Event Notification Report for June 14, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/13/2024 - 06/14/2024
Non-Power Reactor
Event Number: 57174
Rep Org: Texas A&M University (TAMN)
Licensee: Texas A&M University
Region: 0
City: College Station State: TX
County: Brazos
License #: R-83
Agreement: Y
Docket: 05000128
NRC Notified By: Jere Jenkins
HQ OPS Officer: Josue Ramirez
Licensee: Texas A&M University
Region: 0
City: College Station State: TX
County: Brazos
License #: R-83
Agreement: Y
Docket: 05000128
NRC Notified By: Jere Jenkins
HQ OPS Officer: Josue Ramirez
Notification Date: 06/14/2024
Notification Time: 15:35 [ET]
Event Date: 06/14/2024
Event Time: 11:00 [CDT]
Last Update Date: 06/25/2024
Notification Time: 15:35 [ET]
Event Date: 06/14/2024
Event Time: 11:00 [CDT]
Last Update Date: 06/25/2024
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Patrick Boyle (NRR PM)
Andrew Waugh (NPR EVEN)
Patrick Boyle (NRR PM)
Andrew Waugh (NPR EVEN)
EN Revision Imported Date: 6/26/2024
EN Revision Text: TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE
The following information was provided by the licensee via email:
"At approximately 1100 CDT on June 14, 2024, during routine fuel inspections required under Technical Specification 4.1.5, a fuel pin (serial number 11420) did not pass the go/no-go test for transverse bend. This measurement is described in Technical Specification 3.1.5.2.a as part of the fuel inspection conducted under the surveillance described in Technical Specification 4.1.5. Failure of an element to meet any one of the specifications listed in Technical Specification 3.1.5.2 specifies that the fuel element is considered 'damaged' and therefore may not be used in reactor operations.
"Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.
"There have been no indications of cladding failure on routine primary coolant analyses.
"The pin has been removed from service and will be replaced with a spare unused element.
"As required by Technical Specification 4.1.5.2, an inspection of the entire core fuel inventory will be initiated and will be completed prior to resuming routine operations.
"After the identification of the failure, the test rig calibration was confirmed and the pin was checked again, confirming the element failed the transverse bend specification.
"The reactor was not operating at the time of the event."
NRC Project Manager has been notified.
* * * UPDATE ON 6/25/2024 AT 1537 EDT FROM JERE JENKINS TO SAMUEL COLVARD * * *
The following information was provided by the licensee via email:
"During the Technical Specification (TS) 4.1.5.2 required inspection of the entire core resulting from the finding detailed above, an additional element [SN 11391] failed to pass the inspection for transverse bend on Friday, June 21, 2024, requiring that element to be declared as 'damaged' in accordance with TS 3.1.5.2 (same as above). As this meets the definition of a 'reportable occurrence' under the definitions in TS 1.3. In accordance with the requirements of TS 6.6.2 and 6.7.2, we have hereby notified the HOO [Headquarters Operations Officer] by a revision or update of the previous report of damaged fuel, Event Number 57174.
"Additional details:
1. Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.
2. There have been no indications of cladding failure on routine primary coolant analyses.
3. The pin (SN 11391) has been removed from service and will be replaced with a spare element.
4. We have also informed our project managers.
5. The inspection of the remaining uninspected elements is almost complete, as of this writing no further "damaged" elements have been identified."
Notified NRR PM (Boyle), NPR Event Coordinator (Waugh)
EN Revision Text: TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE
The following information was provided by the licensee via email:
"At approximately 1100 CDT on June 14, 2024, during routine fuel inspections required under Technical Specification 4.1.5, a fuel pin (serial number 11420) did not pass the go/no-go test for transverse bend. This measurement is described in Technical Specification 3.1.5.2.a as part of the fuel inspection conducted under the surveillance described in Technical Specification 4.1.5. Failure of an element to meet any one of the specifications listed in Technical Specification 3.1.5.2 specifies that the fuel element is considered 'damaged' and therefore may not be used in reactor operations.
"Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.
"There have been no indications of cladding failure on routine primary coolant analyses.
"The pin has been removed from service and will be replaced with a spare unused element.
"As required by Technical Specification 4.1.5.2, an inspection of the entire core fuel inventory will be initiated and will be completed prior to resuming routine operations.
"After the identification of the failure, the test rig calibration was confirmed and the pin was checked again, confirming the element failed the transverse bend specification.
"The reactor was not operating at the time of the event."
NRC Project Manager has been notified.
* * * UPDATE ON 6/25/2024 AT 1537 EDT FROM JERE JENKINS TO SAMUEL COLVARD * * *
The following information was provided by the licensee via email:
"During the Technical Specification (TS) 4.1.5.2 required inspection of the entire core resulting from the finding detailed above, an additional element [SN 11391] failed to pass the inspection for transverse bend on Friday, June 21, 2024, requiring that element to be declared as 'damaged' in accordance with TS 3.1.5.2 (same as above). As this meets the definition of a 'reportable occurrence' under the definitions in TS 1.3. In accordance with the requirements of TS 6.6.2 and 6.7.2, we have hereby notified the HOO [Headquarters Operations Officer] by a revision or update of the previous report of damaged fuel, Event Number 57174.
"Additional details:
1. Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.
2. There have been no indications of cladding failure on routine primary coolant analyses.
3. The pin (SN 11391) has been removed from service and will be replaced with a spare element.
4. We have also informed our project managers.
5. The inspection of the remaining uninspected elements is almost complete, as of this writing no further "damaged" elements have been identified."
Notified NRR PM (Boyle), NPR Event Coordinator (Waugh)
Agreement State
Event Number: 57176
Rep Org: OR Dept of Health Rad Protection
Licensee: Oregon Health & Sciences University
Region: 4
City: Portland State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Tenisha Meadows
Licensee: Oregon Health & Sciences University
Region: 4
City: Portland State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Tenisha Meadows
Notification Date: 06/17/2024
Notification Time: 15:05 [ET]
Event Date: 06/14/2024
Event Time: 12:26 [PDT]
Last Update Date: 06/17/2024
Notification Time: 15:05 [ET]
Event Date: 06/14/2024
Event Time: 12:26 [PDT]
Last Update Date: 06/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
Grethcen Rivera-Capella (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
Grethcen Rivera-Capella (NMSS)
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was provided by the Oregon Department of Health Radiation Protection (the Department) via email:
"During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT.
"The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee."
Oregon Event Report ID Number: OR-24-0030
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 Oregon Department of Health Radiation Protection (the Department) via email:
"During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT.
"The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee."
Oregon Event Report ID Number: OR-24-0030
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: 57173
Rep Org: PA Bureau of Radiation Protection
Licensee: Earth Engineering, Inc.
Region: 1
City: Philadelphia State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Robert A. Thompson
Licensee: Earth Engineering, Inc.
Region: 1
City: Philadelphia State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Robert A. Thompson
Notification Date: 06/14/2024
Notification Time: 12:28 [ET]
Event Date: 06/14/2024
Event Time: 00:00 [EDT]
Last Update Date: 06/25/2024
Notification Time: 12:28 [ET]
Event Date: 06/14/2024
Event Time: 00:00 [EDT]
Last Update Date: 06/25/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL) (EMAIL)
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL) (EMAIL)
EN Revision Imported Date: 6/26/2024
EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.
"Manufacturer and Model Number: Troxler Electronic Laboratories
"Model Number: 3440
"Serial Number: 35459
"Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries."
PA Event Report ID No: PA240012
Surrounding States and the Pennsylvania emergency response team have been notified.
* * * UPDATE ON 6/25/2024 AT 0730 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"On June 24, 2024, the car and gauge were recovered. The gauge was still inside of the vehicle with no damage or evidence of tampering. Survey meter readings of the gauge showed normal levels and it was returned to the licensee. Representatives of the Philadelphia Fire Company accompanied the licensee to retrieve the gauge."
Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (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: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.
"Manufacturer and Model Number: Troxler Electronic Laboratories
"Model Number: 3440
"Serial Number: 35459
"Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries."
PA Event Report ID No: PA240012
Surrounding States and the Pennsylvania emergency response team have been notified.
* * * UPDATE ON 6/25/2024 AT 0730 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"On June 24, 2024, the car and gauge were recovered. The gauge was still inside of the vehicle with no damage or evidence of tampering. Survey meter readings of the gauge showed normal levels and it was returned to the licensee. Representatives of the Philadelphia Fire Company accompanied the licensee to retrieve the gauge."
Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (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: 57179
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Alton Steel Inc.
Region: 3
City: Alton State: IL
County:
License #: IL-01738-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Robert A. Thompson
Licensee: Alton Steel Inc.
Region: 3
City: Alton State: IL
County:
License #: IL-01738-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Robert A. Thompson
Notification Date: 06/18/2024
Notification Time: 15:58 [ET]
Event Date: 06/14/2024
Event Time: 00:00 [CDT]
Last Update Date: 06/20/2024
Notification Time: 15:58 [ET]
Event Date: 06/14/2024
Event Time: 00:00 [CDT]
Last Update Date: 06/20/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"Alton Steel Inc. contacted the Agency on June 17, 2024, to advise of an incident in which molten steel impacted and damaged a 2.3 mCi Co-60 sealed source. This incident reportedly occurred on June 14, 2024, and results from the same ongoing conditions (source susceptible to molten steel flowing down the dip tube) identified in the licensee's March 2024 incident (refer to EN 57016). The licensee is still working with the source manufacturer to identify an engineered solution.
"The source and casting mold lid were collectively moved into a restricted area under the oversight of the radiation safety officer. The damaged source was then secured pending a site visit by the source manufacturer's authorized representative on June 18, 2024. The licensee missed the reporting timeline (24 hours). Agency staff will be on site the morning of June 20, 2024, for a reactive inspection. That inspection will assess contamination potential, discuss reporting timelines (reportedly missed due to multiple heat injuries and facility damage), address ongoing susceptibility of sources to damage, review contaminated area remediation timelines, and address proposed corrective actions for the April 19, 2024, Notice of Violation.
"Based on the information available at this time, there does not appear to be any impact to public health and safety. A description of the event indicates licensed material was not dispersed or incorporated into any product. This will collectively be assessed and this report [will be] updated thereafter."
Illinois Item Number: IL240014
THIS MATERIAL EVENT CONTAINS A 'Not Recorded' LEVEL OF RADIOACTIVE MATERIAL
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"Alton Steel Inc. contacted the Agency on June 17, 2024, to advise of an incident in which molten steel impacted and damaged a 2.3 mCi Co-60 sealed source. This incident reportedly occurred on June 14, 2024, and results from the same ongoing conditions (source susceptible to molten steel flowing down the dip tube) identified in the licensee's March 2024 incident (refer to EN 57016). The licensee is still working with the source manufacturer to identify an engineered solution.
"The source and casting mold lid were collectively moved into a restricted area under the oversight of the radiation safety officer. The damaged source was then secured pending a site visit by the source manufacturer's authorized representative on June 18, 2024. The licensee missed the reporting timeline (24 hours). Agency staff will be on site the morning of June 20, 2024, for a reactive inspection. That inspection will assess contamination potential, discuss reporting timelines (reportedly missed due to multiple heat injuries and facility damage), address ongoing susceptibility of sources to damage, review contaminated area remediation timelines, and address proposed corrective actions for the April 19, 2024, Notice of Violation.
"Based on the information available at this time, there does not appear to be any impact to public health and safety. A description of the event indicates licensed material was not dispersed or incorporated into any product. This will collectively be assessed and this report [will be] updated thereafter."
Illinois Item Number: IL240014
THIS MATERIAL EVENT CONTAINS A 'Not Recorded' LEVEL OF RADIOACTIVE MATERIAL