Event Notification Report for September 20, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/19/2023 - 09/20/2023
Power Reactor
Event Number: 56753
Facility: Peach Bottom
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Mike Hoffmaster
HQ OPS Officer: Michael Bloodgood
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Mike Hoffmaster
HQ OPS Officer: Michael Bloodgood
Notification Date: 09/21/2023
Notification Time: 10:31 [ET]
Event Date: 09/20/2023
Event Time: 15:15 [EDT]
Last Update Date: 09/21/2023
Notification Time: 10:31 [ET]
Event Date: 09/20/2023
Event Time: 15:15 [EDT]
Last Update Date: 09/21/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 86 | Power Operation | 86 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via phone and email:
"A licensed operator had a confirmed positive test for alcohol during another entity's pre-access fitness-for-duty screening for unescorted access authorization. The individual's unescorted access at Peach Bottom Atomic Power Station has been denied.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"A licensed operator had a confirmed positive test for alcohol during another entity's pre-access fitness-for-duty screening for unescorted access authorization. The individual's unescorted access at Peach Bottom Atomic Power Station has been denied.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 56752
Rep Org: Texas Dept of State Health Services
Licensee: Professional Service Industries, Inc.
Region: 4
City: Austin State: TX
County:
License #: 04947
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Lawrence Criscione
Licensee: Professional Service Industries, Inc.
Region: 4
City: Austin State: TX
County:
License #: 04947
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/20/2023
Notification Time: 22:33 [ET]
Event Date: 09/20/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/22/2023
Notification Time: 22:33 [ET]
Event Date: 09/20/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE
The following information was received from the Texas Department of State Health Services (the Department) via email:
"On September 20, 2023, the Department received notification of a lost moisture density gauge. The gauge is a Troxler 3430 (serial 39365) with 40 millicuries of americium-241 and 8 millicuries of cesium-137. The gauge was last seen at a job site with the licensee reporting that the handle of the gauge was locked. The gauge was placed inside a transportation case which was also locked. At the job site, the package was placed inside a holding frame in the back of a pickup truck, but the chains were not secured to the case. The tailgate of the truck was also left down. The technician drove about a mile down the road. Someone honking at him alerted him to the fact that the tailgate was down. He pulled over and found the gauge was missing and started searching for it. He alerted his radiation safety officer to the loss and the licensee now has several crews searching for the gauge. The licensee has reported that they believe the gauge might have been picked up by someone and has contacted the state police. This Department has also contacted the State, county, and local city emergency management coordinators. The licensee reported that with the device inside the case they do not expect significant exposure to anyone, but they would expect some exposure in an unrestricted area should someone get near the case. This investigation is ongoing and further information will be provided per SA-300."
* * * UPDATE ON 09/22/23 AT 1912 EDT FROM ART TUCKER TO LAWRENCE CRISCIONE * * *
The following information was received from the Texas Department of State Health Services (the Department) via email:
"The Department was contacted by the licensee's radiation safety officer (RSO) who reported the licensee's Regional Director was on-site and had checked with the local pawn shops. The director provided a picture of the device and offered a reward for the return of the gauge. The director did not receive any additional information. RSO stated they had talked to an eyewitness who said they saw the gauge fall out of the truck and then a few minutes later a black pickup truck pulled up and put the gauge in the back of their truck. The RSO stated there is camera footage of the area near where the gauge was dropped (which is at the exit gate to where they were working) and they have viewed the footage for the time they believe the gauge would have been picked up. The gauge did not appear in the video, but the video did help establish an elapsed time of 15 minutes between when the technician left the site until they returned. A second individual stated that there was a contractor working at the same site that had a dark colored truck and had left shortly after the licensee's truck left the site. The licensee has requested additional video footage to see if they can identify that truck."
Notified the R4DO (Groom). Emailed NMSS, ILTAB and Mexico (CNSNS).
Texas Incident Number: 10052
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 from the Texas Department of State Health Services (the Department) via email:
"On September 20, 2023, the Department received notification of a lost moisture density gauge. The gauge is a Troxler 3430 (serial 39365) with 40 millicuries of americium-241 and 8 millicuries of cesium-137. The gauge was last seen at a job site with the licensee reporting that the handle of the gauge was locked. The gauge was placed inside a transportation case which was also locked. At the job site, the package was placed inside a holding frame in the back of a pickup truck, but the chains were not secured to the case. The tailgate of the truck was also left down. The technician drove about a mile down the road. Someone honking at him alerted him to the fact that the tailgate was down. He pulled over and found the gauge was missing and started searching for it. He alerted his radiation safety officer to the loss and the licensee now has several crews searching for the gauge. The licensee has reported that they believe the gauge might have been picked up by someone and has contacted the state police. This Department has also contacted the State, county, and local city emergency management coordinators. The licensee reported that with the device inside the case they do not expect significant exposure to anyone, but they would expect some exposure in an unrestricted area should someone get near the case. This investigation is ongoing and further information will be provided per SA-300."
* * * UPDATE ON 09/22/23 AT 1912 EDT FROM ART TUCKER TO LAWRENCE CRISCIONE * * *
The following information was received from the Texas Department of State Health Services (the Department) via email:
"The Department was contacted by the licensee's radiation safety officer (RSO) who reported the licensee's Regional Director was on-site and had checked with the local pawn shops. The director provided a picture of the device and offered a reward for the return of the gauge. The director did not receive any additional information. RSO stated they had talked to an eyewitness who said they saw the gauge fall out of the truck and then a few minutes later a black pickup truck pulled up and put the gauge in the back of their truck. The RSO stated there is camera footage of the area near where the gauge was dropped (which is at the exit gate to where they were working) and they have viewed the footage for the time they believe the gauge would have been picked up. The gauge did not appear in the video, but the video did help establish an elapsed time of 15 minutes between when the technician left the site until they returned. A second individual stated that there was a contractor working at the same site that had a dark colored truck and had left shortly after the licensee's truck left the site. The licensee has requested additional video footage to see if they can identify that truck."
Notified the R4DO (Groom). Emailed NMSS, ILTAB and Mexico (CNSNS).
Texas Incident Number: 10052
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: 56754
Rep Org: Florida Bureau of Radiation Control
Licensee: Cleveland Clinic
Region: 1
City: Weston State: FL
County:
License #: 4818-2
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Lawrence Criscione
Licensee: Cleveland Clinic
Region: 1
City: Weston State: FL
County:
License #: 4818-2
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/22/2023
Notification Time: 16:16 [ET]
Event Date: 09/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/22/2023
Notification Time: 16:16 [ET]
Event Date: 09/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - MISSING I-125 SEED
The following was reported by the Florida Bureau of Radiation Control (BRC) via email:
"At 1537 EDT on 9/22/23, BRC received a call from Cleveland Clinic stating an I-125 source was lost after removal from a patient. The patient was suspected to have breast cancer, and two I-125 sources were implanted in the breast tissue. The patient returned home 9/18/23 with the implanted seeds, and returned to the clinic 9/20/23 to receive a Tc-99m injection prior to tissue removal. The licensee states they confirmed both seeds were no longer in the patient after surgery, however, when the samples were taken by pathology, only one seed was located in the removed tissue. Cleveland Clinic has completed surveys of the operating room and pathology."
Florida incident number: FL23-149
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 reported by the Florida Bureau of Radiation Control (BRC) via email:
"At 1537 EDT on 9/22/23, BRC received a call from Cleveland Clinic stating an I-125 source was lost after removal from a patient. The patient was suspected to have breast cancer, and two I-125 sources were implanted in the breast tissue. The patient returned home 9/18/23 with the implanted seeds, and returned to the clinic 9/20/23 to receive a Tc-99m injection prior to tissue removal. The licensee states they confirmed both seeds were no longer in the patient after surgery, however, when the samples were taken by pathology, only one seed was located in the removed tissue. Cleveland Clinic has completed surveys of the operating room and pathology."
Florida incident number: FL23-149
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