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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
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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
EN Revision Imported Date: 6/7/2022
EN Revision Text: 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
The following was received from the Illinois Emergency Management Agency (the agency) via email:
"On 6/6/22, the licensee provided the required written report. The carrier has not provided any updates and the package is still lost. At this point, the radioactive material has decayed to less than 0.5 uCi. Pending no additional developments, this matter is considered closed."
Notified R3DO (Szwarc) and R1DO (Grieves), and NMSS Event Notifications and ILTAB 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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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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MA Radiation Control Program - Burlington MA
Report Date 05/27/2022 12:48:00
Event Date 05/27/2022 7:50:00
EN Revision Imported Date: 6/6/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST SEALED SOURCES IN TRANSIT
The following report was received via e-mail from the Massachusetts Radiation Control Program [the Agency]:
"The licensee (QSA Global, Inc., License No. 12-8361) reported at 0851 [EDT] on May 27, 2022 that it discovered on the same day (May 27, 2022) at 0750 [CDT] that a package (Yellow-III, T.I. 2.6, Type A) containing 9 sealed sources (Cs-137; 13.89 Ci total) was reported missing by the shipper. The package was shipped in a 924CO Type A with P496 lead shield pot.
"The package was shipped on April 15, 2022. The destination for the shipment is Schlumberger Technology Corp (c/o: NSSI), Houston, TX, 77087, TX License: L02991. QSA Global received email update on May 27, 2022 that the [common carrier] couldn't physically locate the package. The last known location according to the [common carrier] is their facility in Memphis, TN. Schlumberger Technology Corp confirmed that they have not received the package on May 27, 2022.
"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
The following information was provided by the Agency via email:
"The licensee reported at 1014 EDT on June 2, 2022, that the package had been found at the Houston, TX [common carrier] facility. It was delivered to its intended destination undamaged at 1500 EDT on June 2, 2022."
Notified R1DO (Jackson) and NMSS Events Notification and ILTAB via email.
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
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NJ Rad Prot And Rel Prevention Pgm - New Brunswick NJ
Report Date 05/27/2022 15:54:00
Event Date 04/01/2022 12:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following report was received via e-mail from the New Jersey Radiation Department and Release Prevention Program [the Department]:
"The Radiation Safety Officer of Rutgers University informed the Department that one H-3 (Tritium) exit sign cannot be found and is considered lost. The exit sign was last inventoried in October 2021 and was noticed to be missing in April 2022. After extensive investigation/searching, the licensee considers the sign lost. The Exit sign in question is an Isolite H-3 Exit sign, model 880-126R10BA, S/N H138883, originally containing 7.59 Ci of H-3. Rutgers will forward a written report within 30 days concerning the loss and their investigation."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Illinois Emergency Mgmt. Agency - Good Hope IL
Report Date 05/31/2022 9:55:00
Event Date 05/27/2022 0:00:00
EN Revision Imported Date: 6/2/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GAUGE LOCATED IN OKLAHOMA
The following information was provided by the Illinois Emergency Management Agency (IEMA, The Agency) via email:
"On 05/17/22, a shipment of scrap metal being hauled from Sallisaw, OK to Rogers, AR tripped a portal monitor at the receiving recycling company. It was returned to Oklahoma under DOT-SP AR-OK-22-007. The load was surveyed once returned to Oklahoma and a Thermo Measure Tech model 5201 fixed gauge containing 50 mCi of Cs-137 (s/n B4473) was identified.
"The gauge has since been isolated in a drum and secured in a shed at the Oklahoma recycling facility. Efforts to identify the owner resulted in a call from Oklahoma Department of Environmental Quality (OK DEQ) to the Illinois program on 5/27/22. IEMA staff were able to identify Mid America Dredging in Good Hope, IL as the owner. Mid America Dredging is registered with the Agency under #9223884 and last reported the gauge as present on 2/15/22.
"Agency staff requested the licensee confirm the gauge was on site and send pictures. Apparently, the `device' the registrant has been exercising control over since 2015 was the outer housing for the gauge which may have a secondary label according to the Sealed Source and Device (SSD) sheet. The licensee suspects the gauge was inadvertently disposed of or abandoned during work in Sallisaw, OK in or around 2015.
"IEMA will address noncompliance with the registrant. This device is generally licensed and registered under 32 Ill. Adm. Code 330.220(a)(4). Due to the activity involved, any loss, theft or diversion is immediately reportable under 32 Ill. Adm. Code 340.1210(a). The registrant did not report, nor was seemingly aware of the loss.
"OK DEQ notified the Headquarters Operations Officer on 5/18/22, and provided an update on 5/27/22. This NMED entry is made to document IEMA actions and track until the gauge is properly returned and/or disposed of. Updates will be provided as they become available."
Reference Event Number 55900 for the initial notification from OK DEQ to the NRC.
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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 05/31/2022 17:10:00
Event Date 03/02/2022 0:00:00
EN Revision Imported Date: 6/17/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO EMBRYO/FETUS
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"The RSO [(Radiation Safety Officer)] for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate.
"The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads)."
Illinois Item Number: IL220018
The following was received from the Illinois Emergency Management Agency (IMEA) via email:
"A reactionary inspection was performed 6/2/22. The required 15-day report was received on 6/12/22 and put forward root cause and corrective action. The cause of the event was determined to be the ineffectiveness of the pregnancy testing policy to account for very early stage (i.e., first week of gestation) pregnancies that standard pregnancy tests cannot detect. The licensee revised its pregnancy testing policy to include patient instruction to abstain from intercourse for at least ten days prior to the administration of the dose. The licensee will be cited for failing to provide timely notification and corrective action to prevent a recurrence sought in the response. Pending no further developments and resolution of appropriate enforcement action, this matter is considered closed."
Notified R3DO (Feliz-Adorno) and NMSS Events Notification E-mail Group.
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California Radiation Control Prgm - Corona CA
Report Date 05/31/2022 18:51:00
Event Date 05/31/2022 0:00:00
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following was received from the California Department of Public Health via email:
"On May 31, 2022, the RSO of Alta California Geotechnical, Inc. (Alta), contacted the Brea office of the California Department of Public Health to report a stolen moisture density gauge. The gauge was a CPN model MC-3 S/N M3811862 (10 mCi Cs-137, 50 mCi Am-241:Be). On May 27, at approximately 1700 PDT, the gauge was placed in a locked Mobile Mini (temporary storage) container in a fenced (also locked) area of the construction site in Jurupa Valley, California. The theft occurred sometime between Friday, May 27 and Tuesday, May 31. When Alta personnel arrived at the construction site at approximately 0500 PDT Tuesday morning, they discovered that the storage container lock (a hidden shank/"hockey puck" style) was drilled through and the locked transportation case containing the gauge was removed, along with other equipment. Alta personnel searched the surrounding area until approximately 0630 PDT and then contacted the Riverside County Sheriff to report the theft. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."
5010 Number: 053122
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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Quad Cities - Cordova IL
Report Date 06/01/2022 13:58:00
Event Date 06/01/2022 10:43:00
INADVERTENT SIREN ACTIVATION
The following information was provided by the licensee via email followed by phone call:
"At approximately 1043 CDT, the Quad Cities Main Control Room was notified that the Scott County Iowa warning sirens were activated in error at 1001 CDT. The sirens were not intentionally activated to notify the public of severe weather or pending emergency.
"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 Quad Cities NRC Resident has been notified."
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Mississippi Div of Rad Health - Stennis Space Center MS
Report Date 06/01/2022 17:28:00
Event Date 05/31/2022 7:00:00
EN Revision Imported Date: 6/3/2022
EN Revision Text: AGREEMENT STATE REPORT - DELIVERED SOURCE NOT SECURED
The following licensee provided information was forwarded from the Mississippi State Department of Health via email:
"A replacement Ir-192 source [(100 Ci)] was ordered from QSA Global on 3-24-22. QSA sent an `Advanced Shipping Notice' email after hours at 1800 CDT on 5-26-22. The source arrived the following day, Friday, 5-27-22. The source was delivered to the Shipping/Receiving dock (building 9145), operated by S3 [(Syncom Space Services)]. (Note: the standard practice is for the source to be delivered directly to the building where S3 licensed sources are secured.) The Receiving worker signed for the shipment at 1000 CDT on 5-27-22. The Receiving worker is not a radiation safety qualified employee. The RSO [(Radiation Safety Officer)], nor any other radiation safety qualified personnel were contacted upon delivery of source. The RSO was not at work on Friday, and unaware the source was being delivered that day. The source was in the Shipping/Receiving building (locked when personnel are not on site) until Tuesday morning, 5-31-22. Upon arrival to work at 0600 CDT Tuesday morning, the RSO read the email from QSA Global and checked the tracking information. At that time, he realized the source had been delivered. The RSO identified which Receiving worker signed for the source. Their shift starts at 0700 CDT. Upon their arrival, the RSO verified that the source was at the Shipping/Receiving building. The RSO immediately picked up the source and brought it to the secure vault. Management was then notified, and the investigation began.
The S3 Heath Physics Coordinator and RSO (with concurrence from NASA HP [(Health Physicist)]) concluded that no employee was exposed to an unallowable amount of radiation based on where the source was placed and its proximity to employees in the area. The investigation is ongoing to identify the process failures that lead to this incident. NASA has been notified and the incident has been entered into a formal tracking system."
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Florida Bureau of Radiation Control - Ft Meade FL
Report Date 06/03/2022 13:20:00
Event Date 06/03/2022 11:30:00
EN Revision Imported Date: 6/9/2022
EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGE SOURCE FOUND
The following was received from the Florida Department of Health (the department) via email:
"[The Radiation Safety Officer] from Mosaic Fertilizer called at 1130 EDT this morning to report a failed fixed density gauge on a pipeline. They reported that an employee found a [5 mCi Cs-137] sealed source on the ground, picked it up, held it in their hand for anywhere between 30 to 60 seconds before realizing what it was, then dropped it and reported it to management. The source was transported in an empty bucket and placed on a shelf in the onsite RAM [(Radioactive Material)] storage cabinet. The department's Materials Licensing was notified and will be sending out an inspector as soon as possible to conduct an immediate onsite inspection. The NRC was also notified. Source Assay Date June 2009."
The following additional information was obtained from the department in accordance with Headquarters Operations Officers Report Guidance:
Based on the information provided, the department calculated 1.42 R dose. They shared the information with the Radiation Emergency Assistance Center/Training Site (REAC/TS), which calculated 2.24 R dose, with no decay correction. It was determined that no medical attention is required.
Florida Incident Number: FL22-062
"Decay corrected calculations done by Bureau of Radiation Control, and verified by REAC/TS [Radiation Emergency Assistance Center/Training Site], for a 30 second dose to the hand was 1.42 R. (Contact dose rate constant to the hand of 770 R/min/Ci x 1 min/60 sec x 0.0037 Ci x 30 sec = 1.42 R) REAC/TS calculation = 2.24 R w/no decay correction. REAC/TS comments: there was very little to no medical concern, just observe the employee's hand. The Radiation Safety Officer [was] notified the morning of 6/8/22 of the inspectors' findings, dose calculation results and REAC/TS comments."
Notified R1DO (Greives) and NMSS Events Notification via email.
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New York State Dept. of Health - Confidential- Medical Licensee NY
Report Date 06/03/2022 17:58:00
Event Date 06/03/2022 0:00:00
AGREEMENT STATE REPORT - HDR THERAPY ADMINISTERED TO WRONG SITE
The following was received from the New York State Department of Health Bureau of Environmental Radiation Protection (the Department, BERP) via email:
"A New York State licensee informed the Department on June 3 that a patient received a HDR [(High Dose Rate)] therapy to the wrong site. The male patient was diagnosed with Basal Carcinoma of the skin on the left scalp. The patient received a total of 36 Gy over 6 weeks (6 Gy per week). Doses were delivered using a Varian Model Vari-Source XI.
"The Physician/Authorized User discovered the event and made the initial report to the Department. He indicated he misidentified the treatment site. It seems the error was discovered June 3, 2022. Treatment dates, notification of patient/family and other details regarding this event are not available to BERP yet.
"The Radiation Safety Officer is conducting an investigation. The Department will follow-up and provide an update."
New York Report ID No. NY-22-04
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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Palo Verde - Wintersburg AZ
Report Date 06/03/2022 20:32:00
Event Date 04/11/2022 20:45:00
INVALID SYSTEM ACTUATION
The following information was provided by the licensee via email:
"The following event description is based on information currently available. If, through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.
"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe invalid actuations of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 B Train Auxiliary Feedwater (AF) system and Essential Spray Pond (ESP) system that occurred while in a refueling outage.
"On April 11, 2022, at approximately 2045 Mountain Standard Time, an automatic start of the Unit 1 B Train AF and ESP systems occurred during restoration from a surveillance test. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the Engineered Safety Features Actuation Systems to simulated design basis events. The test portion was completed satisfactorily; however, during the restoration portion, the load sequencer inadvertently cycled between Mode 0 and Mode 1 three times in immediate succession.
"At the time of the system actuations, one of the actuation signals associated with this portion of the test had been reset per procedure. Another actuation signal was still in while restoration steps were ongoing, but the sequencer was not expected to cycle between Modes. The system actuations did not occur as a result of actual plant conditions or parameters and are therefore invalid.
"The Unit 1 B Train AF and ESP system actuations were complete and the systems started and functioned successfully. For the systems that did not actuate, the reasons are clearly understood as those systems were in an overridden condition due to test configuration.
"The spurious actuation was not able to be replicated and a direct cause was not identified. There were no adverse impacts to public health and safety nor to plant employees.
"The NRC Resident Inspectors have been informed."
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NJ Rad Prot And Rel Prevention Pgm - Hackensack NJ
Report Date 06/03/2022 21:06:00
Event Date 06/03/2022 0:00:00
EN Revision Imported Date: 6/8/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST COPPER-64 RADIOPHARMACEUTICAL
The following was received from the New Jersey Department of Environmental Protection (NJDEP) via email:
"The NJDEP staff was notified of the loss of a 5 mCi syringe of Cu-64 from the Hackensack University Medical Center (NJ License no. 450695).
"The licensee contacted the NJDEP hotline at approximately 1933 EDT on 6/3/2022. The NJDEP staff was contacted at 1958 EDT. The NJDEP staff contacted the licensee RSO [(Radiation Safety Officer)] at 2002 EDT and asked for an update of the situation. The licensee RSO stated that the search for the syringe was continuing and that they contacted the isotope supplier to confirm its delivery. The supplier confirmed they had delivered the dose in the early morning of 6/3/2022.
"The NJDEP staff is monitoring the situation and more details will be provided as they become available."
The following update was received from the New Jersey Department of Environmental Protection (NJDEP) via email:
"A unit dose of Cu-64 calibrated for 4.4 mCi at 1500 EDT on 6/3/2022 (current activity estimated as 0.023 mCi) was discovered missing at Hackensack University Medical Center (NJ License no. 450695). The licensee reported the missing material to NJDEP who then reported the incident to NRC Operations Center. The NJ licensee followed up with their isotope suppliers to determine what might have happened to the dose. Video surveillance footage confirmed that the dose, in its Type A package was delivered by Nuclear Diagnostic Products to the Hackensack Nuclear Medicine PETCT Department at 0500 EDT on 6/3/2022. The driver was recorded on video leaving the Nuclear Medicine Department with a security guard and one black Type A package as expected. At 1020 EDT a driver from Medical Delivery Services, employed by Sofie Pharmaceuticals, was recorded delivering 1 Type A package and then leaving at 1022 EDT with 3 Type A packages, one of which bore the Yellow II label indicating it was not 'empty'. Sofie interviewed the driver who stated that he only picked up 2 packages, counter to what the video footage portrays. The driver has been suspended while Sofie continues to attempt to locate the package."
Notified R1DO (Greives), NMSS Event Notifications and ILTAB 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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Kentucky Dept of Radiation Control - Butler KY
Report Date 06/06/2022 8:48:00
Event Date 06/01/2022 0:00:00
AGREEMENT STATE REPORT - FIXED GAUGE INADVERTENTLY DISCARDED
The following report was received from the state of Kentucky via email:
"A Berthold fixed gauging device containing 16 milli-Curies of Cs-137 was out of service and scheduled for replacement when it was inappropriately removed from a belt line by a maintenance worker and thrown in a scrap metal hopper for later recycling on May 13, 2022. The licensee conducted scheduled 6 month physical inventory on June 1, 2022 and discovered a gauge was missing from the belt line where it had been installed. Carmeuse personnel conducted a search of the premises and discovered the gauge in scrap metal hopper under additional scrap metal and approximately 10 inches of gravel. The licensee reported the material contained in the hopper is placed there using equipment (e.g. forklifts, etc.). The licensee removed the device from scrap the metal bin and conducted radiation surveys. Reported exposure rates approximately were 30 mR/hr on contact. The gauge was placed in a steel cabinet for storage with reported exposure rates of less-than 1 mR/hr on exterior. All was work performed without notification to or consultation with [Radiation Health Branch] RHB. The licensee indicated the metal cabinet is located in a warehouse on premises, but made no mention of security, access control, posting, relationship to occupied spaces, etc. The licensee reported to RHB in written response that 'device was rusted and shutter was not reliable' which was itself reportable. No mention was made of lock out/tag out, position of shutter mechanism, condition of labels, presence of posting, training of worker who performed removal work, etc. A reactive inspection planned for June 8, 2022."
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PA Bureau of Radiation Protection - Philadelphia PA
Report Date 06/07/2022 8:28:00
Event Date 06/05/2022 0:00:00
AGREEMENT STATE REPORT - SUSPICIOUS ACTIVITY RELATED TO IRRADIATOR MOVE
The following was received from the Pennsylvania Department (DEP) Bureau of Radiation Protection via email:
"On June 5, 2022, the DEP was present for the removal of an irradiator at Children's Hospital of Philadelphia, a location on University of Pennsylvania license (PA-0131). A crew member of the rigging subcontractor was seen livestreaming the operation. Campus police were immediately notified, the filming was stopped, and the crew member was removed from the site. The DEP is investigating and will update this event as soon as more information is provided."
Event Report Identification Number: PA220020
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Louisiana Energy Services - Eunice NM
Report Date 06/07/2022 21:50:00
Event Date 06/07/2022 19:00:00
EN Revision Imported Date: 6/13/2022
EN Revision Text: UF6 LEAKAGE INSIDE AUTOCLAVE
The following information was provided by the licensee via email:
"The plant is in a safe configuration. On June 3, 2022, isolated pressure fall (IPF) and isolated pressure rise (IPR) tests were completed satisfactory on manifold 1. A satisfactory Item Relied on For Safety [IROFS] surveillance was completed for manifold 1 and 1003 Autoclave was placed in service. On June 7, 2022 during the disconnect of 1003 Autoclave, an Operator noticed a white/yellowish film on the hex nut of the manifold and the upper portion of the cylinder valve. The Operator surveyed the film and found 4,000 to 6,000 dpm alpha and beta contamination. Prior to opening the door of 1003 Autoclave, the internal atmosphere was sampled for hydrogen fluoride (HF). No HF was detected by HF monitor. 1003 Autoclave has been taken out of service. Autoclave sampling manifold 1 has been isolated and IROFS 28 declared INOPERABLE."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No employee exposures occurred. The leakage was contained inside the autoclave.
The following was provided by the licensee via email:
"The IROFS28 boundary, components, associated accident sequences and manifold leak were evaluated by Urenco-USA (UUSA) engineering. The evaluation determined that the leakage from the manifold did not result in IROFS28 being inoperable. IROFS28 was determined to be operable during this event.
"Based on this reevaluation, UUSA is retracting event notification EN 55930.
"UUSA will be notifying Region II."
Notified R2DO (Miller), and NMSS (Clark), NMSS Day (Rivera-Capella), NMSS Events (email).
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Louisiana Energy Services - Eunice NM
Report Date 06/08/2022 12:03:00
Event Date 06/07/2022 1:52:00
UNEXPECTED CONTAMINATION DISCOVERED IN URANIUM AUTOCLAVE
The following information was provided by the licensee via email:
"The plant is in a safe configuration.
"On June 7, 2022, while performing a disconnect on the 3LS1 autoclave, an Operator noticed a white/yellowish film on the hex nut of the manifold and the upper portion of the cylinder valve. The Operator surveyed the film and found 4,000 to 6,000 dpm alpha and beta contamination.
"The 3LS1 autoclave was posted as a Contamination Area at 0152 MDT on June 7th. Surveys of the cylinder and manifold were 1,500 dpm alpha and 3,000 dpm beta/gamma after the disconnect. Decontamination efforts continued throughout the day. The area was still posted as a contamination area on the morning of June 8th. UUSA [Urenco, USA] is reporting this event per 10 CFR 70.50.(b)(1)(i). Decontamination efforts are continuing.
"This issue has been entered in UUSA's corrective action program as EV151830."
The licensee reported leakage inside the autoclave under EN 55930.
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WA Office of Radiation Protection - Spokane WA
Report Date 06/08/2022 15:35:00
Event Date 06/07/2022 0:00:00
EN Revision Imported Date: 6/17/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE
The following information was received from the Washington State Department of Health via email:
"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."
WA incident No.: WA-19-004
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 is a summary of information received via E-mail:
"There has been no indication of non-target embolization delivered to the patient. Crucially, no patient harm has resulted from this medical event. The patient has been contacted and notified by the Authorized User as to the reduced dosage administration during the procedure and is doing well with no indication of post procedure complications.
"The conclusion that was arrived at, after the span of this investigation, is that a definitive root cause cannot be drawn as to why this event occurred. Given all of the information that has been gathered, the source of this medical event can be attributed to microspheres settling out and/or clogging in the delivery system. Whether this can be attributed to the technique used by the performing physician or an equipment failure I cannot definitively say. What is known is over 70 percent of the activity remained in the delivery system and more specifically the tubing. Had the activity that remained in the delivery system been delivered to the patient, there would not have been a medical event occurrence. The known documented and published cases of the microspheres settling out and/or clogging in the delivery system are attributed more commonly to equipment failure as opposed to administration techniques. Given this data it is reasonable to conclude that equipment failure is the most likely cause of this medical event.
"What is also know through the investigation, is that all proper procedures were followed throughout the entire duration of this procedure. Because of that, there are no corrective actions that can be identified to prevent recurrence. This concludes the investigation."
Notified the R4DO (Azua) and the NMSS Events Notification E-mail group.
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SC Dept of Health & Env Control - Fort Mill SC
Report Date 06/09/2022 16:18:00
Event Date 03/23/2022 0:00:00
EN Revision Imported Date: 7/12/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS
The following information was provided by the South Carolina Department of Health and Environmental Control via email:
"On June 8, 2022 inspectors [names redacted] went to Domtar Paper Company, LLC (SCRAM License Number 438) to perform a periodic re-inspection. During their inspection, they were presented with a copy of the inventory and their shutter check information. While reviewing the information, the inspectors saw that there were items on the checklist dated March 23, 2022, and March 30, 2022 that denoted the failed functionality of some of their gauge shutters. After discussion with radiation safety officer (RSO), it was determined that the shutters did, in fact, fail to operate as designed. There were other instances that were similar that the licensee stated that they will pull together and evaluate. At this time, the only information given by the licensee is the information below. The inspectors went to each of the source housings during the inspection and all shutters were all operational.
"The sources and housings are the following: Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007C Activity: 5 Curies
"Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007F Activity: 5 Curies"
The following information was provided by the licensee via email:
"The licensee submitted a report on June 24, 2022. The Radiation Safety Officer, submitted an update to the report that was submitted on July 9, 2022. Upon further review, it was found that the gauges were stuck or inoperable on several other occasions. Gauge 27007C was listed as stuck on April 8, 2021, September 2, 2020, October 31, 2019, and April 16, 2019. Since the completion of the inspection, the licensee stated that they now understand the reporting requirements. Additionally, the licensee has a better understanding of what needs to be done in the event that the gauge is first reported as stuck."
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Colorado Dept of Health - Commerce City CO
Report Date 06/11/2022 19:44:00
Event Date 06/11/2022 6:47:00
EN Revision Imported Date: 6/14/2022
EN Revision Text: AGREEMENT STATE REPORT - ARMED BREAK-IN AT LICENSED FACILITY
The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail:
"Two armed individuals broke into the Colorado location for Acuren Inspection, Inc. The licensee described this event as part of a chain of local break-ins. The individuals were able to access the vault which contained the radiography cameras but were unsuccessful in accessing the radiography cameras stored within a secure container in the vault. It appears that no radioactive materials were accessed or removed in any way from the licensee's storage area. LLEA (Denver Police) was dispatched and responded to the facility. According to the [National Source Tracking System] (NSTS), as of June 11 the licensee is currently in possession of six Ir-192 sources, ranging from 98 curies to 24 curies."
CO Event Report ID No.: CO220016
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Texas Dept of State Health Services - Point Comfort TX
Report Date 06/11/2022 23:33:00
Event Date 06/11/2022 11:20:00
AGREEMENT STATE REPORT - MISSING FIXED LEVEL DENSITY GAUGE
The following was received from the Texas Department of State Health Services via email:
"On June 11, 2022, the licensee's Radiation Safety Officer (RSO) reported that at approximately 1120 CDT the technicians performing routine (6 month) surveys discovered that a Ronan GS400 (SN: 7192CO) level/density gauge, containing 100 millicuries of cesium-137, that had been mounted on the side of a vessel was not there and neither was its mounting bracket. Some demolition work had been performed on areas of the unit but there was no work being done on that particular vessel. Repeated searches were conducted at the facility. The licensee has been contacting supervisors and employees but has had some difficulty since it is the weekend. The search and interviews of employees and the demolition contractor's employees will continue. The gauge was mounted on the first (lower) level and there is another mounted higher on the vessel. Therefore, the fact it had been removed had not been identified by operations prior to the physical survey. Further information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: I- 9933
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 - Round Rock TX
Report Date 06/13/2022 17:48:00
Event Date 06/13/2022 0:00:00
EN Revision Imported Date: 6/14/2022
EN Revision Text: AGREEMENT STATE REPRT - STOLEN TRUCK CONTAINING A MOISTURE DENSITY GAUGE
The following was reported by the Texas Department of State Health Services (the Agency) via email:
"On June 13, 2022, the licensee notified the Agency that on Friday, June 10, 2022, a truck containing a Insto Tek 3500 moisture density gauge was stolen. The gauge contained a 44 millicurie americium-241 source, and an 11 millicurie cesium-137 source. The licensee reported that the technician had stopped at a convenience store to buy some items and when they came back out the truck was missing. The licensee stated the gauge was locked in the back of the truck but was unsure if the keys to the locks were also taken. The licensee stated the gauge has an old [Global Positioning System] (GPS) tracking device that was inactive. The licensee stated they had contacted the GPS service company to see if the tracking device was still active and the gauge tracked that way. The licensee stated it would take up to 24 hours to determine if the tracking device could be used. The licensee stated the local police was notified of the theft. The individual who contacted the Agency stated they had not interviewed the technician about the event so some of the information requested by the Agency was unknown. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9934
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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Columbia Generating Station - Richland WA
Report Date 06/13/2022 18:21:00
Event Date 06/13/2022 9:23:00
EN Revision Imported Date: 6/17/2022
EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE
The following information was provided by the licensee via email:
"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.
"Emergency assessment capability was restored at 1008 PDT upon system restoration."
The NRC resident was notified by the licensee.
The following information was received via email:
"This event is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) only for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.
"The containment isolation was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered an invalid actuation.
"Updated ENS Text: "During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing Incore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.
"This is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.
"Emergency assessment capability was restored at 1008 PDT upon system restoration.
"The plant is stable, and all effected systems have been restored.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC resident has been notified."
Notified R4DO (Azua).
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Kansas Dept of Health & Environment - Lenexa KS
Report Date 06/14/2022 11:29:00
Event Date 06/13/2022 14:15:00
AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY GUIDE TUBE
The following information was provided by the Kansas Department of Health and Environment via email:
"On June 13, 2022, at approximately 1415 CDT the licensee experienced an incident with the 9 Ci Ir-192 source in their 880 Delta radiography camera at their Lenexa, Kansas office location. They reported that during routine maintenance, the source became restricted in the source tube while cranking the source back into the shielded position. When the source was being retracted back into the camera, the cart on which it was sitting shifted. This put the guide tube into a bind which restricted the source from easily being returned into the camera. The Radiation Safety Officer (RSO) was immediately notified and arrived shortly thereafter to evaluate the situation. The licensee reported that once they realized it was just the position of the source tube putting the source in a bind, they were able to move the cart back to the position that then allowed them to retract the source back into the shielded position of the camera. The licensee reports that the source was exposed for no more than three minutes.
"The Kansas Radiation Control Program is currently performing a reactive inspection on June 14, 2022, and additional information will be provided at a later date."
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Iowa Department of Public Health - IA
Report Date 06/14/2022 1:09:00
Event Date 06/14/2022 2:29:00
AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE INTO RADIOGRAPHY EXPOSURE DEVICE
The following information was received by the Iowa Department of Public Health via e-mail:
"At 0229 CDT on 06-14-22, the Assistant RSO (ARSO) received a phone call from one of the radiographers involved stating that he was working at a temporary jobsite and was unable to fully expose the source into the guide tube/collimator (Device Model: QSA 880D, Source Model: QSA A424-9, Source Activity: 80.8 Ci). Upon noticing the resistance, the radiographer extended his Restricted Area boundaries, notified the on-site personnel to maintain clearance of the area and proceeded to contact the ARSO.
"During the phone conversation, the ARSO was able to guide the radiographer through disassembly of the crank body to the point that he could manually pull the drive cable and retract the source into a fully shielded position within the exposure device. Once the source was successfully locked into the exposure device and the appropriate surveys were completed, the ARSO instructed the radiographer to perform an inspection of the drive cables and guide tube to look for the presence of any bends, kinks or dents that could have contributed to the binding of the drive cable. It was at this point that the radiographer noted an area on the drive cable sheathing that appeared to be melted on the `retract' side of the drive cable assembly.
"At this point (approximately 0254 CDT), The ARSO contacted the PROtect, LLC RSO and informed him of the details of the incident. A follow-up Corrective Action Report and additional detail regarding the cause of the event will be submitted to the State of Iowa within 30 days.
"Reporting requirements: 30.50(b)(2)(ii) - The 24 hour report of an event where required equipment is disabled or fails to function as designed when the equipment is required to be available and operable when it is disabled or fails to function. IAC 40.96(2)'c'(2)."
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OR Dept of Health Rad Protection - Portland OR
Report Date 06/14/2022 2:39:00
Event Date 06/07/2022 0:00:00
EN Revision Imported Date: 6/17/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - DOSE TO SKIN OTHER THAN WRITTEN DIRECTIVE TREATMENT SITE
The following information was received from the Oregon Health Authority via e-mail:
"The following is a report of a medical event corresponding to Subpart M, 35.3045(a)(1)(iii) for a high dose rate afterloader (HDR) dose to the skin other than the treatment site that exceeds 50 rem and 50% of expected dose to the location.
"Description of event: A patient was scheduled for two HDR (Varian GammaMed Plus iX) treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total; 17 fractions @ 300 cGy ea) was performed in February without incident. The first fraction of 500 cGy for the second lesion was performed on June 7th. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's treatment on June 7th were compared to the February treatment and found to be the same location as the first lesion. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was 'well tolerated' by the patient and 'the additional one HDR fraction of 500 cGy is likely of benefit to the patient.' The patient's written directive was updated to reflect an additional fraction to be given to the second lesion.
"Cause and corrective actions: The licensee is still gathering information but from the preliminary data received, verification of the treatment site was not performed for the June 7th fraction and former treatment plan location was used. No corrective actions have been submitted at this time.
"Concerns: Verification of treatment site may not be robust enough in separating separate treatment sites that are close together. Only through patient notification was this event identified. Awaiting further information/explanation from licensee."
Oregon Report Identification Number: 22-0028
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 / revised information was received via E-mail:
"Description of event: The patient was scheduled for two treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total dose; 17 fractions @ 300 cGy ea) using beam therapy (SBRT) was performed in February without incident. The second lesion was not present during this treatment but appeared shortly after. On June 7th, the first fraction of 500 cGy (4000 cGy total dose; 8 fractions at 500 cGy ea) was performed. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's HDR fractionated dose on June 7th were compared to the February external beam treatment and found to be the same location. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was "well tolerated" by the patient and "the additional one HDR fraction of 500 cGy is likely of benefit to the patient". The patient's written directive was updated to reflect an additional fraction to be given to the second lesion.
"Cause and corrective actions:
"Facts to note: - The second lesion was not present during the February external beam treatment.
- The written directive for the HDR treatment plan for the second lesion stated it was "lateral" than the "more medial" first lesion. Both were within approximately 1.5 inches of each other. - The patient positioning for external beam was supine and for the HDR, prone.
"This event occurred due to human error. The licensee failed to note the change in patient positioning from supine to prone while using photos of the treatment area resulting in `visual flip' of image nor confirm treatment site from the written directive. A contributing factor is the proximity of the two lesions and another is that the second lesion was not present during the February external beam treatment.
"Stated corrections are to add a pretreatment step for multiple lesions close to each other that include: - Asking the patient to point to the site to be treated. - Verification by including more images of the body (hand or foot) along with the lesions to better identify the site and orient treatment personnel.
"Source: Irridium-192
Activity: Approximately 4.8 Ci Model: Gammamed 232 Serial number: 24-01-0285-001-020422-15242-99 Leak test date: March 17, 2022."
Notified R4DO (Azua) and the NMSS Events Notification E-mail group.
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Prairie Island - Welch MN
Report Date 06/14/2022 15:57:00
Event Date 06/14/2022 8:47:00
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"A licensed operator supervisor had a confirmed positive for alcohol during a random 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 NRC Senior Resident Inspector has been notified."
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Beaver Valley - Shippingport PA
Report Date 06/15/2022 9:47:00
Event Date 06/15/2022 7:24:00
MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION
The following information was provided by the licensee via email:
"At 0724 EDT on 6/15/2022, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering Steam Generator levels due to a secondary plant perturbation in the Heater Drain System. All control rods fully inserted into the core and the Auxiliary Feedwater System automatically started as designed in response to the full power reactor trip. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves. Unit 2 is not affected and remains at 100 percent power and stable.
"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). Additionally, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 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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WA Office of Radiation Protection - Seattle WA
Report Date 06/15/2022 15:17:00
Event Date 06/14/2022 0:00:00
AGREEMENT STATE REPORT - LOST THEN FOUND I-125 SEED
The following information was received via E-mail:
"On 6/14/22, one Theragenics, I-125 brachytherapy seed (0.501 mCi) from the inventory was discovered missing. It was one of 10 spare seeds used for a patient prostate implant should they be needed. The inventory of concern was that required for a patient who was implanted with 88 seeds using 16 needles as planned. He did not need any of the spare seeds for his implant.
"In accord with our standard procedure, five of the 10 spare seeds were prepared in spare needles by one of our radiation oncology dosimetrists, one seed per needle, on Monday, 06/13/22. All prepared needles and loose seeds remained in the hot lab (SP 22244) until the patient's surgery. This means that five loose I-125 seeds should have remained in their transport vial in the hot lab (SP 2244) adjacent to the surgery room (SP 2245). However, when preparing to return the five spare needle prepared seeds to the transport vial, post patient implant, it was evident that there were only four rather than the expected five loose seeds in the vial. I surveyed the hot lab (SP 2244) but could not locate the missing seed in the hot lab or its surrounding area. The five spare needle prepared seeds were returned to the transport vial for a total of nine seeds rather than the inventory of 10. This vial was taken to the radiation oncology hot lab safe. Several surveys were performed of the Surgery Pavilion area (SP 2244) but the seed was not found.
"On 6/15/2022, the missing I-125 seed (0.501 mCi) was found and returned with the other loose seeds to the 'Medak' vial now located in the radiation oncology hot lab. On an inspired guess, the dosimetrist returned to the SP 2244 hot lab in the prostate pavilion and in a high cupboard searched a steel container used for sterilizing all 10 loose seeds before creating the five spare needles. This is where the missing seed was found.
"As corrective actions, the unused seeds will be visually counted and the checklist updated to include this process."
Washington Incident Number: WA-22-015
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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NV Div of Rad Health - Las Vegas NV
Report Date 06/15/2022 18:04:00
Event Date 06/15/2022 13:50:00
AGREEMENT STATE REPORT - STOLEN PORTABLE NUCLEAR GAUGE
The following information was received from the State of Nevada via email:
"At approximately 1350 PDT, the RSO/CEO for IQC Southwest LLC, 00-11-0745-01 notified the Nevada Radiation Control Program (NRCP) that a Portable Nuclear Gauge (PNG) had been stolen from a work site located near the intersection of Sierra Vista and Paradise Road working off of Paradise Road in Las Vegas, Nevada. In addition, Las Vegas Metro Police Department was on scene and taking a report during the Radiation Safety Officers (RSO) notification call to the NRCP.
"The RSO stated that they had video of the theft as it occurred. An unknown (possibly transient) individual walked through the work site, picked up the gauge and walked off, appearing to hide the gauge with his body while the Authorized User (AU) was getting material from his vehicle. The source rod was not locked when the gauge was taken.
"The gauge was a Troxler model 4640-B with a 9 mCi Cs-137 source.
"An incident inspection will be performed June 16, 2022 by the NRCP."
Nevada Item Number: NV220006
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 - Seattle WA
Report Date 06/15/2022 20:01:00
Event Date 06/14/2022 0:00:00
AGREEMENT STATE REPORT - HDR AFTERLOADER MOTOR FAILURE RESULTS IN ABORTED TREATMENT
The following information was received via E-mail:
"The following is preliminary information, and will be updated as the State of Washington learns more about this event:
"A mechanical incident occurred with the HDR (high dose rate) afterloader unit, and a treatment had to be aborted. It appears that a motor in the afterloader failed. The manufacturer's representative removed the active and dummy wires and is in the process of making the necessary repairs. There does not appear to be any radioactive material contamination in the system. No staff or patients received any excess dose. Plans are to exchange the source and complete all of the needed QA checks so that patient treatments may resume.
"The equipment involved was a Varian HDR remote afterloader, Model VariSource iX, Serial Number 600501, containing less than 11 curies of Iridium-192."
Washington Incident Number: WA-22-016
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Minnesota Department of Health - Minneapolis MN
Report Date 06/16/2022 10:19:00
Event Date 06/14/2022 0:00:00
EN Revision Imported Date: 7/7/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the Minnesota Department of Health (MDH) via email:
"We (MDH) received an initial report on 6/15/22 at 1515 CDT of a reportable medical event. The event occurred at the University of Minnesota, license number 1049, in Minneapolis on 6/14/22. The event involved a treatment with Y-90 SirSpheres where 2.2 GBq was ordered but a 5.1 GBq unit dose was delivered and administered. The licensee is working through dose calculations. No additional details are available at this time. Follow up information will be sent when it becomes available."
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 normal procedure for this therapy is to order a dose from the manufacturer a couple of weeks prior to the treatment so the radiopharmacy has the material on hand. The dosage ordered from the manufacturer is limited to few vial activities (want to make sure there will be enough for the therapy), and the actual dose to administer to the patient is drawn up by the pharmacy the day of the procedure. The pharmacy delivers the patient dose to the nuclear medicine department. Nuclear Medicine will check the activity compared to the shipping paper to make sure it is within range. They will also do the pre-measurements for determining the residual after the treatment. They will write the activity on the top of the Nalgene jar and bring it to interventional radiology. Interventional radiology will verify the dose on the lid and perform the administration. The residual is determined from the waste in the Nalgene jar per the standard microsphere procedure. The written directive is signed by the authorized user once the residual and actual dose given is determined.
"In the case on June 14, 2022, there was a communication error between the radiopharmacy (Jubilant) and the person ordering the dose. The pharmacy verified and the person who ordered the dose confirmed the dose was 5.6 GBq (the entire vial amount from the manufacturer). After drawing the dose, the activity in the vial the pharmacy sent was 5.1 GBq (they are not able to draw 100% of the material). Once received in nuclear medicine, the nuclear medicine technologist did their process, including comparing the dose in the vial with the shipping papers from the pharmacy (not the dose prescribed). The dose was brought to interventional radiology for the administration. The interventional radiologist did not see the activity on the Nalgene jar and was unaware that the activity was on the label. Without verifying the activity the interventional radiologist administered the dose. After the procedure the residual was calculated and it was determined that 5.1 GBq was administered (139 mCi prescribed and 137 mCi administered). The Authorized User signed the written directive after the procedure with the 139 mCi prescribed and 137 mCi administered activity. The prescribing physician (interventional radiologist) realized the error the next day when reading the post report.
"The State performed an on-site investigation and is pursuing enforcement actions. The event is still open. Minnesota will continue to keep NRC informed of the status of the investigation."
Notified R3DO (Lafranzo) and NMSS (Rivera-Cappella)
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NE Div of Radioactive Materials - Imperial NE
Report Date 06/16/2022 15:24:00
Event Date 06/16/2022 0:00:00
AGREEMENT STATE REPORT - LOSS OF TWO TRITIUM EXIT SIGNS
The following is a synopsis of information received via E-mail:
Upon inventory inspection, Frenchman Valley discovered that two tritium exit signs that had been in their possession had been replaced. The property was then thoroughly searched twice and the signs were not located. The whereabouts of the signs are unknown and no replacement records were found.
The signs were manufactured by Isolite. Both signs were model SLX60. The serial numbers were 12-01067 and 12-01068 with each sign containing 8 Curies of tritium.
Nebraska Item Number: NE220002
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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Colorado Dept of Health - Fort Collins CO
Report Date 06/16/2022 15:23:00
Event Date 06/16/2022 0:00:00
AGREEMENT STATE REPORT - SOURCE DETACHED FROM PORTABLE GAUGE
The following information was received via E-mail:
"During the morning of 6/16/22, a portable gauge user noticed that the tub and the radioactive source were detached from the gauge cable and stuck approximately 5 ft. underground when the user was trying to retrieve the tub and the source back to the gauge. The portable gauge is a CPN model 503, serial number 50543, containing 50 mCi of americium-241:beryllium. The sealed source is not compromised.
"This event occurred in Kersey, Colorado."
Colorado Event Report ID No.: CO220017
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Nutherm International, Inc - Mount Vernon IL
Report Date 06/17/2022 12:39:00
Event Date 06/16/2022 0:00:00
PART 21 REPORT - FAILURE OF AN ARNOLD MAGNETICS POWER SUPPLY
The following is a synopsis of information received via facsimile:
On June 16, 2022, vendor Nutherm International, Inc. was informed that a defect caused the failure of Arnold Magnetics power supply PBM-24-106. The unit had been supplied by Nutherm to a nuclear power plant. The unit failed on or before March 15, 2022 during a 24-hour burn in period and was returned to Nutherm which did an inspection and analysis. Nutherm then returned the unit to Arnold Magnetics, the manufacturer, which completed further analysis. The manufacturer determined the unit failed due to the EMI filter assembly not functioning as designed as a result of the manufacturer's assembler not installing no-mex paper and thus not in accordance with manufacturer's procedure. Both the manufacturer and Nutherm have initiated corrective actions to prevent recurrence.
One facility is listed as being affected: TVA - Browns Ferry. Nutherm notified the affected facility on June 17, 2022.
If you have any questions or wish to discuss this matter or this report, please contact: Adrienne Smith at adrienne.smith@nutherm.com or at (618) 244-6000 x3034.
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Illinois Emergency Mgmt. Agency - Carol Stream IL
Report Date 06/17/2022 13:18:00
Event Date 06/16/2022 16:00:00
AGREEMENT STATE REPORT - SHIPMENT LOST THEN FOUND
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"Representatives for Bard Brachytherapy contacted IEMA at close of business on 6/16/22 to report a shipment of I-125 brachytherapy seeds in route from their Carol Stream, IL facility to Tortola in the British Virgin Islands could not be accounted for after a flight change in Miami, FL. The shipment consisted of two overpacks: One containing five boxes with 350 seeds and a cumulative activity of 241 mCi, and one containing four boxes with 385 seeds and a cumulative activity of 265 mCi. The licensee shipped the packages on 6/7/2022 to O'Hare airport where they were received [and] placed on a commercial flight to Miami. After arrival at Miami, the packages missed two different flights scheduled for Tortola. After an inquiry by the licensee, the carrier reported the package could not be immediately accounted for.
"The incident was reported to IEMA shortly before 1600 CDT and then notification was received at 1627 CDT that the packages were located. This matter is considered closed.
"There were no breaches to packages reported and no resulting public exposures. The packages remained incident to transportation and secure.
"Due to the activity involved (A > 1000x the value in Appendix C to 10 CFR Part 20), the loss is immediately reportable under 32 Ill. Adm. Code 340.1210 and 10 CFR 20.2201(a)(1)(i). Unlike missing shipments of lesser activity, a review of SA-300, Appendix A reporting requirements doesn't give the same caveat that the package must still be missing at the time of reporting."
Illinois # IL220020
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 - Princeton NJ
Report Date 06/20/2022 14:40:00
Event Date 05/27/2022 0:00:00
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following was received from the state of New Jersey, Radioactive Materials Program via email:
"The Radiation Safety Officer [RSO] of Bristol Myers Squibb notified the NJ Department of Environmental Protection that two H-3 exits signs were unable to be located and cannot be found. The RSO believes that the signs were improperly disposed of during facility renovations as demolition waste. The licensee conducted an in-depth exit sign inventory but was unable to locate the two exit signs.
"Loss of material was confirmed on 5/27/2022."
Equipment: H-3 exit sign, SRBT model BR-20-BK, serial numbers C083389 and C083421, 21.6 Ci per exit sign.
State Event Report ID Number: NJ-22-New
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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Beaver Valley - Shippingport PA
Report Date 06/21/2022 16:52:00
Event Date 06/21/2022 15:47:00
OFFSITE AGENCY NOTIFICATION DUE TO CHEMICAL LEAK
The following information was provided by the licensee via fax or email:
"At 1547 EDT on June 21, 2022, it was determined that Beaver Valley Power Station Unit No. 1 experienced a reportable chemical leak. Approximately 261 gallons of a Sodium Hypochlorite/Sodium Bromine mixture reached the ground and approximately 130.5 gallons (of the 261 gallons) progressed to the Ohio River (via storm drain). The source of the leakage has been isolated and absorbent material has been placed to contain the leakage. Following confirmation of this leakage, notifications were made to the following offsite agencies starting at 1615 EDT:
"National Response Center (Incident Report # 1339391) "Pennsylvania Department Of Environmental Protection "Beaver County Emergency Management
"This condition is being reported as a four-hour, non-emergency notification per 10CFR50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 06/21/2022 17:00:00
Event Date 06/21/2022 0:00:00
EN Revision Imported Date: 6/23/2022
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF X-RAY FLUORESCENCE ANALYZER
The following was received from the Illinois Emergency Management Agency via email:
"Agency efforts to annually verify the inventory of registrant's generally licensed devices resulted in a declaration of loss by a registrant, Universal Scrap Metals, 9223657. Specifically, a Niton LLC, x-ray fluorescence analyzer (model XLp-818 PQ, serial number 9690), containing 30.0 mCi of Am-241 could not be located. The device was one of five, and the other four have been verified. On May 31, 2022 the registrant indicated they could not locate the device, but wanted to check several other departments before declaring it lost.
"The amount of americium present, although not representing a significant public safety concern, requires immediate reporting to the US NRC. The registrant failed to notify the Agency of disposal, transfer or loss. This matter will be [tracked until corrective action is provided.]"
Illinois Item Number: IL220021
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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McGuire - Cornelius NC
Report Date 06/22/2022 2:26:00
Event Date 06/21/2022 22:40:00
EN Revision Imported Date: 6/22/2022
EN Revision Text: CONTROL ROOM VENTILATION AND CONTROL AREA CHILLED WATER SYSTEM INOPERABLE
The following information was provided by the licensee via email:
"At 2240 on 06/21/2022, it was discovered that both required trains of Control Room Ventilation and Control Area Chilled Water System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(v)(d).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The 'B' train was restored at 2315.
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Louisiana Energy Services - Eunice NM
Report Date 06/22/2022 8:12:00
Event Date 06/21/2022 9:00:00
LOSS OF AN ITEM RELIED ON FOR SAFETY
The following information was provided by the licensee via email:
"The plant is in a safe condition.
"On June 21, 2022, while performing a routine management observation, an employee noticed that only a single individual was performing the administrative actions required to implement both [items relied on for safety] IROFS 50b and IROFS 50c. These IROFS are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Since only one individual was performing the administrative action, the independence of the IROFS was not being maintained and the performance requirement of 10 CFR 70.61 was not being met. At the time of the event, there were not any heavy vehicles that threatened damage to equipment.
"[Urenco USA] (UUSA) is reporting this event per 10 CFR 70. Appendix A(b)(2).
"All work that requires utilizing person(s) to control the proximity of vehicles to equipment that could release UF6 has been stopped. This issue has been entered in UUSA's corrective action program as EV 152996."
The licensee will notify the NRC Regional inspector.
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Kentucky Dept of Radiation Control - Lexington KY
Report Date 06/23/2022 14:55:00
Event Date 06/23/2022 0:00:00
AGREEMENT STATE REPORT - CONTAMINATION OF THE HOT LAB
The following was received from the state of Kentucky, Radiation Health Branch via email:
"Kentucky [Radiation Health Branch] RHB was notified on 6/23/222 by a representative from University Of Kentucky Medical Broadscope, of a contamination event. Early in the afternoon of 6/22/2022 while preparing the assay, a 150 mCi liquid I-131 NaI dose, the vial cracked (the vial head and septum separated from the main body while the [Certified Nuclear Medical Technician] CNMT was attempting to remove excess packing material with forceps) and there was a subsequent spill and contamination event of the Nuclear Medicine hot lab. The area was controlled immediately, additional contamination controls put in place and cleanup efforts initiated.
"No significant personal (skin) contamination occurred.
"Preliminary assessment on 6/22 did not indicate gross iodine uptake in any affected staff.
"24-Hour thyroid bioassay results were negative for detected iodine uptake in the thyroid for staff present during the spill, but will be repeated at 48h.
"Decontamination efforts are ongoing."
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Curtiss Wright Flow Control Co. - Middleburg Heights OH
Report Date 06/24/2022 13:33:00
Event Date 04/24/2022 0:00:00
EN Revision Imported Date: 6/27/2022
EN Revision Text: PART 21 REPORT - POTENTIAL DEFECT IN QUICK DISCONNECT CONNECTOR CABLE ASSEMBLIES
The following is a synopsis of information received via facsimile:
On April 24, 2022, a potential defect was discovered in a configuration of the 1 « inch Quick Disconnect Connector (P/N: 913602-111) cable assemblies supplied to Duke [(McGuire Nuclear Station)] under procurement document 30129014. During post installation testing by Duke, it was found that one of the cable wires was shorted to ground. This damage could cause the cable assembly to not perform its intended safety function. Upon further investigation, Duke found 9 other cable assemblies to have similar damage. Duke returned the identified cable assemblies to Curtiss Wright who is investigating the issue. Although some testing and verification activities have been completed, additional testing and research is necessary and in progress. The current testing and research is projected to take 30 days and a follow-up letter with results and status will be provided by July 24, 2022.
Currently, McGuire Nuclear Station is the only affected facility.
For additional information, please contact Jim Tumlinson, Director of Operations (256-425-8037), Christopher Covan, Quality Assurance Manager (256-624-7301), or Tim Franchuk of Quality (513-201-2176).
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Perry - Perry OH
Report Date 06/24/2022 16:28:00
Event Date 06/24/2022 12:57:00
EN Revision Imported Date: 6/27/2022
EN Revision Text: LOW PRESSURE CORE SPRAY INOPERABLE
The following information was provided by the licensee via telephone:
"At 1257 EDT on June 24, 2022, it was discovered the Low Pressure Core Spray System (LPCS) was inoperable. At Perry, the Low Pressure Core Spray System is considered a single train system in Modes 1, 2, and 3; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Inoperability of the Low Pressure Core Spray system was caused by a loss of power to the LPCS Minimum Flow Valve during surveillance activities.
"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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Waterford - Killona LA
Report Date 06/25/2022 0:44:00
Event Date 06/24/2022 20:12:00
EN Revision Imported Date: 6/27/2022
EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO MAIN STEAM ISOLATION VALVE CLOSURE
The following information was provided by the licensee via email:
"At 2012 CDT, Waterford 3 Steam Electric Station, Unit 3 was operating at 100 percent power when an automatic reactor trip occurred due to Main Steam Isolation Valve MS-124B going closed unexpectedly. Subsequently, both main feedwater isolation valves shut. Emergency Feedwater (EFW) was automatically actuated. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip. The unit is currently stable in Mode 3. All control rods fully inserted as expected and all other plant equipment functioned as expected. This was an uncomplicated trip.
"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system.
"The NRC Resident Inspector has been notified."
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Fermi - Newport MI
Report Date 06/25/2022 1:00:00
Event Date 06/24/2022 23:38:00
AUTOMATIC REACTOR SCRAM DUE TO MAIN TURBINE TRIP
The following information was provided by the licensee via email:
"At 2338 EDT, on June 24, 2022, with the unit in Mode 1 at 100 percent power, the reactor automatically scrammed due to an RPS actuation following a Main Turbine Trip. The cause of the turbine trip is not known at this time. The scram was not complex, with systems responding normally post-scram.
"Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at the normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred with no surveillances or activities in progress. Investigation into the cause of the Turbine Trip is in progress.
"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). The low reactor water level caused an isolation of Primary Containment (Groups 4/13/15) as expected. The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."
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Columbia Generating Station - Richland WA
Report Date 06/28/2022 18:03:00
Event Date 06/28/2022 11:16:00
FITNESS FOR DUTY REPORT
A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access has been terminated.
The NRC Resident Inspector has been notified.
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