Event Notification Report for May 23, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/22/2023 - 05/23/2023
Non-Power Reactor
Event Number: 56534
Rep Org: Univ Of Missouri-Columbia (MISC)
Licensee: University Of Missouri
Region: 0
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Ronald Astrino
HQ OPS Officer: Ian Howard
Licensee: University Of Missouri
Region: 0
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Ronald Astrino
HQ OPS Officer: Ian Howard
Notification Date: 05/23/2023
Notification Time: 18:08 [ET]
Event Date: 05/23/2023
Event Time: 08:45 [CDT]
Last Update Date: 05/23/2023
Notification Time: 18:08 [ET]
Event Date: 05/23/2023
Event Time: 08:45 [CDT]
Last Update Date: 05/23/2023
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Geoffrey Wertz (NRR)
Andrew Waugh (NRR)
Geoffrey Wertz (NRR)
Andrew Waugh (NRR)
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the University of Missouri-Columbia Research Reactor (MURR) via phone and email:
"During a normal reactor start up on 5/23/2023, while still approaching criticality, reactor power peaked slightly above 100 kW with a single control blade 1.4 inches below the other three control blades. This is a violation of Technical Specification (TS) 3.2.b which states that above 100 kW, the reactor shall be operated so that the maximum distance between the highest and lowest shim blade shall not exceed 1 inch.
"As part of a normal reactor startup, three control blades were at 23 inches and the core was approaching criticality. As the fourth control blade was being pulled to the bank height, the Lead Senior Reactor Operator stated power was approaching 100 kW, alerting the Reactor Operator to the TS of no more than a one-inch height differential between control blades. Reactor power slowly increased. The Reactor Operator stopped shimming out on Control Blade 'A' and shimmed the other three rods inward individually to stop the power rise. He continued to then pull Control Blade 'A' out while leveling power by shimming the other three rods in. The control room continued the startup. No other issues occurred during the approach to full power (10 MW).
"After the startup, the Lead Senior Reactor Operator raised a concern that it was possible power peaked slightly above 100 kW with Control Blade 'A' at 1.4 inches below the other three control blades. Strip charts confirmed power peaked at 103.5 kW during this time. Total duration in this unapproved control blade configuration was less than one minute.
"The Reactor Manager was informed of the problem, and he informed the Interim Facility Director. MURR Licensee Event Report (LER) 13-03 discusses a similar event. Calculations performed for that event show that a control blade can differ by as much as 4 inches from the bank with no adverse effects to the core. MURR reactor operations were continued.
"MURR will follow up with an LER to address this issue."
The following information was provided by the University of Missouri-Columbia Research Reactor (MURR) via phone and email:
"During a normal reactor start up on 5/23/2023, while still approaching criticality, reactor power peaked slightly above 100 kW with a single control blade 1.4 inches below the other three control blades. This is a violation of Technical Specification (TS) 3.2.b which states that above 100 kW, the reactor shall be operated so that the maximum distance between the highest and lowest shim blade shall not exceed 1 inch.
"As part of a normal reactor startup, three control blades were at 23 inches and the core was approaching criticality. As the fourth control blade was being pulled to the bank height, the Lead Senior Reactor Operator stated power was approaching 100 kW, alerting the Reactor Operator to the TS of no more than a one-inch height differential between control blades. Reactor power slowly increased. The Reactor Operator stopped shimming out on Control Blade 'A' and shimmed the other three rods inward individually to stop the power rise. He continued to then pull Control Blade 'A' out while leveling power by shimming the other three rods in. The control room continued the startup. No other issues occurred during the approach to full power (10 MW).
"After the startup, the Lead Senior Reactor Operator raised a concern that it was possible power peaked slightly above 100 kW with Control Blade 'A' at 1.4 inches below the other three control blades. Strip charts confirmed power peaked at 103.5 kW during this time. Total duration in this unapproved control blade configuration was less than one minute.
"The Reactor Manager was informed of the problem, and he informed the Interim Facility Director. MURR Licensee Event Report (LER) 13-03 discusses a similar event. Calculations performed for that event show that a control blade can differ by as much as 4 inches from the bank with no adverse effects to the core. MURR reactor operations were continued.
"MURR will follow up with an LER to address this issue."
Agreement State
Event Number: 56536
Rep Org: PA Bureau of Radiation Protection
Licensee: Earth Engineering, Inc.
Region: 1
City: East Norriton State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ernest West
Licensee: Earth Engineering, Inc.
Region: 1
City: East Norriton State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ernest West
Notification Date: 05/24/2023
Notification Time: 08:37 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/24/2023
Notification Time: 08:37 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/24/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (FAX)
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (FAX)
STOLEN NUCLEAR DENSITY GAUGE
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:
"On May 24, 2023, the Department was notified of a stolen nuclear density gauge. This event is reportable within 24-hours per 10 CFR 20.2201(a)(1)(i).
"On May 23, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. Local, Regional, and State Police are aware of the incident and a bulletin has been issued. [The Department] has been in contact with the licensee and will update this event as soon as more information is provided.
"The Department will perform a reactive inspection."
Stolen gauge details:
Troxler Model Number: 3440
Serial Number: 33833
Sources: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries
* * * UPDATE ON 5/24/2023 AT 1340 EDT FROM JOHN CHIPPO TO IAN HOWARD * * *
The following information was provided by the Department via email:
"The vehicle has been recovered with the device still secure and intact in the trunk."
Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (email).
PA Event Report Number: PA230016
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 Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:
"On May 24, 2023, the Department was notified of a stolen nuclear density gauge. This event is reportable within 24-hours per 10 CFR 20.2201(a)(1)(i).
"On May 23, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. Local, Regional, and State Police are aware of the incident and a bulletin has been issued. [The Department] has been in contact with the licensee and will update this event as soon as more information is provided.
"The Department will perform a reactive inspection."
Stolen gauge details:
Troxler Model Number: 3440
Serial Number: 33833
Sources: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries
* * * UPDATE ON 5/24/2023 AT 1340 EDT FROM JOHN CHIPPO TO IAN HOWARD * * *
The following information was provided by the Department via email:
"The vehicle has been recovered with the device still secure and intact in the trunk."
Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (email).
PA Event Report Number: PA230016
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: 56533
Rep Org: Texas Dept of State Health Services
Licensee: Nextier Completion Solutions, Inc
Region: 4
City: Pleasanton State: TX
County:
License #: L 06712
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Licensee: Nextier Completion Solutions, Inc
Region: 4
City: Pleasanton State: TX
County:
License #: L 06712
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Notification Date: 05/23/2023
Notification Time: 15:00 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/23/2023
Notification Time: 15:00 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/23/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SHUTTER MISSING
The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email:
"On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) [Cs-137] source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10022
Texas NMED No.: TX230025
The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email:
"On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) [Cs-137] source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10022
Texas NMED No.: TX230025
Agreement State
Event Number: 56549
Rep Org: Minnesota Department of Health
Licensee: Regions Hospital
Region: 3
City: St. Paul State: MN
County:
License #: 1026
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: John Russell
Licensee: Regions Hospital
Region: 3
City: St. Paul State: MN
County:
License #: 1026
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: John Russell
Notification Date: 06/01/2023
Notification Time: 15:34 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 06/01/2023
Notification Time: 15:34 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 06/01/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
AGREEMENT STATE REPORT - LOST IODINE LOCALIZATION SEED
The following was received by email from the Minnesota Department of Health:
"An Iodine-125 localization seed (approximately 270 microcuries) was lost following removal from the specimen. The seed is suspected to have been placed on a surgical towel and never put into the source vial. Prior to discovery of the missing seed, the pathology department linens were taken to a laundry facility where the towel was washed. The licensee surveyed the pathology department and the laundry facility and were not able to find the seed."
State event report number: MN230003
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 was received by email from the Minnesota Department of Health:
"An Iodine-125 localization seed (approximately 270 microcuries) was lost following removal from the specimen. The seed is suspected to have been placed on a surgical towel and never put into the source vial. Prior to discovery of the missing seed, the pathology department linens were taken to a laundry facility where the towel was washed. The licensee surveyed the pathology department and the laundry facility and were not able to find the seed."
State event report number: MN230003
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