Report a Safety Concern
Search

The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for March 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/28/2019 - 3/1/2019

** EVENT NUMBERS **


538845388553886538875388853903


Non-Agreement State Event Number: 53884
Rep Org: US ARMY TACOM
Licensee: US ARMY
Region: 3
City: WARREN   State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN McGUIRE
HQ OPS Officer: JOANNA BRIDGE 		Notification Date: 02/20/2019
Notification Time: 13:25 [ET]
Event Date: 02/20/2019
Event Time: 09:30 [EST]
Last Update Date: 02/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ANNE DeFRANCISCO (R1DO)
ERIC DUNCAN (R3DO)
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

REPORT OF LOSS OF NI-63 SOURCES USED IN IMPROVED CHEMICAL AGENT MONITORS

The following was received from the licensee via e-mail:

"The concerned radioactive material is part of an Army Chemical Detection Equipment (CDE) and is called an Improved Chemical Agent Monitor (ICAM) NSN [National Stock Number] 6665-01-357-8502 and Chemical Agent Monitor (CAM), NSN 6665-01-199-4153. Each ICAM and CAM contains 10 mCi of Ni-63. The items with the radioactive material are under US Army NRC License 21-32838-01 issued to the Tank-Automotive and Armaments Command (TACOM). TACOM is located in Warren, MI.

"The reporting was based on 10 CFR 20.2201(a)(ii) (Reports of Theft or Loss of Licensed Material). Licensed material in a quantity greater than 10 times the quantity specified in Appendix C. The quantity specified in Appendix C is 100 microCi. One ICAM/CAM containing 10 mCi is 10,000 microCi. [The Radiation Safety Officer (RSO)] had reported nine CDE, but after confirming the serial numbers, we determined that one of the CDE (serial number 11769) was under another NRC license 19-10306-01 issued to the US Army Edgewood Chemical Biological Center (ECBC) located in Aberdeen Proving Ground (APG), Maryland. This report is for eight CDE under TACOM's NRC license. We have six ICAMs and two CAMs that are lost for a total of 80,000 microCi. The serial numbers for the ICAMs are Z47-M-13972, Z47-M-13526, Z47-M-01859, Z47-M-15832, Z47-M-21980 and Z47-M-18759. The serial numbers for the CAMs are Z16-M-01075 and Z16-M-01025.

"The ICAMs/CAMs are not known to leak and do not have a leak test requirement. The Ni-63 is inside the ICAM/CAM.

"[The RSO] was notified via e-mail on February 19, 2019, at 1545 EST, by the Army Rad waste agency (Joint Munitions Command [JMC] located in Rock Island, IL) of the following:

"'A package containing nine each CDE was in route from APG, Maryland to Pine Bluff Arsenal (PBA), Alabama via [a Common Carrier] and was lost in the possession of [the Common Carrier]. The CDE were being sent for demilitarization and eventual disposal of the Ni-63. The subject package was dropped off at [the Common Carrier] in Baltimore, MD on 26 Nov 2018. The tracking system showing the package as 'In [Common Carrier] Possession'.'

"Prior to the notification on February 19, 2019, JMC called PBA shipping and receiving. PBA personnel indicated that subject package was not received at their location. Also, APG personnel traveled to the [Common Carrier] facility where the items were dropped off. Personnel confirmed that the package was not at that facility.

"As of February 19, 2019, JMC indicated that [the Common Carrier] has not formally issued the a statement of loss, but that JMC will continue to track this for APG. It was a Local Project for JMC with ID number of APG 2018-001.

"On February 20, 2019, at 0847 EST, the [RSO] called [the Common Carrier] with the tracking number. [The RSO] spoke to [an individual] who indicated that a case was assigned to the shipment and a claim was put in. [The RSO] was put in contact with the Trace Department, and was then told that the shipment was considered lost. Shipments after 14 days are considered lost."

This event is related to NRC Event Number 53888.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State Event Number: 53885
Rep Org: CA DEPARTMENT OF PUBLIC HEALTH
Licensee: G3SOILWORKS, INC.
Region: 4
City: NEWPORT BEACH   State: CA
County:
License #: 6492-30
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERL
HQ OPS Officer: JOANNA BRIDGE 		Notification Date: 02/20/2019
Notification Time: 15:15 [ET]
Event Date: 02/20/2019
Event Time: 09:03 [PST]
Last Update Date: 02/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received from the State of California via email:

"On February 20, 2019, the RSO [Radiation Safety Officer] of G3SoilWorks, Inc. contacted the California Office of Emergency Services about a moisture density gauge that was stolen from the operators vehicle at an apartment complex [in] Newport Beach, CA. The gauge was a CPN MC-3, Serial Number M390705215 (10 mCi Cs-137, 50 mCi Am:Be-241). The incident was reported to the Newport Beach Police Department. The gauge has not been found at this time."

California 5010 number: 022019

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State Event Number: 53886
Rep Org: COLORADO DEPT OF PUBLIC HEALTH
Licensee: CARDINAL HEALTH 414, LLC
Region: 4
City: DENVER   State: CO
County:
License #: CO 1219-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOANNA BRIDGE 		Notification Date: 02/20/2019
Notification Time: 17:21 [ET]
Event Date: 02/11/2019
Event Time: 00:00 [MST]
Last Update Date: 02/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST PACKAGE CONTAINING RA-223

The following report was received from the State of Colorado via email:

"On February 14th, 2019, a written report was received from Cardinal Health detailing the events of a lost package containing 180.3 microCi (shipped activity) Ra-223. The package was lost in transit on February 11th, the intended recipient was in Savannah, GA. The courier for the package was a [Common Carrier]. A search by the [Common Carrier] located the package on the side of the road on February 12th in the Savannah, GA area. Regional Cardinal Health technicians were dispatched to the found package and determined that the transport index was as expected and the package indicated no removable contamination. Cardinal Health took possession of the package for decay-in-storage."

CO Event Report ID No.: CO190002

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


Non-Agreement State Event Number: 53887
Rep Org: AVERA MCKENNAN HOSPITAL
Licensee: AVERA MCKENNAN HOSPITAL
Region: 4
City: SIOUX FALLS   State: SD
County:
License #: 40-16571-01
Agreement: N
Docket:
NRC Notified By: TRACI HOLLINGSHEAD
HQ OPS Officer: BETHANY CECERE 		Notification Date: 02/21/2019
Notification Time: 11:28 [ET]
Event Date: 02/21/2019
Event Time: 07:00 [MST]
Last Update Date: 02/21/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
RICK DEESE (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
WILLIAM GOTT (IRD)

Event Text

MOBILE DIAGNOSTIC TRUCK INVOLVED IN FATAL TRANSPORTATION ACCIDENT

The Avera McKennan Hospital mobile diagnostic truck was in an accident where the truck went off the road, the cab and box detached, and the driver was killed. The truck contained various used sources and medical materials used in nuclear diagnostic medicine. The sources, although ejected from the truck, were found nearby in their respective transport boxes with the exception of the Tc-99 used syringes (sharps). Surveys and wipe tests show no contamination. The sealed sources will be leak checked. The transport box for the Co-60 source was damaged with a small hole. Radiation readings are slightly higher in the proximity of the hole. All the recovered sources are in storage at the hospital. The sharps container was empty with the sharps strewn along the snow bank alongside the road. Residual materials may be within the sharps. Cleanup of the material is underway but may be delayed until the snow melts.

The accident occurred on I-29, north of Sioux Falls, between the Baltic and Dell Rapids exits. The truck was headed north. The South Dakota Highway Patrol responded to the scene.

Notified South Dakota Health Agency, DOT Crisis Management Center, DOE Ops Center, and DHS SWO.


Non-Agreement State Event Number: 53888
Rep Org: ABERDEEN PROVING GROUNDS
Licensee: U. S. ARMY
Region: 1
City: ABERDEEN   State: MD
County:
License #: 19-10306-01
Agreement: Y
Docket:
NRC Notified By: AMY RAMSEY
HQ OPS Officer: MARK ABRAMOVITZ 		Notification Date: 02/21/2019
Notification Time: 13:27 [ET]
Event Date: 02/21/2019
Event Time: 11:20 [EST]
Last Update Date: 02/21/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANNE DeFRANCISCO (R1DO)
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

NI-63 SOURCE LOST DURING SHIPMENT

The following was received from the licensee via e-mail:

"On 21 February 2019 the Aberdeen Proving Ground Garrison Radiation Safety Officer (RSO) notified [the Combat Capabilities Development Command Chemical Biological Center RSO] of a lost [commercial carrier shipment] containing multiple Chemical Agent Monitor (CAM) detectors. Shipment, dated November 26, 2018.

"On November 26, 2018, the Garrison RSO shipped a package containing multiple chemical detectors with radioactive sources. One CAM, serial # 11769, containing 10 mCi of Ni-63 which is owned by the Chemical Biological Center under NRC license 19-10306-01, was included in the package.

"The shipment was going to Pine Bluff, Arkansas for final waste disposal.

"The Garrison RSO stated that a search for the packaged had been conducted at two [commercial carrier] locations, one in Maryland and one at the Pine Bluff final destination location with no package being found."

This event is related to NRC Event Number 53884.

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 Event Number: 53903
Facility: LASALLE
Region: 3     State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: JOANNA BRIDGE 		Notification Date: 03/01/2019
Notification Time: 04:03 [ET]
Event Date: 02/28/2019
Event Time: 22:17 [CST]
Last Update Date: 03/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN HANNA (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

SPECIFIED SYSTEM ACTUATION - TRIP OF SAFETY RELATED BUS

"On February 28, 2019, at 2217 CST, LaSalle Unit 2 experienced a trip of the 241Y Safety Related Bus during surveillance testing resulting in a valid undervoltage actuation signal to the Common Emergency Diesel Generator ('O' EDG), causing it to start and load to Bus 241Y. The purpose of the surveillance testing was to demonstrate the operability of the breakers necessary to provide the second off site source to Unit 2. This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A), as an event that results in a valid actuation of the emergency AC electrical power system. In addition to the 241Y bus trip and 'O' EDG actuation signal, the following plant responses occurred as designed due to the momentary loss of this AC Bus: "A" RPS de-energized due to the loss of the 2A Reactor Protection System Motor-Generator Set, and the running Unit 2 Fuel Pool Cooling pump tripped. The Non-Safety Related Bus 241X de-energized resulting in a trip of the Unit 2 Station Air Compressor. All systems have been restored and troubleshooting is currently in progress. Unit 1 remained in MODE 1 during this event.

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 24, 2021