Event Notification Report for September 05, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/04/2023 - 09/05/2023
Agreement State
Event Number: 56697
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Notification Date: 08/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 08/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 08/25/2023
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)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE
The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
Illinois Item Number: IL230021
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 received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
Illinois Item Number: IL230021
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: 56699
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Health Care Southern Lakes
Region: 3
City: Mount Pleasant State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Karen Cotton-Gross
Licensee: Aurora Health Care Southern Lakes
Region: 3
City: Mount Pleasant State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/29/2023
Notification Time: 10:45 [ET]
Event Date: 08/28/2023
Event Time: 09:16 [CDT]
Last Update Date: 08/29/2023
Notification Time: 10:45 [ET]
Event Date: 08/28/2023
Event Time: 09:16 [CDT]
Last Update Date: 08/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - MEDICAL UNDERDOSE
The following information was provided by the Wisconsin Radiation Protection (the Department) via email:
"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."
Wisconsin Event Report ID Number: WI230015
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 Wisconsin Radiation Protection (the Department) via email:
"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."
Wisconsin Event Report ID Number: WI230015
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.
Agreement State
Event Number: 56700
Rep Org: Florida Bureau of Radiation Control
Licensee: Mineral Development LLC
Region: 1
City: Bartow State: FL
County:
License #: 13-32721-01
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Lawrence Criscione
Licensee: Mineral Development LLC
Region: 1
City: Bartow State: FL
County:
License #: 13-32721-01
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Lawrence Criscione
Notification Date: 08/29/2023
Notification Time: 15:24 [ET]
Event Date: 08/28/2023
Event Time: 10:00 [EDT]
Last Update Date: 08/29/2023
Notification Time: 15:24 [ET]
Event Date: 08/28/2023
Event Time: 10:00 [EDT]
Last Update Date: 08/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - RECOVERED LOOSE SOURCE FOR FLOW METER
The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.
On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.
The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.
Florida Incident Number: FL23-131
The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.
On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.
The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.
Florida Incident Number: FL23-131
Power Reactor
Event Number: 56707
Facility: Monticello
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Jake Styrbicky
HQ OPS Officer: Lawrence Criscione
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Jake Styrbicky
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/01/2023
Notification Time: 18:05 [ET]
Event Date: 09/01/2023
Event Time: 09:00 [CDT]
Last Update Date: 09/01/2023
Notification Time: 18:05 [ET]
Event Date: 09/01/2023
Event Time: 09:00 [CDT]
Last Update Date: 09/01/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Skokowski, Richard (R3DO)
FFD Group, (EMAIL)
Skokowski, Richard (R3DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROLLED SUBSTANCE FOUND IN THE PROTECTED AREA
The following information was provided by the licensee via email:
"On 9/1/23 at 0900 hours, site personnel identified a 1 ounce bottle of vanilla extract in the protected area. Alcohol was identified as an ingredient on the ingredients label. It was determined that the alcohol by volume (ABV) for vanilla extract was 35 percent, above the 0.5 percent ABV considered low alcohol content."
The following information was provided by the licensee via email:
"On 9/1/23 at 0900 hours, site personnel identified a 1 ounce bottle of vanilla extract in the protected area. Alcohol was identified as an ingredient on the ingredients label. It was determined that the alcohol by volume (ABV) for vanilla extract was 35 percent, above the 0.5 percent ABV considered low alcohol content."
Power Reactor
Event Number: 56710
Facility: Nine Mile Point
Region: 1 State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Kiersten Walker
HQ OPS Officer: Bill Gott
Region: 1 State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Kiersten Walker
HQ OPS Officer: Bill Gott
Notification Date: 09/02/2023
Notification Time: 09:46 [ET]
Event Date: 09/02/2023
Event Time: 06:32 [EDT]
Last Update Date: 09/02/2023
Notification Time: 09:46 [ET]
Event Date: 09/02/2023
Event Time: 06:32 [EDT]
Last Update Date: 09/02/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(A) - Eccs Injection 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(A) - Eccs Injection 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Dentel, Glenn (R1DO)
Dentel, Glenn (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM DUE TO FEEDWATER TRANSIENT
The following information was provided by the licensee via email:
"On 9/2/2023 at 0632 EDT, a feedwater transient occurred resulting in an reactor protection system (RPS) automatic reactor scram on low level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 recirculation sample system isolation, Group 3 traveling in-core probe (TIP) isolation valve isolation, Group 6 and 7 reactor water cleanup isolation, and Group 9 containment purge isolations. All control rods inserted as expected. High pressure core spray and reactor core isolation cooling initiated and injected as expected. ECCS systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable and in Mode 3.
"These 4 hour and 8 hour non-emergency reports are being made in accordance with 10 CFR 50.72(b)(2) (iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident was informed. There was no impact on Unit 1."
The following information was provided by the licensee via email:
"On 9/2/2023 at 0632 EDT, a feedwater transient occurred resulting in an reactor protection system (RPS) automatic reactor scram on low level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 recirculation sample system isolation, Group 3 traveling in-core probe (TIP) isolation valve isolation, Group 6 and 7 reactor water cleanup isolation, and Group 9 containment purge isolations. All control rods inserted as expected. High pressure core spray and reactor core isolation cooling initiated and injected as expected. ECCS systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable and in Mode 3.
"These 4 hour and 8 hour non-emergency reports are being made in accordance with 10 CFR 50.72(b)(2) (iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident was informed. There was no impact on Unit 1."
Fuel Cycle Facility
Event Number: 56711
Facility: Honeywell International, Inc.
Region: 2 State: IL
Unit: [] [] []
RX Type: Uranium Hexafluoride Production
NRC Notified By: Jon Bernard
HQ OPS Officer: Bill Gott
Region: 2 State: IL
Unit: [] [] []
RX Type: Uranium Hexafluoride Production
NRC Notified By: Jon Bernard
HQ OPS Officer: Bill Gott
Notification Date: 09/02/2023
Notification Time: 10:06 [ET]
Event Date: 09/02/2023
Event Time: 08:17 [CDT]
Last Update Date: 09/02/2023
Notification Time: 10:06 [ET]
Event Date: 09/02/2023
Event Time: 08:17 [CDT]
Last Update Date: 09/02/2023
Emergency Class: Alert
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dudes, Laura (Region 2)
Lubinski, John (NMSS)
Grant, Jeffery (IR)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dudes, Laura (Region 2)
Lubinski, John (NMSS)
Grant, Jeffery (IR)
ALERT DECLARED DUE TO UF6 RELEASE
The following information was provided by the licensee via email:
"On 09/02/2023, Honeywell declared a 'Plant Emergency' at 0815 CDT and upgraded to an 'Alert' at 0835 CDT in accordance with the Honeywell Emergency Response Plan due to a uranium hexafluoride leak on the kinney pump system."
Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center, HHS Operations Center, EPA Emergency Operations Center, USDA Operations Center, FDA EOC (email), FEMA NWC (email), and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
* * * UPDATE ON 9/2/2023 AT 2241 EDT FROM HONEYWELL INTERNATIONAL TO IAN B. HOWARD * * *
"The 'All Clear' was declared at 2115 CDT on 09/02/2023. There were no injuries related to this incident. This statement constitutes the NRC notification related to the incident. Honeywell is currently investigating the cause of the event."
Notified R2DO (Miller), NMSS/DFM Division Director (Helton), NMSS Events Notification (email), IRMOC (Grant), DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email).
The following information was provided by the licensee via email:
"On 09/02/2023, Honeywell declared a 'Plant Emergency' at 0815 CDT and upgraded to an 'Alert' at 0835 CDT in accordance with the Honeywell Emergency Response Plan due to a uranium hexafluoride leak on the kinney pump system."
Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center, HHS Operations Center, EPA Emergency Operations Center, USDA Operations Center, FDA EOC (email), FEMA NWC (email), and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
* * * UPDATE ON 9/2/2023 AT 2241 EDT FROM HONEYWELL INTERNATIONAL TO IAN B. HOWARD * * *
"The 'All Clear' was declared at 2115 CDT on 09/02/2023. There were no injuries related to this incident. This statement constitutes the NRC notification related to the incident. Honeywell is currently investigating the cause of the event."
Notified R2DO (Miller), NMSS/DFM Division Director (Helton), NMSS Events Notification (email), IRMOC (Grant), DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email).
Non-Agreement State
Event Number: 56693
Rep Org: Alliance Healthcare Services
Licensee: Alliance Healthcare Services
Region: 3
City: State: MI
County:
License #: 47-25570-01
Agreement: N
Docket:
NRC Notified By: Kay Kassel
HQ OPS Officer: Lawrence Criscione
Licensee: Alliance Healthcare Services
Region: 3
City: State: MI
County:
License #: 47-25570-01
Agreement: N
Docket:
NRC Notified By: Kay Kassel
HQ OPS Officer: Lawrence Criscione
Notification Date: 08/23/2023
Notification Time: 09:30 [ET]
Event Date: 08/21/2023
Event Time: 07:00 [EDT]
Last Update Date: 09/05/2023
Notification Time: 09:30 [ET]
Event Date: 08/21/2023
Event Time: 07:00 [EDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
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)
EN Revision Imported Date: 9/6/2023
EN Revision Text: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE
The following is a summary of information provided by the licensee via phone and email:
The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.
* * * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *
"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."
Notified R3DO Skokowski, NMSS Events Notification, and ILTAB 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: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE
The following is a summary of information provided by the licensee via phone and email:
The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.
* * * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *
"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."
Notified R3DO Skokowski, NMSS Events Notification, and ILTAB 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
Agreement State
Event Number: 56701
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA Medi Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Lawrence Criscione
Licensee: G.E. Healthcare DBA Medi Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Lawrence Criscione
Notification Date: 08/30/2023
Notification Time: 12:55 [ET]
Event Date: 08/29/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2023
Notification Time: 12:55 [ET]
Event Date: 08/29/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2023
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)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE
The following is a summary of information received via email from the Illinois Emergency Management Agency (IEMA):
IEMA was notified August 29, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise a radiopharmaceutical package was missing - presumably in transit. This package contained (3) shielded vials of In-111, accounting for 12.3 mCi at the time of shipment. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
The radiopharmaceutical package was offered for shipment on August 24, 2023, for delivery to the customer the following day. The package was labeled Yellow-II (TI of 0.1), UN2915. At of the time of the report, the activity has since decayed to approximately 2.8 mCi. The licensee advised that on August 29, 2023, [common carrier] declared the package as lost with an unknown status.
Illinois Item Number: IL230022
See EN56682 and EN56697 for similar events.
* * * UPDATE ON 9/5/203 AT 1448 EDT FROM GARY FORSEE TO ERNEST WEST * * *
"This package was located at a landfill in Indiana on 9/5/2023"
Notified R3DO (Ruiz), NMSS Event Notifications and ILTAB 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
The following is a summary of information received via email from the Illinois Emergency Management Agency (IEMA):
IEMA was notified August 29, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise a radiopharmaceutical package was missing - presumably in transit. This package contained (3) shielded vials of In-111, accounting for 12.3 mCi at the time of shipment. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
The radiopharmaceutical package was offered for shipment on August 24, 2023, for delivery to the customer the following day. The package was labeled Yellow-II (TI of 0.1), UN2915. At of the time of the report, the activity has since decayed to approximately 2.8 mCi. The licensee advised that on August 29, 2023, [common carrier] declared the package as lost with an unknown status.
Illinois Item Number: IL230022
See EN56682 and EN56697 for similar events.
* * * UPDATE ON 9/5/203 AT 1448 EDT FROM GARY FORSEE TO ERNEST WEST * * *
"This package was located at a landfill in Indiana on 9/5/2023"
Notified R3DO (Ruiz), NMSS Event Notifications and ILTAB 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
Power Reactor
Event Number: 56714
Facility: McGuire
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Eric Palmer
HQ OPS Officer: Brian P. Smith
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Eric Palmer
HQ OPS Officer: Brian P. Smith
Notification Date: 09/05/2023
Notification Time: 17:05 [ET]
Event Date: 09/05/2023
Event Time: 12:00 [EDT]
Last Update Date: 09/05/2023
Notification Time: 17:05 [ET]
Event Date: 09/05/2023
Event Time: 12:00 [EDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Miller, Mark (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY VIOLATION
The following information was provided by the licensee via email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated.
The following information was provided by the licensee via email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated.
Power Reactor
Event Number: 56715
Facility: Comanche Peak
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Karl
HQ OPS Officer: Ernest West
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Karl
HQ OPS Officer: Ernest West
Notification Date: 09/05/2023
Notification Time: 17:22 [ET]
Event Date: 09/05/2023
Event Time: 09:52 [CDT]
Last Update Date: 09/05/2023
Notification Time: 17:22 [ET]
Event Date: 09/05/2023
Event Time: 09:52 [CDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Azua, Ray (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY VIOLATION
The following information was provided by the licensee via email:
A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The following information was provided by the licensee via email:
A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.