire had occurred at approximately 1900 CDT on Sunday, May 22, 2022, at a Renewable Energy Group, LLC. Renewable Energy Group, LLC (Facility) is a biodiesel refinery located in Seneca, IL.
"The fire reportedly impacted two Vega model SHLD-1 generally licensed devices containing 10 millicuries of Cs-137 each. Serial numbers are unknown at this time and the registrant has not been able to make any radiation measurements or leak tests. It is noteworthy, the sealed source device registry sheet indicates the manufacturer subjected these devices to the 'Accident Condition Fire Test' in ANSI N43.8-2008. The resultant accident condition indicates it would not lose shielding when subjected to 538 degrees Celsius (1000 degrees Fahrenheit) for five minutes. Regardless, Agency staff have been dispatched to determine the status of shielding, potential contamination and source security.
"The facility representatives have been advised to contact the manufacturer or a licensed service provider to have the gauges removed and properly packaged for service/disposal. Provided the device is not moved from its current mounting, the pipe (with the device attached) may be relocated to facilitate source security. Facility representatives advised there is no safety concern at the remaining structure. The licensee was required to report within 24 hours, but missed the reporting deadline. Updates will be provided as they become available."
IL Reference Number: IL220016
The following update was provided by the Illinois Emergency Management Agency via email:
"Details: Two Vega Americas Inc., model SHLD1 fixed gauges were confirmed to have been impacted by fire. Serial number A-T604 did not appear to have its integrity compromised. Serial number A-T509 exhibited an exposure rate of approximately 350 - 400 mR/hour near contact. Large area wipes showed no indication of contamination. An exclusion zone was established at approximately 4 feet in diameter and six feet above the damaged gauge. (The second floor was far enough as to not warrant exposure concerns). In order to prevent public exposures, it was determined the gauges should be isolated. Consistent with the sealed source device registry, both devices will remain mounted to their pipes - and the pipe/gauge assembly will be moved to a secure location. The devices were bagged to prevent the spread of any contamination that could not be detected by large area wipes. Serial number A-T509 will be inverted to direct the unshielded beam into the ground. Inspectors are overseeing the work and will verify the gauges are locked and access restricted until appropriately licensed personnel can dismount and properly package the devices for disposal.
"Safety Analysis: No evidence of removable contamination. Exposure rates were elevated, but no personnel had been exposed. Pending placement of the devices into secure storage in an orientation that will shield the source, the Agency does not anticipate any exposures in excess of regulatory limits.
"Reportability: Device A-T509 met the reportable criteria in 32 Ill. Adm. Code 340.1220(c)(4). The incident was reported to the [(NRC Headquarters Operations Officer)] HOO at 1209 CST today under event number 55912. A written report is due from Renewable Energy Group, LLC within 30 days that details suspected root cause and corrective action. The [(Nuclear Material Events Database)] NMED report will be updated and electronically transmitted to [(Idaho National Laboratory)] INL."
The following update was provided by the Illinois Emergency Management Agency via email:
"A licensed service provider was on site 5/31/22 to properly remove and package the gauge for disposal. Agency staff were on site to oversee operations. Agency staff verified leak tests on both gauges indicated no contamination, the area of the fire was able to be released for unrestricted use (relative to radioactive material) and the gauges were properly stored and secured. Both gauges were successfully locked in a 40 ft single Conex box. Max reading of 1.9 mrem/hr measured at surface of the Conex box. Survey of affected deck area (with gauges removed) verified as at background. Gauges were chained inside the Conex box and the box itself was padlocked shut . The box will be labeled with a CRAM (Caution Radioactive Material) sticker and is sitting in the back of the property. Licensee was informed of the need for proper disposal within 2 years in accordance with 32 Ill. Adm. Code 330.220(a)(6). This report will be updated with any additional information. Pending receipt of the registrant's written report, this matter is considered closed."
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Tennessee Div of Rad Health - Memphis TN
Report Date 05/24/2022 13:19:00
Event Date 05/23/2022 0:00:00
AGREEMENT STATE REPORT - SOURCE HOLDER AFFECTED BY MOLTEN METAL
The following was received from Tennessee Division of Radiological Health via email:
"On May 22, 2022 at 1048 [CDT], molten metal came into contact with the source holder. Damage occurred to the lifting ears of the gauge. The source was not affected by the event. The source and holder are locked away with other gauges with the shutter in the closed position. No elevated readings were detected after the event. NuCor Steel is going to contract with Radiometrix in Ohio to transfer the source to a new gauge. The following is the technical information on the gauge:
"Manufacturer: Berthold; Model: LB 300 MLT; Gauge SN: 45132-004-10003; Isotope: Co-60, 3.405 mCi; Source SN: 1344-08-09; Source Model: Berthold P 2608-100
"Any corrective actions will be updated with a report within 30 days."
State Event Report ID Number: TN-22-037
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Univ Of Utah (UTAT) - Salt Lake City UT
Report Date 05/24/2022 18:00:00
Event Date 05/24/2022 11:15:00
DEGRADATION TO A FUEL ELEMENT CLADDING
The following information was provided by the University Of Utah Training Reactor (UUTR) via email:
"This is a written report to NRC regarding minor damage to a fuel element identified during routine fuel inspection operations, filed per UUTR Technical Specification para 6.7.2, 'Special Reports' noting degradation in a reactor fuel element cladding. On Tuesday, May 24 2022, at 1115 [MDT], during a routine UUTR bi-annual fuel inspection, one stainless steel U-235 TRIGA fuel element removed from core position D-14, element number 4138E, was noted to have low-level surface pitting and severe discoloration at several locations along the element length. When this fuel element was moved toward the inspection apparatus, at one of the pitted locations on the surface of the fuel element, a small stream of clear bubbles began to evolve. This was captured on high resolution video; the bubbles were presumed to be fission gas. Reinspection of this same fuel element one hour later with high resolution video showed no evolution of gas bubbles, and the element remained intact. Radiation levels throughout the facility remained constant and consistent with background levels.
"Response to this Event: After initial observation of the pitting and bubble evolution, the fuel element number 4138E was placed in a fuel element storage rack; local radiation levels remained at measured background levels at all times from multiple instruments. On the facility continuous air monitor, no noted deviations from background levels were observed over the entire period of concern. Radiation readings throughout the duration of this observation remained at background levels, and no significant issues or safety concerns were noted; the reactor and facility remain secure, and fuel inspection operations will continue over the next week.
"Follow-up Actions: UUTR reactor personnel will permanently remove fuel element number 4138E from service, and continue to monitor for any instance of elevated radiation levels from the reactor pool. All levels remain stable at background levels."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The Non-Power Reactor Project Manager will be notified and the Utah State Radiation Safety Officer was notified.
The estimated time for restart is one week.
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Grand Gulf - Port Gibson MS
Report Date 05/26/2022 10:34:00
Event Date 05/26/2022 6:30:00
SPURIOUS SIREN ACTUATION
The following information was provided by the licensee via phone and email:
"On May 26, 2022, at 0753 CDT, the Grand Gulf Nuclear Station was notified of a spurious actuation of a single Alert Notification System siren in Tensas Parish, Louisiana. The actuation occurred during siren testing conducted at approximately 0630 CDT - no emergency conditions are present at Grand Gulf Nuclear Station.
"A press release from Entergy is not planned at this time.
"This condition is reportable under 10 CFR 50.72(b)(2)(xi) as a notification of an offsite government agency.
"The NRC Senior Resident Inspector has been notified."
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South Texas - Wadsworth TX
Report Date 05/27/2022 22:53:00
Event Date 05/25/2022 13:54:00
OFFSITE NOTIFICATION FOR INADVERTENT DISCHARGE OF HALON
The following information was provided by the licensee via email:
"On 5/25/2022 at 1354 [CDT], during the replacement of two detectors, a halon actuation occurred which resulted in an unintentional release of approximately 384 pounds of halon gas into an enclosed room in the Unit 1 Electrical Auxiliary Building. There was no impact to plant operations or plant personnel. The room was verified by station Safety Personnel to be safe for normal access.
"On 5/27/2022 at 2038 [CDT], Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of an event which met the requirements of "Emission Event" for the TCEQ of a halon release that exceeded the reportable quantity threshold of 100 pounds in a 24 hour period. The halon discharge was contained within the site protected area. Therefore, this event is not significant with respect to the health and safety of the public.
"The licensee has notified the NRC Resident Inspector."
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