Event Notification Report for September 14, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/13/2023 - 09/14/2023
Non-Power Reactor
Event Number: 56740
Rep Org: Idaho State University (IDAH)
Licensee: Idaho State University
Region: 0
City: Pocatello State: ID
County: Bannock
License #: R-110
Agreement: N
Docket: 05000284
NRC Notified By: Mary Lou Dunzik-Gougar
HQ OPS Officer: Kerby Scales
Licensee: Idaho State University
Region: 0
City: Pocatello State: ID
County: Bannock
License #: R-110
Agreement: N
Docket: 05000284
NRC Notified By: Mary Lou Dunzik-Gougar
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 13:34 [ET]
Event Date: 09/14/2023
Event Time: 16:00 [MDT]
Last Update Date: 09/15/2023
Notification Time: 13:34 [ET]
Event Date: 09/14/2023
Event Time: 16:00 [MDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Yin, XIaosong (PM)
Waugh, Andrew (NPR COOR)
Yin, XIaosong (PM)
Waugh, Andrew (NPR COOR)
TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE
The following information is a summary provided by the licensee via phone and email:
On September 7, 2023, a Senior Reactor Operator (SRO) noted that power indication channel 1 and channel 2 initially responded abnormally during preoperational checks. It was determined that the data acquisition system (DAS) system had been de-energized possibly by a power outage the night before. The DAS was re-energized and channel 1 and channel 2 both returned to normal. Preoperational checks were able to be completed but the reactor start up was not completed due to time.
On September 14, 2023, the licensee was concerned regarding the initial abnormal response of the power indications when the DAS was de-energized, and it was determined that further investigation was needed to fully understand the potential effects on the reactor power channel indications. A plan was developed and approved by the Reactor Administrator to perform applicable steps of OP-1 to perform pre-operational and rod-drop tests with DAS energized and with DAS de-energized. All indications and pre-operational checks were normal with DAS energized.
A rod drop test was performed while de-energizing DAS to determine the effect if any on reactor power and scram functionality. Safety rod 1 and 2 were raised (reactor not critical), data recorded, then the power to DAS was removed. The power readings after DAS was de-energized were as follows: channel 1 - 150 cps (counts per second), channel 2 - off scale high on meter and chart recorder, channel 3 - 33 percent of 10 mW. The SRO noted that reactor did not scram when channel 2 indicated off scale high. The SRO manually scram the reactor, power to DAS was restored, and all indications returned to normal. An attempt to perform the pre-operational checks with DAS de-energized was aborted due to channel 1 and 2 indicating abnormally.
The licensee contacted the NRC Project Manager.
The following information is a summary provided by the licensee via phone and email:
On September 7, 2023, a Senior Reactor Operator (SRO) noted that power indication channel 1 and channel 2 initially responded abnormally during preoperational checks. It was determined that the data acquisition system (DAS) system had been de-energized possibly by a power outage the night before. The DAS was re-energized and channel 1 and channel 2 both returned to normal. Preoperational checks were able to be completed but the reactor start up was not completed due to time.
On September 14, 2023, the licensee was concerned regarding the initial abnormal response of the power indications when the DAS was de-energized, and it was determined that further investigation was needed to fully understand the potential effects on the reactor power channel indications. A plan was developed and approved by the Reactor Administrator to perform applicable steps of OP-1 to perform pre-operational and rod-drop tests with DAS energized and with DAS de-energized. All indications and pre-operational checks were normal with DAS energized.
A rod drop test was performed while de-energizing DAS to determine the effect if any on reactor power and scram functionality. Safety rod 1 and 2 were raised (reactor not critical), data recorded, then the power to DAS was removed. The power readings after DAS was de-energized were as follows: channel 1 - 150 cps (counts per second), channel 2 - off scale high on meter and chart recorder, channel 3 - 33 percent of 10 mW. The SRO noted that reactor did not scram when channel 2 indicated off scale high. The SRO manually scram the reactor, power to DAS was restored, and all indications returned to normal. An attempt to perform the pre-operational checks with DAS de-energized was aborted due to channel 1 and 2 indicating abnormally.
The licensee contacted the NRC Project Manager.
Agreement State
Event Number: 56742
Rep Org: Alabama Radiation Control
Licensee: Applied Technical Services
Region: 1
City: East Mobile State: AL
County:
License #: RML 1454
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Kerby Scales
Licensee: Applied Technical Services
Region: 1
City: East Mobile State: AL
County:
License #: RML 1454
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 18:00 [ET]
Event Date: 09/14/2023
Event Time: 17:00 [CDT]
Last Update Date: 09/15/2023
Notification Time: 18:00 [ET]
Event Date: 09/14/2023
Event Time: 17:00 [CDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by Alabama Radiation Control via email:
"The licensee's representative called an Alabama Radiation Control staff member to report that an RT [radiographic testing] crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS [Applied Technical Services] office in Marietta, Georgia to respond.
"Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident Number: To Be Determined
The following information was provided by Alabama Radiation Control via email:
"The licensee's representative called an Alabama Radiation Control staff member to report that an RT [radiographic testing] crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS [Applied Technical Services] office in Marietta, Georgia to respond.
"Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident Number: To Be Determined
Agreement State
Event Number: 56799
Rep Org: Georgia Radioactive Material Pgm
Licensee: Grady Memorial Hospital Corp
Region: 1
City: Atlanta State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Adam Koziol
Licensee: Grady Memorial Hospital Corp
Region: 1
City: Atlanta State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Adam Koziol
Notification Date: 10/16/2023
Notification Time: 13:14 [ET]
Event Date: 09/14/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2023
Notification Time: 13:14 [ET]
Event Date: 09/14/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2023
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)
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST SEED SOURCE
The following is a summary of information provided by the Georgia Radioactive Materials Program via email:
On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023.
Georgia NMED Incident Number: 71
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 provided by the Georgia Radioactive Materials Program via email:
On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023.
Georgia NMED Incident Number: 71
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