Event Desc|En No|Site Name|Licensee Name|Region No|City Name|State Cd|County Name|License No|Agreement State Ind|Docket No|Unit Ind1|Unit Ind2|Unit Ind3|Reactor Type|Nrc Notified By|Ops Officer|Notification Dt|Notification Time|Event Dt|Event Time|Time Zone|Last Updated Dt|Emergency Class|Cfr Cd1|Cfr Descr1|Cfr Cd2|Cfr Descr2|Cfr Cd3|Cfr Descr3|Cfr Cd4|Cfr Descr4|Staff Name1|Org Abbrev1|Staff Name2|Org Abbrev2|Staff Name3|Org Abbrev3|Staff Name4|Org Abbrev4|Staff Name5|Org Abbrev5|Staff Name6|Org Abbrev6|Staff Name7|Org Abbrev7|Staff Name8|Org Abbrev8|Staff Name9|Org Abbrev9|Staff Name10|Org Abbrev10|Scram Code 1|RX CRIT 1|Initial PWR 1|Initial RX Mode1|Current PWR 1|Current RX Mode 1|Scram Code 2|RX CRIT 2|Initial PWR 2|Initial RX Mode 2|Current PWR 2|Current RX Mode 2|Scram Code 3|RX CRIT 3|Initial PWR 3|Initial RX Mode 3|Current PWR 3|Current RX Mode 3|Event Text|
Power Reactor|55235|Diablo Canyon|Pacific Gas & Electric Co.|4|Avila Beach|CA|San Luis Obispo||Y|05000275|1|2||[1] W-4-LP,[2] W-4-LP|Don Townsend|Thomas Kendzia|05/05/2021|13:22:00|05/04/2021|21:39:00|PDT|4/5/2022 5:08:00 PM|Non Emergency|26.719|Fitness For Duty|||||||DEESE, RICK|R4|FFD GROUP, |EMAIL|||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation| |N|0||0||EN Revision Imported Date: 4/15/2022
EN Revision Text: FITNESS FOR DUTY REPORT A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. * * * UPDATE ON 4/5/22 AT 1651 (EDT) FROM D.TOWNSEND TO T. HERRITY * * * The initial event notification should have characterized the test type as a follow-up fitness-for-duty test, rather than a random test. R4DO (Dixon) and FFD Group via email. |
Fuel Cycle Facility|55770|Louisiana Energy Services|Louisiana Energy Services, Llc|2|Eunice|NM|Lea|SNM-2010|Y|70-3103|||| |Barry Love|Kerby Scales|03/07/2022|13:44:00|03/07/2022|10:45:00|MST|4/25/2022 12:33:00 PM|Non Emergency|PART 70 APP A (a)(4)|All Safety Items Unavailable|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Miller, Mark|R2DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/26/2022
EN Revision Text: ITEM RELIED ON FOR SAFETY (IROFS) INOPERABLE The following information was provided by the licensee via email: "The plant is in a safe configuration. Three construction vehicles, a front end loader, road grader and roller, were allowed within the Controlled Access Area [CAA] boundary without IROFS50b and IROFS50c being declared Operable. "The Administrative Control IROFS require physical barriers to be placed around the building of concern. Barriers had been placed but the IROFS had not been declared Operable by a Shift Manager. "The construction vehicles were removed from the CAA and UUSA [Urenco USA] is conservatively reporting this event as a 1-hour Report. This event has been entered in UUSA's corrective action program as EV 149740 and a causal investigation will be performed." The licensee will notify NRC Region 2. * * * RETRACTION ON 04/25/2022 AT 1206 EDT FROM BARRY LOVE TO OSSY FONT * * * The following retraction was received from Urenco USA (UUSA) via telephone and email: "The accident sequence was originally evaluated for UUSA being in a construction phase and the applicable IROFS were applied based on these construction conditions. The accident scenario has been re-evaluated based on probabilities with current site conditions and assessed that the initiating events would be `highly unlikely' or less than 1E-06 per year, and therefore `not credible.' IROFS50b/c would not be required to meet the performance criteria of 10 CFR 70.61 for the construction vehicles on this project. "Based on the reassessment of the accident scenarios, UUSA is retracting event notification EN 55770. "UUSA will be notifying Region 2. "EN 55802 is not being retracted." Notified R2DO (Miller) and NMSS Events Notification via email. |
Power Reactor|55785|Turkey Point|Florida Power And Light|2|Miami|FL|Dade||Y||4|||[3] W-3-LP,[4] W-3-LP|James Jackson|Lloyd Desotell|03/12/2022|6:56:00|03/12/2022|0:50:00|EST|4/26/2022 2:46:00 PM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||Miller, Mark|R2DO|||||||||||||||||||N|N|0|Hot Standby|0|Hot Shutdown| |N|0||0|| |N|0||0||EN Revision Imported Date: 4/27/2022
EN Revision Text: MAIN STEAM ISOLATION VALVE FAILED TO SHUT The following information was provided by the licensee via email: "At 0050 EST on 3/12/22, while shutting down for entry into a scheduled refueling outage, the station discovered that a single Main Steam Isolation Valve (4A MSIV) did not fully close on demand. All other equipment operated as expected. "This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v). "The NRC Resident Inspector has been notified." * * * RETRACTION ON 04/26/22 AT 1422 EDT FROM DAVID STOIA TO BRIAN PARKS * * * The following information was provided by the licensee via email: "On 3/12/2022 at 0656 EDT Turkey Point Unit 4 notified the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) that a single Main Steam Isolation Valve (MSIV) did not fully close when manually demanded from the control room during shutdown of Unit 4 for a refueling outage. Following disassembly and inspection of the MSIV, Florida Power & Light Engineering identified the cause of the deficiency and determined that the valve would have fully seated under its design accident conditions. "This notification is a retraction of EN# 55785. The NRC Resident Inspector has been notified of this retraction." Notified R2DO (Miller). |
Non-Agreement State|55797|Agilent Technologies|Agilent Technologies|1|Wilmington|DE||07-28762-01|N||||||David Bennett|Thomas Kendzia|03/22/2022|12:33:00|02/22/2022|10:00:00|EST|4/21/2022 12:47:00 PM|Non Emergency|20.2201(a)(1)(ii)|Lost/Stolen LNM>10x|||||||Jackson, Don|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|Elizabeth Ullrich|R1|ILTAB, |EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/22/2022
EN Revision Text: LOST SOURCE The following information was provided by the licensee via phone and email: "Agilent Technologies manufacturers ECDs [Electron Capture Detectors], containing 15 millicuries each, of Ni-63 for use in Gas Chromatographs (for generation of ionized atmospheres for chemical analysis). We have a number of ECDs in use at our facility as addressed below for customer support and R&D. We are required by our license to perform wipe (swipe) tests every six months. The ECD in question was last wiped in August. We were in the process of performing our most recent wipe test last month (February) when we discovered the ECD and its host GC were no longer in the lab they were being used in. [Source was determined to be missing on February 22, 2022 at 1000 EDT when it could not be found for the scheduled swipe test.] We discovered quickly that the individual chemist with ownership of the ECD retired in November of 2021 [last date the device was accounted for]. Investigations to date have not been successful in recovering the ECD. Information pertinent to the incident to follow. I will also be submitting a letter to the appropriate address in one month if we are still unable to recover the ECD." "ECD Model # G2397A ECD Serial Number # U25487 Activity: 15 millicurie Ni-63 Facility security: Access to building is limited to those issued electronic badges. Labs are further secured by electronic access only to necessary personnel. [Therefore the source is not suspected to have been stolen.]" * * * UPDATE ON 4/21/2022 AT 1244 EDT FROM DAVID BENNETT TO BETHANY CECERE * * * The following information was provided by the licensee via phone: The source is still lost. The licensee is submitting a written report to Region 1. Notified R1DO (Dentel), ILTAB, and NMSS Events Notification by email. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
Agreement State|55803|SC Dept of Health & Env Control|International Paper-Georgetown Mill|1|Georgetown|SC| |060|Y||||||Andrew M. Roxburgh|Mike Stafford|03/28/2022|4:45:00|03/27/2022|14:00:00|EDT|3/28/2022 4:50:00 AM|Non Emergency| |Agreement State|||||||Jackson, Don|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGE TO GAUGE FROM FIRE The following event was received from the South Carolina Department of Health [the Department] via email: "On 3/27/2022, the Department was notified by the licensee's [radiation safety officer] RSO that one of its fixed gauges was damaged during a fire at the plant. The fixed gauge is a TN Technologies Model 5206 containing 200 mCi of Cs-137. The licensee took radiation readings around the gauge and has contacted System Services. Systems Services is arriving on the evening of 3/27/22 to service the gauge. The licensee's radiation readings were 3 mR/hr on the surface of the bottom of the gauge, 250 mR/hr on the top of the gauge. The licensee also took a radiation reading on the walkway three feet above the gauge and the reading was 0.3 mR/hr. The licensee also took a reading at the bottom of the ladder, and it was 0.1 mR/hr. The licensee has barricaded roped off areas on the walkway and at the bottom of the ladder. The gauge is located approximately 12 feet off the floor and is not readily accessible by employees."|
Agreement State|55805|NJ Dept of Environmental Protection|Merck (Schering)|1|Rahway|NJ| |456557|Y||||||Sarah Sanderlin|Kerby Scales|03/28/2022|15:25:00|03/28/2022|0:00:00|EDT|3/28/2022 3:52:00 PM|Non Emergency| |Agreement State|||||||Werkheiser, Dave|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST MASS SPEC-GAS CHROMATOGRAPH The following information was received from the state of New Jersey Bureau of Environmental Radiation (the Bureau), Radioactive Materials Program (RMP) via email: "On 3/28/2022 RMP staff was notified via [Radiation Safety Officer] RSO that a mass spec-gas chromatograph with a 15 mCi Ni-63 source (S/N U11650) was sold from their Rahway site without the source being removed. On 10/18/2021, the unit was moved to a surplus warehouse in Kenilworth, NJ. At the time it arrived at the warehouse, the radiation safety label was removed. On 12/30/2021, the unit was sold by the contract service. The RSO will update the Bureau throughout their investigation to find the root cause." 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|55806|New York State Dept. of Health|Northwell Health Imaging|1|Lake Success|NY| |5255|Y||||||Daniel Samson|Howie Crouch|03/29/2022|9:34:00|03/17/2022|0:00:00|EDT|4/21/2022 1:28:00 PM|Non Emergency| |Agreement State|||||||Werkheiser, Dave|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|CNSC (Canada), -|Email|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/22/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 and CO-57 SOURCES The following information was received from the state of New York (NYSDOH) via fax: "Four transmission/reference/calibration sources were shipped out in two separate shipments via [a common carrier] to Eckert & Ziegler on 3/17/2022 under two-day shipping and have been listed as 'delayed' since 3/18/2022. Upon contacting [the common carrier], an incident (No. C-61803614) was opened to attempt to locate the sources as [the common carrier] was unable to locate the two shipments. The licensee formally reported the sources as missing to NYSDOH on 3/28/2022. "The Gd-153 source, (1.27 mCi as of 3/17/22), is deemed a reportable quantity under 20.2201 (a)(1)(ii), as greater than 10 times the Appendix C to Part 20 value (10 microCi), but less than 1000 times. The three other sources (Cobalt-57) fall below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201. "The licensee is continuing to contact [the common carrier] regarding these sources and keeping NYSDOH updated on the status. NYS is consistently monitoring this situation under Incident No. 1389: Device Manufacturer: Eckart & Zeigler Device Model: TBD Device S/N: S5-864 Source Manufacturer: Eckart & Zeigler Source Model: TBD Source S/N: S5-864 Isotope: Gd-153 Activity: 1.27 millicuries on 3/17/2022 (10 mCi assayed on 4/1/2020) * * * UPDATE ON 04/21/22 AT 1216 EDT FROM DANIEL SAMSON TO TOM HERRITY * * * The following information was received from the state of New York (NYSDOH) via fax: "Updated Event description: "The previously reported Gd-153 source (1.27 mCi on 3/17/22) was recovered on Friday, April 1, 2022. The Gd-153 source was successfully delivered to the intended recipient (Eckert & Ziegler) without any signs of tampering, opening, or modification. All sources in question were accounted for by the NY state medical licensee and Eckert & Ziegler. This event is attributed to a logistical error in transporting these packages by the common courier. "As previously reported, the Gd-153 source was deemed a reportable quantity under 20.2201(a)(1)(ii) (1.27 mCi as of 3/17/22), as greater than 10 times the Appendix C to Part 20 Value, but less than 1000 times (10 micro-Ci). The 3 other sources (Cobalt-57) fell below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201. All other Cobalt-57 sources were also recovered without any signs of tampering, opening, or modification, and were all accounted for by the NY state medical licensee and Eckert & Ziegler on 4/1/2022. "NYS opened Incident No.1389 to track this event. As of today, Incident No.1389 has been closed. Device Manufacturer: Eckert & Ziegler Device Model: HEGL-0133 Device S/N: S5-864 Source Manufacturer: Eckert & Ziegler Source Model: HEGL-0133 Source S/N: S5-864 Isotope: Gd-153 Activity: 1.27 milliCuries on 3/17/2022 (10 mCi assayed on 4/1/2020)" Event Report ID No.: Update to NYDOH - 22-02 Notified R1DO (Dentel), NMSS Events Notification, ILTAB, CNSC (Canada) 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|
Part 21|55807|Engine Systems, Inc.|Engine Systems, Inc.|2|Rocky Mount|NC| | |Y||||||Dan Roberts|Karen Cotton-Gross|03/29/2022|16:38:00|01/27/2022|0:00:00|EDT|3/29/2022 5:33:00 PM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||Miller, Mark|R2DO|Part 21/50.55 Reactors, -|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - ELECTRO-MOTIVE DIESEL (EMD) CYLINDER HEAD WITH FIREFACE THICKNESS BELOW SPECIFICATION The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax: ESI reported that a fatigue crack was discovered in the fireface of an EMD cylinder head, P/N 40121485, D/C 18K, installed on an emergency diesel generator set. The crack initiated on the coolant side and propagated through the fireface wall of the combustion side resulting in a water leak. Fatigue failure was likely caused by a reduced fireface thickness which reduced overall rigidity of the fireface, allowing increased deformation and ultimately failure due to high tensile stress at the blend between the fireface and valve seat. A reduced fireface thickness could result in a through wall crack that would introduce jacket water into the combustion chamber. Over time if the crack propagated or went undetected engine damage may occur. Ultimately, a crack in the fireface could lead to a failure of the diesel engine which would prevent the emergency diesel generator set from performing during a safety-event. This Part 21 applies to the Cylinder heads from D/C 18K, supplied within some power pack assemblies at Watts Bar Nuclear Power Plant. Corrective Actions: ESI recommends an ultrasonic thickness inspection on the fireface to confirm thickness is within specified range to plants with these power pack assemblies. ESI has also revised its dedication package to increase the number of ultrasonic thickness inspection points. An additional enhancement is the inclusion of an inspection map for guidance and clarity of the locations to be measured. The revision was implemented on March 15, 2022. Technical questions concerning this notification can be directed to Dan Roberts, Quality Manager and John Kriesel, Engineering Manager at (252) 977-2720. |
Agreement State|55809|Iowa Department of Public Health|Equistar Chemicals, LP|3|Clinton|IA| |0101123FG|Y||||||Derek Elling|Lloyd Desotell|03/30/2022|15:22:00|03/29/2022|0:00:00|CDT|4/27/2022 4:57:00 PM|Non Emergency| |Agreement State|||||||Kozak, Laura|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/28/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER The following information was obtained from the state of Iowa via e-mail: "When conducting routine shutter checks on an Ohmart/Vega SHLG-2 fixed gauge, the operator was not able to extend the plunger to move the source into a shielded position (use of hands and basic tools). The device is in a facility that is restricted access and unmanned due to chemical production. Unless manually operated for shutter checks or vessel maintenance, the standard position of this device is open. No increase of radiation levels compared to standard operating conditions. Radiation Safety Officer (RSO) has contacted Vega for corrective action guidance and direct support. Initial guidance is the application of a coil lubricant and rotating the handle. Any action above this will be performed by a Vega service technician. The Licensee has a scheduled shutdown of the production line next week when they will schedule the Vega tech for support." "Source/Radioactive Material: SEALED SOURCE GAUGE Manufacturer: OHMART CORP. Model Number: A-2102 IAEA Category: 3 Serial Number: 9849CN Radionuclide: Cs-137 Activity: 4 Ci (148 GBq) Iowa Event Number: IA220002" * * * UPDATE ON 04/27/2022 AT 1331 EDT FROM STUART JORDAN TO BRIAN PARKS * * * The following information was received from the state of Iowa via email: "Update to Iowa Event No. IA220002 involving a stuck fixed nuclear gauge shutter operating on a low pressure separator on top of a vessel within the low-density production unit. On March 30, 2022, the RSO, under the direction of the manufacturer, removed a small amount of debris, applied Kroil lubricant to the shutter plunger, and was able to successfully close the Vega SHLG-2 gauge shutter. After an additional application of the Kroil lubricant, the gauge shutter operation was back to normal without resistance and no additional actions were necessary. The manufacturer instructed the RSO to apply the Kroil lubricant annually as a preventative measure which the licensee is planning on doing and there are no generic concerns. The 30-day written report was provided to the Iowa Department of Public Health (IDPH) on April 26, 2022. There was no exposure to any individuals to radiation from this event and IDPH considers this to be closed." Notified R3DO (Ziolkowski)|
Agreement State|55810|SC Dept of Health & Env Control|DAK Americas LLC |1|Gaston|SC| |189|Y||||||Leland R. Cave|Lloyd Desotell|03/30/2022|15:24:00|03/29/2022|0:00:00|EDT|3/30/2022 4:51:00 PM|Non Emergency| |Agreement State|||||||Werkheiser, Dave|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER The following is a summary of information provided by the South Carolina Department of Health and Environmental Control (the Department) via email and phone: On 3/4/2022, the Department was notified by the licensee's Radiation Safety Officer that while an engineer was attempting to retract the source from a fixed gauge, the gauge became locked with the source in an unshielded position. The source was subsequently retracted to a shielded position. The source is a 70 milliCi Cs-137 source (serial number 6280CO) contained in a VEGA SHLM-CR-2 housing. The manufacturer is expected to come to the plant on March 31, 2022 to evaluate the gauge and make any necessary repairs. No overexposures occurred as a result of this event. |
Agreement State|55811|OK Deq Rad Management|Goodyear Tire and Rubber Co.|4| |OK| |GLD0013|Y||||||Kevin Sampon|Brian Lin|03/31/2022|11:17:00|03/01/2022|0:00:00|CDT|3/31/2022 11:25:00 AM|Non Emergency| |Agreement State|||||||Deese, Rick|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC METER The following information was received from the State of Oklahoma via email: "Goodyear Tire and Rubber Co. has reported the loss of a 3M Model 703 Static Meter (S/N 411617). This device was possessed under Oklahoma GLD [generally licensed device] registration GLD0013. It was manufactured in 1977 and initially contained 250 mCi of tritium, which would have decayed to approximately 20 mCi today. Goodyear obtained the device in 2002 and used it for 2 or 3 years before placing it into storage. It was discovered missing earlier this month." 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|55812|Oregon Health Authority|Salem Hospital|4|Salem|OR|||Y||||||Daryl A. Leon |Karen Cotton-Gross|03/31/2022|12:56:00|03/22/2022|0:00:00|PDT|3/31/2022 2:40:00 PM|Non Emergency| |Agreement State|||||||Deese, Rick|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST/RECOVERED SOURCE The following information was provided by the Oregon Health Authority via email: "On March 22, 2022, a High Dose Rate Delivery (HDR) sealed source of Iridium-192 was delivered by a common carrier to the wrong floor and clinic in a licensed (Salem Hospital) hospital. Instead of the shipping destination (given as Radiation Oncology/Attn: Dr xxx) on the 1st floor, the package was delivered to the 4th floor of the same building. The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was and placed it on the floor of an access-controlled staff working area. "On March 28, 2022, the licensee received an email request from the vendor (Varian) to schedule a date/time for installation of the new source. It was at this time that the licensee realized that the source had not arrived at their location and found the source had been delivered on March 22, 2022. An investigation was initiated and the source package was located in the 4th floor clinic. The package was surveyed and observed to be intact with no evidence of tampering . The transport index for the Type A Yellow -II package was noted at 0.9. The package was taken to the licensee's office and secured in locked storage. "The licensee evaluated the dose received by clinic staff working in the proximity of the package. Clinic staff does not work a full shift in the area (five hours maximum/day) and the closest estimated distance from the package was measured at 2 feet (60 cm). The exposure period was 5 working days. The licensee performed dose measurements on and near the source package at various distances and orientations with a survey meter. The maximum dose received was while sitting in a chair and was calculated to be 0.4 mR/hr. "Total dose received was given as: 0.4 mR/hr * 5 hrs/day * 5 days = 10 mR total exposure (~10 mrem or 0.01 rem equivalent dose). This dose-risk standard was based upon National Council on Radiation Protection and Measurements (NCRP) Report No. 91. "Cause and corrective actions : "The two subsequent causes are of the same nature, human error. First, the carrier failed to deliver the package to the labeled destination and person. Second, the hospital clinic signed for the package without checking the proper destination or person it was intended for. A potential third cause of human error is that the licensee failed to check on package delivery sooner if a tracking number was associated with this shipment. Corrective actions have not been instituted at this time since not all information has been collected for this event. The licensee indicated that they receive these shipments quarterly and wait for the vendor to schedule an installation. There was no indication given of tracking a replacement source package while it is in transit to the licensee's site. This is being investigated further. "Information regarding the source activity, manufacturer, model, serial number and leak test date will be provided to the NRC Headquarters Operation Center when it is received from the Licensee." Oregon Report Identification Number: 22-0016 |
Non-Agreement State|55813|Pearl Harbor Naval Shipyard IMF|US Navy|1|Pearl Harbor|HI||45-23675-01NA |N||||||Mark Tamisharo|Lloyd Desotell|03/31/2022|15:25:00|03/30/2022|15:02:00|HST|4/1/2022 5:11:00 PM|Non Emergency|30.50(b)(2)|Safety Equipment Failure|||||||Werkheiser, Dave|R1DO|NMSS_Events_Notification, |EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - LEAKING SEALED SOURCE The following information was provided by the licensee via phone: The licensee reported that a generally licensed device has tested positive on a routine leak test (0.006 microCurie). The leaking sealed source was Ni-63 (15 milliCurie), which is used in an Agilent Gas Chromatograph (model G2397A). The gas chromatograph has been tagged out and no exposures were identified. * * * UPDATE FROM MARK TAMASHIRO TO DONALD NORWOOD AT 1217 EDT ON 4/1/2022 * * * The following information was received via E-mail: "Please change the CFR reference to the subject call from 10 CFR 30.50(b)(2) to 10 CFR 31.5(c)(5)." Notified R1DO (Werkheiser) and NMSS Events Notification E-mail group.|
Agreement State|55814|WA Office of Radiation Protection|Kaiser Permanente Bellevue |4|St. Bellevue|WA| |WN-M021|Y||||||Morgan Bullock |Lloyd Desotell|03/31/2022|20:48:00|03/31/2022|0:00:00|PDT|5/2/2022 4:05:00 PM|Non Emergency| |Agreement State|||||||Deese, Rick|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|CNSC (Canada), - |EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 5/3/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE The following was received from the Washington State Department of Health, Office of Radiation Protection, via email: "The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago. "Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill." WA incident no.: WA-022-006 * * * UPDATE ON 05/02/2022 AT 1526 EDT FROM TRISTAN HAY TO LLOYD DESOTELL * * * The following update was received from the state of Washington via email: "Based on their [licensee] corrective actions we [the state of Washington] have closed the incident. The lost source will most likely not be findable due to it making it into the landfill already and still being in its shielded container. " Notified R4DO (Warnick) and ILTAB, NMSS Events Notification and CNSC via email. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf|
Agreement State|55815|SC Dept of Health & Env Control|Southern Felt Company Inc.|1|Bethune|SC| |GL|Y||||||Korina Koci|Brian Lin|04/01/2022|9:42:00|03/30/2022|0:00:00|EDT|4/1/2022 9:47:00 AM|Non Emergency| |Agreement State|||||||Werkheiser, Dave|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FAILED INDICATOR The following information was received from the South Carolina Department of Health and Environmental Control via email: "During a routine inspection of a licensee's specific license on 03/23/22, the South Carolina Department of Health and Environmental Control was informed that a generally licensed fixed gauging device (80 milliCurie, Kr-85, Mahlo Model 6270, serial number PH847) had a failed indicator and had been repaired by the manufacturer on 01/11/22. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry certificate. The licensee submitted a written notification of the event to the Department on 03/30/22. This event is still under investigation by the South Carolina Department of Health and Environmental Control." |
Agreement State|55816|Louisiana Radiation Protection Div|Inspection Specialist Inc.|4|Marrero|LA| |LA-4266-L01|Y||||||James Pate|Brian Lin|04/01/2022|11:07:00|04/01/2022|0:00:00|CDT|4/1/2022 11:18:00 AM|Non Emergency| |Agreement State|||||||Deese, Rick|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - SOURCE DISCONNECT OF AN INDUSTRIAL RADIOGRAPHY CAMERA The following information was received from the Louisiana Department of Environmental Quality (LDEQ) via email: "On April 1, 2022, LDEQ received this event notification. The licensee was working at Bayer Crop Science, LP performing industrial radiography work on March 28, 2022. At approximately 1051 CDT, the RSO [(Radiation Safety Officer)] was notified of a source disconnect. The event involved a QSA 880 Delta, serial number 7511, source serial number 4806514. The source was an Ir-192 with an activity of 59 Ci. The drive cable end connector had broken off from the drive cable. The source was retrieved back into a shielded condition. "The person performing the source retrieval received 460 mR exposure. "The radiographer involved had his pocket ion chamber go off scale and his badge was sent in. The badge read 337 mR which was at the end of the working month." Louisiana Event Report ID No.: LA 20220004 |
Non-Agreement State|55817|Ind Univ-IUPUI/IU Med Center Campus|Ind Univ-IUPUI/IU Med Center Campus|3|Indianapolis|IN||13-02752-03|N||||||Michael Martin|Donald Norwood|04/01/2022|14:25:00|03/31/2022|0:00:00|EDT|4/1/2022 3:18:00 PM|Non Emergency|20.2201(a)(1)(i)|Lost/Stolen LNM>1000x|||||||Kozak, Laura|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE The following information was provided by the licensee via telephone and email: "Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT. "At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received. "The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)." 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|
Power Reactor|55818|Browns Ferry|Tennessee Valley Authority|2|Decatur|AL|Limestone||Y||3|||[1] GE-4,[2] GE-4,[3] GE-4|Chase Hensley|Donald Norwood|04/02/2022|15:10:00|04/02/2022|13:45:00|CDT|4/2/2022 3:33:00 PM|Unusual Event|50.72(a) (1) (i)|Emergency Declared|||||||Miller, Mark|R2DO|Kennedy, Silas|IR|Dudes, Laura|R2RA|Veil, Andrea|NRR|Screnci, Diane|PAO|Felts, Russell|NRR-EO|||||||||N|Y|10|Power Operation|10|Power Operation| |N|0||0|| |N|0||0||EN Revision Imported Date: 4/15/2022
EN Revision Text: UNUSUAL EVENT DECLARED DUE TO A FIRE AT THE 3B REACTOR FEEDWATER PUMP The following information was provided by the licensee via fax: "At 1345 CDT, Browns Ferry declared a Notification of Unusual Event due to a fire at the 3B Reactor Feedwater Pump within the Turbine Building which was not extinguished within 15 minutes. Subsequently, the fire was extinguished at 1402 CDT. Unit 3 remains in Mode 1 at approximately 9.5 percent rated thermal power (RTP). Unit 1 and 2 remain at 100 percent RTP and unaffected." The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The fire began at 1332 CDT. It is believed that the fire was in the oil system of the Feedwater Pump. The fire was extinguished by the on-site fire brigade. No off-site assistance was requested. The Unusual Event was declared under Emergency Action Level HU-4. The licensee notified the NRC Resident Inspector and required State and local government agencies. Unit 3 is currently stable. Notified DHS-SWO, FEMA Ops Center, and CISA Central Watch Officer, and FEMA NWC, DHS NRCC THD Desk, and DHS NuclearSSA via email. * * * UPDATE FROM CHASE HENSLEY TO DONALD NORWOOD AT 1650 EDT ON 4/2/2022 * * * "The Notification of Unusual Event was exited at 1544 CDT." Notified R2DO (Miller), IR-MOC (Kennedy), NRR-EO (Felts), DHS-SWO, FEMA Ops Center, and CISA Central Watch Officer.|
Agreement State|55819|Ohio Bureau of Radiation Protection|Eurofins Environment Testing North Central, LLC|3|Barberton|OH| |GL|Y||||||Stephen James|Ossy Font|04/04/2022|10:57:00|03/29/2022|0:00:00|EDT|4/5/2022 2:36:00 PM|Non Emergency| |Agreement State|||||||Kozak, Laura|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - ELECTRON CAPUTRE DETECTOR LEAKING SOURCE The following information was received from the Ohio Bureau of Radiation Protection via email: "Report of a leaking General License Ni-63 source (Model: G2397A, S/N: U3951) on an Electron Capture Detector. The source was returned to the manufacturer. "Leak test result: 20 microcuries (740 kBq)" NMED Item Number: OH220004 * * * UPDATE ON 4/5/22 AT 1413 EDT FROM S. JAMES TO T. HERRITY * * * "UPDATES/CORRECTIONS ON LICENSEE NAME, ACTIVITY AND LEAK TEST RESULTS: Leak test was taken on Electron Capture Detector (ECD) in storage as part of 6-month cycle. ECD contained 15 mCi Ni-63 source. Results came back indicating leaking source at 2000 pCi. No contamination of the ECD was found. The ECD will be permanently taken out of service and returned to manufacturer." Licensee name updated to full name: Eurofins Environment Testing North Central, LLC Notified R3DO (McCraw) and NMSS Events via email. |
Agreement State|55820|California Radiation Control Prgm|Miller Pacific Engineering Group|4|Novato|CA| |5411-21|Y||||||Arunika Hewadikaram|Donald Norwood|04/04/2022|15:58:00|04/01/2022|0:00:00|PDT|4/4/2022 4:11:00 PM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - TWO STOLEN THEN RECOVERED MOISTURE DENSITY GAUGES The following information was received via E-mail from the California Department of Public Health - Radiologic Health Branch (RHB): "On 4/1/22, at 1934 PDT, California Office of Emergency Services (CalOES) contacted RHB to report two moisture density gauges stolen from a licensee's storage facility. The stolen gauges included a CPN Model MC1-DR, S/N MD 80709102 and a CPN Model MC1-Elite, S/N MD 70408697, each containing 10 mCi of Cs-137 and 40 mCi of Am-241. Both gauges were stolen between the hours of approximately 1700 PDT on 3/31/22 and 0900 PDT on Friday, 4/1/2022, from the locked storage shed located in the lower parking lot of the licensee's office [redacted] in Novato, CA. The licensee had notified the Novato Police Department of the theft immediately after it was discovered. On 4/2/22, RHB contacted the licensee and learned that both gauges had been recovered by the Novato PD. They were located on a paved walking trail south of the licensee's office building. Per the RSO [(Radiation Safety Officer)], the gauges did not have any evidence of tampering except minor damage to one of the Type A containers. On 4/4/22, both gauges will be taken to Instrotek for further evaluation and leak testing. " California 5010 Number: 040122 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|
Power Reactor|55821|Nine Mile Point|Constellation Nuclear|1|Syracuse|NY|Oswego||Y||2|||[1] GE-2,[2] GE-5|Roman Arnold|Ossy Font|04/05/2022|6:08:00|04/05/2022|2:23:00|EDT|4/5/2022 3:58:00 PM|Non Emergency|50.72(b)(2)(iv)(A)|Eccs Injection|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||Defrancisco, Anne|R1DO|||||||||||||||||||A/R|Y|100|Power Operation|0|Hot Standby| |N|0||0|| |N|0||0||EN Revision Imported Date: 4/15/2022
EN Revision Text: SCRAM ON LOW LEVEL The following information was provided by the licensee via telephone and email: "On 4/5/2022, at time 0223 EDT, during maintenance on Feedwater Level Control Valve 2FWS-LV10B, a Feedwater transient occurred resulting in an RPS Automatic Reactor Scram on Low Level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 Recirculation Sample System Isolation, Group 3 TIP [(Traversing Incore Probe)] Isolation Valve Isolation, Group 6 and 7 Reactor Water Cleanup Isolation and Group 9 Containment Purge Isolations. "All control rods inserted as expected. High Pressure Core Spray and Reactor Core Isolation Cooling initiated and injected as expected. ECCS Systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable in Mode 3. "These 4 hour and 8-hour non-emergency ENS [(Emergency Notification System)] reports are being made in accordance with 10 CFR 50.72(b)(2)(iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A). "The NRC Resident was informed." The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: There was no impact on Unit 1. |
Agreement State|55822|Ohio Bureau of Radiation Protection|I. H. Schlezinger, Inc.|3|Columbus|OH||N/A|Y||||||Stephen James|Thomas Herrity|04/05/2022|14:13:00|03/30/2022|0:00:00|EDT|4/5/2022 2:39:00 PM|Non Emergency| |Agreement State|||||||McCraw, Aaron|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE GAUGE DISCOVERED IN SCRAP METAL The following information was received from the Ohio Department of Health Bureau (ODH) of Environmental Health and Radiation Protection via email: "On 3/30/22, ODH received notification of a load that tripped radiation detectors at a scrap facility in Marion, Ohio. The load returned to point of origin in Columbus, Ohio under DOT SP OH-OH-22-014. The Originator contacted ODH on 4/4/22 to report that they had surveyed the load and isolated a device that was box shaped, perhaps 8x4x4 inches. The item reportedly pegged the facility's Ludlum 19 (5 mR/hr), and was secured in a quarantine area. "ODH staff responded to site on 4/5/22 and identified a Ronan Engineering Model RLL-1 gauge containing a 0.27 mCi Cs-137 source with a reading of 750 microR/hr on the side of the gauge. No contamination was detected. The facility will keep the device secure while disposal options are arranged. ODH will contact the manufacturer (Ronan Engineering) to attempt to identify the owner based on mode; and serial number on the device." Ohio item number: OH220005 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|55823|Nevada Radiological Health|Comprehensive Cancer Centers, NV|4|Las Vegas|NV||03-12-0491-01|Y||||||Corey Creveling|Thomas Herrity|04/05/2022|18:37:00|04/05/2022|0:00:00|PDT|4/5/2022 6:46:00 PM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE The following was received from the State of Nevada via email: "The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site. "The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose. "For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem. "However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses. "The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place." Nevada Event Number: NV220002 |
Agreement State|55824|WA Office of Radiation Protection|Nelson Geotechnical Asso|4|Trinidad|WA| |WN-I0421-1|Y||||||RAJ MAHARJAN|Lloyd Desotell|04/07/2022|12:31:00|04/06/2022|9:00:00|PDT|4/7/2022 1:07:00 AM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE The following was received from the Washington State Department of Health, Office of Radiation Protection, via email: "Washington State received a report of a portable gauge incident on 4/6/2022. The incident took place on the same day around 0900 PDT at Trinidad, WA. A Troxler 3440 portable gauge [containing 9 mCi Cs-137 and 44 mCi Am/Be-241 sources] was run over by a bulldozer at a construction site. The gauge was damaged. No over exposure or contamination [occurred]. The sources appear to be intact pending further report. Washington State will provide a detailed report once available within the required time frame." Washington State Incident Number: WA-22-009. |
Agreement State|55825|New Mexico Rad Control Program|Freeport-McMorin - Chino Mine |4|Vanadium|NM| |GA045-46|Y||||||Carl Sullivan|Thomas Herrity|04/07/2022|12:03:00|04/06/2022|14:52:00|MDT|4/7/2022 12:47:00 PM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS The following is a synopsis of a report received from the state of New Mexico via phone call: The Chino Mine in Vanadium, NM has two Berthold model LB7440 gauge devices malfunctioning. Unit Serial Number 3175, with a 250 milliCi Cs-137 source, has a broken latch and cannot be held in the closed position. Unit Serial Number DZ256A, 150 milliCi Cs-137 source, is stuck in the open position. Open is the normal operating position for both units and the units will remain in service until the service contractor arrives in May 2022. Both units have been roped off to prevent personnel from exposure. NM item number: N/A|
Agreement State|55826|Pennsylvania, DEP|KAKS and Co|1|Harleysville|PA||PA-1394|Y||||||John Chippo |Thomas Herrity|04/07/2022|14:06:00|04/07/2022|0:00:00|EDT|4/7/2022 2:44:00 PM|Non Emergency| |Agreement State|||||||Defrancisco, Anne|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|CNSC (Canada), -|EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE The following was received from the Commonwealth of Pennsylvania (the department or DEP) via email: "On April 7, 2022, the licensee informed the department that a Troxler Model 3440 nuclear density gauge, serial number 31109, containing 8 milliCuries of cesium-137 and 40 milliCuries of americium-241 had been stolen. The gauge was secured in the back of the technician's vehicle at his residence. The technician was leaving his residence this morning around 0800 EDT and the vehicle was missing with the gauge inside. The incident was reported to the Philadelphia Police Department and they have yet to respond to the situation. "The DEP will update this event as soon as more information is provided." Event Report ID No: PA220012 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|
Part 21|55827|Curtiss Wright Flow Control Co.|Tennessee Valley Authority|3|Cincinnati|OH| | |N||||||Margie Hover|Brian Lin|04/07/2022|15:15:00|02/07/2022|0:00:00|EDT|4/7/2022 3:15:00 PM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||Miller, Mark|R2DO|McCraw, Aaron|R3DO|Part 21/50.55 Reactors, -|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - CURTISS-WRIGHT ACTUATOR BRAKE WIRING DEFICENCY REPORT The following information was provided by Curtiss-Wright Nuclear Division via fax: "The Tennessee Valley Authority (TVA) Browns Ferry Plant notified us (QualTech NP, Curtiss-Wright Nuclear Division) of two separate RCS/Dresser actuator failures which we had provided as safety related components. According to TVA, the first failure occurred on February 7, 2022, after being installed for approximately 167 days. The 2nd failure occurred on February 9, 2022, and was in service for approximately 24 hours when it failed. "According to TVA in both cases the actuator's brake assembly wire harness shorted out to the frame, causing the on-board fuse to blow, disabling the actuator. The electrical short was caused by the wire harness laying against a sharp edge of the metal frame, which over time led to fraying of the wire insulation and subsequent bare wire to frame contact. "Both units were returned to QualTech NP for evaluation and our findings confirmed TVA's assessment. "The root cause of the issue is friction between the wires and the sharp metallic edge that over time cut through the insulation via vibration, which in turn shorted the power leads to the frame. This shorting effect was due to poor positioning and restraint of the wire harness/bundle by the manufacturer during assembly. It is not considered a design flaw, but a workmanship issue caused by the factory assembler. "The corrective action taken with the two units was to install new brake assemblies and reposition the wire harness to prevent contact with the sharp edge. In addition, wire ties were added to restrain the wire's movement and keep it away from the sharp edge. As a follow up action, the associated dedication plan will be revised to inspect for this workmanship issue and correct as needed. "Additional details are provided in the failure evaluation. QualTech NP has only sold this part to TVA (Browns Ferry) and could not find any additional failures of this type reported by the industry. Identification of the customer's orders and hardware involved are provided in the evaluation. "Please phone (513) 528-7900 if you should have any questions." |
Power Reactor|55828|Surry|Dominion Generation|2|Surry|VA|Surry||N|05000280|1|2||[1] W-3-LP,[2] W-3-LP|Alan Bidlowas|Thomas Herrity|04/07/2022|16:12:00|04/07/2022|9:09:00|EDT|4/7/2022 4:13:00 PM|Non Emergency|26.719|Fitness For Duty|||||||Miller, Mark|R2DO|FFD Group, |EMAIL|||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation||N|0||0||EN Revision Imported Date: 4/15/2022
EN Revision Text: FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST The following information was provided by the licensee via phone call: "At 0909 EDT on 4/7/2022, it was determined that a security officer tested positive during a random fitness-for-duty test. The individual's authorization for site access has been terminated. "The NRC Resident Inspector has been notified." |
Agreement State|55829|Georgia Radioactive Material Pgm|Graphic Packaging International |1||GA||GA 179-2|Y||||||Stacy Allman|Thomas Herrity|04/07/2022|16:58:00|04/07/2022|0:00:00|EDT|4/7/2022 5:13:00 PM|Non Emergency| |Agreement State|||||||Defrancisco, Anne|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING GAUGE The following was received from the State of Georgia, via email: "Graphic Packaging International called us this afternoon to report a missing gauge. The gauge is a Berthold Model LB7441 S/N 2212 and is believed to be about 41 milliCuries. It is unknown to us at this time if the source is Cobalt-60 or Cesium-137. The last leak test was conducted on December 13, 2021. The licensee says that the gauge was installed on a part of the line that they haven't used in a long time. The Radioactivity Safety Officer (RSO) went to that part of the line to clean the tags and discovered that entire end of the line was gone. They have been having demolition work done, so it is his belief that the gauge was in the demolition. The demolition company is Grey Wolf. We are following up with the licensee and the company for more information and will keep you informed." Georgia item number: N/A 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|55830|California Radiation Control Prgm|Loma Linda University Health|4|San Bernardino|CA| |0060-36 |Y||||||Robert Greger|Thomas Herrity|04/07/2022|21:09:00|04/06/2022|0:00:00|PDT|4/8/2022 12:00:00 PM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|Rivera-Capella, Gretchen|NMSS DAY|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE TO PATIENT The following was received from the State of California, Department of Public Health (RHB), via email: "On April 6, 2022, Loma Linda University Health's (LLUH) Radiation Safety Officer was notified by a medical authorized user that a reportable medical event had occurred during a Y-90 Therasphere patient brachytherapy treatment on April 5, 2022. "There were two patients scheduled for brachytherapy on the same day. Patient 1 had two tailored dose vials of Y-90 and Patient 2 had three tailored dose vials of Y-90 stored in the hot lab. A certified nuclear medical technologist mistakenly selected one of Patient 2's vials for Patient 1's treatment. The selected vial contained 4.0 GBq (108 milliCuries) with calibration date April 3, 2022 at 1200 PDT. It contained approximately 58.6 milliCuries at the time of administration. "The two vials were taken to the therapy suite, where they were approved and used by the authorized user. The authorized user's written directive for Patient 1's liver segments 2 and 3 was to deliver a dose of 120 Gy. However, the mistake resulted in a dose of 750 Gy to the two liver segments. If the proper vial had been selected, the administered activity would have been 9.6 milliCuries. "The error also resulted in the cancellation of Patient 2's treatment, as the Y-90 dose was no longer available. LLUH will be submitting a 15-day report to RHB. Abnormal Occurrence criteria for Medical Event's: Unplanned dose greater than or equal to 1000 rad to any other organ AND dose is greater than 150 percent of the prescribed dose." California Event Number: 040622 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.|
Power Reactor|55831|Turkey Point|Florida Power And Light|2|Miami|FL|Dade||Y||4|||[3] W-3-LP,[4] W-3-LP|Ryan Frank|Lloyd Desotell|04/08/2022|1:10:00|04/07/2022|19:00:00|EDT|4/11/2022 11:25:00 AM|Non Emergency|50.72(b)(3)(v)(B)|Pot Rhr Inop|||||||Miller, Mark|R2DO|||||||||||||||||||N|N|0|Hot Shutdown|0|Hot Shutdown| |N|0||0|| |N|0||0||EN Revision Imported Date: 4/15/2022
EN Revision Text: BOTH TRAINS OF RESIDUAL HEAT REMOVAL INOPERABLE The following information was provided by the licensee via fax or email: "At 1900 EDT on 04/07/22, while Unit 4 was in Mode 4 following a refueling outage, it was discovered that both trains of residual heat removal (RHR) were simultaneously inoperable due to gas voiding. At 2032 EDT corrective actions were completed and both trains of RHR were declared operable. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B). "The NRC Resident Inspector has been notified." * * * RETRACTION ON 04/11/22 AT 1022 EST FROM DAVID STOIA TO BRIAN SMITH * * * The following information was provided by the licensee via email: "On 4/8/2022 at 0110 EDT Turkey Point Unit 4 notified the [NRC Operations Center (NRCOC)] pursuant to 10 CFR 50.72(b)(3)(v)(B) that both trains of Residual Heat Removal (RHR) were simultaneously inoperable due to the presence of gas voids that were identified during scheduled system gas accumulation testing. Subsequent evaluation by [Florida Power & Light (FPL)] Engineering has concluded that both trains of RHR remained operable and capable of performing their specified safety function. "This NRCOC notification is a retraction of EN# 55831." The licensee notified the NRC Resident Inspector. Notified R2DO (Miller) |
Agreement State|55832|WA Office of Radiation Protection|US Ecology Washington Inc.|4|Richland|WA| |WN-I019-2|Y||||||Gregorio Rosado|Brian Lin|04/08/2022|14:10:00|04/07/2022|14:40:00|PDT|4/8/2022 2:36:00 PM|Non Emergency| |Agreement State|||||||Dixon, John|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PROPORTIONAL COUNTER FAILURE The following information was received from the Washington State Department of Health via email: "The Radiation Protection Manager (RPM) for US Ecology (USE) notified the Washington State Department of Health (WDOH) on April 7, 2022, at 1440 PDT, of equipment which failed to function as designed in accordance with WAC 246-221-250 (2)(d). This was identified during an internal surveillance of the calibration program by the licensee. Specifically, the equipment is a Canberra Series 5 Extreme Low Background Alpha Beta Proportional counter (XLB). The spreadsheet used to calculate alpha efficiency to determine alpha activity from smears and air samples was off by 1 percent. The error for this matter will require USE to review all data from September 2021 through April 6, 2022. The preliminary cause was identified as a human performance error. An investigation is ongoing to determine the impact to health and safety. WDOH is planning a follow up investigation the week of May 9, 2022, to follow up for this matter. No media attention currently." WA incident no.: WMS-INC-22-01 |
Agreement State|55833|NC Div of Radiation Protection|Kleinfelder|1|Charlotte|NC| |060-0712-2|Y||||||Travis Cartoski|Mike Stafford|04/11/2022|11:20:00|04/11/2022|0:00:00|EDT|4/11/2022 12:18:00 PM|Non Emergency| |Agreement State|||||||Cahill, Christopher|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE The following was received via an email from the state of North Carolina: "A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box. "An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report." North Carolina Tracking Number: 220003. 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|55835|Colorado Dept of Health|Service King #342|4|Thornton|CO| |GL002621|Y||||||Kathryn Mote|Bethany Cecere|04/11/2022|17:20:00|04/11/2022|0:00:00|MDT|4/11/2022 5:36:00 PM|Non Emergency| |Agreement State|||||||Azua, Ray|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR The following information was provided by the state of Colorado via email: "Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found. "Isotope: Po-210 Manufacturer: NRD, LLC. Model: P-2021 Device: Static Eliminator Serial number: A2LT196 Activity: .01 Ci" CO Event Report ID No.: CO220009 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|
Part 21|55836|Westinghouse Electric Company|Westinghouse Electric Company|1|Cranberry Township|PA| | |Y||||||Camille Zozula|Mike Stafford|04/11/2022|21:01:00|04/06/2022|0:00:00|EDT|4/11/2022 9:13:00 PM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||Cahill, Christopher|R1DO|McCraw, Aaron|R3DO|Part 21/50.55 Reactors, -|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT The following information was provided by the licensee via email: "The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard. "Name and address of the individual informing the Commission: Camille T. Zozula Westinghouse Electric Company 1000 Westinghouse Drive Cranberry Township, Pennsylvania 16066 (412) 374-2577 zozulact@westinghouse.com "Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018. "The [FVRs] are designed and qualified to open and close on demand. The FVR contactors sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position. "Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related FVR contactors that are potentially affected between 2014 and 2022. "Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022. "Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding. "Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available. "Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts. "Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022. "The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event. "Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."|
Agreement State|55838|Illinois Emergency Mgmt. Agency|Isomedix Operations, Inc.|3|Libertyville|IL| |IL-01123-02|Y||||||Zach Mengel|Lloyd Desotell|04/12/2022|12:38:00|04/11/2022|12:00:00|CDT|4/12/2022 1:20:00 PM|Non Emergency| |Agreement State|||||||McCraw, Aaron|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: "At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures. "As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required. "No personnel injuries or exposures and no adverse effects on the security system were reported." Item Number: IL220011 |
Agreement State|55839|Texas Dept of State Health Services|Qal Tek Associates LLC|4|Round Rock|TX|Williamson|L05965|Y||||||Randall Redd|Brian Parks|04/12/2022|16:37:00|03/25/2022|0:00:00|CDT|4/12/2022 5:02:00 PM|Non Emergency| |Agreement State|||||||Azua, Ray|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - SOURCE NOT SECURE WITHIN GAUGE The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: "On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite. Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300." Texas Incident Number: I-9925|
Agreement State|55840|California Radiation Control Prgm|Loma Linda University Health|4|Loma Linda|CA| |0060-36|Y||||||Donald Oesterle|Mike Stafford|04/12/2022|19:47:00|04/11/2022|0:00:00|PDT|4/12/2022 7:57:00 PM|Non Emergency| |Agreement State|||||||Azua, Ray|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email: "The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045." California Event Number: 041222 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.|
Fuel Cycle Facility|55841|Nuclear Fuel Services Inc.|Nuclear Fuel Services Inc.|2|Erwin|TN|Unicoi|SNM-124|Y|07000143||||Uranium Fuel Fabrication|Tom Holly|Lloyd Desotell|04/13/2022|14:58:00|04/12/2022|0:00:00|EDT|4/13/2022 3:50:00 PM|Non Emergency|26.719|Fitness For Duty|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Miller, Mark|R2DO|Fuels Group, -|EMAIL|FFD Group, |EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: FITNESS FOR DUTY The following information was provided by the licensee via email: Two contract employees admitted to being involved in the use, sale, or possession of a controlled substance. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |
Agreement State|55842|Illinois Emergency Mgmt. Agency|Northwestern Memorial Hospital|3|Chicago|IL| |IL-01037-02|Y||||||Robin Muzzalupo|Mike Stafford|04/13/2022|13:10:00|04/11/2022|0:00:00|CDT|4/13/2022 4:59:00 PM|Non Emergency| |Agreement State|||||||McCraw, Aaron|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: "The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the [authorized user] noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The [authorized user] was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause." Item Number: IL220012 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.|
Power Reactor|55843|North Anna|Dominion Generation|2|Richmond|VA|Louisa||N|05000338|1|||[1] W-3-LP,[2] W-3-LP,[3] M-4-LP|Bob Page|Kerby Scales|04/14/2022|11:18:00|04/14/2022|9:28:00|EDT|4/14/2022 11:37:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||Miller, Mark|R2DO|||||||||||||||||||A/R|Y|100|Power Operation|0|Hot Standby| |N|0||0|| |N|0||0||AUTOMATIC REACTOR TRIP DURING CONTROL ROD TESTING The following information was provided by the licensee via email: "On April 14, 2022, at 0928 [EDT] hours, Unit 1 automatically tripped from 100 percent power during the control rod operability periodic test. The reactor trip occurred during the manipulation of the rod control mode selector switch as part of the rod operability testing. The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated, and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The Auxiliary Feedwater pumps actuated as designed because of the reactor trip and provide makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater system is reportable per 10 CFR 50.72(b)(3)(iv) (A) for a valid actuation of an ESF [Engineered Safety Features] system. The Auxiliary Feedwater pumps were subsequently secured and returned to automatic. Decay heat is being removed by the condenser steam dump system. Unit 1 is in a normal shutdown electrical lineup. An investigation into the cause of the reactor trip is underway." The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: There was no affect to Unit 2. Unit 2 is operating at 100 percent power. |
Power Reactor|55844|Pilgrim|Holtec International|1|Plymouth|MA|Plymouth||N|05000293|1|||[1] GE-3|David Noyes|Brian Parks|04/15/2022|11:31:00|04/15/2022|10:00:00|EDT|4/15/2022 11:31:00 AM|Non Emergency|50.72(b)(2)(xi)|Offsite Notification|||||||Cahill, Christopher|R1DO|||||||||||||||||||N|N|0|Defueled|0|Defueled| |N|0||0|| |N|0||0||NOTIFICATION OF ENVIRONMENTAL REPORT TO ANOTHER GOVERNMENT AGENCY The following information was provided by the licensee via email: "On April 15, 2022 at 1000 hours (EDT), four off-site notifications were made to the Commonwealth of Massachusetts Department of Environmental ÿProtection (MADEP) in accordance with the Massachusetts Contingency Plan (310 CMR 40.0000). ÿThe notifications document non-radiological contaminants found slightly above reportable concentrations in select soil and groundwater samples collected during site characterization efforts, as part of the decommissioning process, from four parcels of land at the property.ÿ ÿReportable concentrations in soil were identified in a composite sample for Polychlorinated Biphenyls (PCBs). ÿReportable concentrations in groundwater were identified in samples for per- and polyfluoroalkyl substances (PFAS) and Semi Volatile Organic Compound (SVOC). Additionally, the reports include sample results where laboratory reporting limits equaled or exceeded reporting thresholds. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency in accordance with 10 CFR 50.72(b)(2)(xi).ÿ There was no impact on the health and safety of the public or plant personnel. The NRC Lead Decommissioning Inspector and NMSS Project Manager assigned to Pilgrim have been notified." |
Agreement State|55845|Virginia Rad Materials Program|Newport News Shipbuilding|1|Newport News|VA| |700-383-1|Y||||||Rose Yankoski |Brian Parks|04/15/2022|14:50:00|04/14/2022|11:03:00|EDT|4/15/2022 3:02:00 PM|Non Emergency| |Agreement State|||||||Cahill, Christopher|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - SOURCE UNABLE TO RETRACT TO SAFE POSITION The following was received from the Commonwealth of Virginia via email: "On April 14, 2022 at 2249 hours EDT, the Office of Radiological Health Radioactive Materials Program (ORH) received an incident report from the licensee, Huntington Ingalls Incorporated Newport News Shipbuilding. The source, 79 curies of Ir-192, could not be retracted to its shielded position during radiographic work. The incident occurred on April 14, 2022 at about 1103, while a radiographic work was being performed in a permanent radiography booth to inspect a pipe for use upon a naval vessel at Newport News Shipbuilding. The incident occurred because the metal pipe fell off of the metal sawhorse, crushing the source tube and preventing full retraction back into the shielded position. The root cause of the pipe falling off of the sawhorse has yet to be determined. The radiography crew immediately closed the permanent radiography booth, took radiation surveys to ensure that with the door closed the radiation levels were below 2 mR/hr, and notified the Radiation Safety Officer (RSO). The site was supervised by the radiography crew constantly between the time of the incident until the source was retracted at approximately 1310 on April 15, 2022. The highest exposure of the crew from the pocket dosimeters was 5.5 mrem. In addition, the whole body dosimeters were sent to the licensee's internal dosimetry program for analysis. The results are not yet available. The RMP Southeast regional inspector responded to the incident and performed radiation safety assessment at the event site." Virginia Event Report ID Number: VA220001 |
Agreement State|55846|Nebraska Dept. of Health |Central Valley Agriculture|4|Wakefield|NE||GL0746|Y||||||Deb Wilson |Thomas Herrity|04/15/2022|14:56:00|04/15/2022|0:00:00|CDT|4/15/2022 3:10:00 PM|Non Emergency| |Agreement State|||||||Azua, Ray|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS The following was received from the state of Nebraska, Office of Radiological Health via email: "We [Office of Radiological Health] received Central Valley Agriculture GL0746's Annual Radioactive Material Current Inventory and they indicated that they were no longer in possession of 2 tritium exit signs. We spoke with them and they said that the Oak Street property had been sold several years ago and the building torn down. We contacted the new property tenant to confirm, and it was determined that the signs were not on the property, assumed to have been demolished with the previous building. Follow-up complete, no further investigation is needed." Nebraska event number: NE220001 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|55847|California Radiation Control Prgm|SF Medical Center|4|San Francisco|CA| |1725-38|Y||||||K. Arunika Hewadikaram|Thomas Herrity|04/15/2022|18:58:00|04/08/2022|0:00:00|PDT|4/15/2022 7:42:00 PM|Non Emergency| |Agreement State|||||||Azua, Ray|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT The following was received from the state of California Radiologic Health Branch (RHB) via email: "On 4/14/22, Radiation Safety Officer (RSO) contacted RHB to report a Medical Event associated with a High Dose Rate (HDR) unit. "Licensee's written notification on 4/15/22, stated the following: "Sometime on Friday, April 8th [2022], an HDR therapist replaced a source transfer tube/catheter with a longer length transfer tube/catheter than intended for the three HDR treatments planned for that day. The difference in lengths was 123 mm. Since the treatment plan was with a shorter transfer tube/catheter, the source didn't make it all the way to the treatment locations and resulted in underdosing the three patients on that day, and likely delivering unplanned doses to non-treatment sites for the three patients. The error was discovered on Wednesday, April 13th, as another HDR therapist was getting ready for an HDR treatment. No HDR treatments had occurred since Friday, April 8. The first therapist wasn't certain if she changed the transfer tube/catheter in the morning or after the patients, but she thinks she likely changed it in the morning. The licensee is still evaluating the delivered doses to the patients treated on that Friday, but at least two of them are believed to have received an underdose that is reportable. The doses to non-treatment sites have not been fully evaluated. All three patients and their referring physicians were notified on Thursday, April 14th. "RHB is continuing to follow up with the investigation." California Event Number: 041422 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. |
Power Reactor|55848|Callaway|Ameren Ue|4|Fulton|MO|Callaway||N|05000483|1|||[1] W-4-LP|John Lauf|Jeffrey Whited|04/19/2022|18:02:00|04/19/2022|10:30:00|CDT|4/19/2022 6:08:00 PM|Non Emergency|26.719|Fitness For Duty|||||||Proulx, David|R4DO|FFD Group, |EMAIL|||||||||||||||||N|N|0|Defueled|0|Defueled||N|0||0|||N|0||0||FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST The following information was provided by the licensee via email: A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated. The licensee notified the NRC Resident Inspector. |
Agreement State|55849|WA Office of Radiation Protection|Packaging Corporation|4|Wallula|WA| |WN-I004-1|Y||||||Jasmin Hernandez|Jeffrey Whited|04/19/2022|19:45:00|04/15/2022|8:00:00|PDT|4/19/2022 8:32:00 PM|Non Emergency| |Agreement State|||||||Proulx, David|R4DO|NMSS_Events_Notification, |EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - EQUIPMENT MISUSE The following was received from the Washington Office of Radiation Protection via email: "Incident took place on 4/15/22 at approximately 0800 PDT Wallula, WA. A fixed gauge [KayRay model 7062 bp; 50mCi Cs-137] was found unmounted and uncontrolled, nearby it's normally installed location. Source is intact and shutter mechanism has remained in the locked/closed position. No over exposure or spread of contamination. The fixed gauge is currently reinstalled at it's normal location, pending further investigation and report. Incident Number: WA-22-010 |
Agreement State|55850|Georgia Radioactive Material Pgm|Emory University|1|Atlanta|GA| |GA 153-1|Y||||||Leslines Leveque|Mike Stafford|04/20/2022|9:36:00|04/11/2022|0:00:00|EDT|4/25/2022 1:49:00 PM|Non Emergency| |Agreement State|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|Dentel, Glenn|R1DO|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 4/26/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING SOURCE The following is a synopsis of an email received from the state of Georgia: On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier. Georgia Incident Number: 53 * * * UPDATE ON 04/25/2022 AT 0945 EDT FROM LESLINES LEVEQUE TO THOMAS HERRITY * * * The following is update was received from the state of Georgia via email: On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident. Notified R1DO (Young) and ILTAB and NMSS Events Notification 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 |
Agreement State|55851|PA Bureau of Radiation Protection|University of Pennsylvania|1|Philadelphia|PA| |PA-0131|Y||||||John Chippo|Brian Parks|04/20/2022|11:49:00|04/18/2022|0:00:00|EDT|4/20/2022 12:09:00 PM|Non Emergency| |Agreement State|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Dentel, Glenn|R1DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - PATIENT UNDERDOSE The following was received from the Pennsylvania Bureau of Radiation Protection by e-mail: "On April 18, 2022, a patient underwent a Y-90 SIR-Sphere treatment. The prescribed dosage was 7.07 milliCuries, however only 5.27 milliCuries was able to be delivered, or 74.5 percent. The apparent cause is that the blood vessel the catheter was placed in had a complicated vasculature which inhibited the flow of the spheres. No harm is expected to the patient. The referring physician and the patient have been informed." Event Report ID Number: PA220014 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|55852|Ohio Bureau of Radiation Protection|Riverside Methodist Hospital|3|Columbus|OH| |02120250070|Y||||||Stephen James|Brian Parks|04/20/2022|14:09:00|04/18/2022|0:00:00|EDT|4/20/2022 2:58:00 PM|Non Emergency| |Agreement State|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Pelke, Patricia|R3DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - PATIENT UNDERDOSE The following was received from the Ohio Bureau of Radiation Protection by e-mail: "On 4/18/22, a patient was scheduled to receive 120 Gy to the right hepatic lobe of the liver [involving Y-90 TheraSpheres], however only 94.2 Gy was delivered, resulting in an underdose of 21.5 percent. The [authorized user] notified the [Radiation Safety Officer] on 4/19/22. Stasis was not reached and at this time no cause was identified." Item Number: OH220006 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. |
Fuel Cycle Facility|55853|Global Nuclear Fuel - Americas|Global Nuclear Fuel - Americas|2|Wilmington|NC|New Hanover|SNM-1097|Y|07001113||||Uranium Fuel Fabrication|Phillip Ollis|Brian Parks|04/22/2022|13:35:00|04/21/2022|14:54:00|EDT|4/22/2022 1:40:00 PM|Non Emergency|PART 70 APP A (c)|Offsite Notification/News Rel|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Miller, Mark|R2DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|OFFSITE NOTIFICATION The following information was provided by the licensee via email: "At approximately 1300 EDT on April 21st, the New Hanover County Deputy Fire Marshal was notified that a roll up fire door located between a boiler room and the rad waste system malfunctioned in the open position. The door was approximately 3/4 closed. Compensatory measures were discussed with the Deputy Fire Marshall and then implemented. The door was repaired at approximately 1045 EDT on April 22nd. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)." The licensee will notify the State and NRC Region II.|
Agreement State|55854|Utah Division of Radiation Control|EnergySolutions|4|Clive|UT| |UT 2300249 & UT 2300478|Y||||||Jalynn Knudsen|Caty Nolan|04/22/2022|16:10:00|04/18/2022|7:30:00|MDT|5/16/2022 4:24:00 PM|Non Emergency| |Agreement State|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Proulx, David|R4DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 5/17/2022
EN Revision Text: AGREEMENT STATE REPORT - GROUNDWATER CONTAINING URANIUM IDENTIFIED DURING EXCAVATION The following was received from the Utah Department of Environmental Quality via email: "On April 18, 2022, Licensee personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The excavations for sumps extended into the groundwater and were not included on the conditionally approved plans. The smell triggered an investigation where groundwater samples were collected for both chemical and radiological analysis. One sample indicated a concentration of 12,000 pCi/L of uranium (preliminary findings). The presence of uranium in the groundwater was unanticipated. Subsequently, the Division of Waste Management and Radiation Control has communicated to the licensee to characterize the nature and extent of the contamination. The Division is waiting for additional information from the licensee." Event Report ID No.: UT220003 * * * UPDATE AT 1612 EDT ON MAY 16, 2022, FROM JALYNN KNUDSEN TO BRIAN P. SMITH * * * The following update was received from the Utah Department of Environmental Quality (the agency) via email: "On April 18, 2022, [Licensee] personnel reported a strong fuel smell coming from a recent excavation associated with a new facility under construction. The [Licensee] did not anticipate encountering groundwater at the depth of excavation. Upon encountering the groundwater and observing a hydrocarbon odor, the Licensee collected groundwater samples for both organic and radiological analysis. The preliminary screening of one sample indicated a potentially high concentration of uranium. The preliminary result of the analysis was reported to the agency with the intent to conduct additional confirmatory work. The Licensee contends that the initial high concentrations were in error due to improper analytical methodology. These results were presented to the agency prior to confirmation. Results of further investigation by the Licensee indicate that the contaminant was thorium, not uranium, and that all radionuclides were below detection limits. "The agency collected confirmatory samples for analysis and is awaiting results of both organic and radiological analysis. "The Licensee is preparing an investigation plan to fully characterize the nature and extent of the contamination." Event Report ID No.: UT220003 (updated) Notified R4DO (Gepford) and NMSS Events Notification (email).|
Agreement State|55855|Kansas Dept of Health & Environment|Kansas State University|4|Hutchinson|KS| |38-C011-01|Y||||||Kimberly Steves|Kerby Scales|04/22/2022|17:03:00|07/21/2021|0:00:00|CDT|4/22/2022 5:07:00 PM|Non Emergency| |Agreement State|||||||NMSS_EVENTS_NOTIFICATION|EMAIL|Proulx, David|R4DO|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE The following was received from the state of Kansas via email: "On 4/21/22 during the course of an inspection of the facility, the State of Kansas discovered that an incident involving one of their portable gauges occurred on 7/21/2021. This incident was never reported to Kansas and was discovered through the inspection process. "Licensee Kansas State University (# 38-C011-01) had a Campbell Pacific Nuclear model 503 portable gauge (serial number 50505) damaged while being used in a field at the Hutchinson, Kansas field research station. The gauge contained 50 mCi of AmBe. The gauge was run over when the student who was using the gauge under the oversight of the local RSO [Radiation Safety Officer] (unknown at this time if the local RSO was present at the site) backed a vehicle over it. At this time Kansas has not been able to determine if the student left the gauge unattended for a brief time or if the student did not properly secure the gauge into the vehicle and it fell out. The gauge was inspected immediately after the incident, and it was found that, though the gauge shielding appeared to be intact, the shipping case was damaged. Immediately following the incident, the student contacted their Primary Investigator (PI), who is a university instructor overseeing the student's project, to inform him of the incident, but it was reported that the PI asked if it was urgent and the student said no. The gauge was discovered damaged by the PI a week later on 7/28/2021. "Upon discovery, the PI reported that he ordered a new shipping case and ordered leak tests. The leak tests were performed on 7/29/2021 and did not show damage to the source. The damage to the gauge housing was on the opposite side of the machine from the source and did not interfere with the source's insertion or retraction. Because of this, the licensee stated that they decided it was not reportable to Kansas. An investigation is underway to determine what steps were taken by the licensee, including possible repairs to the unit. Follow-up information will be provided as it is obtained." |
Power Reactor|55856|Catawba|Duke Energy Nuclear Llc|2|York|SC|York||Y||2|||[1] W-4-LP,[2] W-4-LP|Wil Fowler|Thomas Herrity|04/23/2022|6:04:00|04/23/2022|2:24:00|EDT|4/23/2022 6:22:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||Miller, Mark|R2DO|||||||||||||||||||M/R|Y|100|Power Operation|0|Hot Standby| |N|0||0|| |N|0||0||MANUAL REACTOR TRIP DURING CONTROL ROD TESTING The following information was provided by the licensee via fax or email: "On April 23, 2022, at 0224 [EDT] hours, with Unit 2 in Mode 1 at 100 percent power, two control rods dropped during control rod testing resulting in misalignment, which required a manual reactor trip in accordance with plant procedure. All safety systems functioned as expected. The Auxiliary Feedwater system actuated as designed to provide makeup flow to the steam generators. Operations responded and stabilized the plant. Decay heat is being removed by the steam generator power operated relief valves. 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 automatic start of the Auxiliary Feedwater system is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). The cause of the dropped rods is being investigated. Unit 1 is not affected. "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: Electrical power is in normal off-site arrangement. All emergency electrical supplies are available. |
Power Reactor|55857|Byron|Exelon Nuclear Co.|3|Byron|IL|Ogle||Y||2|||[1] W-4-LP,[2] W-4-LP|Bryan Lykkebak|Kerby Scales|04/23/2022|16:27:00|04/23/2022|8:54:00|CDT|4/29/2022 11:35:00 AM|Non Emergency|50.72(b)(3)(ii)(A)|Degraded Condition|||||||Pelke, Patricia|R3DO|||||||||||||||||||N|N|0|Refueling|0|Refueling||N|0||0|||N|0||0||EN Revision Imported Date: 5/2/2022
EN Revision Text: ULTRASONIC EXAMINATION RESULTS - REACTOR VESSEL HEAD PENETRATION The following information was provided by the licensee via email: "At 0854 [CDT] on April 23, 2022, while performing volumetric inspections required by ASME Code Case N-729-6, a rejectable indication on Reactor Vessel Head Penetration 75 Core Exit Thermocouple (CETC) was identified. The indication is located inboard of the J-groove weld and is OD-initiated [outer diameter - initiated]. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified." The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The repair is scheduled during the refueling outage. * * * UPDATE ON 04/29/22 AT 1112 EDT FROM BRYAN LYKKEBAK TO OSSY FONT * * * The following information was provided by the licensee via telephone and email: "The rejectable indication on Reactor Vessel Head Penetration 75 Core Exit Thermocouple (CETC) initiated on the outside diameter (OD) of the nozzle in an area that was not surface stress mitigated (peened). The indication was found to be acceptable for continued operation under CFR and ASME requirements and will not be repaired during this outage. "The licensee notified the NRC Resident Inspector." Notified R3DO (Ziolkowski). |
Power Reactor|55859|Brunswick|Carolina Power And Light Co.|2|Southport|NC|Brunswick||Y|05000325|1|||[1] GE-4,[2] GE-4|Christopher Denton|Brian P. Smith|04/26/2022|13:13:00|03/07/2022|0:40:00|EDT|4/26/2022 1:23:00 PM|Non Emergency|50.73(a)(1)|Invalid Specif System Actuation|||||||Miller, Mark|R2DO|||||||||||||||||||N|N|0|Cold Shutdown|100|Power Operation| |N|0||0|| |N|0||0||INVALID ACTUATION 60-DAY TELEPHONE NOTIFICATION The following information was provided by the licensee via fax or email: "This 60-day telephone notification is being made in lieu of an LER submittal per 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for invalid actuations of systems listed in 10 CFR 50.73(a)(2)(iv)(B). "At approximately 0040 Eastern Standard Time (EST) on March 7, 2022, Unit 1 received inadvertent High-Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) initiation signals. Subsequently, at approximately 0148 EST on March 7, 2022, Unit 1 received inadvertent Low-Pressure Coolant Injection (LPCI) and Core Spray initiation signals. In addition, all four Emergency Diesel Generators auto started, Group 10 (Instrument Air) Primary Containment Isolation System actuations occurred, and the Residual Heat Removal (RHR) Service Water Booster pumps tripped resulting in a brief interruption (approximately 9 minutes) to the Shutdown Cooling (SDC) heatsink. Jumpers, installed per planned refueling outage activities, prevented discharge of Emergency Core Cooling Systems into the reactor. HPCI, RCIC, and RHR Loop `A' were removed from service and under clearance. RHR SDC remained operable via RHR Loop `B' and forced circulation was maintained in the reactor. "At the time of these events, Unit 1 was shutdown for refueling and the `A' and `C' reactor water level transmitters had been isolated in preparation for planned replacement. Leak-by of the instrument isolation valves occurred on both transmitters. Leak-by on the `C' instrument occurred at a faster rate with the `A' instrument providing the confirmatory signals resulting in Low Level 2 (LL2) and Low Level 3 (LL3) indication at approximately 0040 EST and 0148 EST, respectively. All actuations occurred as designed for LL2 and LL3 signals. During these events, reactor water level remained stable at the Reactor Vessel Head Flange and the `B' and `D' reactor water level transmitters remained off-scale-high, as expected under these conditions. Therefore, the actuations were not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system (i.e., there was no low reactor water level condition). Considering the above, these actuations were invalid." "There was no impact on the health and safety of the public or plant personnel." |
Fuel Cycle Facility|55861|Louisiana Energy Services|Louisiana Energy Services, Llc|2|Eunice|NM|Lea|SNM-2010|Y|70-3103|||| |Barry Love|Brian Lin|04/27/2022|11:23:00|02/28/2022|7:35:00|MDT|5/17/2022 1:25:00 PM|Non Emergency|70.50(b)(1)|Unplanned Contamination|||||||Miller, Mark|R2DO|NMSS_Events_Notification, |EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 5/18/2022
EN Revision Text: UNPLANNED CONTAMINATION EVENT The following information was provided by the licensee via email: "The plant is in a safe configuration. NRC Region II re-exited an inspection on April 26, 2022 from an inspection which was conducted March 21st through the 24th. During this exit, an event was reclassified as a Non-Cited Violation for failure to report an event. As a result, UUSA [Urenco-USA] is reporting this event as a 24-hour Report per the NRC's inspection. "On February 28, 2022, water was discovered on the floor of the Liquid Effluent Collection and Transfer System (LECTS) room. The water was leaking from the slab tanks berm into the non-Radiological Controlled Area floor. The area was conservatively and promptly roped off and signage was posted. Radiological readings in the area were taken and found to be less than background and the the spill was cleaned up that day. "Historical issues are being reviewed and will be added to this notification per the NRC's position shared with UUSA. "This issue has been entered in UUSA's corrective action program as EV 149668 and 149975." * * * UPDATE ON 5/17/22 AT 1305 EDT FROM BARRY LOVE TO BRIAN PARKS * * * The following update was provided by the licensee via email: "As a result of this Event Notification, a review of Extent of Condition was performed. "This Extent of Condition revealed nine historical examples of unplanned contamination events that resulted in expansions of Contaminated Areas that were not reported under 10 CFR 70.50(b)(1) as required by regulation. "These conditions occurred on March 3, 2016 (EV 111023), April 14, 2016 (EV 1129221), August 4, 2016 (EV 113877), December 7, 2016 (EV 116283), February 23, 2017 (EV 117238), November 24, 2019 (EV 136211), November 29, 2021 (EV 148894), February 28, 2022 (EV 149668), and April 14, 2022 (EV 151253). "These events have been investigated and corrected during the approximate time period in which they were identified. No contamination events are ongoing at UUSA at this time." The Licensee will notify the NRC Region 2 Inspector. Notified R2DO (Miller) and NMSS Events Notifications via e-mail.|
Power Reactor|55866|Sequoyah|Tennessee Valley Authority|2|Soddy-Daisy|TN|Hamilton||Y|05000327|1|2||[1] W-4-LP,[2] W-4-LP|Brian Klein|Ossy Font|04/29/2022|0:19:00|04/28/2022|23:55:00|EDT|5/2/2022 9:51:00 PM|Unusual Event|50.72(a) (1) (i)|Emergency Declared|||||||Miller, Mark|R2DO|Andrea Veil|NRR|Laura Dudes|R2RA|Gott, William|IR|||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation| |N|0||0||EN Revision Imported Date: 5/3/2022
EN Revision Text: NOTICE OF UNUSUAL EVENT The following is a summary of information provided by the licensee via telephone: On 04/28/22, at 2355 EDT, with both Sequoyah Unit 1 and 2 in Mode-1, 100 percent, a Notice of Unusual Event was declared due to receiving two seismic alarms and security feeling ground movement. Additionally, security in a tower heard an explosion. Both units remain in Mode-1, 100 percent and they are investigating the validity of the seismic alarms before proceeding with the Abnormal Operating Procedure required shutdown. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified. Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email). * * * UPDATE ON 04/29/2022 AT 0410 EDT FROM BRIAN KLEIN TO OSSY FONT * * * The following is a summary of information provided by the licensee via telephone: On 4/29/22, at 0406 EDT, Sequoyah Unit 1 and Unit 2 terminated the Notice of Unusual Event. The Civil Engineers determined that the alarms were due to a failed seismic indicator channel. Through interviews, only one security officer felt ground movement for a couple of seconds and heard a faint rumbling sound. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified. Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Gott) via email. Additionally, notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email). * * * RETRACTION ON 05/02/2022 AT 2118 EDT FROM SCOTT SEAL TO LLOYD DESOTELL * * * The following information was provided by the licensee via email: "SQN [Sequoyah Nuclear Plant] is retracting the previous NOUE [Notice of Unusual Event] declaration made on 4/28/22 at 2355 [EDT] based on Emergency Action Level HU2 for a seismic event greater than Operating Basis Earthquake levels. Following the declaration of the NOUE, the station reviewed all available indications and determined that a seismic event had not occurred. The instrumentation failure was documented under Event Notification #55867." Notified R2DO (Miller), and IR MOC (Gott), NRR EO (Miller) via email. |
Power Reactor|55867|Sequoyah|Tennessee Valley Authority|2|Soddy-Daisy|TN|Hamilton||Y|05000327|1|2||[1] W-4-LP,[2] W-4-LP|Alton Crenshaw|Bethany Cecere|04/29/2022|7:04:00|04/28/2022|23:38:00|EDT|4/29/2022 7:10:00 AM|Non Emergency|50.72(b)(3)(xiii)|Loss Comm/Asmt/Response|||||||Miller, Mark|R2DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation| |N|0||0||LOSS OF ASSESSMENT CAPABILITY The following information was provided by the licensee via fax: "On 4/28/2022, at 2338 EDT, Sequoyah received an unexpected alarm for seismological recording initiated. At 2341 EDT, unexpected alarm 1/2 Safe Shutdown Earthquake response spectra exceeded was received. The National Earthquake Information Center was contacted to confirm there was no seismic activity, and this was also confirmed on the U.S. Geological Survey website. The alarms were determined to be invalid, and they occurred due to a failure in the seismic monitoring system. This failure results in loss of ability to assess the Emergency Action Level for Initiating Condition HU2 `Seismic event greater than Operating Basis Earthquake (OBE) levels' per procedure EPIP-1, `Emergency Plan Classification Matrix.' "If an actual seismic event had occurred, HU2 could not be assessed. However, compensatory measures have been implemented and include assessing OBE criteria based on alternative criteria contained in procedure AOP-N.05, `Earthquake,' which provides conservative guidance when seismic instruments are unavailable. "This is an eight-hour, non-emergency notification for an event resulting in a major loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii). There is 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 faulty detector was removed from service, so the remaining detector provides conservative detection as the only source to make-up the logic for a seismological alarm. |
Power Reactor|55868|Harris|Carolina Power & Light Co.|2|Raleigh|NC|Wake & Chatham||Y|05000400|1|||[1] W-3-LP|Timothy Manfredi|Bethany Cecere|04/29/2022|7:49:00|04/29/2022|4:05:00|EDT|4/29/2022 7:57:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||Miller, Mark|R2DO|||||||||||||||||||M/R|Y|100|Power Operation|0|Hot Standby| |N|0||0|| |N|0||0||MANUAL REACTOR TRIP AND AUXILIARY FEEDWATER SYSTEM ACTUATION The following information was provided by the licensee via email: "At 0405 Eastern Daylight Time (EDT), with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to degrading condenser vacuum. The trip was not complex, with all systems responding normally post-trip. The Auxiliary Feedwater System started automatically as expected. "Operations responded and stabilized the plant. Decay heat is being removed by the Main Steam System to the main condenser using the turbine bypass valves. "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). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted 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. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No Tech Spec limits were exceeded. Offsite power is available. The suspected cause for the loss of condenser vacuum is when performing the scheduled monthly swap of condenser vacuum pumps, a suction valve failed to shut. |
Power Reactor|55871|FitzPatrick|Entergy Nuclear|1|Lycoming|NY|Oswego||Y|05000333|1|||[1] GE-4|Caleb Wallace|Lloyd Desotell|04/29/2022|20:44:00|04/29/2022|12:51:00|EDT|4/29/2022 8:43:00 PM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||Young, Matt|R1DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE The following information was provided by the licensee via email: "At 1251 EDT on April 29, 2022, while troubleshooting the failure of the High Pressure Coolant Injection (HPCI) Exhaust Drain Pot High Level Alarm to clear, it was discovered that the High Pressure Coolant Injection exhaust line condensate drain system was not functioning as designed to support removal of condensate from the turbine exhaust. This resulted in some water accumulation in the turbine casing. Subsequently, the High Pressure Coolant Injection System was declared inoperable. As a result, this condition is being reported under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented fulfillment of the safety function at the time of discovery. " |