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: 56483
Rep Org: Texas Dept of State Health Services
Licensee: Great Lakes Dredge and Dock Company
Region: 1
City: Jacksonville State: FL
County:
License #: FL 3608-1
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Bill Gott
Licensee: Great Lakes Dredge and Dock Company
Region: 1
City: Jacksonville State: FL
County:
License #: FL 3608-1
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Bill Gott
Notification Date: 04/21/2023
Notification Time: 15:55 [ET]
Event Date: 04/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 04/21/2023
Notification Time: 15:55 [ET]
Event Date: 04/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 04/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werner, Greg (R4DO)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werner, Greg (R4DO)
AGREEMENT STATE REPORT - GAUGE SHUTTER CAN NOT BE CLOSED DUE TO BROKEN LEVER
The following information was provided by the Texas Department of Health Services (the Department) via email:
"On April 21, 2023, the Department was notified of a gauge with a shutter that could not be moved into the closed position because the lever which moves the shutter broke off. The owner of the gauge reports the lever broke because of corrosion and vibrations. The gauge is a Texas Nuclear 5204 with 8 curies of cesium-137. It is on the side of a dredging vessel that is dredging the entrance channel in Corpus Christi in a 24 hours of work per day operation. During dredging operations, the gauge is normally in the open position and the beam is directed inwards towards the ship. The crew of the vessel normally avoid that side of the vessel and will continue to do so. A survey of the gauge was performed and there is no change. The owner of the gauge reports that they expect the gauge to be repaired by a servicing company on May 9, 2023.
"The Department discussed the possibility of the vessel being docked with the gauge still in the open position and will continue to monitor the situation. Further information will be provided per SA-300.
"The Department will also forward this to the Florida Radiation Control Program as this is a Florida licensee operating in Texas under reciprocity."
Texas incident number: 10013
The following information was provided by the Texas Department of Health Services (the Department) via email:
"On April 21, 2023, the Department was notified of a gauge with a shutter that could not be moved into the closed position because the lever which moves the shutter broke off. The owner of the gauge reports the lever broke because of corrosion and vibrations. The gauge is a Texas Nuclear 5204 with 8 curies of cesium-137. It is on the side of a dredging vessel that is dredging the entrance channel in Corpus Christi in a 24 hours of work per day operation. During dredging operations, the gauge is normally in the open position and the beam is directed inwards towards the ship. The crew of the vessel normally avoid that side of the vessel and will continue to do so. A survey of the gauge was performed and there is no change. The owner of the gauge reports that they expect the gauge to be repaired by a servicing company on May 9, 2023.
"The Department discussed the possibility of the vessel being docked with the gauge still in the open position and will continue to monitor the situation. Further information will be provided per SA-300.
"The Department will also forward this to the Florida Radiation Control Program as this is a Florida licensee operating in Texas under reciprocity."
Texas incident number: 10013
Fuel Cycle Facility
Event Number: 56484
Facility: Louisiana Energy Services
Region: 2 State: NM
Unit: [] [] []
RX Type:
Comments: Uranium Enrichment Facility
Gas Centrifuge Facility
NRC Notified By: Jim Rickman
HQ OPS Officer: Bill Gott
Region: 2 State: NM
Unit: [] [] []
RX Type:
Comments: Uranium Enrichment Facility
Gas Centrifuge Facility
NRC Notified By: Jim Rickman
HQ OPS Officer: Bill Gott
Notification Date: 04/21/2023
Notification Time: 16:24 [ET]
Event Date: 04/21/2023
Event Time: 13:45 [MDT]
Last Update Date: 04/25/2023
Notification Time: 16:24 [ET]
Event Date: 04/21/2023
Event Time: 13:45 [MDT]
Last Update Date: 04/25/2023
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (b)(2) - Loss Or Degraded Safety Items
10 CFR Section:
PART 70 APP A (b)(2) - Loss Or Degraded Safety Items
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/26/2023
EN Revision Text: ITEM RELIED ON FOR SAFETY (IROFS) NOT ESTABLISHED
The following information was provided by the licensee via email:
"The plant is in a safe condition.
"On April 21, 2023, Urenco, USA (UUSA) was staging a construction crane to be used the following week and failed to maintain procedural compliance while implementing IROFS50f and IROFS50g. The crane was properly permitted and placed inside the Controlled Access Area but was not properly permitted for operation. At all times the required spotters for IROFS50f and IROFS50g were in place and the movement of the crane was sufficiently controlled to restrict its movement to not swing into an area where damage could occur. However, visual indicators (reference markers) were not established as required by procedure. Spotters were in place and exercised appropriate control.
"IROFS50f/g are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61.
"Work has been stopped and the crane has been demobilized. UUSA is conservatively reporting this event under 10 CFR 70 Appendix A (a)(4)."
The licensee will notify Region 2.
* * * UPDATE ON 04/22/2022 AT 1501 EDT FROM JIM RICKMAN TO BILL GOTT* * *
"This issue has been entered into the corrective actions program as EV 160170.
"Following a more detailed review, IROFS50g was determined to be operable and adequately implemented. As a result, the appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (b)(2)."
Notified R2DO (Miller) and NMSS Events Notification (email).
* * * UPDATE ON 04/25/2022 AT 1501 EDT FROM JIM RICKMAN TO THOMAS HERRITY * * *
"2nd Update:
"The operation of the crane has stopped and it remains south of Separation Building Module (SBM) 1001.
"Contrary to the initial report, the required spotters were not present and controlling the movement of the boom. As a result, IROFS50f/g have been determined not to be available and reliable. The appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (a)(4).
"The stop work involving the use of construction vehicles and IROFS50 remains in place. All work performed by site projects has been stopped."
The licensee has notified Region 2.
Notified R2DO (Miller) and NMSS Events Notification (email).
EN Revision Text: ITEM RELIED ON FOR SAFETY (IROFS) NOT ESTABLISHED
The following information was provided by the licensee via email:
"The plant is in a safe condition.
"On April 21, 2023, Urenco, USA (UUSA) was staging a construction crane to be used the following week and failed to maintain procedural compliance while implementing IROFS50f and IROFS50g. The crane was properly permitted and placed inside the Controlled Access Area but was not properly permitted for operation. At all times the required spotters for IROFS50f and IROFS50g were in place and the movement of the crane was sufficiently controlled to restrict its movement to not swing into an area where damage could occur. However, visual indicators (reference markers) were not established as required by procedure. Spotters were in place and exercised appropriate control.
"IROFS50f/g are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61.
"Work has been stopped and the crane has been demobilized. UUSA is conservatively reporting this event under 10 CFR 70 Appendix A (a)(4)."
The licensee will notify Region 2.
* * * UPDATE ON 04/22/2022 AT 1501 EDT FROM JIM RICKMAN TO BILL GOTT* * *
"This issue has been entered into the corrective actions program as EV 160170.
"Following a more detailed review, IROFS50g was determined to be operable and adequately implemented. As a result, the appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (b)(2)."
Notified R2DO (Miller) and NMSS Events Notification (email).
* * * UPDATE ON 04/25/2022 AT 1501 EDT FROM JIM RICKMAN TO THOMAS HERRITY * * *
"2nd Update:
"The operation of the crane has stopped and it remains south of Separation Building Module (SBM) 1001.
"Contrary to the initial report, the required spotters were not present and controlling the movement of the boom. As a result, IROFS50f/g have been determined not to be available and reliable. The appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (a)(4).
"The stop work involving the use of construction vehicles and IROFS50 remains in place. All work performed by site projects has been stopped."
The licensee has notified Region 2.
Notified R2DO (Miller) and NMSS Events Notification (email).
Agreement State
Event Number: 56552
Rep Org: SC Dept of Health & Env Control
Licensee: Medical University Hospital Auth.
Region: 1
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Thomas Herrity
Licensee: Medical University Hospital Auth.
Region: 1
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Thomas Herrity
Notification Date: 06/02/2023
Notification Time: 11:39 [ET]
Event Date: 04/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/21/2023
Notification Time: 11:39 [ET]
Event Date: 04/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 6/22/2023
EN Revision Text: AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for.
"Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
SC internal ID number is: SC230011
* * * UPDATE ON 6/21/2023 AT 0959 EDT FROM ADAM GAUSE TO BRIAN LIN * * *
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"A 30-day written report was submitted to the Department on 05/15/23 and a revised 30-day written report was submitted to the Department on 05/17/23. The licensee reported no exposure above background to individuals. The lot number of the manual brachytherapy sealed sources involved in the procedure is BBHQ0080, last leak tested 03/21/23. The licensee has also revised and adopted, or plan to adopt new procedures related to manual brachytherapy implant procedures. This event is considered closed."
Notified R1DO (Eve), ILTAB, and NMSS Notifications via email.
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
EN Revision Text: AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for.
"Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
SC internal ID number is: SC230011
* * * UPDATE ON 6/21/2023 AT 0959 EDT FROM ADAM GAUSE TO BRIAN LIN * * *
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"A 30-day written report was submitted to the Department on 05/15/23 and a revised 30-day written report was submitted to the Department on 05/17/23. The licensee reported no exposure above background to individuals. The lot number of the manual brachytherapy sealed sources involved in the procedure is BBHQ0080, last leak tested 03/21/23. The licensee has also revised and adopted, or plan to adopt new procedures related to manual brachytherapy implant procedures. This event is considered closed."
Notified R1DO (Eve), ILTAB, and NMSS Notifications via email.
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