Event Notification Report for May 13, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/12/2021 - 05/13/2021
Agreement State
Event Number: 55234
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Universal Pressure Pumping
Region: 4
City: CLEBURNE State: TX
County:
License #: L 06871
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Lloyd Desotell
Notification Date: 05/05/2021
Notification Time: 11:35 [ET]
Event Date: 05/04/2021
Event Time: 00:00 [CST]
Last Update Date: 05/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER ARM FAILURE
The following was received from the Texas Department of State Health Services (the Agency) by email:
"On May 5, 2021, the Agency was notified by the licensee that while performing fracking operations at a well site, the shutter operating arm roll pin fell out of a Berthold model 8010 nuclear gauge. The gauge contains a 20 milliCurie cesium - 137 source. The licensee was able to close the shutter. The licensee stated that the gauge roll pin had previously failed in November of 2020 (EN 54992). The licensee stated they had been experiencing problems with the gauge roll pins after changing the position of the gauge during operation making it closer to the pump and exposing it to greater vibration. This was the fourth event reported by the licensee since November 2020. The licensee stated that they have begun changing the location of the gauge by moving it further from the pump and therefore exposing it to less vibration. The licensee stated that they had discussed the current location with the manufacturer and was told by the manufacturer that the gauge should not be affected. The roll pin is 5/32 inches in diameter and is friction fitted into the operating rod and held in place by friction. No exposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: I-9846
Agreement State
Event Number: 55236
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Baptist Hospital of Miami
Region: 1
City: Miami State: FL
County:
License #: 0614-2
Agreement: Y
Docket:
NRC Notified By: Dave Pairski
HQ OPS Officer: Thomas Herrity
Notification Date: 05/05/2021
Notification Time: 15:40 [ET]
Event Date: 05/04/2021
Event Time: 16:30 [EDT]
Last Update Date: 05/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, MATT (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION DURING BRACHYTHERAPY TREATMENT
The following was received from the State of Florida:
"Administration of radiation and subsequent received dose to an incorrect area of patient during a gynecological brachytherapy treatment on 5/4/21. The Radiation Safety Officer (RSO) reported that a source transfer tube of incorrect length (approximately 12 cm too long) was used resulting in exposure misadministration.
"The patient was notified. The attending physician and RSO advised patient that no adverse health effects are expected.
"Source Serial #: 02-01-3155-001-020321-11408-84
"Maximum Dose Received: 8-9 Gray, Shallow."
Florida Incident Number: FL21-056
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: 55237
Rep Org: NORTH CAROLINA DIV OF RAD PROTECTIO
Licensee: NV5 Engineers and Consultants, Inc.
Region: 1
City: Durham State: NC
County:
License #: 092-0898-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Thomas Herrity
Notification Date: 05/06/2021
Notification Time: 13:01 [ET]
Event Date: 05/06/2021
Event Time: 00:00 [EDT]
Last Update Date: 05/06/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, MATT (R1DO)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
HARRINGTON, HOLLY (PAO)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following notice was received from the State of North Carolina Radioactive Materials Branch (RMB), via email:
"A portable nuclear density gauge was reported stolen out of a licensee's flatbed truck, sometime during the evening of May 5th. The gauge was reported as secured from unauthorized removal by two independent means and padlocked in its transportation case. The truck was parked in front of the personal residence of one of the licensee's authorized users overnight. The morning of May 6th, the authorized user noticed the gauge case missing with locks and chains broken. The authorized user immediately called 911 and notified the licensee's Radiation Safety Officer immediately, who in turn, notified the RMB who responded to the scene of the theft the morning of [May] 6th. RMB is preparing a press release in an effort to recover the gauge and its investigation is ongoing."
Durham Police Department was notified.
Gauge Information:
Manufacturer: Troxler; Model: 3430P; S/N: 71890
Sources Information:
CS-137 0.300 GBq, 8.0 mCi; Am-241 BE, 40.0 mCi
North Carolina Tracking Number: 210006
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: 55238
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Ascend Performance Materials
Region: 1
City: Cantonment State: FL
County: Escambia
License #: 4145-2
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Thomas Herrity
Notification Date: 05/06/2021
Notification Time: 13:59 [ET]
Event Date: 05/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 05/06/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, MATT (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - FIRE DAMAGE PREVENTS LEVEL GAUGE RETRACTION
The following was reported by the State of Florida via email:
"On 5/5/21 a fire occurred on the same floor as the nylon finishing line using a nuclear gauge (level switch). Fire extinguished by in-house [personnel] on-site as well as Escambia County fire depts. After a structural review was completed and entrance safety assured, continued property examination on 5/6 revealed the nuclear gauge could not be shuttered. No injuries were reported. No exposures were reported. Exclusion zones have been marked on the finishing line floor as well as adjacent floor. At the time of this report, Ascend [Performance Material] is evaluating contractor availability for gauge assessment concerning repair and/or removal. Plant contact person reported the 1500 milliCurie source was purchased in 1962."
Florida Incident Number: FL21-060.
Agreement State
Event Number: 55241
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Chair Rental
Region: 4
City: Sheridan State: CO
County:
License #: GL001987
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Thomas Herrity
Notification Date: 05/06/2021
Notification Time: 17:44 [ET]
Event Date: 06/14/2019
Event Time: 00:00 [MDT]
Last Update Date: 05/06/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following information was received from the State of Colorado via email:
The licensee reported one tritium exit sign lost. The activity was 7.09 Curies of H-3. The sign has been missing since June 2019 and was declared lost on May 6, 2021.
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: 55242
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CSU - Canvas Stadium
Region: 4
City: Colorado Springs State: CO
County:
License #: GL002486
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Thomas Herrity
Notification Date: 05/06/2021
Notification Time: 18:14 [ET]
Event Date: 03/04/2020
Event Time: 00:00 [MDT]
Last Update Date: 05/06/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 5/13/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following information was received from the State of Colorado via email:
The licensee reported three tritium exit signs lost with an activity of 21.6 Curies each. The signs were reported missing and lost on March 4, 2020.
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: 55252
Facility: Wolf Creek
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Tyler Greenfield
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/12/2021
Notification Time: 15:41 [ET]
Event Date: 05/12/2021
Event Time: 11:25 [CDT]
Last Update Date: 05/12/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
GADDY, VINCENT (R4)
Power Reactor Unit Info
| Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
A/R |
Y |
8 |
Power Operation |
0 |
Hot Standby |
Event Text
AUTOMATIC REACTOR TRIP, MAIN FEED ISOLATION, AND AUXILLIARY FEEDWATER SYSTEM ACTUATION
"With Reactor power at approximately 8 percent following a refueling outage, Steam Generator levels began to oscillate while in automatic control. Manual control of Main Feedwater Regulating Valves was unable to stabilize steam generator levels prior to reaching the "C" Steam Generator Low Level Reactor Trip setpoint. Reactor Trip, Main Feedwater Isolation and Auxiliary Feedwater Actuation automatically actuated.
"The plant is stable in Mode 3 at Hot Standby. All equipment has responded as expected.
"The Resident has been contacted."