Event Notification Report for November 23, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/22/2021 - 11/23/2021

EVENT NUMBERS
55577 55578 55579 55581 55582 55597
Non-Agreement State
Event Number: 55577
Rep Org: Alt and Witzig Engineering
Licensee: Alt and Witzig Engineering
Region: 3
City: Carmel   State: IN
County:
License #: 13-18685-01
Agreement: N
Docket:
NRC Notified By: Mark Herber
HQ OPS Officer: Donald Norwood
Notification Date: 11/15/2021
Notification Time: 12:45 [ET]
Event Date: 11/15/2021
Event Time: 00:00 [EST]
Last Update Date: 11/15/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 11/23/2021

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

The following is a synopsis of information received via telephone:

Upon arriving at a jobsite in West Indianapolis, the technician went to remove a Troxler gauge for use. Upon opening the toolbox in the bed of the truck, the technician found that the Troxler gauge was missing from its case. The toolbox is bolted to the bed of the truck, however the locks for the toolbox and case were found not to be locked.

At the present time, the licensee is not sure whether the Troxler gauge was stolen or possibly left at the last jobsite where it was used this past Saturday. The licensee is dispatching individuals to the last jobsite to search for the Troxler gauge. The licensee has also reported this event to the Indianapolis Police Department.

The Troxler gauge is a Model 3430 moisture density gauge, serial number 23266. The Troxler gauge contains 0.3 GBq of Cs-137 and 1.48 GBq of Am-241.

The licensee will provide updated information when available.

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: 55578
Rep Org: Colorado Dept of Health
Licensee: Pindustry
Region: 4
City: Greenwood Village   State: CO
County:
License #: GL002686
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 11/15/2021
Notification Time: 14:50 [ET]
Event Date: 10/20/2021
Event Time: 15:37 [MST]
Last Update Date: 11/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 11/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via E-mail:

"One exit sign, model SLX60 was reported as lost when the State requested registration for 17 exit signs shipped to Pindustry for installation."

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: 55579
Rep Org: California Radiation Control Prgm
Licensee: Regents of the University of California - Los Angeles
Region: 4
City: Los Angeles   State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Donald Norwood
Notification Date: 11/15/2021
Notification Time: 15:12 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [PST]
Last Update Date: 11/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/23/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE DURING Y-90 ADMINISTRATION

The following information was received via E-mail:

"On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification.

"The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose).

"The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver.

"Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred.

"UCLA will be investigating the cause of the underdose and make a 15-day written report."

California 5010 Number: 111221

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: 55581
Rep Org: Ohio Bureau of Radiation Protection
Licensee: The MetroHealth System
Region: 3
City: Cleveland   State: OH
County:
License #: 02110180045
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Thomas Herrity
Notification Date: 11/16/2021
Notification Time: 11:45 [ET]
Event Date: 11/14/2021
Event Time: 00:00 [EST]
Last Update Date: 11/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orth, Steve (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/23/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING CALIBRATION SOURCE

The following was received from the Ohio Department of Health Bureau of Radiation Protection via email:

"The licensee reported a sealed Cs-137 source (IPL Model SRV-137-200U) used to calibrate instruments was leaking. The leak test was taken on November 7, 2021 and the results were reported to the licensee on November 14, 2021. The leak test results were 338 Bq (0.009 microCi). Surveys of the lead pig and source storage area showed no contamination. The source will be returned to the manufacturer for disposal."

Ohio Item Number: OH210009


Agreement State
Event Number: 55582
Rep Org: California Radiation Control Prgm
Licensee: Twining, Inc.
Region: 4
City: Inglewood   State: CA
County:
License #: 6872-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Herrity
Notification Date: 11/16/2021
Notification Time: 13:33 [ET]
Event Date: 11/13/2021
Event Time: 00:00 [PST]
Last Update Date: 11/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Event Text
EN Revision Imported Date: 11/23/2021

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

The following was received from the California Department of Public Health (CDPH) via email:

"On Monday, November 15, 2021, Twining, Inc. reported the theft of a CPN MC-1DR #MD0080857 containing sealed sources of Cs-137 (10 mCi) and Am-241 (50 mCi). The theft occurred after 1700 (PST) on Saturday November 13, 2021 at a temporary job storage site (Clipper's Stadium in Inglewood, CA). There was a locked perimeter fence and a guard onsite. The CPN nuclear gauge was locked in its transport case, locked inside a job box, which was chained to a larger Conex box on site. Other equipment was also stolen from the jobsite. A police report is being filed. Additional information has been requested by CDPH."
California event number: 111521

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: 55597
Facility: Calvert Cliffs
Region: 1     State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Keith Swiger
HQ OPS Officer: Rodney Clagg
Notification Date: 11/21/2021
Notification Time: 14:28 [ET]
Event Date: 11/21/2021
Event Time: 10:46 [EST]
Last Update Date: 11/21/2021
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):
Deboer, Joseph (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby
Event Text
EN Revision Imported Date: 11/23/2021

EN Revision Text: MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION

At 1046 EST on November 21, 2021, with Calvert Cliffs Nuclear Power Plant Unit 2 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering levels in both steam generators following a loss of the 21 and 22 steam generator feed pumps. An Auxiliary Feedwater System actuation occurred to restore steam generator water levels. The trip was not complicated, with all systems responding normally. Decay heat is being removed by the Auxiliary Feedwater System. Calvert Cliffs Nuclear Power Plant Unit 1 is unaffected and remains in Mode 1 at 100 percent power.

Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification. RPS actuation, 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 notification, Specific System Actuation, per 10 CFR 50.72(b)(3)(vi)(A).

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

Page Last Reviewed/Updated Tuesday, November 23, 2021