Event Notification Report for September 13, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/12/2023 - 09/13/2023
Power Reactor
Event Number: 56644
Facility: Waterford
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: William Crowley
HQ OPS Officer: Adam Koziol
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: William Crowley
HQ OPS Officer: Adam Koziol
Notification Date: 07/30/2023
Notification Time: 17:25 [ET]
Event Date: 07/30/2023
Event Time: 11:19 [CDT]
Last Update Date: 09/12/2023
Notification Time: 17:25 [ET]
Event Date: 07/30/2023
Event Time: 11:19 [CDT]
Last Update Date: 09/12/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Young, Cale (R4DO)
Young, Cale (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 9/13/2023
EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE
The following information was provided by the licensee via email:
"On July 30, 2023 at 1119 CDT, Waterford Steam Electric Station Unit 3 declared the control room envelope inoperable in accordance with technical specification (TS) 3.7.6.1 due to the control room envelope doors failing a door seal smoke test creating a breach in the control room envelope.
"Operations entered TS 3.7.6.1 Action b.
"Mitigating actions were implemented and tested satisfactorily by 1215 CDT.
"There was no impact on the health and safety of the public or plant personnel.
"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident, due to the control room envelope being inoperable.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 09/12/23 AT 1357 EDT FROM MONICA PEAK TO THOMAS HERRITY * * *
"The original operability determination of inoperable was made based on a conservative evaluation that with presence of smoke in-leakage through Door 261 and 262, the CRE boundary could not perform its safety function. A more detailed engineering evaluation was subsequently performed. No maintenance or intrusive testing was performed on the doors after initial test failure. As documented in version 2 operability determination for condition report WF3-2023-14604, the CRE boundary remained intact for the condition identified and was able to fulfill its safety function."
The licensee has notified the NRC Resident Inspector. Notified R4DO (Warnick).
EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE
The following information was provided by the licensee via email:
"On July 30, 2023 at 1119 CDT, Waterford Steam Electric Station Unit 3 declared the control room envelope inoperable in accordance with technical specification (TS) 3.7.6.1 due to the control room envelope doors failing a door seal smoke test creating a breach in the control room envelope.
"Operations entered TS 3.7.6.1 Action b.
"Mitigating actions were implemented and tested satisfactorily by 1215 CDT.
"There was no impact on the health and safety of the public or plant personnel.
"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident, due to the control room envelope being inoperable.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 09/12/23 AT 1357 EDT FROM MONICA PEAK TO THOMAS HERRITY * * *
"The original operability determination of inoperable was made based on a conservative evaluation that with presence of smoke in-leakage through Door 261 and 262, the CRE boundary could not perform its safety function. A more detailed engineering evaluation was subsequently performed. No maintenance or intrusive testing was performed on the doors after initial test failure. As documented in version 2 operability determination for condition report WF3-2023-14604, the CRE boundary remained intact for the condition identified and was able to fulfill its safety function."
The licensee has notified the NRC Resident Inspector. Notified R4DO (Warnick).
Agreement State
Event Number: 56712
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Licensee: G.E. Healthcare
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Notification Date: 09/05/2023
Notification Time: 13:48 [ET]
Event Date: 09/01/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2023
Notification Time: 13:48 [ET]
Event Date: 09/01/2023
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):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - MISSING PACKAGES
The following information was provided by the Illinois Emergency Management Agency (the Agency) email:
"The Agency was notified after hours on September 1, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of three radiopharmaceutical packages missing in transit. This is in addition to the four previously reported missing shipments [See EN56682, EN56697, and EN56701]. All three were shipped on August 24, 2023, and marked as 'missing' by the common carrier on September 1, 2023. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. Indiana contacted the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) and reported at least two of these packages were located in an Indiana landfill and were recovered by their responders. [One of the two packages recovered from the landfill is for a previous event, See EN56701]. This investigation is ongoing.
"The radiopharmaceutical packages were offered for shipment on August 24, 2023, for delivery to three customers (Nuclear Medicine Associates in Redding, CA; Cardinal Health in Southfield, MI; and RLS USA INC - New Orleans in Harahan, LA). The Nuclear Medicine Associates package contained three 14.3 mCi vials of I-123; the Cardinal Health package contained one 4.1 mCi vial of In-111 and the RLS package contained one 4.1 mCi vial of In-111. Activities are those at time of shipment. Information available at this time indicates the Nuclear Medicine Associates package and at least one other package containing In-111 [see EN56701] were located at a landfill by State of Indiana officials."
NMED report number: IL230023
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 Illinois Emergency Management Agency (the Agency) email:
"The Agency was notified after hours on September 1, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of three radiopharmaceutical packages missing in transit. This is in addition to the four previously reported missing shipments [See EN56682, EN56697, and EN56701]. All three were shipped on August 24, 2023, and marked as 'missing' by the common carrier on September 1, 2023. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. Indiana contacted the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) and reported at least two of these packages were located in an Indiana landfill and were recovered by their responders. [One of the two packages recovered from the landfill is for a previous event, See EN56701]. This investigation is ongoing.
"The radiopharmaceutical packages were offered for shipment on August 24, 2023, for delivery to three customers (Nuclear Medicine Associates in Redding, CA; Cardinal Health in Southfield, MI; and RLS USA INC - New Orleans in Harahan, LA). The Nuclear Medicine Associates package contained three 14.3 mCi vials of I-123; the Cardinal Health package contained one 4.1 mCi vial of In-111 and the RLS package contained one 4.1 mCi vial of In-111. Activities are those at time of shipment. Information available at this time indicates the Nuclear Medicine Associates package and at least one other package containing In-111 [see EN56701] were located at a landfill by State of Indiana officials."
NMED report number: IL230023
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: 56713
Rep Org: Georgia Radioactive Material Pgm
Licensee: Eckert and Ziegler Analytics Inc.
Region: 1
City: Atlanta State: GA
County:
License #: GA 742-1
Agreement: Y
Docket:
NRC Notified By: Walter Levich
HQ OPS Officer: Brian P. Smith
Licensee: Eckert and Ziegler Analytics Inc.
Region: 1
City: Atlanta State: GA
County:
License #: GA 742-1
Agreement: Y
Docket:
NRC Notified By: Walter Levich
HQ OPS Officer: Brian P. Smith
Notification Date: 09/05/2023
Notification Time: 14:23 [ET]
Event Date: 06/02/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/05/2023
Notification Time: 14:23 [ET]
Event Date: 06/02/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - MISSING SOURCES
The following report was received via email from the Georgia Radioactive Material Program [the Department]:
"On Thursday, August 31, 2023, the radiation safety officer (RSO) reported two missing solution standard sources of Am-241, 1.0 microcurie each (37 kBq each) to the Department. These two sources were lost during transportation to Nuclear Fuel Services located in Erwin, Tennessee on June 2, 2023. The customer, Nuclear Fuel Services, notified the licensee that they did not receive the shipment package. The RSO contacted the common carrier to trace its whereabouts. On June 26, 2023, the common carrier's records show that the shipment was signed for by an individual at Nuclear Fuel Services. However, Nuclear Fuel Services confirmed that they did not receive this shipment. There is a communication discrepancy between the common carrier and Nuclear Fuel Services. Currently, the licensee is waiting for a detailed response from the customer regarding this shipment."
Georgia Incident Report Number: 69
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 report was received via email from the Georgia Radioactive Material Program [the Department]:
"On Thursday, August 31, 2023, the radiation safety officer (RSO) reported two missing solution standard sources of Am-241, 1.0 microcurie each (37 kBq each) to the Department. These two sources were lost during transportation to Nuclear Fuel Services located in Erwin, Tennessee on June 2, 2023. The customer, Nuclear Fuel Services, notified the licensee that they did not receive the shipment package. The RSO contacted the common carrier to trace its whereabouts. On June 26, 2023, the common carrier's records show that the shipment was signed for by an individual at Nuclear Fuel Services. However, Nuclear Fuel Services confirmed that they did not receive this shipment. There is a communication discrepancy between the common carrier and Nuclear Fuel Services. Currently, the licensee is waiting for a detailed response from the customer regarding this shipment."
Georgia Incident Report Number: 69
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: 56716
Rep Org: WA Office of Radiation Protection
Licensee: Nelson Geotechnical Associates
Region: 4
City: Trinidad State: WA
County:
License #: WN-I0421-1
Agreement: Y
Docket:
NRC Notified By: Jasmin Hernandez
HQ OPS Officer: Brian P. Smith
Licensee: Nelson Geotechnical Associates
Region: 4
City: Trinidad State: WA
County:
License #: WN-I0421-1
Agreement: Y
Docket:
NRC Notified By: Jasmin Hernandez
HQ OPS Officer: Brian P. Smith
Notification Date: 09/05/2023
Notification Time: 19:51 [ET]
Event Date: 08/29/2023
Event Time: 14:30 [PDT]
Last Update Date: 09/05/2023
Notification Time: 19:51 [ET]
Event Date: 08/29/2023
Event Time: 14:30 [PDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following is a summary from a report received via email from the Washington State Department of Health:
A Troxler 3440 portable gauge (two sealed sources containing 9 mCi of Cs-137 and 44mCi of Am/Be-241) was run over by a bulldozer at a construction site. The full report with corrective actions has yet to be issued. No significant releases of radioactivity occurred.
Washington Incident Number: WA-23-015
The following is a summary from a report received via email from the Washington State Department of Health:
A Troxler 3440 portable gauge (two sealed sources containing 9 mCi of Cs-137 and 44mCi of Am/Be-241) was run over by a bulldozer at a construction site. The full report with corrective actions has yet to be issued. No significant releases of radioactivity occurred.
Washington Incident Number: WA-23-015
Agreement State
Event Number: 56717
Rep Org: Colorado Dept of Health
Licensee: UC Health University
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Shiya Wang
HQ OPS Officer: Thomas Herrity
Licensee: UC Health University
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Shiya Wang
HQ OPS Officer: Thomas Herrity
Notification Date: 09/06/2023
Notification Time: 11:01 [ET]
Event Date: 09/05/2023
Event Time: 13:00 [MDT]
Last Update Date: 09/06/2023
Notification Time: 11:01 [ET]
Event Date: 09/05/2023
Event Time: 13:00 [MDT]
Last Update Date: 09/06/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT RECEIVED 29 PERCENT OVERDOSE
The following was received from the Colorado Department of Public Health and Environment via email:
"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."
Colorado Event Report ID No.: CO230028
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 was received from the Colorado Department of Public Health and Environment via email:
"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."
Colorado Event Report ID No.: CO230028
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.
Non-Agreement State
Event Number: 56718
Rep Org: Adventist Health Castle
Licensee: Adventist Health Castle
Region: 4
City: Kailua State: HI
County:
License #: 53-16929-01
Agreement: N
Docket:
NRC Notified By: Ronald Frick
HQ OPS Officer: Brian P. Smith
Licensee: Adventist Health Castle
Region: 4
City: Kailua State: HI
County:
License #: 53-16929-01
Agreement: N
Docket:
NRC Notified By: Ronald Frick
HQ OPS Officer: Brian P. Smith
Notification Date: 09/06/2023
Notification Time: 15:53 [ET]
Event Date: 09/06/2023
Event Time: 07:37 [HST]
Last Update Date: 09/06/2023
Notification Time: 15:53 [ET]
Event Date: 09/06/2023
Event Time: 07:37 [HST]
Last Update Date: 09/06/2023
Emergency Class: Non Emergency
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
SURFACE CONTAMINATION LEVELS OF PACKAGE EXCEEDED LIMIT
The following information was provided by the licensee via telephone:
On September 6, 2023, Adventist Health Castle received an expected package of TC-99M from Cardinal Health. During a wipe test that was conducted at 0737 HST, it was determined that the package had removable surface contamination levels of 17836 disintegrations per minute (dpm) per 300 centimeters squared (cm^2). The radiation safety officer (RSO)'s determination was that this exceeded a limit that he stated was 2400 dpm per 100 cm^2. The RSO notified the Headquarters Operations Officer and the carrier for follow-up. The package was stored in a secure location for the contamination level to decay. Adventist Health Castle plans to return the package to the originator following its decay to a suitable level.
The following information was provided by the licensee via telephone:
On September 6, 2023, Adventist Health Castle received an expected package of TC-99M from Cardinal Health. During a wipe test that was conducted at 0737 HST, it was determined that the package had removable surface contamination levels of 17836 disintegrations per minute (dpm) per 300 centimeters squared (cm^2). The radiation safety officer (RSO)'s determination was that this exceeded a limit that he stated was 2400 dpm per 100 cm^2. The RSO notified the Headquarters Operations Officer and the carrier for follow-up. The package was stored in a secure location for the contamination level to decay. Adventist Health Castle plans to return the package to the originator following its decay to a suitable level.
Fuel Cycle Facility
Event Number: 56199
Facility: Westinghouse Electric Corporation
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Eric Simpson
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Eric Simpson
Notification Date: 11/02/2022
Notification Time: 11:12 [ET]
Event Date: 11/01/2022
Event Time: 11:29 [EDT]
Last Update Date: 09/13/2023
Notification Time: 11:12 [ET]
Event Date: 11/01/2022
Event Time: 11:29 [EDT]
Last Update Date: 09/13/2023
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (b)(1) - Unanalyzed Condition
10 CFR Section:
PART 70 APP A (b)(1) - Unanalyzed Condition
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
EN Revision Imported Date: 9/14/2023
EN Revision Text: UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS
The following is a synopsis of information provided by the licensee via email:
Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.
This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.
This issue has been entered into the licensee's corrective action program as IR-2022-9728.
* * * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHANE SUBOSITS TO THOMAS HERRITY * * *
The following is a synopsis of information provided by the licensee via email:
On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done.
This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition.
Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953.
Notified R2DO (Endress) and NMSS_EVENTS via email.
EN Revision Text: UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS
The following is a synopsis of information provided by the licensee via email:
Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.
This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.
This issue has been entered into the licensee's corrective action program as IR-2022-9728.
* * * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHANE SUBOSITS TO THOMAS HERRITY * * *
The following is a synopsis of information provided by the licensee via email:
On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done.
This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition.
Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953.
Notified R2DO (Endress) and NMSS_EVENTS via email.
Agreement State
Event Number: 56725
Rep Org: PA Bureau of Radiation Protection
Licensee: Powers Engineering and Construction Testing, LLC
Region: 1
City: Whitehall Borough State: PA
County: Allegheny
License #: PA-1540
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Dan Livermore
Licensee: Powers Engineering and Construction Testing, LLC
Region: 1
City: Whitehall Borough State: PA
County: Allegheny
License #: PA-1540
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Dan Livermore
Notification Date: 09/07/2023
Notification Time: 12:40 [ET]
Event Date: 09/06/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2023
Notification Time: 12:40 [ET]
Event Date: 09/06/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2023
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)
TROXLER GAUGE DAMAGED
The following summary information was provided by the PA Bureau of Radiation Protection (PA DEP) via email"
"On September 6, 2023 a Troxler gauge, model 3411, serial number 6829 was hit by a vehicle while on a job site. This gauge contained a 9 millicurie Cesium-137 source and a 44 millicurie Americium 241:Be source. The area was secured, and the PA DEP responded to the site. The owner/radiation safety officer (RSO) retrieved the sources with long handled pliers and secured them in the transportation box for the gauge. The area and gauge were surveyed and smears were taken for contamination. The case was also surveyed and the owner/RSO has contacted a consultant/vendor to leak test the sources and arrange for disposal."
Pennsylvania Event Number: PA230024
The following summary information was provided by the PA Bureau of Radiation Protection (PA DEP) via email"
"On September 6, 2023 a Troxler gauge, model 3411, serial number 6829 was hit by a vehicle while on a job site. This gauge contained a 9 millicurie Cesium-137 source and a 44 millicurie Americium 241:Be source. The area was secured, and the PA DEP responded to the site. The owner/radiation safety officer (RSO) retrieved the sources with long handled pliers and secured them in the transportation box for the gauge. The area and gauge were surveyed and smears were taken for contamination. The case was also surveyed and the owner/RSO has contacted a consultant/vendor to leak test the sources and arrange for disposal."
Pennsylvania Event Number: PA230024
Agreement State
Event Number: 56726
Rep Org: Florida Bureau of Radiation Control
Licensee: Tierra Inc.
Region: 1
City: Winter Garden State: FL
County:
License #: 2307-3
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Ernest West
Licensee: Tierra Inc.
Region: 1
City: Winter Garden State: FL
County:
License #: 2307-3
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Ernest West
Notification Date: 09/07/2023
Notification Time: 17:40 [ET]
Event Date: 09/07/2023
Event Time: 17:15 [EDT]
Last Update Date: 09/08/2023
Notification Time: 17:40 [ET]
Event Date: 09/07/2023
Event Time: 17:15 [EDT]
Last Update Date: 09/08/2023
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 - LOST AND RECOVERED TROXLER GAUGE
The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email:
"On or about 1715 [EDT], 9/7/23, [the licensee's] Assistant Radiation Safety Officer (RSO) notified [the Bureau] of a missing soil moisture density gauge. Operator [deleted] believed the gauge to be absent due to the storage/transport box 'feeling light' when the box was moved at 1700 EDT. Sanford Police Department (PD) was notified by the licensee. [A Bureau investigator] was notified. The NRC was notified.
"Upon a subsequent thorough search of job site with Sanford PD, [the licensee] called the [Bureau's] duty officer at approximately 1800 EDT to report the gauge was located in the storage/transport box, which was within a locked and fenced area."
Florida Incident Number: FL23-141
* * * UPDATE ON 09/08/23 AT 0930 EDT FROM ROBERT LATHAM TO TOM HERRITY * * *
"Just to clarify, I talked to the RSO this morning and he said the gauge user assumed the gauge was left at the job site that morning because when he got back to the office that evening to remove his samples, he had to move the gauge case and it felt light. It wasn't until they went back to the job site to meet with the PD that someone actually looked in the case and then realized the gauge was still in there. So the gauge was never out of their possession or control, they just assumed it was.
"I will be submitting an investigation and incident report, but not a radioactive material license inspection report since there was no violation for loss of control."
Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.
* * * RETRACTION ON 09/08/23 AT 1037 EDT FROM MONROE A. COOPER TO TOM HERRITY * * *
"On 9/8/23, at 1026 EDT, the Bureau spoke with Tierra and it was explained that the gauge was misidentified as missing. This occurred because a user determined the Troxler case felt light, and reported the object missing without ensuring the gauge was not present."
Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.
The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email:
"On or about 1715 [EDT], 9/7/23, [the licensee's] Assistant Radiation Safety Officer (RSO) notified [the Bureau] of a missing soil moisture density gauge. Operator [deleted] believed the gauge to be absent due to the storage/transport box 'feeling light' when the box was moved at 1700 EDT. Sanford Police Department (PD) was notified by the licensee. [A Bureau investigator] was notified. The NRC was notified.
"Upon a subsequent thorough search of job site with Sanford PD, [the licensee] called the [Bureau's] duty officer at approximately 1800 EDT to report the gauge was located in the storage/transport box, which was within a locked and fenced area."
Florida Incident Number: FL23-141
* * * UPDATE ON 09/08/23 AT 0930 EDT FROM ROBERT LATHAM TO TOM HERRITY * * *
"Just to clarify, I talked to the RSO this morning and he said the gauge user assumed the gauge was left at the job site that morning because when he got back to the office that evening to remove his samples, he had to move the gauge case and it felt light. It wasn't until they went back to the job site to meet with the PD that someone actually looked in the case and then realized the gauge was still in there. So the gauge was never out of their possession or control, they just assumed it was.
"I will be submitting an investigation and incident report, but not a radioactive material license inspection report since there was no violation for loss of control."
Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.
* * * RETRACTION ON 09/08/23 AT 1037 EDT FROM MONROE A. COOPER TO TOM HERRITY * * *
"On 9/8/23, at 1026 EDT, the Bureau spoke with Tierra and it was explained that the gauge was misidentified as missing. This occurred because a user determined the Troxler case felt light, and reported the object missing without ensuring the gauge was not present."
Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.