Event Notification Report for January 31, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/30/2023 - 01/31/2023
Non-Power Reactor
Event Number: 56331
Rep Org: Univ Of California Davis Mcclellan (CALD)
Licensee: United States Air Force
Region: 0
City: Sacramento State: CA
County: Sacramento
License #: R-130
Agreement: Y
Docket: 05000607
NRC Notified By: Wesley Frey
HQ OPS Officer: Brian P. Smith
Licensee: United States Air Force
Region: 0
City: Sacramento State: CA
County: Sacramento
License #: R-130
Agreement: Y
Docket: 05000607
NRC Notified By: Wesley Frey
HQ OPS Officer: Brian P. Smith
Notification Date: 02/01/2023
Notification Time: 16:51 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [PST]
Last Update Date: 02/01/2023
Notification Time: 16:51 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [PST]
Last Update Date: 02/01/2023
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Takacs, Michael (NRR)
Tran, Linh (NRR)
Takacs, Michael (NRR)
Tran, Linh (NRR)
LIMITING CONDITION OF OPERATION NOT MET
The following information was provided by the licensee via email:
"[University of California, Davis McClellan Nuclear Research Center] MNRC received its new 20 year operating license from the NRC on November 21, 2022. As part of the new license, several new conditions in the technical specification were added for consistency with other non-power reactors and to give greater assurances of public safety beyond the previous technical specifications.
"The license condition involved in this event is Technical Specification 3.3 specification 4 concerning the maximum allowable activity of radionuclides in MNRC's primary cooling water with half-lives greater than 24 hours. The specific requirement is that these radionuclide concentrations shall be less than the 10 CFR 20 Appendix B table 3 values for the reactor to be operated. When agreeing to this new technical specification, MNRC staff looked at the historical values for all non-tritium nuclides having half-lives greater than 24 hours. These nuclides are assayed at MNRC via high resolution gamma-ray spectroscopy. For these nuclides MNRC is able to meet the new [limiting condition of operation] LCO limit easily. Separately, MNRC staff evaluated the tritium activity that was provided to MNRC via a 3rd party laboratory. The latest result from the 3rd party laboratory appeared to confirm that MNRC would meet the new tritium limit of 0.01 uCi/ml by having a tritium concentration of approximately 1/40th of this value.
"On January 31, 2023, during the planning for the required surveillance of technical specification 3.3 item 4, it was discovered that the 3rd party laboratory result was incorrect and they mistakenly underreported tritium concentrations by a factor of 100. At approximately 1600 (PST) on the same day, it was verified that MNRC's primary water tritium concentration was approximately 2.5 times the new technical specification limit given in section 3.3 item 4, resulting in not being able to meet an LCO. A more thorough data review shows that historical concentrations of the tritium in MNRC's primary coolant are very constant (except for the misreported data used to evaluation MNRC's ability to meet the new technical specification 3.3 item 4). Therefore, failing to meet this LCO is a condition that has likely existed since the issuing of the new license on November 21, 2022. MNRC was not operating at the time of this discovery and has not resumed reactor operations.
"There has likely been no increase in the amount of tritium in MNRC's primary cooling water nor has any primary cooling water been released from the reactor tank since the new technical specification took effect. There are no safety or security concerns generated as a result of this event.
"The facility license holder (level 1 management), the chair of the MNRC safety committee, MNRC's NRC program manager, assistant program manager, and inspector have been notified of this event. The ultimate resolution of this issue will need to be a license amendment increasing the permissible tritium concentration in the primary cooling water as a condition for reactor operation as it is physically impossible to lower the tritium concentration in order to meet the LCO."
The following information was provided by the licensee via email:
"[University of California, Davis McClellan Nuclear Research Center] MNRC received its new 20 year operating license from the NRC on November 21, 2022. As part of the new license, several new conditions in the technical specification were added for consistency with other non-power reactors and to give greater assurances of public safety beyond the previous technical specifications.
"The license condition involved in this event is Technical Specification 3.3 specification 4 concerning the maximum allowable activity of radionuclides in MNRC's primary cooling water with half-lives greater than 24 hours. The specific requirement is that these radionuclide concentrations shall be less than the 10 CFR 20 Appendix B table 3 values for the reactor to be operated. When agreeing to this new technical specification, MNRC staff looked at the historical values for all non-tritium nuclides having half-lives greater than 24 hours. These nuclides are assayed at MNRC via high resolution gamma-ray spectroscopy. For these nuclides MNRC is able to meet the new [limiting condition of operation] LCO limit easily. Separately, MNRC staff evaluated the tritium activity that was provided to MNRC via a 3rd party laboratory. The latest result from the 3rd party laboratory appeared to confirm that MNRC would meet the new tritium limit of 0.01 uCi/ml by having a tritium concentration of approximately 1/40th of this value.
"On January 31, 2023, during the planning for the required surveillance of technical specification 3.3 item 4, it was discovered that the 3rd party laboratory result was incorrect and they mistakenly underreported tritium concentrations by a factor of 100. At approximately 1600 (PST) on the same day, it was verified that MNRC's primary water tritium concentration was approximately 2.5 times the new technical specification limit given in section 3.3 item 4, resulting in not being able to meet an LCO. A more thorough data review shows that historical concentrations of the tritium in MNRC's primary coolant are very constant (except for the misreported data used to evaluation MNRC's ability to meet the new technical specification 3.3 item 4). Therefore, failing to meet this LCO is a condition that has likely existed since the issuing of the new license on November 21, 2022. MNRC was not operating at the time of this discovery and has not resumed reactor operations.
"There has likely been no increase in the amount of tritium in MNRC's primary cooling water nor has any primary cooling water been released from the reactor tank since the new technical specification took effect. There are no safety or security concerns generated as a result of this event.
"The facility license holder (level 1 management), the chair of the MNRC safety committee, MNRC's NRC program manager, assistant program manager, and inspector have been notified of this event. The ultimate resolution of this issue will need to be a license amendment increasing the permissible tritium concentration in the primary cooling water as a condition for reactor operation as it is physically impossible to lower the tritium concentration in order to meet the LCO."
Power Reactor
Event Number: 56328
Facility: Clinton
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: David Dorn
HQ OPS Officer: Adam Koziol
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: David Dorn
HQ OPS Officer: Adam Koziol
Notification Date: 02/01/2023
Notification Time: 01:40 [ET]
Event Date: 01/31/2023
Event Time: 23:43 [CST]
Last Update Date: 02/01/2023
Notification Time: 01:40 [ET]
Event Date: 01/31/2023
Event Time: 23:43 [CST]
Last Update Date: 02/01/2023
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):
Szwarc, Dariusz (R3DO)
Szwarc, Dariusz (R3DO)
| 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 |
AUTOMATIC SCRAM DUE TO TURBINE TRIP
The following information was provided by the licensee via fax and telephone:
"Generator trip due to power load unbalance which caused a turbine trip and subsequent reactor scram. Experienced a trip on circulating water pump A.
"NRC Resident Inspector notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Off-site power available and unaffected. Decay heat removal via main steam line and drains to condenser. Plant is stable in mode 3.
The following information was provided by the licensee via fax and telephone:
"Generator trip due to power load unbalance which caused a turbine trip and subsequent reactor scram. Experienced a trip on circulating water pump A.
"NRC Resident Inspector notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Off-site power available and unaffected. Decay heat removal via main steam line and drains to condenser. Plant is stable in mode 3.
Agreement State
Event Number: 56330
Rep Org: Utah Division of Radiation Control
Licensee: Intermountain Medical Center
Region: 4
City: Murray State: UT
County:
License #: UT1800494
Agreement: Y
Docket:
NRC Notified By: Philip Goble
HQ OPS Officer: Karen Cotton-Gross
Licensee: Intermountain Medical Center
Region: 4
City: Murray State: UT
County:
License #: UT1800494
Agreement: Y
Docket:
NRC Notified By: Philip Goble
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/01/2023
Notification Time: 14:23 [ET]
Event Date: 01/31/2023
Event Time: 14:45 [MST]
Last Update Date: 02/01/2023
Notification Time: 14:23 [ET]
Event Date: 01/31/2023
Event Time: 14:45 [MST]
Last Update Date: 02/01/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LIQUID RADIOACTIVE CONTAMINATION
The following information was provided by Utah Department of Environmental Quality, Division of Waste Management [the Division] and Radiation Control, via email:
"On January 31, 2023 at 1600 MST, the Intermountain Heart Institute, Cardiac Molecular Imaging Coordinator reported to the RSO [Radiation Safety Officer] that at 1445 MST a technologist, removing a Rb-82 (rubidium-82) generator from service, found liquid radioactive contamination in the bottom of the well chamber of the Infusion System. A syringe was used to remove the saline from the well of the Infusion System and the liquid was placed in the liquid radioactive liquid waste storage. Decontamination procedures were followed. The Infusion System well was wiped dry with paper towel(s). All radioactive waste was placed in approved radioactive waste storage. Wipe test(s) were performed.
"This incident has no impact on patient treatment. All Quality Control procedures passed while the generator was in use which verifies that patient treatments were within all requirements.
"The manufacturer was contacted for assistance and it is planned that the generator will be shipped back for investigation. We will follow the manufacturer's instructions for the shipment. A new generator has been placed in the Infusion System so that patient care can continue today.
"The Division will investigate this matter and update the record upon completion of the investigation."
Utah Event Report ID No.: UT23-0002
The following information was provided by Utah Department of Environmental Quality, Division of Waste Management [the Division] and Radiation Control, via email:
"On January 31, 2023 at 1600 MST, the Intermountain Heart Institute, Cardiac Molecular Imaging Coordinator reported to the RSO [Radiation Safety Officer] that at 1445 MST a technologist, removing a Rb-82 (rubidium-82) generator from service, found liquid radioactive contamination in the bottom of the well chamber of the Infusion System. A syringe was used to remove the saline from the well of the Infusion System and the liquid was placed in the liquid radioactive liquid waste storage. Decontamination procedures were followed. The Infusion System well was wiped dry with paper towel(s). All radioactive waste was placed in approved radioactive waste storage. Wipe test(s) were performed.
"This incident has no impact on patient treatment. All Quality Control procedures passed while the generator was in use which verifies that patient treatments were within all requirements.
"The manufacturer was contacted for assistance and it is planned that the generator will be shipped back for investigation. We will follow the manufacturer's instructions for the shipment. A new generator has been placed in the Infusion System so that patient care can continue today.
"The Division will investigate this matter and update the record upon completion of the investigation."
Utah Event Report ID No.: UT23-0002
Agreement State
Event Number: 56332
Rep Org: Iowa Department of Public Health
Licensee: Team Services Inc.
Region: 3
City: Shellsburg State: IA
County:
License #: 0244-1-77-PG
Agreement: Y
Docket:
NRC Notified By: Stuart Jordan
HQ OPS Officer: Karen Cotton-Gross
Licensee: Team Services Inc.
Region: 3
City: Shellsburg State: IA
County:
License #: 0244-1-77-PG
Agreement: Y
Docket:
NRC Notified By: Stuart Jordan
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/01/2023
Notification Time: 19:56 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [CST]
Last Update Date: 02/02/2023
Notification Time: 19:56 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [CST]
Last Update Date: 02/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
AGREEMENT STATE REPORT - STOLEN GAUGE
The following information was provided by the Iowa Department of Public Health (Iowa HHS) via email:
"During the night or early morning of January 31, 2023 - February 1, 2023, a Troxler portable nuclear gauge (model 3430, containing 9 millicuries Cs-137 and 44 millicuries Am-241:Be) was stolen from the truck of a licensee in Shellsburg, Iowa. It was reported that the employee had an early morning nuclear job on the day of February 1, 2023, in which he took the device home. Upon the early morning of February 1, 23, when the employee went to leave for the job, he discovered that the truck had been broken into. Items in the cab and all materials' testing equipment in the bed of the truck had been stolen, including the licensed portable nuclear gauge.
"The cause is still under investigation. Corrective actions will be determined.
"The Licensee notified the local sheriff's office. Iowa HHS will follow-up to support the response and provide assistance as needed and will update this event as they investigate."
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 Iowa Department of Public Health (Iowa HHS) via email:
"During the night or early morning of January 31, 2023 - February 1, 2023, a Troxler portable nuclear gauge (model 3430, containing 9 millicuries Cs-137 and 44 millicuries Am-241:Be) was stolen from the truck of a licensee in Shellsburg, Iowa. It was reported that the employee had an early morning nuclear job on the day of February 1, 2023, in which he took the device home. Upon the early morning of February 1, 23, when the employee went to leave for the job, he discovered that the truck had been broken into. Items in the cab and all materials' testing equipment in the bed of the truck had been stolen, including the licensed portable nuclear gauge.
"The cause is still under investigation. Corrective actions will be determined.
"The Licensee notified the local sheriff's office. Iowa HHS will follow-up to support the response and provide assistance as needed and will update this event as they investigate."
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: 57086
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Notification Date: 04/22/2024
Notification Time: 13:44 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Notification Time: 13:44 [ET]
Event Date: 01/31/2023
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240010
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 provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240010
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.