Event Notification Report for October 04, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/01/2021 - 10/04/2021

Agreement State
Event Number: 55485
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: NexTier Completion Solutions, Inc.
Region: 4
City: Houston   State: TX
County:
License #: GA 507-06
Agreement: Y
Docket:
NRC Notified By: Michael Ortiz
HQ OPS Officer: Mike Stafford
Notification Date: 09/24/2021
Notification Time: 10:24 [ET]
Event Date: 05/09/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE - DAMAGED DENSITOMETERS

The following information was received via email:

"On Sunday, May 9, 2021 NexTier Completion Solutions, Inc., (NexTier) was conducting fracing operations in Eddy County, New Mexico for XTO Energy. At approximately 1900 MDT a fire at the wellsite damaged equipment including two ThermoFisher Scientific densitometers. Eddy County, Otis, Loving and Malaga fire departments responded to the incident late that evening. The wellsite was secured overnight to allow the damaged equipment to cool.

"The NexTier On-Site RSO, from the Odessa, Texas facility, arrived at the wellsite the morning of May 10, 2021 to visually inspect the damaged densitometers and conduct a radiation survey. The visual inspection revealed each densitometer received heavy heat damage and the results of the survey concluded the lead shielding inside each densitometer had been compromised. It was also confirmed the lead plates on the shutter mechanism of the Model 5190 densitometer had been melted. Leak test samples were collected from each densitometer and sent to NSSI Environmental and Recovery Services, Inc., for emergency assay. A perimeter was set up around each densitometer and all personnel instructed to remain out of the area until the damaged densitometers could be removed. The dose rate at this perimeter was less than 2 millirem per hour.

"After receiving the assay results confirming the source capsules had not been compromised, the Odessa RSO completed the removal of supports and clamps which secured the damaged densitometers to the equipment. Using a large crane, he removed the damaged densitometers, one at a time and placed both in a pre-designated area away from personnel. Bags of barite were placed over the damaged densitometers to reduce dose rates throughout the operation. The area was roped off and marked to keep anyone from entering. Following the removal of the densitometers from the equipment the NexTier Corporate Radiation Safety Officer conducted a survey on and around the equipment using a Ludlum Model 3000 survey meter with a Nal scintillation detector. No readings more than natural background were detected."

Each densitometer contained 0.2 Curie of Cs-137.


Agreement State
Event Number: 55486
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: Earthwork Engineering Group
Region: 4
City: Albuquerque   State: NM
County:
License #: NM-DM-378-10
Agreement: Y
Docket:
NRC Notified By: Michael Ortiz
HQ OPS Officer: Brian Lin
Notification Date: 09/24/2021
Notification Time: 10:24 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE

The following information was received via email:

"Earthwork Engineering Group (EEG) reported the loss and recovery of a moisture/density gauge (Seaman Nuclear model C-300, serial #21279) that contained a 1.48 GBq (40 mCi) Am-Be source (AEA Technologies model AMNV.997) and a 0.333 GBq (9 mCi) Cs-137 source (AEA Technologies model CDC.800).

"An EEG employee was contacted by personnel at a job site (believed to be a city inspector) in Albuquerque, New Mexico, on 7/17/2018. The EEG employee was informed that a gauge was left at the job site. The gauge had apparently fallen off the back of the truck. The employee immediately returned to the job site, secured the gauge, and placed it in the shipping container.

"The gauge was out of EEG's control for between 20 and 30 minutes. The gauge was inspected for cracks and leaks. No damage was observed. The employment of the involved employee was terminated for not securing the gauge as trained."

NMED Item No.: 180513


Agreement State
Event Number: 55487
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: Design Technologies
Region: 4
City: Fairacres   State: NM
County:
License #: DM531-01
Agreement: Y
Docket:
NRC Notified By: Michael Ortiz
HQ OPS Officer: Brian P. Smith
Notification Date: 09/24/2021
Notification Time: 10:24 [ET]
Event Date: 03/30/2020
Event Time: 16:00 [MDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE

The following information was received via email:

"The Radiation Safety Officer (RSO) of Design Technologies was notified at approximately 1600 MDT on 3/30/2020 by the technician that that the technician had lost a Troxler model 3411-B, serial number 7085, moisture density gauge out of the back of his truck. The gauge contains 9 millicuries of Cs-137 and 44 millicuries of Am241/Be.

"The technician claims that while on a paving project at the location, he was discussing a rolling pattern with the roller operator and sat the gauge in the bed of his truck with the tailgate down. The foreman then came by and told the technician that he could leave for the day. The technician then got in his truck and drove back to the office without securing the gauge. When the technician arrived at the office, he then realized the gauge was missing from the truck. The technician and the RSO quickly got in the truck to retrace his route from the jobsite to the office in search of the gauge. After searching for the gauge, the RSO then called the New Mexico State Police to report the lost gauge. The search continued until dark along the route until the next morning, 3/31/2020, at daylight.

"The RSO received a phone call from a local contractor in Las Cruces. The contractor stated that he was behind the technician as they were both making a 90 degree right turn onto Taylor Road from North Valley Drive when the gauge slid off the tailgate. The contractor knew what the gauge was and picked it up and put it in the back of his truck. The contractor then tried to track down the technician but could not find him. The contractor contacted the company that calibrates and leak tests our gauges whom the RSO had already notified and they provided the phone number.

"The contractor contacted the RSO and said the gauge was in good condition and its handle was in the shielded position. The RSO placed the gauge in its case, secured it, and brought it back to the office. Upon arriving at the office, the RSO inspected the gauge to the best of his ability, placed it on the standard block and performed a standardization count. The gauge has been placed out-of-service and a leak test was performed as a precautionary measure before the gauge was put back into service."

New Mexico Item No.: NM200011

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: 55488
Rep Org: West Physics
Licensee: West Physics
Region: 3
City: Rensselaer   State: IN
County:
License #: 22-29403-01
Agreement: N
Docket:
NRC Notified By: David Howard
HQ OPS Officer: Brian P. Smith
Notification Date: 09/24/2021
Notification Time: 13:47 [ET]
Event Date: 09/13/2021
Event Time: 12:00 [EDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
FELIZ-ADORNO, NESTOR (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: MISSING SEALED SOURCES

The following is a summary of a phone call with the physicist at the licensee:

The licensee reported that two small sealed sources (Ge-68, roughly 0.7 mCi each) were discovered to be missing from a mobile PET-CT coach that was parked at a location in Rensselaer, IN. This coach was being refurbished at this site. The sources were discovered missing by a service engineer working on the PET-CT unit on 9/13/2021. The entire facility was thoroughly searched with a GM survey meter and the sources could not be located.

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: 55489
Rep Org: LOUISIANA DEQ
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington   State: LA
County: St. Tammany
License #: LA-0569-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2021
Notification Time: 13:48 [ET]
Event Date: 09/23/2021
Event Time: 16:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERES

The following information was received via email:

"Louisiana Department of Environmental Quality (LDEQ) was notified by the St. Tammany Parish Hospital Director of Radiology via the LDEQ Radiation Hotline at approximately 0915 CDT on September 24, 2021, concerning a medical event which took place at the licensee's facility between 1500 and 1600 CDT on September 22, 2021. According to the Director of Radiology, the patient received 366.2 Gray of the radiation dose of Y-90 TheraSpheres, instead of the prescribed radiation dose of 720 Gray, which is more than 20 percent below the prescribed dose.

"The facility Physicist was notified by the Director of Radiology concerning the above medical event on or about 1600 CDT on September 22, 2021. The Physicist in turn notified the hospital Radiation Safety Officer (RSO), who notified the hospital administration concerning the medical event at approximately 0955 CDT on September 23, 2021. According to the Physicist (during a conference call with LDEQ), the remaining Y-90 dose was not shunted, but remained within the TheraSphere kit. According to the Director of Radiology and the Physicist, the prescribing physician stated the patient nevertheless received an adequate therapeutic dose of Y-90."

LDEQ Event Report ID No.: LA 20210008

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: 55491
Rep Org: Alabama Dept. of Public Health
Licensee: West Rock Mill
Region: 1
City: Demopolis   State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2021
Notification Time: 17:40 [ET]
Event Date: 09/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
LALLY, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE - FIXED GAUGE SHUTTER WILL NOT FULLY CLOSE

The following was received via email:

"On 9/23/2021, the Radiation Safety Officer (RSO) for West Rock Mill Company, LLC in Demopolis, AL reported that a fixed gauge was found to have a defective shutter on 9/22/2021. The RSO reported that the gauge's shutter will not rotate fully to the 'locked off' position. The gauge is still mounted in place until a replacement device and tungsten shielding plate is received. No inadvertent exposures to personnel or members of the public were indicated or reported. The gauge is an Ohmart SHF-1B-45, s/n 4-2425, with a 100 millicurie cesium-137 source, assayed in 1994."

Alabama Event: 21-31


Agreement State
Event Number: 55493
Rep Org: S.C. Dept. of Health & Env. Cntrl
Licensee: Infrastructure Consulting and Engineering
Region: 1
City: Gaffney   State: SC
County:
License #: SC-946
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Thomas Herrity
Notification Date: 09/25/2021
Notification Time: 11:38 [ET]
Event Date: 09/24/2021
Event Time: 17:11 [EDT]
Last Update Date: 09/25/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
LALLY, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE STRUCK BY CONSTUCTION VEHICLE

The following was received via email:

"The South Carolina Department of Health and Environmental Control was notified at 1711 EDT via telephone that a Humboldt Model 5001 moisture density gauge (serial number 5189) had been hit by a piece of construction equipment and the source rod was broken off. A Department Inspector was dispatched to the location and assisted the licensee in packing the device and source rod back into the transport container using remote handling tools and survey instruments. Additional shielding (fill dirt) was added to the transport container. Dose rate readings using an ND-2000A (calibrated 9/14/21) indicated readings as high as 38 mR/hr on the surface of the transport container and 0.8 mR/hr at 1 meter. The Humboldt Model 5001 moisture density gauge was transported and secured at the licensee's temporary storage location and is awaiting shipment back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

SC event number: not yet assigned.


Agreement State
Event Number: 55494
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Twining, Inc
Region: 4
City: Long Beach   State: CA
County:
License #: 6872-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Herrity
Notification Date: 09/27/2021
Notification Time: 17:59 [ET]
Event Date: 09/25/2021
Event Time: 08:00 [PDT]
Last Update Date: 09/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 10/4/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

"On Monday, September 27, 2021, Twining, Inc. reported the theft of a CPN MC-1DR #MD01005907 containing sealed sources of Cs-137 (10 mCi) and Am-241 (50 mCi). The theft of a vehicle containing the gauge was reported to the San Bernardino Police Dept. on Sunday, September 26, 2021, when the theft was discovered. Additional information has been requested by CDPH."

California 5010 No.: 092721

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: 55503
Facility: Prairie Island
Region: 3     State: MN
Unit: [2] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Jonathon Tepley
HQ OPS Officer: Thomas Herrity
Notification Date: 10/03/2021
Notification Time: 22:38 [ET]
Event Date: 10/03/2021
Event Time: 15:25 [CDT]
Last Update Date: 10/03/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
KOZAK, LAURA (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown
Event Text
SPECIFIED SYSTEM ACTUATION

"At 1525 CDT, 10/3/2021, with Unit 2 in Mode 5 at 0 percent power for a refueling outage, the 22 Turbine-Driven Auxiliary Feedwater (AFW) pump received an actuation signal during preparations for an Integrated Safety Injection test. The reason for the actuation signal is under investigation. The AFW steam admission valve opened and then, due to plant conditions, received a trip signal due to low discharge pressure. The steam supplies to the TD AFW pump were isolated.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. Unit 1 was not affected by this issue.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."