Event Notification Report for August 26, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/25/2024 - 08/26/2024
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 57291
Facility: Farley
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: David Hershman
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: David Hershman
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/26/2024
Notification Time: 16:54 [ET]
Event Date: 08/26/2024
Event Time: 12:00 [CDT]
Last Update Date: 09/16/2024
Notification Time: 16:54 [ET]
Event Date: 08/26/2024
Event Time: 12:00 [CDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Masters, Anthony (R2DO)
FFD Group, (EMAIL)
Masters, Anthony (R2DO)
FFD Group, (EMAIL)
| 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 |
EN Revision Imported Date: 9/17/2024
EN Revision Text: FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST
The following information was provided by the licensee via email:
"On 8/26/2024 at 1200 CDT, Farley Nuclear Plant Medical Services identified a false negative quality assurance test. [The contracted laboratory] was provided an adulterated sample of hydrocodone and hydromorphone that was part of a blind performance test. The results from the [contracted laboratory] returned a false negative. This false negative test result will be investigated, and the results reported as required.
"This event is being reported in accordance with 10 CFR 26.719(c)(3).
"The NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer Report Guidance:
The contracted laboratory was a U.S. Department of Health and Human Service (HHS) certified laboratory.
* * * RETRACTION ON 09/16/24 AT 1014 EDT FROM RONNIE SUBER TO KERBY SCALES * * *
The following update was provided by the licensee via email:
"Following further review of the event, it has been determined that this issue is not reportable under 10CFR26.719(c)(3) as the unsatisfactory test was not for a validity screening test. This event is reportable for testing errors in accordance with 10CFR26.719(c)(1) and a 30 day report will be submitted."
Notified R2DO (Suber) and FFD Group (email).
EN Revision Text: FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST
The following information was provided by the licensee via email:
"On 8/26/2024 at 1200 CDT, Farley Nuclear Plant Medical Services identified a false negative quality assurance test. [The contracted laboratory] was provided an adulterated sample of hydrocodone and hydromorphone that was part of a blind performance test. The results from the [contracted laboratory] returned a false negative. This false negative test result will be investigated, and the results reported as required.
"This event is being reported in accordance with 10 CFR 26.719(c)(3).
"The NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer Report Guidance:
The contracted laboratory was a U.S. Department of Health and Human Service (HHS) certified laboratory.
* * * RETRACTION ON 09/16/24 AT 1014 EDT FROM RONNIE SUBER TO KERBY SCALES * * *
The following update was provided by the licensee via email:
"Following further review of the event, it has been determined that this issue is not reportable under 10CFR26.719(c)(3) as the unsatisfactory test was not for a validity screening test. This event is reportable for testing errors in accordance with 10CFR26.719(c)(1) and a 30 day report will be submitted."
Notified R2DO (Suber) and FFD Group (email).
Agreement State
Event Number: 57289
Rep Org: Utah Division of Radiation Control
Licensee: Epic Engineering
Region: 4
City: East Salt Lake City State: UT
County:
License #: UT 2600414
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Robert A. Thompson
Licensee: Epic Engineering
Region: 4
City: East Salt Lake City State: UT
County:
License #: UT 2600414
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/26/2024
Notification Time: 12:43 [ET]
Event Date: 08/26/2024
Event Time: 08:00 [MDT]
Last Update Date: 08/26/2024
Notification Time: 12:43 [ET]
Event Date: 08/26/2024
Event Time: 08:00 [MDT]
Last Update Date: 08/26/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE
The Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) reported the following via email:
"On August 26, 2024, an Epic Engineering gauge user was at the gym from 0700-0800 MDT. While at the gym, a Troxler nuclear density gauge was locked in the bed of the company truck. When the user returned to the truck after completing their workout, the company truck had been stolen along with the nuclear density gauge. The local police department has been contacted. The Division was notified by the company owner later that morning."
Utah Event Report ID: UT 24-0007
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 Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) reported the following via email:
"On August 26, 2024, an Epic Engineering gauge user was at the gym from 0700-0800 MDT. While at the gym, a Troxler nuclear density gauge was locked in the bed of the company truck. When the user returned to the truck after completing their workout, the company truck had been stolen along with the nuclear density gauge. The local police department has been contacted. The Division was notified by the company owner later that morning."
Utah Event Report ID: UT 24-0007
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: 57290
Rep Org: Florida Bureau of Radiation Control
Licensee: Universal Engineering Sciences
Region: 1
City: Cape Coral State: FL
County:
License #: 4696-4
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Robert A. Thompson
Licensee: Universal Engineering Sciences
Region: 1
City: Cape Coral State: FL
County:
License #: 4696-4
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/26/2024
Notification Time: 12:46 [ET]
Event Date: 08/26/2024
Event Time: 11:45 [EDT]
Last Update Date: 08/26/2024
Notification Time: 12:46 [ET]
Event Date: 08/26/2024
Event Time: 11:45 [EDT]
Last Update Date: 08/26/2024
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 - DAMAGED MOISTURE/DENSITY GAUGE
The following was reported by the Florida Department of Health, Bureau of Radiation Control (BRC), via email:
"The BRC received notification from Universal Engineering Sciences of a Troxler gauge being hit by a passing car. The Troxler gauge was being standardized by a technician when a passing car made contact with the device. The source rod was retracted at the time and has not been exposed. The only identified damage was a crack in the plastic near the LCD screen."
Device Type: Soil Moisture Density Gauge
Manufacturer: Troxler
Model Number: 3430
Activity: 8mCi of Cs-137, 40 mCi of Am-241/Be
Florida Incident Number: FL24-077
The following was reported by the Florida Department of Health, Bureau of Radiation Control (BRC), via email:
"The BRC received notification from Universal Engineering Sciences of a Troxler gauge being hit by a passing car. The Troxler gauge was being standardized by a technician when a passing car made contact with the device. The source rod was retracted at the time and has not been exposed. The only identified damage was a crack in the plastic near the LCD screen."
Device Type: Soil Moisture Density Gauge
Manufacturer: Troxler
Model Number: 3430
Activity: 8mCi of Cs-137, 40 mCi of Am-241/Be
Florida Incident Number: FL24-077
Agreement State
Event Number: 57292
Rep Org: Texas Dept of State Health Services
Licensee: Protech LLC
Region: 4
City: Houston State: TX
County:
License #: L07110
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Jordan Wingate
Licensee: Protech LLC
Region: 4
City: Houston State: TX
County:
License #: L07110
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Jordan Wingate
Notification Date: 08/27/2024
Notification Time: 09:07 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [CDT]
Last Update Date: 08/27/2024
Notification Time: 09:07 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [CDT]
Last Update Date: 08/27/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - DAMAGED RADIOGRAPHY EQUIPMENT
The following information was provided by the Texas Department of State Health Service (the Department) via email:
"On August 27, 2024, the Department was notified by the licensee that one of its crews was working at a job site with a QSA 880D exposure device containing a 48 curie Iridium - 192 source. The crew was working in a shooting bay surrounded by concrete walls. While performing an exposure, the camera fell 18 inches from the pipe it was on, onto the guide tube, crimping the tube and preventing the crew from retracting the source into the camera. The radiographers drove the source back into the collimator and isolated the area. The radiographers contacted the radiation safety officer (RSO). The site RSO (SRSO) responded to the location. The SRSO added additional shielding to the collimator. The crimped section of the guide tube was removed, and the source was successfully retracted to the fully shielded position. The event was resolved in less than 2 hours. No individual received an exposure that exceeded any limit."
Device Type: QSA
Model Number: 880D
Activity: 48 Ci of Ir-192
Texas Incident Number: 10122
Texas NMED # TX24024
The following information was provided by the Texas Department of State Health Service (the Department) via email:
"On August 27, 2024, the Department was notified by the licensee that one of its crews was working at a job site with a QSA 880D exposure device containing a 48 curie Iridium - 192 source. The crew was working in a shooting bay surrounded by concrete walls. While performing an exposure, the camera fell 18 inches from the pipe it was on, onto the guide tube, crimping the tube and preventing the crew from retracting the source into the camera. The radiographers drove the source back into the collimator and isolated the area. The radiographers contacted the radiation safety officer (RSO). The site RSO (SRSO) responded to the location. The SRSO added additional shielding to the collimator. The crimped section of the guide tube was removed, and the source was successfully retracted to the fully shielded position. The event was resolved in less than 2 hours. No individual received an exposure that exceeded any limit."
Device Type: QSA
Model Number: 880D
Activity: 48 Ci of Ir-192
Texas Incident Number: 10122
Texas NMED # TX24024
Agreement State
Event Number: 57293
Rep Org: Georgia Radioactive Material Pgm
Licensee: PIEDMONT ATHENS REGIONAL MED CENTER
Region: 1
City: Athens State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Robert A. Thompson
Licensee: PIEDMONT ATHENS REGIONAL MED CENTER
Region: 1
City: Athens State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/27/2024
Notification Time: 15:12 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Notification Time: 15:12 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 9/18/2024
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE
The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:
The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.
The RSO will send an official written report to the Program within 15 days.
Georgia Incident Number: 86
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.
* * * UPDATE ON 9/17/2024 AT 1131 EDT FROM KAAMILYA NAJEEULLAH TO ROBERT THOMPSON * * *
The following information was provided by the Georgia Radioactive Materials Program (the Program) via email:
"The Program received the official written report from the licensee radiation safety officer (RSO) on September 12, 2024. The RSO stated that one dosage was successfully delivered. The second dosage was not fully delivered due to a kink in the catheter.
"Prescribed dosage: 15.68 mCi and 16.76 mCi Y-90 microspheres
"Administered dosage: 5.39 mCi and 16.87 mCi Y-90 microspheres"
Notified R1DO (Werkheiser), NMSS Events Notification (email).
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE
The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:
The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.
The RSO will send an official written report to the Program within 15 days.
Georgia Incident Number: 86
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.
* * * UPDATE ON 9/17/2024 AT 1131 EDT FROM KAAMILYA NAJEEULLAH TO ROBERT THOMPSON * * *
The following information was provided by the Georgia Radioactive Materials Program (the Program) via email:
"The Program received the official written report from the licensee radiation safety officer (RSO) on September 12, 2024. The RSO stated that one dosage was successfully delivered. The second dosage was not fully delivered due to a kink in the catheter.
"Prescribed dosage: 15.68 mCi and 16.76 mCi Y-90 microspheres
"Administered dosage: 5.39 mCi and 16.87 mCi Y-90 microspheres"
Notified R1DO (Werkheiser), NMSS Events Notification (email).