Event Notification Report for October 05, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/04/2021 - 10/05/2021
Agreement State
Event Number: 55525
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: University of Iowa
Region: 3
City: Iowa City State: IA
County:
License #: 0037152AAB
Agreement: Y
Docket:
NRC Notified By: Stuart Jordan
HQ OPS Officer: Mike Stafford
Licensee: University of Iowa
Region: 3
City: Iowa City State: IA
County:
License #: 0037152AAB
Agreement: Y
Docket:
NRC Notified By: Stuart Jordan
HQ OPS Officer: Mike Stafford
Notification Date: 10/15/2021
Notification Time: 15:16 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [CDT]
Last Update Date: 10/15/2021
Notification Time: 15:16 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [CDT]
Last Update Date: 10/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 11/15/2021
EN Revision Text: AGREEMENT STATE - LOST I-125 RADIOACTIVE SEED
The following was received from the Iowa Department of Public Health (IDPH) via email:
"On October 5, 2021, the University of Iowa's radiation safety officer [RSO] contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21.
"At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr.
"Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can.
"When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2.
"On October 6, the RSO surveyed all of the waste containers and bags that were in the [University of Iowa Health Care] (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight."
Iowa Event Number: IA210004
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 - LOST I-125 RADIOACTIVE SEED
The following was received from the Iowa Department of Public Health (IDPH) via email:
"On October 5, 2021, the University of Iowa's radiation safety officer [RSO] contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21.
"At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr.
"Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can.
"When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2.
"On October 6, the RSO surveyed all of the waste containers and bags that were in the [University of Iowa Health Care] (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight."
Iowa Event Number: IA210004
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: 55536
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: Infiana USA, Inc
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Licensee: Infiana USA, Inc
Region: 1
City: Malvern State: PA
County:
License #: PA-G0087
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Notification Time: 11:04 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 11/19/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 5, 2020, the licensee identified a failed return spring on one of its NDC 103 (serial number 3020641) devices. The device contains 148 mCi (5.55 GBq) of Am-241. The written report received from the service provider on Oct 5, 2020 stated that the secondary shutter device for the device in question failed to close. The primary shutter assembly remained operational at all times. The secondary shutter assembly defect was addressed and corrected by the service provider at the earliest possible time (next scheduled machine downtime event). No overexposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210017
EN Revision Text: AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTER
The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:
"On October 5, 2020, the licensee identified a failed return spring on one of its NDC 103 (serial number 3020641) devices. The device contains 148 mCi (5.55 GBq) of Am-241. The written report received from the service provider on Oct 5, 2020 stated that the secondary shutter device for the device in question failed to close. The primary shutter assembly remained operational at all times. The secondary shutter assembly defect was addressed and corrected by the service provider at the earliest possible time (next scheduled machine downtime event). No overexposures resulted from this event.
"The Department will perform a reactive inspection. A service provider has already corrected the problem."
Event Report ID No: PA210017
Power Reactor
Event Number: 55507
Facility: Beaver Valley
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: James Schwer
HQ OPS Officer: Donald Norwood
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: James Schwer
HQ OPS Officer: Donald Norwood
Notification Date: 10/05/2021
Notification Time: 10:07 [ET]
Event Date: 10/05/2021
Event Time: 06:32 [EDT]
Last Update Date: 10/05/2021
Notification Time: 10:07 [ET]
Event Date: 10/05/2021
Event Time: 06:32 [EDT]
Last Update Date: 10/05/2021
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
CARFANG, ERIN (R1)
CARFANG, ERIN (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | N | 90 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 11/5/2021
EN Revision Text: AUTOMATIC REACTOR TRIP AND AUXILIARY FEEDWATER ACTUATION
"At 0632 EDT on October 5, 2021, with Unit 2 in Mode 1 at approximately 90 percent power for an end of cycle coastdown, the reactor automatically tripped due to an unexpected unblocking of the low power trip logic. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. The Auxiliary Feedwater System automatically started as designed in response to the reactor trip. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves.
"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, the automatic actuation of the Auxiliary Feedwater System is being reported as an eight hour, non-emergency Specific System Actuation per 10 CFR 50.72(b)(3)(iv)(A).
"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 REACTOR TRIP AND AUXILIARY FEEDWATER ACTUATION
"At 0632 EDT on October 5, 2021, with Unit 2 in Mode 1 at approximately 90 percent power for an end of cycle coastdown, the reactor automatically tripped due to an unexpected unblocking of the low power trip logic. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. The Auxiliary Feedwater System automatically started as designed in response to the reactor trip. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves.
"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, the automatic actuation of the Auxiliary Feedwater System is being reported as an eight hour, non-emergency Specific System Actuation per 10 CFR 50.72(b)(3)(iv)(A).
"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: 55510
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Geostruct Engineers, Inc. dba RMG-Rocky Mountain Group
Region: 4
City: Denver State: CO
County:
License #: CO 758-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Brian Lin
Licensee: Geostruct Engineers, Inc. dba RMG-Rocky Mountain Group
Region: 4
City: Denver State: CO
County:
License #: CO 758-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Brian Lin
Notification Date: 10/06/2021
Notification Time: 12:07 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [MDT]
Last Update Date: 10/06/2021
Notification Time: 12:07 [ET]
Event Date: 10/05/2021
Event Time: 00:00 [MDT]
Last Update Date: 10/06/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 11/5/2021
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE
The following information was received via email:
"The morning of Wednesday, October 6, 2021, the Authorized User (AU) discovered that an InstroTek, Inc. model 3500, S/N 3360 (10 mCi Cs-137 and 40 mCi Am-241/Be) portable gauge had been stolen from the back of his work vehicle at his residence. The night before, the AU had secured the gauge with 2 chains and 2 locks to the bed of the truck and the box and trigger were locked as well. The chains had been cut according to the Radiation Safety Officer (RSO). Upon questioning, the RSO assured that gauge storage at personal residences overnight is not an acceptable practice and that the AU has current Department of Transportation training, which has not been verified by Colorado Department of Public Health and Environment. The incident was reported with the Denver Police Department. "
Colorado incident no.: CO210032
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 - STOLEN GAUGE
The following information was received via email:
"The morning of Wednesday, October 6, 2021, the Authorized User (AU) discovered that an InstroTek, Inc. model 3500, S/N 3360 (10 mCi Cs-137 and 40 mCi Am-241/Be) portable gauge had been stolen from the back of his work vehicle at his residence. The night before, the AU had secured the gauge with 2 chains and 2 locks to the bed of the truck and the box and trigger were locked as well. The chains had been cut according to the Radiation Safety Officer (RSO). Upon questioning, the RSO assured that gauge storage at personal residences overnight is not an acceptable practice and that the AU has current Department of Transportation training, which has not been verified by Colorado Department of Public Health and Environment. The incident was reported with the Denver Police Department. "
Colorado incident no.: CO210032
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