Event Notification Report for July 20, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/19/2021 - 07/20/2021
Fuel Cycle Facility
Event Number: 55480
Facility: Louisiana Energy Services
Region: 2 State: NM
Unit: [] [] []
RX Type:
Comments: Uranium Enrichment Facility
Gas Centrifuge Facility
NRC Notified By: Blake Bixenman
HQ OPS Officer: Ossy Font
Region: 2 State: NM
Unit: [] [] []
RX Type:
Comments: Uranium Enrichment Facility
Gas Centrifuge Facility
NRC Notified By: Blake Bixenman
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 16:55 [ET]
Event Date: 07/20/2021
Event Time: 14:01 [MDT]
Last Update Date: 11/08/2021
Notification Time: 16:55 [ET]
Event Date: 07/20/2021
Event Time: 14:01 [MDT]
Last Update Date: 11/08/2021
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
EN Revision Imported Date: 12/8/2021
EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE
During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.
On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).
The licensee will notify the NRC Region 2.
* * * UPDATE ON 11/8/21 AT 1502 FROM BLAKE BIXEMAN TO KERBY SCALES * * *
During the Apparent Cause Evaluation related to Event Notification 55480, an extent of condition was performed. This extent of condition revealed three historical examples of inaudible CAAS alarms that were not reported under 10 CFR 70.50(b)(2) as required by regulation.
These conditions occurred on April 12th, 2014, August 15th, 2014, and August 20th, 2015.
Corrective actions were implemented for these deficiencies during the approximate time period in which they were identified. The affected systems are currently compliant with 10 CFR 70.24 regulations. Details of this extent of condition are documented in UUSA's Corrective Action Program, EV 148663.
The licensee notified NRC Region 2 personnel.
Notified R2DO (Miller) and NMSS Event Notifications via email.
EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE
During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.
On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).
The licensee will notify the NRC Region 2.
* * * UPDATE ON 11/8/21 AT 1502 FROM BLAKE BIXEMAN TO KERBY SCALES * * *
During the Apparent Cause Evaluation related to Event Notification 55480, an extent of condition was performed. This extent of condition revealed three historical examples of inaudible CAAS alarms that were not reported under 10 CFR 70.50(b)(2) as required by regulation.
These conditions occurred on April 12th, 2014, August 15th, 2014, and August 20th, 2015.
Corrective actions were implemented for these deficiencies during the approximate time period in which they were identified. The affected systems are currently compliant with 10 CFR 70.24 regulations. Details of this extent of condition are documented in UUSA's Corrective Action Program, EV 148663.
The licensee notified NRC Region 2 personnel.
Notified R2DO (Miller) and NMSS Event Notifications via email.
Power Reactor
Event Number: 55365
Facility: Farley
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Roosevelt Scott
HQ OPS Officer: Solomon Sahle
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Roosevelt Scott
HQ OPS Officer: Solomon Sahle
Notification Date: 07/20/2021
Notification Time: 13:06 [ET]
Event Date: 07/20/2021
Event Time: 09:52 [CDT]
Last Update Date: 07/20/2021
Notification Time: 13:06 [ET]
Event Date: 07/20/2021
Event Time: 09:52 [CDT]
Last Update Date: 07/20/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 100 | Power Operation | 100 | Power Operation |
| 2 | N | N | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 8/20/2021
EN Revision Text: FITNESS FOR DUTY REPORT
A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
EN Revision Text: FITNESS FOR DUTY REPORT
A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 55366
Rep Org: LOUISIANA DEQ
Licensee: Acuren Inspection, Inc.
Region: 4
City: Laporte State: LA
County:
License #: LA-7072-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Ossy Font
Licensee: Acuren Inspection, Inc.
Region: 4
City: Laporte State: LA
County:
License #: LA-7072-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Ossy Font
Notification Date: 07/20/2021
Notification Time: 19:44 [ET]
Event Date: 07/20/2021
Event Time: 15:30 [CDT]
Last Update Date: 07/20/2021
Notification Time: 19:44 [ET]
Event Date: 07/20/2021
Event Time: 15:30 [CDT]
Last Update Date: 07/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/20/2021
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT
The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone:
The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs.
The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT
The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone:
The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs.
The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.
Agreement State
Event Number: 55367
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Prime NDT Services, Inc.
Region: 3
City: Strasburg State: OH
County:
License #: 03320990003
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Jeffrey Whited
Licensee: Prime NDT Services, Inc.
Region: 3
City: Strasburg State: OH
County:
License #: 03320990003
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/21/2021
Notification Time: 10:00 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/30/2021
Notification Time: 10:00 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
KENNEDY, SILAS (IR)
DESIREE DAVIS (ILTAB) (ILTAB)
MILLIGAN, PATRICIA (INES)
PELKE, PATRICIA (R3)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
KENNEDY, SILAS (IR)
DESIREE DAVIS (ILTAB) (ILTAB)
MILLIGAN, PATRICIA (INES)
EN Revision Imported Date: 8/30/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following was received from the Ohio Bureau of Radiation Protection via email:
"Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via [the common carrier] on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by [the common carrier]. [The common carrier] is aware of the situation and believes that the package was delayed at their facility. On July 20, [the common carrier] informed Prime NDT Services, Inc. that the package could not be located.
"The State of Tennessee has been informed."
Ohio Item Number: OH210007
Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
* * * UPDATE ON 7/30/2021 AT 1030 EDT FROM MICHAEL SNEE TO SOLOMON SAHLE * * *
The following update was received via an email from the Ohio Department of Health Radiation Protection:
"On July 23, 2021 Prime NDT reported that the source has been located. [The common carrier] indicated that the source was located in their Canton, Ohio facility. Contrary to an earlier report, the source was never transported to [the common carrier] in Memphis, TN. Prime NDT retrieved the source from [the common carrier] facility in Canton."
Notified R3DO (Hanna), INES-National Officer (Smith), ILTAB (Richardson), IR MOC (Grant), NMSS Day (Rivera-Capella), NMSS Events Notification (email), CNSC Canada (email), DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (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 - LOST SOURCE
The following was received from the Ohio Bureau of Radiation Protection via email:
"Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via [the common carrier] on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by [the common carrier]. [The common carrier] is aware of the situation and believes that the package was delayed at their facility. On July 20, [the common carrier] informed Prime NDT Services, Inc. that the package could not be located.
"The State of Tennessee has been informed."
Ohio Item Number: OH210007
Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
* * * UPDATE ON 7/30/2021 AT 1030 EDT FROM MICHAEL SNEE TO SOLOMON SAHLE * * *
The following update was received via an email from the Ohio Department of Health Radiation Protection:
"On July 23, 2021 Prime NDT reported that the source has been located. [The common carrier] indicated that the source was located in their Canton, Ohio facility. Contrary to an earlier report, the source was never transported to [the common carrier] in Memphis, TN. Prime NDT retrieved the source from [the common carrier] facility in Canton."
Notified R3DO (Hanna), INES-National Officer (Smith), ILTAB (Richardson), IR MOC (Grant), NMSS Day (Rivera-Capella), NMSS Events Notification (email), CNSC Canada (email), DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (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
Agreement State
Event Number: 55368
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: University of California, San Diego
Region: 4
City: La Jolla State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ossy Font
Licensee: University of California, San Diego
Region: 4
City: La Jolla State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ossy Font
Notification Date: 07/21/2021
Notification Time: 17:21 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/21/2021
Notification Time: 17:21 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/20/2021
EN Revision Text: AGREEMENT STATE REPORT - Y-90 BRACHYTHERAPY UNDERDOSE
The following was received from the California Department of Public Health via email:
"A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000.
"Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent).
"Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure.
"Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021."
5010 Number: 072121
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 - Y-90 BRACHYTHERAPY UNDERDOSE
The following was received from the California Department of Public Health via email:
"A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000.
"Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent).
"Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure.
"Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021."
5010 Number: 072121
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.