Event Notification Report for July 25, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/22/2022 - 07/25/2022

Agreement State
Event Number: 55995
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: GE Healthcare
Region: 3
City: Arlington Heights   State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Brian P. Smith
Notification Date: 07/15/2022
Notification Time: 15:21 [ET]
Event Date: 07/13/2022
Event Time: 20:22 [CDT]
Last Update Date: 07/15/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Bickett, Brice (R1DO)
Event Text
AGREEMENT STATE REPORT - LOST SOURCES

The following report was received by the Illinois Emergency Management Agency [the Agency] via email:

"The Agency was contacted 7/15/22 by GE Healthcare (RML, IL-01109-01) to advise that a radiopharmaceutical package containing two vials of Iodine-123 had not arrived at an Atlanta, Georgia radiopharmacy as scheduled. The package contained two vials of Iodine-123, each with an activity of 32 millicuries at the time of shipment (shipment date 7/13/22). The last confirmed scan was 7/13/22 at 2022 [EDT] at the Atlanta Airport. The package now contains approximately 3.3 millicuries. The licensee is in continuous communication with the carrier, who is still actively searching for the package. This matter has a 30-day reporting requirement to the USNRC and was phoned into the NRC HOO. There is no indication of intentional theft or diversion and the contents would not be useful for illicit intent. Updates will be provided as they become available."

Illinois Event Number IL220024

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


Agreement State
Event Number: 55998
Rep Org: PA Bureau of Radiation Protection
Licensee: Johnson and Johnson Consumer Inc.
Region: 1
City: Lititz   State: PA
County:
License #: PA-G0230
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Bill Gott
Notification Date: 07/18/2022
Notification Time: 06:58 [ET]
Event Date: 07/15/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST SOURCE

The following information was provided by the Pennsylvania Bureau of Radiation Protection via email:

"On July 15, 2022, the licensee discovered a lost Americium-241 source. The 100 millicurie source is in a FILTEC model FT-50 gauge (Serial Number 116888). During an inventory for its license renewal, the licensee discovered the device missing from its location in storage and has been unable to locate the device. The licensee has notified its facilities and engineering departments, plans on contacting the manufacturer on July 18th to see if the gauge was returned, and is actively searching for the source. The DEP [Department of Environmental Protection] was in contact with the licensee over the weekend for information and will update this event as soon as more information is provided."

Pennsylvania event number: PA220023


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


Agreement State
Event Number: 56000
Rep Org: Florida Bureau of Radiation Control
Licensee: KSM Engineering & Testing, Inc
Region: 1
City: Sebastian   State: FL
County:
License #: 3686-1
Agreement: Y
Docket:
NRC Notified By: Mark Seidensticker
HQ OPS Officer: Donald Norwood
Notification Date: 07/18/2022
Notification Time: 11:22 [ET]
Event Date: 07/18/2022
Event Time: 09:23 [EDT]
Last Update Date: 07/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOSS OF CONTROL OF MOISTURE DENSITY GAUGE

The following is a synopsis of information received via email:

"The Florida Bureau of Radiation Control (BRC) received a call at 1030 EDT this morning from the licensee reporting a Loss of Control regarding a soil moisture density gauge at a jobsite in Rockledge, FL. The gauge was reported to be on the back of a pickup truck, out of its case, and unsecured. The driver drove off this morning, the gauge fell out and a City of Rockledge Public Works worker found the gauge. The worker knew what it was, retrieved it and contacted the company on the decal on the gauge. A technician from KSM is enroute with a radiation detector to investigate the incident and take readings of the gauge. The licensee technician got to the site and checked over the gauge and confirmed that the source was secure. The technician then started to transport the gauge to Atlantic Supply in Orlando for verification. Pictures showed only minor scratches and no obvious substantial damage to the gauge."

The moisture density gauge was a CPN/Instrotek model MC-1 Elite, s/n 30630, containing 10 mCi of Cs-137 and 44 mCi of Am-241/Be.

Florida Incident Number: FL22-081

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


Agreement State
Event Number: 56001
Rep Org: Texas Dept of State Health Services
Licensee: Houston Methodist Hospital
Region: 4
City: Houston   State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Ernest West
Notification Date: 07/18/2022
Notification Time: 15:07 [ET]
Event Date: 07/18/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNABLE TO LOCATE LICENSED MATERIAL

The following information was provided by the licensee via email:

"On July 18, 2022, the licensee notified [the Texas Department of State Health Services] (the Agency) that it had discovered that a Jubilant Draximage generator [containing Strontium-82 and Strontium-85] that was sent for disposal from its facility on May 11, 2022, had not arrived at the disposal facility in Utah. Current activity today is 8.68 millicuries of Sr-82 and 12.52 millicuries of Sr-85.

"The licensee contacted the common carrier who reported that they did not have the package logged as hazardous material on its records, and that on May 17, 2022, the package was delayed at its facility in North Salt Lake, Utah, and its records are showing it is still there.

"The common carrier has opened, and escalated, a case. The licensee has confirmed with the disposal company that it has not received the generator. The licensee stated the package was properly packaged and labeled and the declaration for shipping hazardous goods was used and the airbill was marked as hazardous goods. The licensee will continue to work with the common carrier to locate the generator. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9941


* * * UPDATE ON 07/18/2022 AT 1824 EDT FROM KAREN BLANCHARD TO ERNEST WEST * * *


The correct current activity of Sr-82 is 1.2 millicuries vice the previously reported amount of 8.68 millicuries.

Notified R4DO (Gaddy) and NMSS (Sun).


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


Agreement State
Event Number: 56002
Rep Org: Kentucky Dept of Radiation Control
Licensee: American Engineers, Inc.
Region: 1
City: Bowling Green   State: KY
County:
License #: 201-386-51
Agreement: Y
Docket:
NRC Notified By: AJ Bhattacharyya
HQ OPS Officer: Donald Norwood
Notification Date: 07/18/2022
Notification Time: 14:51 [ET]
Event Date: 07/15/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was received via E-mail:

"Kentucky Radiation Health Branch (KYRHB) was notified on 7/15/2022 by the Radiation Safety Officer (RSO) from American Engineers, Inc. that a Troxler 3430 portable Moisture Density gauge (Serial Number 20217; Cs-137: 9 mCi; Am-241/Be: 44 mCi) was severely damaged after it fell off the licensee's truck while leaving a worksite. The gauge was unsecured in an open bed and the tailgate left open, resulting in the gauge falling from the truck to the asphalt and being subsequently run over by a semi-trailer truck. The licensee proceeded to pick up all the debris including the source rod and bottom plate and secured it in the bed of the truck and placed a 55-gallon steel drum over the debris and extended a 15-foot caution zone around the truck, until the Fire Department arrived to scan the area for contamination. No outside contamination was detected on the road and readings were the same as background. The KYRHB inspector arrived about 1630 CDT and conducted independent scans and contamination swipes, and no leakage of either source was detected. The shielding around the Cs-137 source remained intact and readings were as expected from the shielded Cs-137 source. The gauge Tungsten shielding block was placed at the exposed source rod end and taped in place to further reduce possible exposure. The Am-241/Be source remained attached to the bottom housing and scans showed the readings to be nominal, and no removable contamination was detected. The debris was transferred to a plastic bucket and secured in the 55-gallon steel drum and transported to the licensee's facility in Glasgow, KY, and was stored in a room with appropriate signage isolated from the gauge storage area. Readings were checked outside the room to ensure that outside exposure rates were at a minimum. A reactive inspection of the licensee is planned at a future date as a follow-up.

"Reporting Criteria required by 10 CFR 30.50(b)(4)."

Kentucky Event Report ID No.: 220003


Agreement State
Event Number: 56003
Rep Org: Texas Dept of State Health Services
Licensee: Biomerics FMI
Region: 4
City: Athens   State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 07/18/2022
Notification Time: 18:46 [ET]
Event Date: 05/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/19/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Event Text
EN Revision Imported Date: 7/20/2022

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF TWO STATIC ELIMINATORS

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On July 18, 2022, the Agency received a report of two generally licensed devices that were lost. The two devices are NRD P-2042-1000 Staticmaster devices containing 5 mCi of Polonium-210 each. The notification to the Agency was a written letter from the licensee and the Agency was unable to reach the responsible person for these devices who is reportedly sick. Additional information will be provided when it is obtained per SA-300."

Texas Incident Number: I-9942

* * * UPDATE FROM RANDALL REDD TO DONALD NORWOOD AT 1654 EDT ON 7/19/2022 * * *

The following information was received via E-mail:

On July 18, 2022, the Agency received a notification of two generally licensed devices that were lost. The two devices are NRD P-2042-1000 Staticmaster devices containing 5 mCi of polonium-210 each. The notificaiton by general licensee was received as a written letter and the Agency was unable to reach the responsible person for these devices who is reportedly sick.

The Agency was able to obtain additional information today, July 19, 2022. One source was lost around October of 2021. The other was lost in May 2021. Both sources were believed to be lost in different buildings on the same site. The licensee has searched for the sources and will continue to do so. They will also contact former employees and request their assistance. Further information will be provided to NMED per SA-300.

Notified R4DO (Gaddy) and via E-mail ILTAB and the NMSS Events Notification E-mail group.

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


Agreement State
Event Number: 56004
Rep Org: Maryland Dept of the Environment
Licensee: BOTA Consulting Engineering, Inc.
Region: 1
City: Lanham   State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Atnatiwos Meshesha
HQ OPS Officer: Ernest West
Notification Date: 07/18/2022
Notification Time: 20:41 [ET]
Event Date: 07/11/2022
Event Time: 11:30 [EDT]
Last Update Date: 07/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DAMAGED DENSITY/MOISTURE GAUGE

The following information was provided by the licensee via email:

"On 7/11/2022, at about 1215 EDT, the Maryland Department of the Environment / Radiological Health Program (MDE/RHP) was contacted via telephone by the Field Services Supervisor and Laboratory Manager of BOTA Consulting Engineering, Inc. stating that a Troxler density gauge was over-run and damaged by a dump truck at the project jobsite. The MDE/RHP inspectors spoke to the RSO [Radiation Safety Officer] and Lab Manager and responded the same day to the accident site located near Laurel, Maryland.

"On the day of the accident, the project contractor was working excavation, pipes installation, backfilling and compaction works. Approximately at about 1130 EDT, after compaction jobs were completed, the gauge technician was preparing to take in-place density testing on the material. The technician placed the gauge on the side of the road near to the trench and went down to the ditch for setup. A dump truck working at the excavation area drove over the gauge by the front left side rubber tire. The source rod of the gauge was in its safe (parking) position and the top cover of the gauge was damaged. The Troxler gauge is a Model 3430, with device serial number 32015 which contains a Cesium-137 sealed source with estimated nominal activity of 8 millicuries, and Am-241/Be with estimated nominal activity of 40 millicuries.

"The gauge was later locked and put into a transportation case and taken to BOTA Consulting Engineering, Inc. office located in Lanham, Maryland. Results of the leak test conducted on 7/13/2022 shows no leakage. The case has been reported to the Nuclear Material Events Database (NMED) on 7/12/2022.

"MDE/RHP will finalize a reactive investigation."


Power Reactor
Event Number: 56013
Facility: Wolf Creek
Region: 4     State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Michael Payne
HQ OPS Officer: Donald Norwood
Notification Date: 07/23/2022
Notification Time: 02:52 [ET]
Event Date: 07/22/2022
Event Time: 19:49 [CDT]
Last Update Date: 07/23/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Gaddy, Vincent (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 46 Power Operation 47 Power Operation
Event Text
EN Revision Imported Date: 7/25/2022

EN Revision Text: AUXILIARY FEEDWATER ACTUATION SIGNAL RECEIVED DUE TO HUMAN PERFORMANCE ERROR

The following information was provided by the licensee via email:

"At 1949 CDT, while operating in Mode 1 at 46 percent power, an Auxiliary Feedwater actuation signal resulted from a human performance error while performing SYS AE-121 to place a second main feedwater pump in service. All systems responded correctly and were restored to standby condition. The Unit remained in Mode 1, at 47 percent power following the actuation. 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.

"The Senior NRC Resident Inspector has been informed."