Event Notification Report for April 13, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/12/2021 - 04/13/2021
Agreement State
Event Number: 55168
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Mid-Tex Testing, LLC
Region: 4
City: Waco State: TX
County:
License #: L 06674
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Licensee: Mid-Tex Testing, LLC
Region: 4
City: Waco State: TX
County:
License #: L 06674
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Notification Date: 04/02/2021
Notification Time: 08:45 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/02/2021
Notification Time: 08:45 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On April 1, 2021, at 1647 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 moisture density gauge containing an eight millicurie cesium-137 source and a 40 millicurie americium-241 source had been run over at a field site by a piece of equipment.
"The RSO stated the technician using the gauge stated that the cesium-137 source was in the fully shielded position when the event occurred. The RSO stated the technician was moving his equipment to a new test location at the site when the gauge was damaged. The RSO stated the gauge case was shattered and he was not sure how they would recover the gauge. He stated the gauge was reading 40 millirem per hour on contact near the cesium source. The RSO stated a barrier was establish around the gauge and the dose rate readings at the barrier were at background.
"The Agency advised the RSO to contact the manufacturer and request assistance in recovering the gauge. The RSO contacted the Agency a short time later and reported the manufacturer could not assist in the recovery. The RSO also stated that during his inspection of the gauge they discovered the cesium source was not in the fully shielded position. Also, it appeared that the source rod was no longer attached to the gauge housing. The RSO stated the source rod was bent so they could not retract the source into the shield.
"The licensee decided to recover the source by picking the source rod up from the end opposite of the source using channel locks and placing it in a thirty gallon can half full with sand and then covering the source with sand. The RSO reported the highest dose rate on the container after placing the source in the can and covering it with sand was 0.8 millirem per hour. The RSO contacted the Agency at 1828 CDT on April 1, 2021, and reported that the source was locked in their storage facility. The RSO stated they would work with the manufacturer to dispose of the gauge and sources. The RSO stated the gauge would be leak tested on April 2, 2021. The RSO stated the americium-241 source was not affected by the event. No individual received a significant exposure from the event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9835
EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On April 1, 2021, at 1647 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 moisture density gauge containing an eight millicurie cesium-137 source and a 40 millicurie americium-241 source had been run over at a field site by a piece of equipment.
"The RSO stated the technician using the gauge stated that the cesium-137 source was in the fully shielded position when the event occurred. The RSO stated the technician was moving his equipment to a new test location at the site when the gauge was damaged. The RSO stated the gauge case was shattered and he was not sure how they would recover the gauge. He stated the gauge was reading 40 millirem per hour on contact near the cesium source. The RSO stated a barrier was establish around the gauge and the dose rate readings at the barrier were at background.
"The Agency advised the RSO to contact the manufacturer and request assistance in recovering the gauge. The RSO contacted the Agency a short time later and reported the manufacturer could not assist in the recovery. The RSO also stated that during his inspection of the gauge they discovered the cesium source was not in the fully shielded position. Also, it appeared that the source rod was no longer attached to the gauge housing. The RSO stated the source rod was bent so they could not retract the source into the shield.
"The licensee decided to recover the source by picking the source rod up from the end opposite of the source using channel locks and placing it in a thirty gallon can half full with sand and then covering the source with sand. The RSO reported the highest dose rate on the container after placing the source in the can and covering it with sand was 0.8 millirem per hour. The RSO contacted the Agency at 1828 CDT on April 1, 2021, and reported that the source was locked in their storage facility. The RSO stated they would work with the manufacturer to dispose of the gauge and sources. The RSO stated the gauge would be leak tested on April 2, 2021. The RSO stated the americium-241 source was not affected by the event. No individual received a significant exposure from the event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9835
Non-Agreement State
Event Number: 55170
Rep Org: Good Samaritan Hospital
Licensee: Good Samaritan Hospital
Region: 3
City: Vincennes State: IN
County:
License #: 13-01787-01
Agreement: N
Docket:
NRC Notified By: Brook Strahle
HQ OPS Officer: Brian P. Smith
Licensee: Good Samaritan Hospital
Region: 3
City: Vincennes State: IN
County:
License #: 13-01787-01
Agreement: N
Docket:
NRC Notified By: Brook Strahle
HQ OPS Officer: Brian P. Smith
Notification Date: 04/04/2021
Notification Time: 14:57 [ET]
Event Date: 04/04/2021
Event Time: 11:30 [EDT]
Last Update Date: 04/05/2021
Notification Time: 14:57 [ET]
Event Date: 04/04/2021
Event Time: 11:30 [EDT]
Last Update Date: 04/05/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
EN Revision Imported Date: 4/16/2021
EN Revision Text: PATIENT RECEIVES WRONG DOSE
The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:
On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.
* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *
On further evaluation, this event did not meet reportability requirements.
Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by email)
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 Text: PATIENT RECEIVES WRONG DOSE
The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:
On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.
* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *
On further evaluation, this event did not meet reportability requirements.
Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by email)
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 55171
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Universal Pressure Pumping Inc
Region: 4
City: Cleburne State: TX
County: La Salle
License #: L06871
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Bethany Cecere
Licensee: Universal Pressure Pumping Inc
Region: 4
City: Cleburne State: TX
County: La Salle
License #: L06871
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Bethany Cecere
Notification Date: 04/05/2021
Notification Time: 15:19 [ET]
Event Date: 04/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2021
Notification Time: 15:19 [ET]
Event Date: 04/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE
"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.
"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"
Texas Incident Number: 9836
EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE
"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.
"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"
Texas Incident Number: 9836
Agreement State
Event Number: 55173
Rep Org: LOUISIANA DEQ
Licensee: QSA Global
Region: 4
City: Baton Rouge State: LA
County:
License #: LA-5934-L01
Agreement: Y
Docket:
NRC Notified By: Judith Schuerman
HQ OPS Officer: Lloyd Desotell
Licensee: QSA Global
Region: 4
City: Baton Rouge State: LA
County:
License #: LA-5934-L01
Agreement: Y
Docket:
NRC Notified By: Judith Schuerman
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/06/2021
Notification Time: 12:17 [ET]
Event Date: 04/05/2021
Event Time: 09:40 [CDT]
Last Update Date: 04/07/2021
Notification Time: 12:17 [ET]
Event Date: 04/05/2021
Event Time: 09:40 [CDT]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERKHEISER, DAVE (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KENNEDY, SILAS (IR)
RICHARDSON, REBECCA (ILTAB)
MILLIGAN, PATRICIA (INES)
WERKHEISER, DAVE (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KENNEDY, SILAS (IR)
RICHARDSON, REBECCA (ILTAB)
MILLIGAN, PATRICIA (INES)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - SEALED SOURCE MISSING IN TRANSIT
The following information was received from the Louisiana Department of Environmental Quality via email:
"A common carrier picked up a black overpack package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 at 1623 CDT on April 1, 2021.
"[The package] left Baton Rouge, LA via common carrier at 2003 CDT and arrived in Memphis, TN at 2319 CDT on April 1, 2021. [The package] was scanned internally at the common carrier's Memphis facility at 0230 CDT on April 2, 2021. That is the last record of this 54 pound package. The [package] destination was Acuren Inspection [located] at 2060 Afton Place in Farmington, NM 87401. (They have not received it.) "
Common Carrier Tracking Number: 9860 8682 9990
LA Incident Tracking Number: LA20210005
Notified: DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).
* * * UPDATE ON 4/7/2021 AT 1612 EDT FROM JAMES PATE TO JEFFREY WHITED * * *
The following is a summary of information received from the Louisiana Department of Environmental Quality via email:
The lost transportation package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 was delivered to its intended licensee this morning.
Notified: R1DO (Werkheiser), IRMOC (Kennedy), NMSS (Rivera-Capella), INES (Milligan), ILTAB (Roundtree), NMSS Event Notifications (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - SEALED SOURCE MISSING IN TRANSIT
The following information was received from the Louisiana Department of Environmental Quality via email:
"A common carrier picked up a black overpack package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 at 1623 CDT on April 1, 2021.
"[The package] left Baton Rouge, LA via common carrier at 2003 CDT and arrived in Memphis, TN at 2319 CDT on April 1, 2021. [The package] was scanned internally at the common carrier's Memphis facility at 0230 CDT on April 2, 2021. That is the last record of this 54 pound package. The [package] destination was Acuren Inspection [located] at 2060 Afton Place in Farmington, NM 87401. (They have not received it.) "
Common Carrier Tracking Number: 9860 8682 9990
LA Incident Tracking Number: LA20210005
Notified: DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).
* * * UPDATE ON 4/7/2021 AT 1612 EDT FROM JAMES PATE TO JEFFREY WHITED * * *
The following is a summary of information received from the Louisiana Department of Environmental Quality via email:
The lost transportation package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 was delivered to its intended licensee this morning.
Notified: R1DO (Werkheiser), IRMOC (Kennedy), NMSS (Rivera-Capella), INES (Milligan), ILTAB (Roundtree), NMSS Event Notifications (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Power Reactor
Event Number: 55187
Facility: Hatch
Region: 2 State: GA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kevin Carter
HQ OPS Officer: Kerby Scales
Region: 2 State: GA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kevin Carter
HQ OPS Officer: Kerby Scales
Notification Date: 04/12/2021
Notification Time: 09:17 [ET]
Event Date: 02/12/2021
Event Time: 23:23 [EDT]
Last Update Date: 04/12/2021
Notification Time: 09:17 [ET]
Event Date: 02/12/2021
Event Time: 23:23 [EDT]
Last Update Date: 04/12/2021
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
MILLER, MARK (R2)
MILLER, MARK (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 0 | Cold Shutdown | 94 | Power Operation |
EN Revision Imported Date: 4/16/2021
EN Revision Text: AUTOMATIC ACTUATION OF GROUP I CONTAINMENT ISOLATION LOGIC
"At 2323 EST on 02/12/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group I containment isolation logic occurred during fluid flushing of turbine stop valves. The reason for the actuation was due to a maintenance activity resulting in turbine stop valve movement with no condenser vacuum which is a Group I isolation signal. Two Group I isolation valves, 2B31F019 and 2B31F020, reactor water sample valves, automatically isolated as designed when the system actuation signal was received. The other Group I valves had already been removed from service as part of the refueling outage schedule.
"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group I containment isolation system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
EN Revision Text: AUTOMATIC ACTUATION OF GROUP I CONTAINMENT ISOLATION LOGIC
"At 2323 EST on 02/12/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group I containment isolation logic occurred during fluid flushing of turbine stop valves. The reason for the actuation was due to a maintenance activity resulting in turbine stop valve movement with no condenser vacuum which is a Group I isolation signal. Two Group I isolation valves, 2B31F019 and 2B31F020, reactor water sample valves, automatically isolated as designed when the system actuation signal was received. The other Group I valves had already been removed from service as part of the refueling outage schedule.
"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group I containment isolation system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55188
Facility: Hatch
Region: 2 State: GA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kevin Carter
HQ OPS Officer: Kerby Scales
Region: 2 State: GA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kevin Carter
HQ OPS Officer: Kerby Scales
Notification Date: 04/12/2021
Notification Time: 09:17 [ET]
Event Date: 02/17/2021
Event Time: 23:20 [EDT]
Last Update Date: 04/12/2021
Notification Time: 09:17 [ET]
Event Date: 02/17/2021
Event Time: 23:20 [EDT]
Last Update Date: 04/12/2021
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
MILLER, MARK (R2)
MILLER, MARK (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 0 | Cold Shutdown | 94 | Power Operation |
EN Revision Imported Date: 4/16/2021
EN Revision Text: AUTOMATIC ACTUATION OF GROUP 2 CONTAINMENT ISOLATION LOGIC
"At 2320 EST on 02/17/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group 2 containment isolation logic occurred on the inboard valves. The reason for the actuation was most likely due to air entrapment in reactor water level sensing lines following maintenance. Group 2 inboard isolation valves in the drywell floor and equipment drain system and the fission product monitor system automatically isolated as designed. As a corrective action, the variable leg and reference leg of the instrumentation were backfilled with water to ensure all air was removed from the line.
"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group 2 containment isolation system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
EN Revision Text: AUTOMATIC ACTUATION OF GROUP 2 CONTAINMENT ISOLATION LOGIC
"At 2320 EST on 02/17/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group 2 containment isolation logic occurred on the inboard valves. The reason for the actuation was most likely due to air entrapment in reactor water level sensing lines following maintenance. Group 2 inboard isolation valves in the drywell floor and equipment drain system and the fission product monitor system automatically isolated as designed. As a corrective action, the variable leg and reference leg of the instrumentation were backfilled with water to ensure all air was removed from the line.
"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group 2 containment isolation system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55175
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Howell Asphalt Company
Region: 3
City: Mattoon State: IL
County:
License #: IL-01725-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Eric Simpson
Licensee: Howell Asphalt Company
Region: 3
City: Mattoon State: IL
County:
License #: IL-01725-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Eric Simpson
Notification Date: 04/07/2021
Notification Time: 10:45 [ET]
Event Date: 04/06/2021
Event Time: 15:00 [CDT]
Last Update Date: 04/07/2021
Notification Time: 10:45 [ET]
Event Date: 04/06/2021
Event Time: 15:00 [CDT]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT SATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 4/6/21 by the Radiation Safety Officer (RSO) for Howell Asphalt Company to report a damaged Troxler Gauge. The incident occurred at approximately 1500 CDT at a temporary job site on Locust Street in Centralia, IL.
"The RSO for Howell Asphalt Company called to report that a Troxler 3440 gauge was run over by a vehicle and was stuck under a car. Reportedly, the driver of the vehicle dismissed the barriers and entered the construction zone. Emergency response personnel arrived on site to isolate and assist in moving the vehicle off the gauge. At the time of the accident, the gauge was in use for backscatter measurements and therefore, all sources were in the shielded position. The RSO responded to the site and reported that both the Cs-137 and the Am-241 sources appeared to be shielded and that only the gauge housing was damaged.
"At 1555 CDT, the RSO called to provide an update. The RSO reported that both sources were undamaged and had been retrieved. The RSO has secured the gauge and is returning it to the Effingham office for disposal through Troxler. The gauge will be transported in its Troxler case which was undamaged. Source and gauge serial numbers are pending and the report will be updated once available. Agency staff will continue to track this matter pending receipt of leak tests and confirmation of disposal"
Illinois Incident Number: IL210007
EN Revision Text: AGREEMENT SATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 4/6/21 by the Radiation Safety Officer (RSO) for Howell Asphalt Company to report a damaged Troxler Gauge. The incident occurred at approximately 1500 CDT at a temporary job site on Locust Street in Centralia, IL.
"The RSO for Howell Asphalt Company called to report that a Troxler 3440 gauge was run over by a vehicle and was stuck under a car. Reportedly, the driver of the vehicle dismissed the barriers and entered the construction zone. Emergency response personnel arrived on site to isolate and assist in moving the vehicle off the gauge. At the time of the accident, the gauge was in use for backscatter measurements and therefore, all sources were in the shielded position. The RSO responded to the site and reported that both the Cs-137 and the Am-241 sources appeared to be shielded and that only the gauge housing was damaged.
"At 1555 CDT, the RSO called to provide an update. The RSO reported that both sources were undamaged and had been retrieved. The RSO has secured the gauge and is returning it to the Effingham office for disposal through Troxler. The gauge will be transported in its Troxler case which was undamaged. Source and gauge serial numbers are pending and the report will be updated once available. Agency staff will continue to track this matter pending receipt of leak tests and confirmation of disposal"
Illinois Incident Number: IL210007
Agreement State
Event Number: 55176
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CHI St. Luke's Health Baylor College of Medicine
Region: 4
City: Houston State: TX
County:
License #: L-06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Jeffrey Whited
Licensee: CHI St. Luke's Health Baylor College of Medicine
Region: 4
City: Houston State: TX
County:
License #: L-06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/07/2021
Notification Time: 16:46 [ET]
Event Date: 04/06/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/07/2021
Notification Time: 16:46 [ET]
Event Date: 04/06/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Texas Department of State Health Services via email:
"On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The [Radiation Safety Officer] RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: I-9837
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 Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Texas Department of State Health Services via email:
"On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The [Radiation Safety Officer] RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: I-9837
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 55177
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: Anheuser-Busch, Inc.
Region: 1
City: State: NH
County: Merrimack
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Licensee: Anheuser-Busch, Inc.
Region: 1
City: State: NH
County: Merrimack
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 01/31/2017
Event Time: 00:00 [EST]
Last Update Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 01/31/2017
Event Time: 00:00 [EST]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER
The following was received from the New Hampshire Radiological Health Section via email:
"[In January 2017], during routine maintenance of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close by ordinary means. A manual shutter handle within the actuation assembly was used to attempt to close the shutter, but the linkage was binding and causing the shutter to remain open. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure resulted.
"The cause was determined by the service technician as a binding solenoid spool. The spool bushing was reamed out and the shutter linkage was lubricated, which allowed the solenoid spool to resume moving freely as designed."
Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH17-0003
EN Revision Text: AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER
The following was received from the New Hampshire Radiological Health Section via email:
"[In January 2017], during routine maintenance of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close by ordinary means. A manual shutter handle within the actuation assembly was used to attempt to close the shutter, but the linkage was binding and causing the shutter to remain open. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure resulted.
"The cause was determined by the service technician as a binding solenoid spool. The spool bushing was reamed out and the shutter linkage was lubricated, which allowed the solenoid spool to resume moving freely as designed."
Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH17-0003
Agreement State
Event Number: 55178
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: OSRAM Sylvania
Region: 1
City: Hillsboro State: NH
County:
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Licensee: OSRAM Sylvania
Region: 1
City: Hillsboro State: NH
County:
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 04/11/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 04/11/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (FAX)
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (FAX)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS
The following was received from the New Hampshire Radiological Health Section via email:
"[In April 2017], a generally-licensed static eliminator was lost during a routine replacement of a series of 30 static eliminators. The devices are leased from NRD Corporation and are affixed to assembly line machines. Annually, they are removed from service and returned to NRD Corporation. The missing device was last in use during a production run on 3/10/17 between 1500 EDT and 2400 EDT. Device exchange occurred during the 2nd shift after the line was shut down. The missing device was noticed during the subsequent 1st shift when supervision performed accountability. A facility search and employee interviews were conducted. Roll-off containers servicing the 'household' and 'recyclables' waste streams were searched without success, likely because the roll-offs contained a significant amount of waste that impeded the search for the relatively small device. The device was still missing after 30 days. The licensee concluded the device was inadvertently disposed in the 'household' waste stream, which is taken to a waste-to-energy incinerator."
Device Details: Polonium-210, 10 mCi (0.37 GBq); NRD Corporation, Model P-2021-8000 static eliminator, s/n A2KN339
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH17-0004
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
EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS
The following was received from the New Hampshire Radiological Health Section via email:
"[In April 2017], a generally-licensed static eliminator was lost during a routine replacement of a series of 30 static eliminators. The devices are leased from NRD Corporation and are affixed to assembly line machines. Annually, they are removed from service and returned to NRD Corporation. The missing device was last in use during a production run on 3/10/17 between 1500 EDT and 2400 EDT. Device exchange occurred during the 2nd shift after the line was shut down. The missing device was noticed during the subsequent 1st shift when supervision performed accountability. A facility search and employee interviews were conducted. Roll-off containers servicing the 'household' and 'recyclables' waste streams were searched without success, likely because the roll-offs contained a significant amount of waste that impeded the search for the relatively small device. The device was still missing after 30 days. The licensee concluded the device was inadvertently disposed in the 'household' waste stream, which is taken to a waste-to-energy incinerator."
Device Details: Polonium-210, 10 mCi (0.37 GBq); NRD Corporation, Model P-2021-8000 static eliminator, s/n A2KN339
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH17-0004
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: 55179
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: Anheuser-Busch Inc.
Region: 1
City: Merrimack State: NH
County:
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Licensee: Anheuser-Busch Inc.
Region: 1
City: Merrimack State: NH
County:
License #: General Licensee
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 01/25/2018
Event Time: 00:00 [EST]
Last Update Date: 04/07/2021
Notification Time: 13:49 [ET]
Event Date: 01/25/2018
Event Time: 00:00 [EST]
Last Update Date: 04/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WERKHEISER, DAVE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/16/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the New Hampshire Radiological Health Section via email:
"[In January 2018], during routine semi-annual leak testing of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close completely by ordinary means and the red 'Source ON' status indicator lamp remained continuously lit. A manual shutter handle within the actuation assembly was used to close the shutter. While doing so, a green wire was noted as brushing against the shutter linkage and impeding its operation. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure.
"The cause was determined by the service technician as a wire interfering with the path of the shutter linkage, preventing full closer of the shutter. The wire was moved out of the way, allowing the shutter to move along its full path as designed."
Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH18-0001
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the New Hampshire Radiological Health Section via email:
"[In January 2018], during routine semi-annual leak testing of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close completely by ordinary means and the red 'Source ON' status indicator lamp remained continuously lit. A manual shutter handle within the actuation assembly was used to close the shutter. While doing so, a green wire was noted as brushing against the shutter linkage and impeding its operation. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure.
"The cause was determined by the service technician as a wire interfering with the path of the shutter linkage, preventing full closer of the shutter. The wire was moved out of the way, allowing the shutter to move along its full path as designed."
Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage
The New Hampshire Radiological Health Section considers this event closed.
Report ID #: #NH18-0001