Event Notification Report for February 07, 2021

EN Revision Imported Date: 2/7/2021

EN Revision Text: AGREEMENT STATE REPORT - DISCONNECTED RADIOGRAPHY SOURCE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On January 29, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that on January 28, 2021, at 1730 [CST], one of their crews had experienced a source disconnect. The crew was using a Sentry model 330 device containing a 39.5 curie cobalt-60 source. The RSO stated the crew had completed work in one area and moved to a new location. After completing the first shot at the new location, the radiographers could not get the source to lock in the shielded position. The radiographers also noted elevated dose rates. The radiographers decided at this point that the source had disconnected. The radiographers contacted the site RSO who contacted the licensee RSO. The licensee contacted the device manufacturer who responded to the site. The manufacturer was able to retrieve the source by 0330 on January 29, 2021. An inspection of the equipment found that the drive cable connector had separated from the drive cable creating the disconnect. The RSO stated the drive unit was fairly new and did not show any signs of damage or rust. The manufacturer will inspect the drive unit to determine the cause of the disconnect. The RSO stated he was sending the dosimetry for his personnel to the processor for reading. No over exposures occurred during this event. Additional information will be provided as it is received in accordance with SA-300."

TX Incident No.: I - 9982

EN Revision Imported Date: 2/7/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following was received from the New York State Department of Health via Fax:

"Consolidated Edison Company reported a leaking source from their Gas Chromatograph [GC]. Their leak test provider called to inform [them] that that their latest leak test was above the limit of 0.005 microcurie. Consolidated Edison does not yet have the specific results. The detector has been isolated and Perkin-Elmer will be contacted for further instructions.

"According to the registrant, the GC model is a Perkin-Elmer Glarus 680 with a 15 millicurie nickel-63 source, Source Model N610-0133 (October 2004). Additional information on the source and corrective actions will be provided as they become available."

This material event contains a "Less than Cat 3" level of radioactive material.

EN Revision Imported Date: 2/7/2021

EN Revision Text: AGREEMENT STATE REPORT - INADVERTENT SOURCE DISPOSAL

The following was received from the Georgia Environmental Protection Division (EPD) via email:

"Pilgrim's owned and operated three gas chromatographs (GC) units [were in a] poultry feed laboratory in Gainesville, Georgia, pursuant to general license #GA1786-2017-G1-1. This letter is intended to provide notice as required by Ga Comp. R. & Regs.  391-3-17-.02(6)(c)(3)(vii)(II) and 391-3-17-.02(6)(c)(3)(xi) that these three GC units were inadvertently disposed of in the Richland Creek Landfill, owned and operated by Republic Services, Inc. (Republic) in Buford, Georgia. At the direction of Georgia EPD, Pilgrim's is in the process of coordinating with Republic to develop a plan for addressing this inadvertent disposal. That plan will be submitted to EPD for approval as part of a Corrective Action Plan.

"For background, early on the morning of December 29, 2020, Pilgrim's [was] advised that a Republic waste collection truck serviced Pilgrim's municipal solid waste (MSW) container located in Gainesville, Georgia at its poultry feed laboratory. Later that morning, Pilgrim's realized that the three gas chromatography instruments, destined for shipment back to the licensed manufacturer of these radiological materials, were inadvertently moved from the warehouse and placed into a MSW dumpster. Pilgrim's immediately notified Republic of the discovery at approximately 1140 EST. Pilgrim's [was] advised that Republic immediately shifted disposal operations at its landfill away from the area of disposal and flagged off the area of disposal for that day to keep operators out and to prevent additional disposal operations.

"As part of the initial discovery, Pilgrim's confirmed via security video camera footage that the equipment was placed in the dumpster designated for MSW only. Republic confirmed that the truck did arrive at Richland Creek Landfill for disposal. Safety Data Sheets (SDSs) for the gas chromatography instruments were provided to Republic. The SDS indicates that the three instruments contained a small integral component with 15 millicuries (mCi) Nickel-63 (Ni-63), a low-energy beta-emitting radioactive isotope.

"Based on information describing the gas chromatograph instruments provided by the manufacture, it is understood that that the Ni-63 components are enclosed in a stainless-steel housing as part of the instruments' electron capture detectors (ECD's). Each one of the Ni-63 components, enclosed within the stainless-steel housing, are approximately 1-2 inches wide and 2-3 inches tall. The Ni-63 incorporated into the ECDs is a solid-state material, not a liquid, with very low potential of leakage. Republic and EPD's Solid Waste Management Unit were notified of the inadvertent disposal on December 29, 2020.

"Currently, Pilgrim's is coordinating with Republic to develop a plan to address final disposition of the licensed equipment. This plan will be submitted as a Corrective Action Plan for EPD's approval."


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

EN Revision Imported Date: 2/7/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following was received from the Florida Bureau of Radiation Control (BRC) via email:

"The [licensee] reported a failed leak test of a cesuim-137 (activity 197.2 microcuries - January 1, 2006) `E' vial. The test was conducted January 27, 2021. The leaking source has been double-bagged and is being stored in a lead-shield container while awaiting an investigation and eventual transfer for disposal. No detectable contamination was found in the storage area, on personnel, in work spaces, nor on equipment. A formal report is forthcoming. The BRC has been contacted and tasked to investigate."

Florida Incident Number: FL21-013

EN Revision Imported Date: 2/7/2021

EN Revision Text:
AGREEMENT STATE REPORT - TREATMENT AREA LARGER THAN PRESCRIBED

The following information was received from the Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee on January 29, at approximately 1940 [MDT], about a medical event involving a Varian Gamma Medplus iX, HDR [high dose rate] afterloader brachytherapy unit with a 5.853 curie iridium-192 source. A patient was being treated for skin cancer on the right leg with a Varian surface applicator utilizing a 35 mm cone. The prescription was for 5000 cGy in 20 fractions of 250 cGy per fraction. The patient was treated at the correct treatment site but without the 35 mm cone inserted into the applicator for one fraction. The Department has requested additional information and continues to investigate the event."

Arizona Incident No. 21-001


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.

EN Revision Imported Date: 2/7/2021

EN Revision Text: PART 21 REPORT - ACTUATOR FAILURE DUE TO LOOSE CAM PINS

The following is a summary of the report provided by the supplier:

Flowserve - Limitorque was informed that during testing of a SMB-0 actuator prior to installation, the actuator failed to return from the manual handwheel mode to motor operation mode. Site personnel removed the electric motor from the actuator and discovered that the worm shaft gear cam pin had become detached from the worm shaft clutch gear. The actuator was one of six identical actuators supplied to Ontario Power Generation by Limitorque in January 2020. Subsequent site inspection of five other actuators received on the order revealed that the cam pins were loose in the worm shaft clutch gear. The issue was discovered prior to placing any of the actuators into service. The defect was the result of improper assembly of the worm shaft clutch gear. The machinist manufacturing the component failed to complete the step require to permanently retain the cam pin in position.

Although no other occurrences of this issue have been reported, Flowserve is continuing to evaluate this issue regarding the potential extent of condition. Currently, there are no recommended actions for the nuclear plants concerning this Part 21 notification.

The supplier has not identified any affected plants at this time and continue to evaluate the extent of condition.

Part number containing the worm shaft clutch gear: 60-420-0130-1

Corrective Actions:

The six gears affected were returned to Limitorque for evaluation and replacement. All SMB worm shaft gears of similar design were placed on temporary quality assurance hold for enhanced inspection. No defective parts were found. All worm shaft gears currently being manufactured will have an additional quality control inspection point for proper cam pin installation.

Point of contact: Kyle Ramsey, Senior Product Engineer at Flowserve-Limitorque Actuation Systems, 5114 Woodall Road, Lynchburg, VA 24502, Office number: 434-522-4138