Event Notification Report for November 28, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/27/2022 - 11/28/2022
Agreement State
Event Number: 56233
Rep Org: Arkansas Department of Health
Licensee: GTS, Inc.
Region: 4
City: Little Rock State: AR
County:
License #: ARK-0995-03121
Agreement: Y
Docket:
NRC Notified By: Susan Elliot
HQ OPS Officer: Ernest West
Licensee: GTS, Inc.
Region: 4
City: Little Rock State: AR
County:
License #: ARK-0995-03121
Agreement: Y
Docket:
NRC Notified By: Susan Elliot
HQ OPS Officer: Ernest West
Notification Date: 11/18/2022
Notification Time: 16:31 [ET]
Event Date: 10/07/2022
Event Time: 09:15 [CST]
Last Update Date: 11/18/2022
Notification Time: 16:31 [ET]
Event Date: 10/07/2022
Event Time: 09:15 [CST]
Last Update Date: 11/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the The Arkansas Department of Health (The Department) via email:
"The Department received notification on October 7, 2022, from licensee GTS, Inc., that a Troxler gauge model 3430 had been rolled over by a bulldozer while performing routine measurements at a construction site. As a result of the incident, the source was pulled from its testing position and exposed.
"The technician created a thirty (30) foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO mobilized to the event location and contacted the Department.
"The Department's inspectors visited the licensee on October 7, 2022, to investigate the event. Surveys at the exterior of the transport container were determined to be 3 to 5 mR per hour. Surveys performed inside of the transport container were measured to be a maximum of 27 mR per hour at a location close to the surface of the shielded source.
"The RSO returned the handle to the 'safe position' and both radiation sources were placed in the transport box. The gauge was transported back to the designated radiation storage area located at the GTS Little Rock Office in Alexander, Arkansas. The gauge was swabbed for a leak test and then sealed in its transport case and secured in the storage area. Sand and additional temporary screening were installed surrounding the area. GTS then contacted Instrotek Companies for disposal options. On November 9, 2022, the gauge was shipped back to the manufacturer. The licensee performed leak tests of the sources, surveys of the gauge transport container, and surveys of the storage location.
"The Occupational Radiation Exposure Report from October 1, 2022, through December 31, 2022, shows 0 mrem for the RSO and technicians. Leak test certificates showed no leakage.
"Upon review of the licensee's 30 day report, received November 16, 2022, it was noted that the dosimetry badge worn by the RSO during the retraction and transportation of the source showed no measurable dose.
"The report contained leak test results for the sources both on the day of the event, October 7, 2022, and after the event on November 1, 2022. The results for the leak tests in both instances were measured to be below 185 becquerel (0.005 microcuries).
"On October 10, 2022, the company conducted a thorough review of the incident and a safety session was held with the gauge operator involved in the incident prior to the operator returning to field work using a nuclear density gauge. The session included collaborative thinking and planning in performing nuclear density testing safety on unique job sites, especially those with confined work environments.
"Additional topics discussed included utilizing verbal communication with equipment operators prior to accessing a work area, utilizing a 'spotter' while performing testing, and always maintaining possession and visual observation of a nuclear density gauge while the gauge is not inside the transport case in the vehicle.
"The Department considers this event to be closed."
Arkansas Event Number: AR-2022-008
The following information was provided by the The Arkansas Department of Health (The Department) via email:
"The Department received notification on October 7, 2022, from licensee GTS, Inc., that a Troxler gauge model 3430 had been rolled over by a bulldozer while performing routine measurements at a construction site. As a result of the incident, the source was pulled from its testing position and exposed.
"The technician created a thirty (30) foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO mobilized to the event location and contacted the Department.
"The Department's inspectors visited the licensee on October 7, 2022, to investigate the event. Surveys at the exterior of the transport container were determined to be 3 to 5 mR per hour. Surveys performed inside of the transport container were measured to be a maximum of 27 mR per hour at a location close to the surface of the shielded source.
"The RSO returned the handle to the 'safe position' and both radiation sources were placed in the transport box. The gauge was transported back to the designated radiation storage area located at the GTS Little Rock Office in Alexander, Arkansas. The gauge was swabbed for a leak test and then sealed in its transport case and secured in the storage area. Sand and additional temporary screening were installed surrounding the area. GTS then contacted Instrotek Companies for disposal options. On November 9, 2022, the gauge was shipped back to the manufacturer. The licensee performed leak tests of the sources, surveys of the gauge transport container, and surveys of the storage location.
"The Occupational Radiation Exposure Report from October 1, 2022, through December 31, 2022, shows 0 mrem for the RSO and technicians. Leak test certificates showed no leakage.
"Upon review of the licensee's 30 day report, received November 16, 2022, it was noted that the dosimetry badge worn by the RSO during the retraction and transportation of the source showed no measurable dose.
"The report contained leak test results for the sources both on the day of the event, October 7, 2022, and after the event on November 1, 2022. The results for the leak tests in both instances were measured to be below 185 becquerel (0.005 microcuries).
"On October 10, 2022, the company conducted a thorough review of the incident and a safety session was held with the gauge operator involved in the incident prior to the operator returning to field work using a nuclear density gauge. The session included collaborative thinking and planning in performing nuclear density testing safety on unique job sites, especially those with confined work environments.
"Additional topics discussed included utilizing verbal communication with equipment operators prior to accessing a work area, utilizing a 'spotter' while performing testing, and always maintaining possession and visual observation of a nuclear density gauge while the gauge is not inside the transport case in the vehicle.
"The Department considers this event to be closed."
Arkansas Event Number: AR-2022-008
Agreement State
Event Number: 56234
Rep Org: SC Dept of Health & Env Control
Licensee: Mead & Hunt, Inc.
Region: 1
City: West Columbia State: SC
County:
License #: 840
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Ernest West
Licensee: Mead & Hunt, Inc.
Region: 1
City: West Columbia State: SC
County:
License #: 840
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Ernest West
Notification Date: 11/18/2022
Notification Time: 17:12 [ET]
Event Date: 11/18/2022
Event Time: 00:00 [EST]
Last Update Date: 11/18/2022
Notification Time: 17:12 [ET]
Event Date: 11/18/2022
Event Time: 00:00 [EST]
Last Update Date: 11/18/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dimitriadis, Anthony (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dimitriadis, Anthony (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the South Carolina Department of Health and Environmental Control (The Department) via email:
"The Department was notified on 11/18/22 at 1243 EST via telephone that a Troxler 3400 series portable moisture density gauge, serial number 33556, had been hit by a piece of construction equipment.
"The Troxler 3400 series portable moisture density gauge contains a maximum activity of 9 millicuries of Cs-137 and 44 millicuries of Am-241:Be. The licensee reported the source rod had been dislodged but had been successfully inserted back into the shielded position. A Department inspector was dispatched to the location on 11/18/22 and assisted the licensee in packing the damaged Troxler 3400 series device into the transport container. Dose rate readings using a ND-2000A survey instrument, calibrated 09/16/22 indicated readings as high as 30 mR/hr on the surface of the transport container and less than 1 mR/hr at 1 meter.
"The Troxler 3400 series moisture density gauge was transported and secured at the licensee's storage location and is awaiting shipment back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
South Carolina Event Number: To Be Announced
The following information was provided by the South Carolina Department of Health and Environmental Control (The Department) via email:
"The Department was notified on 11/18/22 at 1243 EST via telephone that a Troxler 3400 series portable moisture density gauge, serial number 33556, had been hit by a piece of construction equipment.
"The Troxler 3400 series portable moisture density gauge contains a maximum activity of 9 millicuries of Cs-137 and 44 millicuries of Am-241:Be. The licensee reported the source rod had been dislodged but had been successfully inserted back into the shielded position. A Department inspector was dispatched to the location on 11/18/22 and assisted the licensee in packing the damaged Troxler 3400 series device into the transport container. Dose rate readings using a ND-2000A survey instrument, calibrated 09/16/22 indicated readings as high as 30 mR/hr on the surface of the transport container and less than 1 mR/hr at 1 meter.
"The Troxler 3400 series moisture density gauge was transported and secured at the licensee's storage location and is awaiting shipment back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
South Carolina Event Number: To Be Announced
Agreement State
Event Number: 56235
Rep Org: NE Div of Radioactive Materials
Licensee: BryanLGH Medical Center
Region: 4
City: Lincoln State: NE
County:
License #: 02-06-03
Agreement: Y
Docket:
NRC Notified By: Becki Harisis
HQ OPS Officer: Ian Howard
Licensee: BryanLGH Medical Center
Region: 4
City: Lincoln State: NE
County:
License #: 02-06-03
Agreement: Y
Docket:
NRC Notified By: Becki Harisis
HQ OPS Officer: Ian Howard
Notification Date: 11/22/2022
Notification Time: 15:16 [ET]
Event Date: 10/24/2022
Event Time: 00:00 [CDT]
Last Update Date: 11/22/2022
Notification Time: 15:16 [ET]
Event Date: 10/24/2022
Event Time: 00:00 [CDT]
Last Update Date: 11/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED
The following information was provided by the Nebraska Department of Health and Human Services via email:
"A Radioactive Seed Localization (RSL) contained 247 microcuries of I-125 on 10/24/2022. After the tissue sample containing the seed was surgically removed from the patient, it was placed on a flat plastic pathology grid. It was then placed in a cabinet x-ray unit. The x-ray showed the seed was in the tissue sample and was in fact removed from the patient. The sample was transferred from the plastic grid to a specimen container and then secured with a lid. The container was placed in a bag for transport to the lab. The lab removed the cup from the bag and placed it on the processing bench. The cup was surveyed with a gamma probe to locate the seed. The pathologist was unable to locate the seed using the gamma probe. The pathologist began to slice the sample to locate the seed. All tissue, except the tissue being sent for analysis, was returned to the specimen cup. Pathology then notified the nuclear medicine technologists (NMTs). The NMTs told pathology to control access to the room and not remove any trash or equipment. The NMTs also notified the operating room about the missing seed and had them control access to the room, to include not removing any linens, equipment, or trash. The NMTs then notified the Radiation Safety Officer (RSO) of the missing seed. A NMT surveyed the operating room, the patient, and the operating room staff. Additionally, the x-ray unit, floor, linens, equipment carts, pathology grid, and trash in the operating room were surveyed multiple times. All operating room staff were surveyed, including their shoes, before being allowed out of the room. All surveys were performed with both a GM survey meter and a gamma probe. During this time, another NMT went to the pathology room where the sample was taken and surveyed the room and the staff. The processing bench and hood, floor, and trash of the pathology room were surveyed multiple times. All pathology staff in the room were surveyed multiple times, including their shoes, before being allowed to leave the room. Surveys in the pathology room were also completed with both a GM survey meter and a gamma probe. The RSO viewed the tissue sample x-ray, confirmed that the seed had been removed from the patient and determined the patient was able to go. The RSO performed a survey with the gamma probe of the specimen container, tissue sample, room, processing bench, and trash of the pathology room. The RSO also performed a survey of the operating room, x-ray unit, equipment carts, pathology grid, and trash. The seed was lost sometime after imaging the tissue sample and before the sample was processed by the pathologist in the pathology room. The RSO thinks either the source came loose when being transferred either from the plastic grid into the specimen cup or from the specimen cup onto the processing bench. The RSO thinks it is possible that the seed fell into a seam or opening inside the x-ray cabinet or processing bench and is being shielded by the metal structures. With no shielding the dose rate of the seed is about 0.04 mR/hr at one meter. The RSO stated that since even the most sensitive survey could not find any radiation above background, it is unlikely that any staff or member of the public would, or will, receive any unintended radiation exposure from the missing source. The licensee has revised their procedure to eliminate one of the tissue transfer steps. The tissue sample is now being place directly into the specimen container after removal from the patient. The sample will be x-rayed in the container instead of transferring it to the flat plastic grid."
Source/Radioactive Material: Sealed Source Ionizing
Radionuclide: I-125, 0.000247 Ci
Nebraska Item Number: NE220005
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 provided by the Nebraska Department of Health and Human Services via email:
"A Radioactive Seed Localization (RSL) contained 247 microcuries of I-125 on 10/24/2022. After the tissue sample containing the seed was surgically removed from the patient, it was placed on a flat plastic pathology grid. It was then placed in a cabinet x-ray unit. The x-ray showed the seed was in the tissue sample and was in fact removed from the patient. The sample was transferred from the plastic grid to a specimen container and then secured with a lid. The container was placed in a bag for transport to the lab. The lab removed the cup from the bag and placed it on the processing bench. The cup was surveyed with a gamma probe to locate the seed. The pathologist was unable to locate the seed using the gamma probe. The pathologist began to slice the sample to locate the seed. All tissue, except the tissue being sent for analysis, was returned to the specimen cup. Pathology then notified the nuclear medicine technologists (NMTs). The NMTs told pathology to control access to the room and not remove any trash or equipment. The NMTs also notified the operating room about the missing seed and had them control access to the room, to include not removing any linens, equipment, or trash. The NMTs then notified the Radiation Safety Officer (RSO) of the missing seed. A NMT surveyed the operating room, the patient, and the operating room staff. Additionally, the x-ray unit, floor, linens, equipment carts, pathology grid, and trash in the operating room were surveyed multiple times. All operating room staff were surveyed, including their shoes, before being allowed out of the room. All surveys were performed with both a GM survey meter and a gamma probe. During this time, another NMT went to the pathology room where the sample was taken and surveyed the room and the staff. The processing bench and hood, floor, and trash of the pathology room were surveyed multiple times. All pathology staff in the room were surveyed multiple times, including their shoes, before being allowed to leave the room. Surveys in the pathology room were also completed with both a GM survey meter and a gamma probe. The RSO viewed the tissue sample x-ray, confirmed that the seed had been removed from the patient and determined the patient was able to go. The RSO performed a survey with the gamma probe of the specimen container, tissue sample, room, processing bench, and trash of the pathology room. The RSO also performed a survey of the operating room, x-ray unit, equipment carts, pathology grid, and trash. The seed was lost sometime after imaging the tissue sample and before the sample was processed by the pathologist in the pathology room. The RSO thinks either the source came loose when being transferred either from the plastic grid into the specimen cup or from the specimen cup onto the processing bench. The RSO thinks it is possible that the seed fell into a seam or opening inside the x-ray cabinet or processing bench and is being shielded by the metal structures. With no shielding the dose rate of the seed is about 0.04 mR/hr at one meter. The RSO stated that since even the most sensitive survey could not find any radiation above background, it is unlikely that any staff or member of the public would, or will, receive any unintended radiation exposure from the missing source. The licensee has revised their procedure to eliminate one of the tissue transfer steps. The tissue sample is now being place directly into the specimen container after removal from the patient. The sample will be x-rayed in the container instead of transferring it to the flat plastic grid."
Source/Radioactive Material: Sealed Source Ionizing
Radionuclide: I-125, 0.000247 Ci
Nebraska Item Number: NE220005
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: 56241
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Adam Koziol
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Adam Koziol
Notification Date: 11/28/2022
Notification Time: 08:38 [ET]
Event Date: 11/28/2022
Event Time: 04:00 [EST]
Last Update Date: 11/28/2022
Notification Time: 08:38 [ET]
Event Date: 11/28/2022
Event Time: 04:00 [EST]
Last Update Date: 11/28/2022
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):
Stoedter, Karla (R3DO)
Stoedter, Karla (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE
The following information was provided by the licensee via email:
"At 0400 EST on November 28, 2022, during the performance of Division 2 Residual Heat Removal (RHR) cooling tower fan operability and RHR Service Water valve lineup verification, it was reported that the Main Draft Cooling Tower (MDCT) Fan 'B' was making a loud metallic noise. The cause of the metallic noise is unknown at this time. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on inoperable cooling water to the HPCI room cooler, per LCO 3.0.6.
"Investigation into the Division 2 MDCT Fan 'B' abnormal noise is in progress.
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 0400 EST on November 28, 2022, during the performance of Division 2 Residual Heat Removal (RHR) cooling tower fan operability and RHR Service Water valve lineup verification, it was reported that the Main Draft Cooling Tower (MDCT) Fan 'B' was making a loud metallic noise. The cause of the metallic noise is unknown at this time. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on inoperable cooling water to the HPCI room cooler, per LCO 3.0.6.
"Investigation into the Division 2 MDCT Fan 'B' abnormal noise is in progress.
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56243
Facility: Ginna
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: Jacquelyn Holshouser
HQ OPS Officer: Brian Lin
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: Jacquelyn Holshouser
HQ OPS Officer: Brian Lin
Notification Date: 11/28/2022
Notification Time: 15:34 [ET]
Event Date: 11/28/2022
Event Time: 09:15 [EST]
Last Update Date: 11/28/2022
Notification Time: 15:34 [ET]
Event Date: 11/28/2022
Event Time: 09:15 [EST]
Last Update Date: 11/28/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Cahill, Christopher (R1DO)
FFD Group, (EMAIL)
Cahill, Christopher (R1DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT
A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.