Event Notification Report for April 07, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/06/2022 - 04/07/2022

Agreement State
Event Number: 55809
Rep Org: Iowa Department of Public Health
Licensee: Equistar Chemicals, LP
Region: 3
City: Clinton   State: IA
County:
License #: 0101123FG
Agreement: Y
Docket:
NRC Notified By: Derek Elling
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/30/2022
Notification Time: 15:22 [ET]
Event Date: 03/29/2022
Event Time: 00:00 [CDT]
Last Update Date: 03/30/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was obtained from the state of Iowa via e-mail:

"When conducting routine shutter checks on an Ohmart/Vega SHLG-2 fixed gauge, the operator was not able to extend the plunger to move the source into a shielded position (use of hands and basic tools). The device is in a facility that is restricted access and unmanned due to chemical production. Unless manually operated for shutter checks or vessel maintenance, the standard position of this device is open. No increase of radiation levels compared to standard operating conditions. Radiation Safety Officer has contacted Vega for corrective action guidance and direct support. Initial guidance is the application of a coil lubricant and rotating the handle. Any action above this will be performed by a Vega service technician. The Licensee has a scheduled shutdown of the production line next week when they will schedule the Vega tech for support."

"Source/Radioactive Material: SEALED SOURCE GAUGE
Manufacturer: OHMART CORP.
Model Number: A-2102 IAEA Category: 3
Serial Number: 9849CN
Radionuclide: Cs-137
Activity: 4 Ci (148 GBq)
Iowa Event Number: IA220002"


Agreement State
Event Number: 55810
Rep Org: SC Dept of Health & Env Control
Licensee: DAK Americas LLC
Region: 1
City: Gaston   State: SC
County:
License #: 189
Agreement: Y
Docket:
NRC Notified By: Leland R. Cave
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/30/2022
Notification Time: 15:24 [ET]
Event Date: 03/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 03/30/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER

The following is a summary of information provided by the South Carolina Department of Health and Environmental Control (the Department) via email and phone:

On 3/4/2022, the Department was notified by the licensee's Radiation Safety Officer that while an engineer was attempting to retract the source from a fixed gauge, the gauge became locked with the source in an unshielded position. The source was subsequently retracted to a shielded position. The source is a 70 milliCi Cs-137 source (serial number 6280CO) contained in a VEGA SHLM-CR-2 housing. The manufacturer is expected to come to the plant on March 31, 2022 to evaluate the gauge and make any necessary repairs.

No overexposures occurred as a result of this event.


Agreement State
Event Number: 55811
Rep Org: OK Deq Rad Management
Licensee: Goodyear Tire and Rubber Co.
Region: 4
City:   State: OK
County:
License #: GLD0013
Agreement: Y
Docket:
NRC Notified By: Kevin Sampon
HQ OPS Officer: Brian Lin
Notification Date: 03/31/2022
Notification Time: 11:17 [ET]
Event Date: 03/01/2022
Event Time: 00:00 [CDT]
Last Update Date: 03/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC METER

The following information was received from the State of Oklahoma via email:

"Goodyear Tire and Rubber Co. has reported the loss of a 3M Model 703 Static Meter (S/N 411617). This device was possessed under Oklahoma GLD [generally licensed device] registration GLD0013. It was manufactured in 1977 and initially contained 250 mCi of tritium, which would have decayed to approximately 20 mCi today. Goodyear obtained the device in 2002 and used it for 2 or 3 years before placing it into storage. It was discovered missing earlier this month."

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: 55812
Rep Org: Oregon Health Authority
Licensee: Salem Hospital
Region: 4
City: Salem   State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Daryl A. Leon
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 03/31/2022
Notification Time: 12:56 [ET]
Event Date: 03/22/2022
Event Time: 00:00 [PDT]
Last Update Date: 03/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/RECOVERED SOURCE

The following information was provided by the Oregon Health Authority via email:

"On March 22, 2022, a High Dose Rate Delivery (HDR) sealed source of Iridium-192 was delivered by a common carrier to the wrong floor and clinic in a licensed (Salem Hospital) hospital. Instead of the shipping destination (given as Radiation Oncology/Attn: Dr xxx) on the 1st floor, the package was delivered to the 4th floor of the same building. The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was and placed it on the floor of an access-controlled staff working area.

"On March 28, 2022, the licensee received an email request from the vendor (Varian) to schedule a date/time for installation of the new source. It was at this time that the licensee realized that the source had not arrived at their location and found the source had been delivered on March 22, 2022. An investigation was initiated and the source package was located in the 4th floor clinic. The package was surveyed and observed to be intact with no evidence of tampering . The transport index for the Type A Yellow -II package was noted at 0.9. The package was taken to the licensee's office and secured in locked storage.

"The licensee evaluated the dose received by clinic staff working in the proximity of the package. Clinic staff does not work a full shift in the area (five hours maximum/day) and the closest estimated distance from the package was measured at 2 feet (60 cm). The exposure period was 5 working days. The licensee performed dose measurements on and near the source package at various distances and orientations with a survey meter. The maximum dose received was while sitting in a chair and was calculated to be 0.4 mR/hr.

"Total dose received was given as:
0.4 mR/hr * 5 hrs/day * 5 days = 10 mR total exposure (~10 mrem or 0.01 rem equivalent dose). This dose-risk standard was based upon National Council on Radiation Protection and Measurements (NCRP) Report No. 91.

"Cause and corrective actions :

"The two subsequent causes are of the same nature, human error. First, the carrier failed to deliver the package to the labeled destination and person. Second, the hospital clinic signed for the package without checking the proper destination or person it was intended for. A potential third cause of human error is that the licensee failed to check on package delivery sooner if a tracking number was associated with this shipment. Corrective actions have not been instituted at this time since not all information has been collected for this event. The licensee indicated that they receive these shipments quarterly and wait for the vendor to schedule an installation. There was no indication given of tracking a replacement source package while it is in transit to the licensee's site. This is being investigated further.

"Information regarding the source activity, manufacturer, model, serial number and leak test date will be provided to the NRC Headquarters Operation Center when it is received from the Licensee."

Oregon Report Identification Number: 22-0016


Non-Agreement State
Event Number: 55813
Rep Org: Pearl Harbor Naval Shipyard IMF
Licensee: US Navy
Region: 1
City: Pearl Harbor   State: HI
County:
License #: 45-23675-01NA
Agreement: N
Docket:
NRC Notified By: Mark Tamisharo
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/31/2022
Notification Time: 15:25 [ET]
Event Date: 03/30/2022
Event Time: 15:02 [HST]
Last Update Date: 04/01/2022
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: NON-AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the licensee via phone:

The licensee reported that a generally licensed device has tested positive on a routine leak test (0.006 microCurie). The leaking sealed source was Ni-63 (15 milliCurie), which is used in an Agilent Gas Chromatograph (model G2397A). The gas chromatograph has been tagged out and no exposures were identified.

* * * UPDATE FROM MARK TAMASHIRO TO DONALD NORWOOD AT 1217 EDT ON 4/1/2022 * * *

The following information was received via E-mail:

"Please change the CFR reference to the subject call from 10 CFR 30.50(b)(2) to 10 CFR 31.5(c)(5)."

Notified R1DO (Werkheiser) and NMSS Events Notification E-mail group.


Agreement State
Event Number: 55814
Rep Org: WA Office of Radiation Protection
Licensee: Kaiser Permanente Bellevue
Region: 4
City: St. Bellevue   State: WA
County:
License #: WN-M021
Agreement: Y
Docket:
NRC Notified By: Morgan Bullock
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/31/2022
Notification Time: 20:48 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [PDT]
Last Update Date: 03/31/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (EMAIL)
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE

The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:

"The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago.

"Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill."

WA incident no.: WA-022-006

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: 55821
Facility: Nine Mile Point
Region: 1     State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Roman Arnold
HQ OPS Officer: Ossy Font
Notification Date: 04/05/2022
Notification Time: 06:08 [ET]
Event Date: 04/05/2022
Event Time: 02:23 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(A) - Eccs Injection
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Defrancisco, Anne (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby
Event Text
EN Revision Imported Date: 4/7/2022

EN Revision Text: SCRAM ON LOW LEVEL

The following information was provided by the licensee via telephone and email:

"On 4/5/2022, at time 0223, during maintenance on Feedwater Level Control Valve 2FWS-LV10B, a Feedwater transient occurred resulting in an RPS Automatic Reactor Scram on Low Level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 Recirculation Sample System Isolation, Group 3 TIP [(Traversing Incore Probe)] Isolation Valve Isolation, Group 6 and 7 Reactor Water Cleanup Isolation and Group 9 Containment Purge Isolations.

"All control rods inserted as expected. High Pressure Core Spray and Reactor Core Isolation Cooling initiated and injected as expected. ECCS Systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable in Mode 3.

"These 4 hour and 8-hour non-emergency ENS [(Emergency Notification System)] reports are being made in accordance with 10 CFR 50.72(b)(2)(iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident was informed."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

There was no impact on Unit 1.

Page Last Reviewed/Updated Thursday, April 07, 2022