Event Notification Report for July 14, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/13/2022 - 07/14/2022
Agreement State
Event Number: 55979
Rep Org: Wisconsin Radiation Protection
Licensee: Ahlstrom-Munksjo Rhinelander
Region: 3
City: Rhinelander State: WI
County:
License #: GL700495
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Mike Stafford
Licensee: Ahlstrom-Munksjo Rhinelander
Region: 3
City: Rhinelander State: WI
County:
License #: GL700495
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Mike Stafford
Notification Date: 07/06/2022
Notification Time: 12:20 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/06/2022
Notification Time: 12:20 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/06/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following summary was received from the Wisconsin Department of Public Health (the Department) via email:
"During a recent routine inspection, the licensee told the Department that they disposed all their tritium exit signs in 2021; however, the licensee had no disposal records for six tritium exit signs which were distributed to the licensed location in 2012 and 2017. The licensee has thoroughly searched its facility and nearby buildings owned by the licensee but the signs could not be located. The licensee suspects the signs were discarded when the storage cabinet they were in was repurposed. Five of the signs were Isolite Model SLX60 (s/n 12-14613, 12-14615, 12-14616, 12-14617 and 12-14618, each originally containing 6.2 Ci of tritium). One sign was an Isolite Model 2000 (s/n H76360, originally containing 7.5 Ci of tritium).
"The Department considers this matter to be closed."
Wisconsin Event Report ID No.: WI220013
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
The following summary was received from the Wisconsin Department of Public Health (the Department) via email:
"During a recent routine inspection, the licensee told the Department that they disposed all their tritium exit signs in 2021; however, the licensee had no disposal records for six tritium exit signs which were distributed to the licensed location in 2012 and 2017. The licensee has thoroughly searched its facility and nearby buildings owned by the licensee but the signs could not be located. The licensee suspects the signs were discarded when the storage cabinet they were in was repurposed. Five of the signs were Isolite Model SLX60 (s/n 12-14613, 12-14615, 12-14616, 12-14617 and 12-14618, each originally containing 6.2 Ci of tritium). One sign was an Isolite Model 2000 (s/n H76360, originally containing 7.5 Ci of tritium).
"The Department considers this matter to be closed."
Wisconsin Event Report ID No.: WI220013
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: 55980
Rep Org: OR Dept of Health Rad Protection
Licensee: Salem Hospital
Region: 4
City: Salem State: OR
County:
License #: ORE-91006
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Kerby Scales
Licensee: Salem Hospital
Region: 4
City: Salem State: OR
County:
License #: ORE-91006
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Kerby Scales
Notification Date: 07/07/2022
Notification Time: 16:03 [ET]
Event Date: 06/29/2022
Event Time: 00:00 [PDT]
Last Update Date: 07/07/2022
Notification Time: 16:03 [ET]
Event Date: 06/29/2022
Event Time: 00:00 [PDT]
Last Update Date: 07/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
AGREEMENT STATE REPORT - POTENTIAL HIGH DOSE TO OTHER THAN TREATMENT SITE
The following was received from the state of Oregon via email:
"On June 29, a deviation on the length of the transfer tube was identified where the tube was found to be 2.9 centimeters longer than the vendor's specification (122.9 cm vs. 120 cm). This tube is used specifically with Channel 1 of the afterloader [(source: 10 Ci Ir-192; model: VS2000; s/n: 02-01-0235-001-031622-11038-12)] with a tandem and ring (T and R) applicator. Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 cm of unintended tissue which shall exceed 50 rem and quite probably 50 percent to the location. The transfer tube length was last measured on July 27, 2020 and the licensee noted that the tube "measured length appeared to reflect the specified length by the manufacturer at the time." Because of this, the licensee believes they may have under-dosed some of their T and R patients using this transfer tube with Channel 1 of the afterloader. The licensee has already indicated two T and R treatments where this may be the case, May 13 and June 22, and is putting together a list of all cases since the most recent tube length verification in 2020.
Oregon Report ID Number: 22-0031
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.
The following was received from the state of Oregon via email:
"On June 29, a deviation on the length of the transfer tube was identified where the tube was found to be 2.9 centimeters longer than the vendor's specification (122.9 cm vs. 120 cm). This tube is used specifically with Channel 1 of the afterloader [(source: 10 Ci Ir-192; model: VS2000; s/n: 02-01-0235-001-031622-11038-12)] with a tandem and ring (T and R) applicator. Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 cm of unintended tissue which shall exceed 50 rem and quite probably 50 percent to the location. The transfer tube length was last measured on July 27, 2020 and the licensee noted that the tube "measured length appeared to reflect the specified length by the manufacturer at the time." Because of this, the licensee believes they may have under-dosed some of their T and R patients using this transfer tube with Channel 1 of the afterloader. The licensee has already indicated two T and R treatments where this may be the case, May 13 and June 22, and is putting together a list of all cases since the most recent tube length verification in 2020.
Oregon Report ID Number: 22-0031
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.
Power Reactor
Event Number: 55988
Facility: Dresden
Region: 3 State: IL
Unit: [2] [] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Alexander Rehn
HQ OPS Officer: Bill Gott
Region: 3 State: IL
Unit: [2] [] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Alexander Rehn
HQ OPS Officer: Bill Gott
Notification Date: 07/12/2022
Notification Time: 11:47 [ET]
Event Date: 07/12/2022
Event Time: 08:03 [CDT]
Last Update Date: 07/12/2022
Notification Time: 11:47 [ET]
Event Date: 07/12/2022
Event Time: 08:03 [CDT]
Last Update Date: 07/12/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Kozak, Laura (R3DO)
Kozak, Laura (R3DO)
| 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 |
AUTOMATIC REACTOR SCRAM DUE TO TURBINE TRIP ON HIGH REACTOR WATER LEVEL
The following information was provided by the licensee via fax or email:
"At 0803 EDT on 7/12/2022, with the Unit 2 in Mode 1 at 100% power, an automatic scram was received on Unit 2 following a turbine trip due to high reactor water level. The trip was uncomplicated with all systems responding normally post trip. All rods inserted to their full-in positions.
"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).
"The cause of the transient is under investigation.
"Operations responded using the Emergency Operating Procedure and stabilized the plant in Mode 3. Decay heat is being removed using the steam bypass valves to the condenser and the safety relief valves did not lift as a result of the trip. Reactor vessel inventory and pressure are being maintained in normal control bands.
"Unit 3 was not affected by this transient.
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via fax or email:
"At 0803 EDT on 7/12/2022, with the Unit 2 in Mode 1 at 100% power, an automatic scram was received on Unit 2 following a turbine trip due to high reactor water level. The trip was uncomplicated with all systems responding normally post trip. All rods inserted to their full-in positions.
"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).
"The cause of the transient is under investigation.
"Operations responded using the Emergency Operating Procedure and stabilized the plant in Mode 3. Decay heat is being removed using the steam bypass valves to the condenser and the safety relief valves did not lift as a result of the trip. Reactor vessel inventory and pressure are being maintained in normal control bands.
"Unit 3 was not affected by this transient.
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55989
Facility: Seabrook
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Barry Bradbury
HQ OPS Officer: Thomas Herrity
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Barry Bradbury
HQ OPS Officer: Thomas Herrity
Notification Date: 07/12/2022
Notification Time: 13:22 [ET]
Event Date: 07/12/2022
Event Time: 10:51 [EDT]
Last Update Date: 07/12/2022
Notification Time: 13:22 [ET]
Event Date: 07/12/2022
Event Time: 10:51 [EDT]
Last Update Date: 07/12/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Bickett, Brice (R1DO)
Bickett, Brice (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
INADVERTENT SIREN ACTIVATION
The following information was provided by the licensee via fax or email:
"At 1051 EDT on July 12, 2022, Seabrook Station received report of inadvertent siren activation. Local authorities have been contacted to apprise them of inadvertent activation of sirens. No press release is planned at this time.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(xi).
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The inadvertent activation involved one group of nine (9) sirens in the Seabrook Beach area. The cause of the activation is under investigation.
The following information was provided by the licensee via fax or email:
"At 1051 EDT on July 12, 2022, Seabrook Station received report of inadvertent siren activation. Local authorities have been contacted to apprise them of inadvertent activation of sirens. No press release is planned at this time.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(xi).
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The inadvertent activation involved one group of nine (9) sirens in the Seabrook Beach area. The cause of the activation is under investigation.
Power Reactor
Event Number: 55992
Facility: Browns Ferry
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: LaGrant Maye
HQ OPS Officer: Bill Gott
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: LaGrant Maye
HQ OPS Officer: Bill Gott
Notification Date: 07/12/2022
Notification Time: 17:25 [ET]
Event Date: 07/12/2022
Event Time: 09:17 [CDT]
Last Update Date: 07/12/2022
Notification Time: 17:25 [ET]
Event Date: 07/12/2022
Event Time: 09:17 [CDT]
Last Update Date: 07/12/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 96 | Power Operation | 100 | Power Operation |
HIGH PRESSURE COOLANT INJECTION INOPERABLE
The following information was provided by the licensee via fax or email:
"At 0917 CDT on 7/12/2022, during the performance of U1 [Unit 1] High Pressure Coolant Injection (HPCI) rated flow test, the 1-FCV-73-19 (HPCI governor valve) failed to operate as expected. This condition results in U1 HPCI being inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The Automatic Depressurization System (ADS) and Reactor Core Isolation Cooling (RCIC) system remain operable.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"U1 entered TS LCO 3.5.1 Condition C, 14-day Shutdown LCO [Limiting Condition for Operation], due to the HPCI inoperability."
The following information was provided by the licensee via fax or email:
"At 0917 CDT on 7/12/2022, during the performance of U1 [Unit 1] High Pressure Coolant Injection (HPCI) rated flow test, the 1-FCV-73-19 (HPCI governor valve) failed to operate as expected. This condition results in U1 HPCI being inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The Automatic Depressurization System (ADS) and Reactor Core Isolation Cooling (RCIC) system remain operable.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"U1 entered TS LCO 3.5.1 Condition C, 14-day Shutdown LCO [Limiting Condition for Operation], due to the HPCI inoperability."
Part 21
Event Number: 55993
Rep Org: Framatome Anp
Licensee:
Region: 2
City: Lynchburg State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: Gayle Elliott
HQ OPS Officer: Thomas Herrity
Licensee:
Region: 2
City: Lynchburg State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: Gayle Elliott
HQ OPS Officer: Thomas Herrity
Notification Date: 07/13/2022
Notification Time: 14:28 [ET]
Event Date: 05/02/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2022
Notification Time: 14:28 [ET]
Event Date: 05/02/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
PART 21 REPORT - FAILURE OF AN EATON ELECTRICAL CUTLER HAMMER RELAY
The following information was provided by Framatome Inc. via email:
"Framatome Inc. (Framatome) supplied an Eaton Electrical Cutler Hammer, Inc. (Eaton) D26MRD704A1 Relay to Duke Energy Carolinas, LLC, McGuire Nuclear Station, that failed to change state during testing of their load sequencer. This relay was supplied as a safety related component by Framatome. A molded contact bar in the D26 top adder deck prevented a contact spring from settling into its proper position. Top adder decks manufactured between 2003 and 2022 were inspected for the existence of flashing, but no specific time frame where the excess flashing was found could be identified.
"Testing of additional relays with this similar excess flashing condition, by both Framatome and Eaton, showed that contact springs tended to stay in place and were unaffected by the excess flashing. There have been no past similar relay reports by Framatome customers despite there being at least 587 other relays with top adder decks supplied as commercially dedicated components. Eaton has also indicated that they have had no other reports of this condition or failures associated with it.
"The extent of condition determined that the failure is an isolated incident. Only one relay, supplied to McGuire Nuclear Station, failed to change state.
"In the future, as a precaution, the Framatome commercial grade dedication process will include the inspection of the adder deck contact bars. Relays containing contact bars with excess flashing will be rejected."
The following information was provided by Framatome Inc. via email:
"Framatome Inc. (Framatome) supplied an Eaton Electrical Cutler Hammer, Inc. (Eaton) D26MRD704A1 Relay to Duke Energy Carolinas, LLC, McGuire Nuclear Station, that failed to change state during testing of their load sequencer. This relay was supplied as a safety related component by Framatome. A molded contact bar in the D26 top adder deck prevented a contact spring from settling into its proper position. Top adder decks manufactured between 2003 and 2022 were inspected for the existence of flashing, but no specific time frame where the excess flashing was found could be identified.
"Testing of additional relays with this similar excess flashing condition, by both Framatome and Eaton, showed that contact springs tended to stay in place and were unaffected by the excess flashing. There have been no past similar relay reports by Framatome customers despite there being at least 587 other relays with top adder decks supplied as commercially dedicated components. Eaton has also indicated that they have had no other reports of this condition or failures associated with it.
"The extent of condition determined that the failure is an isolated incident. Only one relay, supplied to McGuire Nuclear Station, failed to change state.
"In the future, as a precaution, the Framatome commercial grade dedication process will include the inspection of the adder deck contact bars. Relays containing contact bars with excess flashing will be rejected."
Agreement State
Event Number: 55982
Rep Org: Wisconsin Radiation Protection
Licensee: 3M Company
Region: 3
City: Menomonie State: WI
County:
License #: 033-2030-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Brian Lin
Licensee: 3M Company
Region: 3
City: Menomonie State: WI
County:
License #: 033-2030-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 12:19 [ET]
Event Date: 07/07/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Notification Time: 12:19 [ET]
Event Date: 07/07/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 7/11/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was received from the Wisconsin Department of Health Services via email:
"On July 8, 2022, the State was contacted by a representative of the licensee to report a radiation event that had been identified on July 7. The licensee was performing routine checks on a fixed gauge device, and the individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. The device is believed to have been stuck open for approximately 13 hours. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized. The device is a Mahlo Model 11-200933, [serial number] SN: 11-011988. It contains an Eckert and Ziegler Pm-147 [Model] PHC.C1 source, SN:AH-4968. It has an assay date of April 15, 2016, 1000 mCi. It currently contains approximately 193 mCi. The licensee performed a dose reconstruction of any individual who would have been at the 8 foot boundary of the gauge, which indicates minimal exposure. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee."
WI incident no.: WI220014
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was received from the Wisconsin Department of Health Services via email:
"On July 8, 2022, the State was contacted by a representative of the licensee to report a radiation event that had been identified on July 7. The licensee was performing routine checks on a fixed gauge device, and the individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. The device is believed to have been stuck open for approximately 13 hours. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized. The device is a Mahlo Model 11-200933, [serial number] SN: 11-011988. It contains an Eckert and Ziegler Pm-147 [Model] PHC.C1 source, SN:AH-4968. It has an assay date of April 15, 2016, 1000 mCi. It currently contains approximately 193 mCi. The licensee performed a dose reconstruction of any individual who would have been at the 8 foot boundary of the gauge, which indicates minimal exposure. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee."
WI incident no.: WI220014
Agreement State
Event Number: 55983
Rep Org: Colorado Dept of Health
Licensee: Facebook-Denver
Region: 4
City: Denver State: CO
County:
License #: GL002581
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Licensee: Facebook-Denver
Region: 4
City: Denver State: CO
County:
License #: GL002581
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 15:39 [ET]
Event Date: 06/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Notification Time: 15:39 [ET]
Event Date: 06/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following information was received from the Colorado Department of Public Health and Environment (the department) via email:
The department was notified on June 6, 2022, that two SLX-60 Exit signs containing 7.62 Ci each of H-3 were lost in 2021. No additional information was provided.
CO incident no.: CO220021
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
The following information was received from the Colorado Department of Public Health and Environment (the department) via email:
The department was notified on June 6, 2022, that two SLX-60 Exit signs containing 7.62 Ci each of H-3 were lost in 2021. No additional information was provided.
CO incident no.: CO220021
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: 55984
Rep Org: Iowa Department of Public Health
Licensee: 3M
Region: 3
City: Knoxville State: IA
County:
License #: 0042163FG
Agreement: Y
Docket:
NRC Notified By: Derek Elling
HQ OPS Officer: Brian Lin
Licensee: 3M
Region: 3
City: Knoxville State: IA
County:
License #: 0042163FG
Agreement: Y
Docket:
NRC Notified By: Derek Elling
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:38 [ET]
Event Date: 07/07/2022
Event Time: 15:15 [CDT]
Last Update Date: 07/08/2022
Notification Time: 17:38 [ET]
Event Date: 07/07/2022
Event Time: 15:15 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was received from the Iowa Department of Public Health (IDPH) via email:
"At 1515 CDT, July 7, 2022, an NDC Technologies, Model 302 fixed gauge with [approximately] 80 mCi of Kr-85 had a shutter stick open when the line was turned off. The shutter was first identified as stuck open around 1600 when the Radiation Safety Officer was conducting their entrance radiation survey. Radiation safety perimeter was established. The service provider was called and arrived the morning of July 8, 2022. They were able to close the shutter but unable to conduct cause analysis. The gauge will be shipped back to vendor to safely analyze for cause. The IDPH will decide on a reactive inspection based on the cause of stuck shutter identified by the vendor.
Licensee aware of 30 day written notification requirement."
IA incident no.: IA220004
The following information was received from the Iowa Department of Public Health (IDPH) via email:
"At 1515 CDT, July 7, 2022, an NDC Technologies, Model 302 fixed gauge with [approximately] 80 mCi of Kr-85 had a shutter stick open when the line was turned off. The shutter was first identified as stuck open around 1600 when the Radiation Safety Officer was conducting their entrance radiation survey. Radiation safety perimeter was established. The service provider was called and arrived the morning of July 8, 2022. They were able to close the shutter but unable to conduct cause analysis. The gauge will be shipped back to vendor to safely analyze for cause. The IDPH will decide on a reactive inspection based on the cause of stuck shutter identified by the vendor.
Licensee aware of 30 day written notification requirement."
IA incident no.: IA220004
Agreement State
Event Number: 55985
Rep Org: Colorado Dept of Health
Licensee: Home Depot
Region: 4
City: Denver State: CO
County:
License #: GL000714
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Licensee: Home Depot
Region: 4
City: Denver State: CO
County:
License #: GL000714
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:06 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Notification Time: 17:06 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following summary was received from the Colorado Department of Public Health and Environment via email:
On June 6, 2022, the Colorado Department of Public Health and Environment reported one model 2040 exit sign containing an unknown amount of tritium lost by the licensee. The incident occurred between 2009-2010.
CO incident no.: CO220022
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
The following summary was received from the Colorado Department of Public Health and Environment via email:
On June 6, 2022, the Colorado Department of Public Health and Environment reported one model 2040 exit sign containing an unknown amount of tritium lost by the licensee. The incident occurred between 2009-2010.
CO incident no.: CO220022
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: 55986
Rep Org: Alabama Radiation Control
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
EN Revision Imported Date: 7/11/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."
AL incident no.: 22-10
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 - DOSE MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."
AL incident no.: 22-10
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: 55987
Rep Org: Alabama Radiation Control
Licensee: Southeast Health
Region: 1
City: Dothan State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Southeast Health
Region: 1
City: Dothan State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."
AL incident no.: 21-29
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.
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."
AL incident no.: 21-29
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.