Event Notification Report for February 21, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/20/2023 - 02/21/2023
Agreement State
Event Number: 56377
Rep Org: Texas Dept of State Health Services
Licensee: University of Texas- MD Anderson CC
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Kerby Scales
Licensee: University of Texas- MD Anderson CC
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Kerby Scales
Notification Date: 02/21/2023
Notification Time: 21:35 [ET]
Event Date: 02/21/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Notification Time: 21:35 [ET]
Event Date: 02/21/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 3/1/2023
EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by the Texas Department of State Health Services (the Group) via email:
"On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9991
* * * UPDATE ON 02/22/23 AT 2049 EST FROM ART TUCKER TO KERBY SCALES * * *
The following update was received from Texas Department of State Health Services (the Agency) via email:
"On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL [Optically Stimulated Luminescence] dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information."
* * * UPDATE ON 02/23/23 AT 1307 EST FROM ART TUCKER TO IAN HOWARD * * *
The following update was received from Texas Department of State Health Services (the Agency) via email:
"On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.
* * * UPDATE ON 02/28/23 AT 2250 EST FROM ART TUCKER TO ERNEST WEST * * *
"The licensee's radiation safety officer provided the following additional information: `[The teletherapy unit that had a stuck source] is a Theratron 780C, and it was the Numatics Mark 8 solenoid valve that failed.'
"Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Vossmar) and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by the Texas Department of State Health Services (the Group) via email:
"On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-9991
* * * UPDATE ON 02/22/23 AT 2049 EST FROM ART TUCKER TO KERBY SCALES * * *
The following update was received from Texas Department of State Health Services (the Agency) via email:
"On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL [Optically Stimulated Luminescence] dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information."
* * * UPDATE ON 02/23/23 AT 1307 EST FROM ART TUCKER TO IAN HOWARD * * *
The following update was received from Texas Department of State Health Services (the Agency) via email:
"On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.
* * * UPDATE ON 02/28/23 AT 2250 EST FROM ART TUCKER TO ERNEST WEST * * *
"The licensee's radiation safety officer provided the following additional information: `[The teletherapy unit that had a stuck source] is a Theratron 780C, and it was the Numatics Mark 8 solenoid valve that failed.'
"Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Vossmar) and NMSS Events Notification via email.
Agreement State
Event Number: 56378
Rep Org: Utah Division of Radiation Control
Licensee: Utah Valley Regional Medical Center
Region: 4
City: Murray State: UT
County:
License #: UT 2500129
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Kerby Scales
Licensee: Utah Valley Regional Medical Center
Region: 4
City: Murray State: UT
County:
License #: UT 2500129
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Kerby Scales
Notification Date: 02/21/2023
Notification Time: 22:25 [ET]
Event Date: 02/21/2023
Event Time: 17:00 [MST]
Last Update Date: 02/21/2023
Notification Time: 22:25 [ET]
Event Date: 02/21/2023
Event Time: 17:00 [MST]
Last Update Date: 02/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LEAKING EQUIPMENT
The following was provided by the Utah Division of Waste Management and Radiation Control:
"On 2/21/23, at 1700 [MST], the Intermountain Heart Institute, Cardiac Molecular Imaging (CMI) Coordinator reported to the RSO [Radiation Safety Officer] that around 1630 a technologist, removing a Rb-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 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."
Utah Event Report Number: UT23-0003
The following was provided by the Utah Division of Waste Management and Radiation Control:
"On 2/21/23, at 1700 [MST], the Intermountain Heart Institute, Cardiac Molecular Imaging (CMI) Coordinator reported to the RSO [Radiation Safety Officer] that around 1630 a technologist, removing a Rb-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 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."
Utah Event Report Number: UT23-0003
Power Reactor
Event Number: 56376
Facility: San Onofre
Region: 4 State: CA
Unit: [] [] []
RX Type: Unit 2
Comments: Transnuclear, Inc./NUHOMS-24PT
NRC Notified By: Guadalupe Robles
HQ OPS Officer: Ian Howard
Region: 4 State: CA
Unit: [] [] []
RX Type: Unit 2
Comments: Transnuclear, Inc./NUHOMS-24PT
NRC Notified By: Guadalupe Robles
HQ OPS Officer: Ian Howard
Notification Date: 02/21/2023
Notification Time: 19:16 [ET]
Event Date: 02/21/2023
Event Time: 14:02 [PST]
Last Update Date: 02/22/2023
Notification Time: 19:16 [ET]
Event Date: 02/21/2023
Event Time: 14:02 [PST]
Last Update Date: 02/22/2023
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):
Roldan-Otero, Lizette (R4DO)
NMSS_Events_Notification, (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_Events_Notification, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|
EN Revision Imported Date: 2/23/2023
EN Revision Text: OFFSITE NOTIFICATION TO LOCAL AGENCY
The following information was provided by the licensee via email:
"On 2/21/2023 at 1402 [PST] SONGS [San Onofre Nuclear Generating Station] notified San Diego Regional Water Quality Control Board (SDRWQCB) regarding the results of a quarterly monitoring report. The report indicated the 24-effluent toxicity sample resulted in a 'Fail.' The results prompted a 24 hour notification to the SDRWQCB in accordance with the NPDES [National Pollutant Discharge Elimination System] permit. There was no significant effect on the health and safety of the public or the environment.
"Action Taken: SCE [Southern California Edison] Environmental notified the SDRWQCB via telephone voice mail at 1402 on 2/21/2023 followed by an e-mail describing the reason for the notification."
* * * UPDATE ON 02/22/2023 AT 1403 EST FROM GUADALUPE ROBLES Jr. TO IAN HOWARD * * *
The following is a summary of information provided by the licensee via email:
The licensee corrected the Unit from ISFSI to Unit 2 and the name of the quarterly test to note it was for the first quarter of 2023.
Notified R4DO (Roldan-Otero), and NMSS Events Notification via email.
EN Revision Text: OFFSITE NOTIFICATION TO LOCAL AGENCY
The following information was provided by the licensee via email:
"On 2/21/2023 at 1402 [PST] SONGS [San Onofre Nuclear Generating Station] notified San Diego Regional Water Quality Control Board (SDRWQCB) regarding the results of a quarterly monitoring report. The report indicated the 24-effluent toxicity sample resulted in a 'Fail.' The results prompted a 24 hour notification to the SDRWQCB in accordance with the NPDES [National Pollutant Discharge Elimination System] permit. There was no significant effect on the health and safety of the public or the environment.
"Action Taken: SCE [Southern California Edison] Environmental notified the SDRWQCB via telephone voice mail at 1402 on 2/21/2023 followed by an e-mail describing the reason for the notification."
* * * UPDATE ON 02/22/2023 AT 1403 EST FROM GUADALUPE ROBLES Jr. TO IAN HOWARD * * *
The following is a summary of information provided by the licensee via email:
The licensee corrected the Unit from ISFSI to Unit 2 and the name of the quarterly test to note it was for the first quarter of 2023.
Notified R4DO (Roldan-Otero), and NMSS Events Notification via email.