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Event Notification Report for August 30, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
08/29/2022 - 08/30/2022

Agreement State
Event Number: 56061
Rep Org: Florida Bureau of Radiation Control
Licensee: Rummel, Klepper and Kahl, LLP
Region: 1
City: Tampa   State: FL
County:
License #: 4234-1
Agreement: Y
Docket:
NRC Notified By: Ashley Pierre-Saint
HQ OPS Officer: Bill Gott
Notification Date: 08/22/2022
Notification Time: 09:04 [ET]
Event Date: 08/20/2022
Event Time: 20:00 [EDT]
Last Update Date: 08/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
Event Text
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGES

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"On 8/20/2022 at approximately 2130 EDT, the RSO for Rummel, Klepper and Kahl, LLP (RK & K) called the BRC to report that two moisture density gauges were stolen from their facility. They noticed the missing gauges sometime this evening and immediately contacted the BRC and the Orlando Police Department (OPD). At the time of the call, the Radiation Safety Officer (RSO) was only able to provide the serial number for both gauges (24588 & 23489) but no additional information as OPD was on site making a report. A follow-up call is scheduled to gather further details.

"Follow-up with the RK & K RSO on 8/22/22:

"RK & K has two field office trailers located in a yard in Orlando , FL, which is operated by CSX Transportation. On the evening of Saturday 8/20/22, at approximately 2000 EDT, CSX maintenance noticed the fence and lock chains were cut and contacted the senior project engineer. He arrived at the facility around 2045 EDT and noticed the Conex was breached with two gauges missing. They have video of the vehicle entering the complex, but, unfortunately, the plates were taken off. A report was filed with Orlando Police Department. Report #2022-00288935.

"An inspector will be stopping by the facility today for further investigation."

FL Incident Number: FL22-098


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: 56062
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: GE Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights   State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Donald Norwood
Notification Date: 08/22/2022
Notification Time: 11:34 [ET]
Event Date: 08/16/2022
Event Time: 00:00 [CDT]
Last Update Date: 08/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pelke, Patricia (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE LOST IN TRANSIT

The following information was received via email:

"The Illinois Emergency Management Agency (the Agency) was contacted on 8/16/22 by GE Healthcare to advise that a radiopharmaceutical package containing one vial of Iodine-123 had not arrived at a Rochester, NY radiopharmacy as scheduled. The package contained one vial of Iodine-123 with an activity of 20 millicuries at the time of shipment (shipment date 8/11/2022). The last confirmed scan was 8/11/2022, at 1721 EDT, at the Greater Rochester International Airport. The package now contains approximately 0.0206 microcuries. The licensee is in continuous communication with the carrier, who is still actively looking for the package. This matter has a 30-day reporting requirement to the US NRC and is being phoned into the NRC HOO under event number IL220029. There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent."

Illinois Reference Number: IL220029

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: 56075
Facility: Harris
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Michael Merletto
HQ OPS Officer: Ernest West
Notification Date: 08/28/2022
Notification Time: 07:08 [ET]
Event Date: 08/28/2022
Event Time: 03:29 [EDT]
Last Update Date: 08/28/2022
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):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby
Event Text
MANUAL REACTOR TRIP AND AUXILIARY FEEDWATER SYSTEM ACTUATION

The following information was provided by the licensee via email:

"[On 8/28/2022] at 0329 Eastern Daylight Time (EDT), with Unit 1 in Mode 1 at 100% power, the reactor was manually tripped due to a 'B' train main feedwater pump trip. The trip was not complex with all systems responding normally post-trip. The auxiliary feedwater (AFW) system started automatically as expected. Operations responded and stabilized the plant. Steam generator levels are being maintained by AFW through the AFW flow control valves. Decay heat is being removed by using the steam generator power-operated relief valves. The reason for the 'B' train main feedwater pump trip is under investigation.

"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). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the auxiliary feedwater system. There was no impact on the health and safety of the public or plant personnel. 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 cause of the 'B' train main feedwater pump trip is suspected to be the result of an electrical transient due to the alarms that the operators received. In addition, the 'A' train main feedwater pump also tripped subsequent to the reactor trip and that cause is still under investigation.


Power Reactor
Event Number: 56076
Facility: Cook
Region: 3     State: MI
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: John Whitten
HQ OPS Officer: Bethany Cecere
Notification Date: 08/28/2022
Notification Time: 15:41 [ET]
Event Date: 08/28/2022
Event Time: 13:48 [EDT]
Last Update Date: 08/28/2022
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):
Pelke, Patricia (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby
Event Text
AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP TRIP

The following information was provided by the licensee via fax or email:

"On August 28, 2022 at 1348 EDT, DC Cook Unit 1 reactor automatically tripped due to a trip of the #13 Reactor Coolant Pump.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. The DC Cook Resident NRC Inspector has been notified.

"Unit 1 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event.

"Unit 2 remains stable at 100% power / Mode 1."


Agreement State
Event Number: 56063
Rep Org: Texas Dept of State Health Services
Licensee: Recon Petrotechnologies Inc.
Region: 4
City: Alvarado   State: TX
County:
License #: L 06839
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Mike Stafford
Notification Date: 08/23/2022
Notification Time: 18:32 [ET]
Event Date: 08/23/2022
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE

The following report was received via email from the Texas Department of State Health Services (the Agency):

"On August 23, 2022, the licensee notified the Agency that a string of well logging tools containing a 1.5 curie cesium-137 source and a 15 curie americium-241 source was lodged downhole in a well in Starr County, Texas. The sources are at 8,772 foot depth. Efforts to remove approximately 1,800 feet of wireline cable from above the tool were unsuccessful. The abandonment plan has been submitted to the Agency and to the Texas Railroad Commission for review. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9950


Agreement State
Event Number: 56064
Rep Org: MA Radiation Control Program
Licensee: Dana Farber Cancer Institute
Region: 1
City: Boston   State: MA
County:
License #: 60-0037
Agreement: Y
Docket:
NRC Notified By: Joshua E. Daehler
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/24/2022
Notification Time: 11:09 [ET]
Event Date: 08/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNINTENDED DOSE TO FETUS

The following information was provided by the Massachusetts Radiation Control Program (The Agency) via email:

"The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure.

"The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report.

"The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant.

"The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received.

"The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4).

"The Agency considers this event to be open."

Massachusetts Event Number: 20-5109

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: 56065
Rep Org: Georgia Radioactive Material Pgm
Licensee:
Region: 1
City:   State: GA
County: Macon
License #: 1392
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 12:51 [ET]
Event Date: 08/23/2022
Event Time: 12:00 [EDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST RADIOACTIVE PORTABLE GAUGE

The following information was received via email:

"The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to [Environmental Protection Division] (EPD) at [1530 EDT]. The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. [The driver was unable to locate the gauge]. We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss."

The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance:
The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241).

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: 56066
Rep Org: Texas Dept of State Health Services
Licensee: Propetro Services Inc
Region: 4
City: Midland   State: TX
County:
License #: G 02571
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 16:36 [ET]
Event Date: 08/23/2022
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - BROKEN SHUTTER

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On August 24, 2022 the Agency received a report of an equipment failure from a general license acknowledgement (GLA) licensee. A lead plate on the shutter was found to no longer be attached to the shutter. An initial possible cause is that vibrations allowed the lead to go through the screws and become detached. The shutter was removed from service and placed into storage. A lead blanket is covering the gauge and a survey found no elevated readings. The device is approximately 8.5 years old and contains a 200 milli-Curie Cs-137 source. Nobody was believed to have received a significant dose from this issue. The licensee is taking pictures and will try to better determine the cause. The device will be repaired by a service company on August 26, 2022. An investigation is ongoing and further information will be provided per SA-300."

Texas Reference Number: 9951


Agreement State
Event Number: 56067
Rep Org: California Radiation Control Prgm
Licensee: CA Department of Transportation - Engineering Services
Region: 4
City: Santa Ana   State: CA
County:
License #: 8131-30
Agreement: Y
Docket:
NRC Notified By: John Fassel
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 17:57 [ET]
Event Date: 08/24/2022
Event Time: 06:00 [PDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST/RECOVERED RADIOACTIVE SOURCE

The following was provided by the California Department of Public Health (CDPH)/Radiation Health Branch (RHP) via email:

"On August 24, 2022, the Caltrans [California Department of Transportation] RSO [Radiation Safety Officer] notified CDPH/RHB of the theft ( Loss of control) and subsequent recovery of a Caltrans vehicle that contained a locked and shielded Cs-137 sealed source. The 3.7 GBq (100 mCi) Cs-137 sealed source is manufactured by Gammatron, Inc. - model GT-GHP. The sealed source is a component of a Mount Sopris Instrument Company gamma probe logging tool.

"The Caltrans vehicle was parked at [1800 PDT] on August 23, 2022, at a Doubletree hotel in Santa Ana and discovered stolen at [0600 PDT] on August 24, 2022, from the hotel parking lot. The RSO was immediately notified. California Highway Patrol was able to track the vehicle's GPS [Global Positioning System] locator signal to a nearby address where the Santa Ana Police located the abandoned vehicle with the sealed source locked inside. Many other items were stolen from the vehicle. There is an ongoing police investigation."

California Reference Number: 082422