Event Notification Report for April 21, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/20/2023 - 04/21/2023

Agreement State
Event Number: 56045
Rep Org: New York State Dept. of Health
Licensee: NRD, LLC
Region: 1
City: Grand Island   State: NY
County:
License #: NYSDOH C1391
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Howie Crouch
Notification Date: 08/16/2022
Notification Time: 11:15 [ET]
Event Date: 08/15/2022
Event Time: 11:45 [EDT]
Last Update Date: 04/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/21/2023

EN Revision Text: AGREEMENT STATE REPORT - INDIVIDUAL EXPOSED TO RADIOACTIVE MATERIALS

The following event was received by the New York State Department of Health [the Department] via email:

"On 8/15/22, the Radiation Safety Officer of NRD, LLC notified the Department that an individual may have been exposed to radioactive materials. At approximately 1145 EDT, the continuous air monitoring system located in the Rolling Room area of the Isotope Production Lab triggered an alarm. All associates immediately exited the lab per established protocol. Nasal smears were collected and counted for all six lab personnel. With exception of one individual, all other personnel's nasal smear results were below the facility's 500 dpm [disintegrations per minute] threshold. One individual produced a nasal smear reading of 725 dpm in the left nostril and 781 dpm in the right nostril. This employee was instructed to blow their nose twice and a second nasal smear test was performed. The nasal smear readings were 27 dpm and 30 dpm respectively. Blank samples that were counted along with the nasal smears were 39 dpm and 7 dpm respectively.

"The effected individual was removed from working with radioactive material and has begun a 24-hour bioassay collection. A root cause investigation into the cause of the air alarm and the positive nasal smear is underway. The air monitor filter paper was replaced and the activity displayed on the continuous air monitor system returned to normal levels, indicating that the cause of the alarm was a very short duration event."

New York Event Number: NYDOH-22-4

NMED Number: 220369

* * * UPDATE ON 4/19/23 AT 1054 EDT FROM DANIEL SAMSON TO ADAM KOZIOL * * *

The following update was received by the New York State Department of Health (NYSDOH) via fax:

NYSDOH contacted Radiation Emergency Assistance Center/Training Site (REAC/TS) to independently review the nasal smear readings. The review revealed a likely overexposure to one worker who was advised to seek medical treatment. Further site investigation identified a defective machine utilized in producing smoke detectors with americium-241 foil. The worker with the overexposure had been using that machine and had to repeatedly open the fume hood to keep the machine operational.

"NYSDOH took administrative action to halt licensee production activities, require modification to radiation safety program, enhance oversight of the licensee through increased inspection frequency, provide specific conditions requiring immediate notification, requirement of an independent safety analysis and adoption of recommendations from these findings, and multiple follow-up site visits by inspection staff to verify progress and status of decontamination and corrective actions."

The investigation showed that several workers had elevated doses and one worker had exceeded occupational dose limits in 10 CFR 20.1201 for Committed Dose Equivalent (CDE) to bone surfaces (56 rem). It was found that the licensee had failed to calculate CDE and committed effective dose equivalent (CEDE) from collected bioassay data from 2019 to the date of the incident. NYSDOH requested the licensee utilize a consultant certified health physicist third-party evaluation of all collected bioassay data for all workers. The one worker with the overdose from this incident was found to have consistently exceeded the occupational dose limits for CDE to bone surfaces for calendar years 2019 (115 rem), 2020 (51 rem), and 2021 (51 rem). Additionally, one previous worker that left employment of the licensee in 2022 received 76 rem CDE to bone surfaces. NYSDOH is following up on the computational methods used by the consultant to clarify and potentially modify the internal doses calculated.

Significant Am-241 contamination was found on floors, tables, walls, light fixtures, and specific equipment. Further directed corrective actions include replacement of equipment, improvement to the air monitoring systems in the labs, implementation of a respiratory protection plan, enhancement of emergency response plans, restructuring of management and organizational structure of the company, hiring of additional radiation safety technicians, enhancement of training and personnel monitoring programs, and modification to proprietary work procedures to prevent recurrence. NYSDOH and licensee are discussing further investigation and corrective actions.

Additionally, Am-241 contamination was found in worker vehicles, shoes and homes. These unrestricted areas were immediately remediated to background levels.

Notified R1DO (Arner), NMSS (Rivera-Capella), NMSS Events Notification


Agreement State
Event Number: 56466
Rep Org: Utah Division of Radiation Control
Licensee: University of Utah
Region: 4
City: Salt Lake City   State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: Gwyn Galloway
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 04/13/2023
Notification Time: 03:26 [ET]
Event Date: 04/04/2023
Event Time: 12:00 [MDT]
Last Update Date: 04/13/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided by the Utah Division of Waste Management and Radiation Control (DWMRC) via email:

"The University of Utah contacted the DWMRC to report that they had found that an Isotope Products Laboratories, Cs-137 Resin Vial Source, Source Number 988-97-3 with an assayed activity of 208.9 microcuries (assay date May 1, 2004), was leaking.

"A routine quarterly leak test was taken of the sealed source. When counted with a PerkinElmer 2480 Wizard2 radiation detector, the wipe showed an elevated reading. The wipe results showed 4531 cpm (background 32 cpm). The technologist who performed the wipe contacted the licensee's Radiological Health Department. The technologist was told to count the wipe in the well counter (Biodex AtomLab 500). The well counter on the Cs-137 channel showed there was 0.6 microcuries with a 0.3 microcuries background on the sample for a leak test result of 0.3 microcuries. Since there was no obvious leak in the resin vial, the licensee suspected it had been contaminated with short lived radioisotopes. The source was doubly bagged and isolated in storage until the next day when it was again verified to be above background. On April 11, 2023, it was retested. The leak test was performed with both an alcohol pad and a gauze pad. The results of these samples were counted with the PerkinElmer instrument, but not the well counter. The result of the wipes was 4248 cpm and 7303 cpm respectively (PerkinElmer 2480 Wizard2 radiation detector for both tests was 32 cpm). This showed it was not a short-lived isotope and the source was leaking.

"The individual stated that when he performed the wipe test on April 11, 2023, he heard the plastic vial crack and the crack opened while the wipe was being taken but returned to a 'closed position' when the wipe was completed. He immediately returned the wipe to the baggies and put it in storage. Since the wipes taken verified the original assessment was correct, the licensee stated that the source would be placed with their waste and disposed in their normal waste shipments to a licensed radioactive waste disposal site.

"After the initial finding on April 4, 2023, radiation surveys of the area and equipment were conducted to verify that no contamination was present. No contamination was found, and the area and equipment were released for use.

"The licensee stated that the vial appeared to be slightly yellowed around the crack and believes the plastic may have cracked due to radiation fatigue. The licensee had ordered two of these sources in 2004. The other source was in use at one of the licensee's other medical facilities but was removed from service and will be disposed of with the leaking source as a precaution."

Utah Event Report ID Number: UT 23-0004


Non-Agreement State
Event Number: 56467
Rep Org: US Army
Licensee: US Army
Region: 4
City: Vicksburg   State: MS
County:
License #: 230154416
Agreement: N
Docket:
NRC Notified By: Anthony Miller
HQ OPS Officer: John Russell
Notification Date: 04/13/2023
Notification Time: 16:50 [ET]
Event Date: 04/13/2023
Event Time: 16:50 [CDT]
Last Update Date: 04/13/2023
Emergency Class: Non Emergency
10 CFR Section:
20.2202(b)(1) - Pers Overexposure/Tede >= 5 Rem
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
UNACCOUNTED FOR TROXLER MOISTURE GAUGE

The following information was provided by the licensee via phone and email:

"While finishing the renewal of our license, I was not able to account for one device found in a 2016 inventory, the number of devices matched the number of devices listed on our 2016 license.
"Both the license and inventory from 2016 listed 10 devices, I could only account for 9 devices.
"On the 11th of April, documentation was found in our property management system that listed the device as transferred to an outside agency, agency is unknown.
"The last leak test preformed on this device was in 2013, so the condition of the shielding in 2016 is not known, when it was transferred.
"The missing device is a Troxler model 3411 device serial number is 13760.
"The device contains two sources americium-241 with 44 millicuries at 1.480 giga becquerels (SN 47-9073), and cesium-137 with 9 millicuries at 0.296 giga becquerels (SN 50-2578)"

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.pdfThe following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:


Power Reactor
Event Number: 56468
Facility: Maine Yankee
Region: 1     State: ME
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: John Pelkington
HQ OPS Officer: John Russell
Notification Date: 04/13/2023
Notification Time: 22:48 [ET]
Event Date: 04/13/2023
Event Time: 19:05 [EDT]
Last Update Date: 04/13/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Lilliendahl, Jon (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled
Event Text
OFFSITE NOTIFICATION FOR SEWAGE DISCHARGE

The following information was provided by the licensee via phone and email:

"At 1905 [EDT], a security force member discovered what appeared to be a sewage leak along the gravel roadway northwest of the gatehouse entrance. The affected area was approximately 12' X 15'. The water was slowly bubbling up from the ground about 20' along one of our access roads.
"Large absorbent spill containment barriers were placed at the scene to minimize the incident. Water usage was stopped within our facility, and sewer pumps isolated. The Maine State Department of Environmental Protection (DEP) was notified of the incident (DEP spill # 23-0004705). The area was inspected at approximately 2130 [EDT], and water discharge was no longer observed.
"Maine Yankee site management is currently in the process of contacting contractors to resolve the issue.
"The site is safe and secure. The concrete cask heat removal system is operable, and the temperature monitoring system is functional."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee notified Region 1 personnel.


Agreement State
Event Number: 56470
Rep Org: Maryland Dept of the Environment
Licensee: Univ. of Maryland Medical Center
Region: 1
City: Baltimore   State: MD
County:
License #: MD-07-014-01
Agreement: Y
Docket:
NRC Notified By: Paul Kovach
HQ OPS Officer: Ernest West
Notification Date: 04/14/2023
Notification Time: 18:29 [ET]
Event Date: 02/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 04/14/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Burgess, Michele (NMSS DAY) (NMSS DAY)
Event Text
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the Maryland Department of the Environment (MDE) via email:

On 04/14/2023 at 0951 [EDT], the MDE discovered an unsigned, undated report from the University of Maryland Medical Center, Baltimore, MD, that a medical misadministration had occurred on 02/28/2023. [After] contacting a health physicist and the Radiation Safety Officer (RSO) [at the University of Maryland], they confirmed that the event had actually occurred. A dose of 104.73 mCi of Ludotadipep [Lu-177] was being administered to a patient as part of a phase 1 clinical trial to treat metastasis. During the procedure, catheter infiltration (catheter movement) occurred resulting in a significant portion of the dose remaining in the upper left arm. The study sponsor was informed. Subsequent gamma scans showed that within 24 to 48 hours the dose had migrated to the intended treatment site. MDE is following up with the RSO and medical staff to confirm that the actual dose delivered to the treatment site was within 20 percent of the dose prescribed in the written directive. The University of Maryland staff has determined that an unintended dose estimated at 157 Rem had been delivered to the upper arm tissue. As of 04/14/2023, no ill effects have been observed, and the patient has been scheduled to resume subsequent treatment. This event is being reported under 10CFR 35.3045 (a)(1)(ii) B `. a dose that exceeds 50 Rem to an organ or tissue from administration of a radioactive drug containing byproduct material by the wrong route of administration'."

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: 56478
Facility: Brunswick
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Chris Denton
HQ OPS Officer: Thomas Herrity
Notification Date: 04/20/2023
Notification Time: 05:24 [ET]
Event Date: 04/20/2023
Event Time: 01:48 [EDT]
Last Update Date: 04/20/2023
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 A/R Y 100 Power Operation 0 Hot Shutdown
Event Text
AUTOMATIC REACTOR TRIP DUE TO A TURBINE TRIP

The following information was provided by the licensee via phone and email:

"At 0148 Eastern Daylight Time (EDT) on April 20, 2023, with Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a turbine trip. Turbine Bypass valves did not open on the trip due to Turbine Protection system power supply failure; the Safety Relief Valves (SRVs) opened automatically to control reactor pressure. Reactor Pressure reached approximately 1095 psig on the trip; exceeding the 1060 psig RPS trip setpoint.

"Operations responded and stabilized the plant. Operations was able to transition from SRVs to main steam line drains to the condenser. Reactor water level is being maintained via the Condensate / Feedwater system. Decay heat is being removed by discharging steam to the main condenser using the main steam line drains. Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Reactor water level reached low level 1 (LL1) following the reactor trip. The LL1 signal causes Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves), and Group 8 (i.e., shutdown cooling isolation valves) isolations. The LL1 isolations occurred as designed; the Group 8 valves were closed at the time of the event. Due to the valid Primary Containment Isolation System (PCIS) actuation and RPS actuation from the reactor pressure signal, this event is also being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"Unit 2 is not affected by this event. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 56480
Facility: Comanche Peak
Region: 4     State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Joe Ricks
HQ OPS Officer: Adam Koziol
Notification Date: 04/20/2023
Notification Time: 13:29 [ET]
Event Date: 04/18/2023
Event Time: 16:30 [CDT]
Last Update Date: 04/20/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Werner, Greg (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
SAFE SHUTDOWN CAPABILITY AND ACCIDENT MITIGATION

The following information was provided by the licensee via email:

"Notification per 10 CFR 50.72 (b)(3)(v)(A) and (v)(D)

"At time 1630 CDT on 4/18/23, Comanche Peak Unit 1 entered TS (Technical Specification) 3.0.3 for 11 minutes due to declaring Train A component cooling water (CCW) inoperable in conjunction with a Train B centrifugal charging pump (CCP) inoperable for scheduled maintenance. This resulted in an event or condition that could have prevented fulfillment of a safety function, high head injection of the emergency core cooling system.

"CCP 1-02 and fan cooler were tagged out of service at 0400 CDT on 4/18/23 due to scheduled maintenance activities. Containment spray (CT) pump 1-03 seal oil cooler CCW leak was found by a watchstander at 0930 CDT on 4/18/23. Engineering determined that leakage was CCW from a pipe flange weld after insulation removal and could not [determine] operability and notified control room at 1630 CDT on 4/18/23. This placed unit 1 in a TS 3.0.3 condition from 1630 to 1641 CDT for approximately 11 minutes until CCP 1-02 was restored back to operable status. CCW was declared operable at 1912 after CT pump 1-03 seal oil cooler was isolated. CT pump 1-03 remained inoperable until weld repair completed. Train A CT pump 1-03 declared operable at 1211 CDT 4/19/23.

"ENS notification should have been made by 0030 CDT on 4/19/23. This report restores compliance."

The NRC Resident Inspector has been notified.