Event Notification Report for December 01, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/30/2022 - 12/01/2022

EVENT NUMBERS
56237 56238 56239 56247
Agreement State
Event Number: 56237
Rep Org: Texas Dept of State Health Services
Licensee: CHI ST LUKES HEALTH BAYLOR
Region: 4
City: Houston   State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 11/23/2022
Notification Time: 11:30 [ET]
Event Date: 11/21/2022
Event Time: 00:00 [CST]
Last Update Date: 11/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 SIR-SPHERES

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

"On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing."

Texas Incident Number: 9965

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.


Agreement State
Event Number: 56238
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Siemens Industry Inc.
Region: 1
City:   State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Joesph Power
HQ OPS Officer: Kerby Scales
Notification Date: 11/23/2022
Notification Time: 14:46 [ET]
Event Date: 10/20/2022
Event Time: 00:00 [EST]
Last Update Date: 11/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - CONTAMINATED WASTE STORAGE ROOM

The following was received from the state of New Jersey via email:

"Siemens has operated a take-back program for smoke detectors containing radiation sources since the 1990s. Most smoke detectors contained Am-241, but Ra-226 sources were also handled. This program has been discontinued and the licensee is now undergoing decommissioning. On October 20, 2022, as part of the license termination process, a consulting Health Physicist was contracted to perform characterization surveys of a waste storage room on site. The storage room was the only room where licensed materials were handled. Here, the licensee would disassemble smoke detectors for ultimate disposal via a licensed radioactive waste broker. The results of the survey indicated that fixed alpha contamination existed across the entire floor surface and on the walls in smaller concentrations. The highest reading observed on the floor was 4,387 cpm [counts per minute]. This equated to 13,282 dpm [disintegrations per minute]/100 centimeters squared with the health physicist's survey instrument. This was the first indication that contamination existed within this facility. This was an unplanned contamination event and possibly involved a quantity of material greater than five times the lowest annual limit on intake specified in Appendix B of 20.1001-20.2401 of 10 CFR Part 20, for Am-241.

"Licensee corrective actions: No more smoke detectors are being received by the licensee, so no changes to procedures will occur. Current decontamination work is underway by a licensed radiation contractor. The facility will need to be decontaminated to acceptable levels meeting New Jersey's 15 mrem/year release criteria.

"On November 17, 2022, the state performed independent surveys of the room to confirm areas of contamination. The presence of fixed contamination was confirmed and removable contamination was also discovered. The state instructed the licensee to cordon off contaminated areas to prevent entry of personnel. The state will also perform confirmatory surveys after decontamination work is completed."


Agreement State
Event Number: 56239
Rep Org: California Radiation Control Prgm
Licensee: Arrow Infrastructure Solutions Inc.
Region: 4
City: Mojave   State: CA
County:
License #: 3412-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ian Howard
Notification Date: 11/24/2022
Notification Time: 15:38 [ET]
Event Date: 11/23/2022
Event Time: 20:34 [PST]
Last Update Date: 11/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST THEN RECOVERED MOISTURE DENSITY GAUGE

The following information was provided by the California Department of Public Health - Radiation Health Branch (RHB) via email:

"On Wednesday night, November 24, 2022, Arrow Infrastructure Solutions Inc. [doing business as] dba Arrow Engineering [Radiation Safety Officer] RSO [redacted] reported to [California Office of Emergency Services] Cal OES the loss or possible theft of a CPN moisture density gauge, MC-1DR-P (MD70803845) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), Cal OES Control :22-6906. The loss or possible theft was noticed by the authorized user [AU] at a gas station in Mojave, CA as the user was returning from a jobsite. The AU noticed the truck tailgate down and the CPN gauge missing as they were leaving the gas station after a restroom break, the gauge possibly fell out of the truck on Highway 58 in between Tehachapi and Mojave. The AU retraced their route on the Highway but had not located the gauge so far, they will search again on 11/24/22 during the daylight. The licensee will gather additional information for the follow up investigation and provide additional information to the department as it becomes available.

"UPDATE: The FBI notified RHB Management that the gauge had been found by a member of the public and turned into the Kern County Law Enforcement Agency. The RSO was notified and provided with contact information so the gauge could be retrieved. The RSO was instructed to do a wipe/leak test, get it analyzed quickly, and secure the gauge in storage until a negative result was returned. If a leak is detected, they will coordinate with a service company for repair or disposal. RHB Brea staff will continue with the investigation."

California 5010 Number: 112322


Part 21
Event Number: 56247
Rep Org: Curtiss-Wright Nuclear Division
Licensee: QualTech NP, Curtiss-Wright Nuclear Division
Region: 3
City: Cincinnati   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: QualTech NP
HQ OPS Officer: Howie Crouch
Notification Date: 11/30/2022
Notification Time: 13:53 [ET]
Event Date: 11/22/2022
Event Time: 00:00 [EST]
Last Update Date: 11/30/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Peterson, Hironori (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 REPORT - INTERIM REPORT FOR EATON TRM5 TIMING RELAYS

The following is a summary of information provided by the Curtiss-Wright Nuclear Division via email:

QualTech NP discovered the presence of a programmable logic device (a flash-based CMOS (complementary metal-oxide-semiconductor) microcontroller) in the timing relays that was not previously identified for this family of relays. The only affected facility is Perry Nuclear Plant. This could potentially lead to unevaluated electromagnetic interference or radiofrequency interference issues when installed in the plant.

For questions concerning this potential 10 CFR 21 issue, please contact:
Tim Franchuk
Quality Assurance Director
QualTech NP, Curtiss-Wright Nuclear Division
(513) 528-7900, ext. 176