Event Notification Report for December 28, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/27/2023 - 12/28/2023
Agreement State
Event Number: 56901
Rep Org: Colorado Dept of Health
Licensee: Medical Center of Aurora
Region: 4
City: Aurora State: CO
County:
License #: CO 205-03
Agreement: Y
Docket:
NRC Notified By: Carrie Romanchek
HQ OPS Officer: Adam Koziol
Licensee: Medical Center of Aurora
Region: 4
City: Aurora State: CO
County:
License #: CO 205-03
Agreement: Y
Docket:
NRC Notified By: Carrie Romanchek
HQ OPS Officer: Adam Koziol
Notification Date: 12/20/2023
Notification Time: 08:04 [ET]
Event Date: 12/18/2023
Event Time: 11:28 [MST]
Last Update Date: 12/20/2023
Notification Time: 08:04 [ET]
Event Date: 12/18/2023
Event Time: 11:28 [MST]
Last Update Date: 12/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
The licensee, Medical Center of Aurora, discovered a leaking sealed source on December 18, 2023, during a routine semi-annual inventory and leak test. The sealed source is an Eckert and Ziegler (Serial Number 1360-6-20) Cs-137 vial with estimated current activity of 0.136 millicuries. The plastic vial had been stored in a lead box since the last inspection, but it was discovered that the plastic was cracked. Wipe test showed 0.052 microcuries of removable activity inside the storage box. No contamination was found outside of the box. The source vial will be wrapped in several layers of plastic to stabilize it and limit contamination inside the box. The licensee has contacted the manufacturer to return the source.
Colorado Event Number: CO230044
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
The licensee, Medical Center of Aurora, discovered a leaking sealed source on December 18, 2023, during a routine semi-annual inventory and leak test. The sealed source is an Eckert and Ziegler (Serial Number 1360-6-20) Cs-137 vial with estimated current activity of 0.136 millicuries. The plastic vial had been stored in a lead box since the last inspection, but it was discovered that the plastic was cracked. Wipe test showed 0.052 microcuries of removable activity inside the storage box. No contamination was found outside of the box. The source vial will be wrapped in several layers of plastic to stabilize it and limit contamination inside the box. The licensee has contacted the manufacturer to return the source.
Colorado Event Number: CO230044
Agreement State
Event Number: 56902
Rep Org: Texas Dept of State Health Services
Licensee: Protect LLC
Region: 4
City: La Porte State: TX
County:
License #: L07110
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Licensee: Protect LLC
Region: 4
City: La Porte State: TX
County:
License #: L07110
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 12/20/2023
Notification Time: 13:05 [ET]
Event Date: 12/19/2023
Event Time: 00:00 [CST]
Last Update Date: 12/20/2023
Notification Time: 13:05 [ET]
Event Date: 12/19/2023
Event Time: 00:00 [CST]
Last Update Date: 12/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SOURCE UNABLE TO RETRACT
The following report was received via phone and email by the Texas Department of State Health Services [the Department]:
"On December 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that on December 19, 2023, they were unable to retract a 52 curie iridium-192 source into a QSA 880D exposure device. The RSO stated its radiographers were performing radiography on a pipe. The pipe fell and struck the guide tube, crimping it far enough to prevent them from retracting the source. The radiographers isolated the area and contacted the RSO. A retrieval team arrived at the location and was able to retract the source. The RSO stated no individual exceeded any exposure limits. Additional information will be provided as it is receive it accordance with SA-300."
Texas Incident Number: 10074
Texas NMED Number: TX230058
The following report was received via phone and email by the Texas Department of State Health Services [the Department]:
"On December 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that on December 19, 2023, they were unable to retract a 52 curie iridium-192 source into a QSA 880D exposure device. The RSO stated its radiographers were performing radiography on a pipe. The pipe fell and struck the guide tube, crimping it far enough to prevent them from retracting the source. The radiographers isolated the area and contacted the RSO. A retrieval team arrived at the location and was able to retract the source. The RSO stated no individual exceeded any exposure limits. Additional information will be provided as it is receive it accordance with SA-300."
Texas Incident Number: 10074
Texas NMED Number: TX230058
Agreement State
Event Number: 56903
Rep Org: Tennessee Div of Rad Health
Licensee: Chemours Company, LLC
Region: 1
City: New Johnsonville State: TN
County:
License #: R-43006-J26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Brian P. Smith
Licensee: Chemours Company, LLC
Region: 1
City: New Johnsonville State: TN
County:
License #: R-43006-J26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Brian P. Smith
Notification Date: 12/20/2023
Notification Time: 16:12 [ET]
Event Date: 12/19/2023
Event Time: 00:00 [EST]
Last Update Date: 12/20/2023
Notification Time: 16:12 [ET]
Event Date: 12/19/2023
Event Time: 00:00 [EST]
Last Update Date: 12/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SHUTTER STUCK IN OPEN POSITION
The following report was received via email from the Tennessee Division of Radiological Health:
"During a scheduled 3-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was in a normal operating position. A vendor field technician has been contacted about the gauge which is an Ohmart/Vega gauge, model SHLG-1, with an isotope of cesium-137, 300 millicuries. Corrective actions as well as additional information will be updated with a NMED report within 30 days."
Tennessee Event Report Number: TN-23-089
The following report was received via email from the Tennessee Division of Radiological Health:
"During a scheduled 3-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was in a normal operating position. A vendor field technician has been contacted about the gauge which is an Ohmart/Vega gauge, model SHLG-1, with an isotope of cesium-137, 300 millicuries. Corrective actions as well as additional information will be updated with a NMED report within 30 days."
Tennessee Event Report Number: TN-23-089
Agreement State
Event Number: 56906
Rep Org: Louisiana DEQ
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington State: LA
County: St. Tammany Parish
License #: LA-0569-L01, Amendment #64
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Bethany Cecere
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington State: LA
County: St. Tammany Parish
License #: LA-0569-L01, Amendment #64
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Bethany Cecere
Notification Date: 12/22/2023
Notification Time: 10:56 [ET]
Event Date: 12/14/2023
Event Time: 00:00 [CST]
Last Update Date: 12/26/2023
Notification Time: 10:56 [ET]
Event Date: 12/14/2023
Event Time: 00:00 [CST]
Last Update Date: 12/26/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILURE LEAD TO UNDERDOSE
The following information was provided by the Louisiana Department of Environmental Quality (DEQ) via email:
"On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved.
"No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024.
"A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific.
"Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration."
LA Event Report ID No.: LA20230013
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 Louisiana Department of Environmental Quality (DEQ) via email:
"On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved.
"No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024.
"A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific.
"Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration."
LA Event Report ID No.: LA20230013
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: 56908
Rep Org: California Radiation Control Prgm
Licensee: University of California, San Fran.
Region: 4
City: San Franciso State: CA
County:
License #: CA-RML 1725-38
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Ernest West
Licensee: University of California, San Fran.
Region: 4
City: San Franciso State: CA
County:
License #: CA-RML 1725-38
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Ernest West
Notification Date: 12/22/2023
Notification Time: 20:11 [ET]
Event Date: 12/22/2023
Event Time: 00:00 [PST]
Last Update Date: 12/26/2023
Notification Time: 20:11 [ET]
Event Date: 12/22/2023
Event Time: 00:00 [PST]
Last Update Date: 12/26/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - CONTAMINATED PACKAGE
The following information was provided by the California Department of Public Health, Radiation Health Branch (RHB) via email:
"On 12/22/2023, the [University of California, San Francisco] notified RHB that a shipment of F-18 radioactive materials received from SOFIE CO FKA ZEVACOR PHARMA [license number: CA-RML 7131-43] was contaminated. The licensee reported that their contamination wipe tests ranged from 65,000 counts per minute (cpm) to over 100,000 cpm per 300-centimeter squared wipe area using a wipe counter with an efficiency of 25 percent. This amount exceeds the non-fixed radioactive contamination limits specified in Department of Transportation regulations 49 CFR 173.443 of 240 cpm per cm squared for beta and gamma emitters and is reportable under 10 CFR 20.1906(d)(1). RHB is in contact with SOFIE and will be investigating this matter further."
The following information was provided by the California Department of Public Health, Radiation Health Branch (RHB) via email:
"On 12/22/2023, the [University of California, San Francisco] notified RHB that a shipment of F-18 radioactive materials received from SOFIE CO FKA ZEVACOR PHARMA [license number: CA-RML 7131-43] was contaminated. The licensee reported that their contamination wipe tests ranged from 65,000 counts per minute (cpm) to over 100,000 cpm per 300-centimeter squared wipe area using a wipe counter with an efficiency of 25 percent. This amount exceeds the non-fixed radioactive contamination limits specified in Department of Transportation regulations 49 CFR 173.443 of 240 cpm per cm squared for beta and gamma emitters and is reportable under 10 CFR 20.1906(d)(1). RHB is in contact with SOFIE and will be investigating this matter further."
Power Reactor
Event Number: 56910
Facility: Watts Bar
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Tony Pate
HQ OPS Officer: Adam Koziol
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Tony Pate
HQ OPS Officer: Adam Koziol
Notification Date: 12/28/2023
Notification Time: 18:55 [ET]
Event Date: 12/28/2023
Event Time: 11:29 [EST]
Last Update Date: 12/28/2023
Notification Time: 18:55 [ET]
Event Date: 12/28/2023
Event Time: 11:29 [EST]
Last Update Date: 12/28/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNANALYZED CONDITION
The following information was provided by the licensee via email:
"Plant alignment caused an unanalyzed condition regarding unit 1 and unit 2 Appendix R procedures.
"[Watts Bar Nuclear] (WBN) unit 1 and unit 2 Appendix R procedures require manual operator action times including [volume control tank] (VCT) isolation. They are calculated with an assumed hydrogen cover gas constant at 20 psig. This is to preclude hydrogen ingestion into the charging pumps with an operator action time of 70 minutes. Due to recent lower hydrogen concentration in the [reactor coolant system] (RCS), [unit 2] VCT hydrogen regulator set point was increased to 28 psig. This increased pressure set point invalidated the initial assumptions made in the Appendix R calculations for manual operator action times.
"WBN unit 1 VCT hydrogen regulator was also verified high out of band at 22 psig.
"WBN has restored unit 1 and unit 2 VCT hydrogen regulators to the required specification.
"The NRC Resident Inspector has been notified of this condition."
The following information was provided by the licensee via email:
"Plant alignment caused an unanalyzed condition regarding unit 1 and unit 2 Appendix R procedures.
"[Watts Bar Nuclear] (WBN) unit 1 and unit 2 Appendix R procedures require manual operator action times including [volume control tank] (VCT) isolation. They are calculated with an assumed hydrogen cover gas constant at 20 psig. This is to preclude hydrogen ingestion into the charging pumps with an operator action time of 70 minutes. Due to recent lower hydrogen concentration in the [reactor coolant system] (RCS), [unit 2] VCT hydrogen regulator set point was increased to 28 psig. This increased pressure set point invalidated the initial assumptions made in the Appendix R calculations for manual operator action times.
"WBN unit 1 VCT hydrogen regulator was also verified high out of band at 22 psig.
"WBN has restored unit 1 and unit 2 VCT hydrogen regulators to the required specification.
"The NRC Resident Inspector has been notified of this condition."