Event Notification Report for August 26, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/25/2021 - 08/26/2021
Agreement State
Event Number: 55414
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Rock Engineering and Testing Laboratory, Inc.
Region: 4
City: San Antonio State: TX
County:
License #: L 05168
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Howie Crouch
Licensee: Rock Engineering and Testing Laboratory, Inc.
Region: 4
City: San Antonio State: TX
County:
License #: L 05168
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Howie Crouch
Notification Date: 08/18/2021
Notification Time: 11:21 [ET]
Event Date: 08/18/2021
Event Time: 01:49 [CDT]
Last Update Date: 08/18/2021
Notification Time: 11:21 [ET]
Event Date: 08/18/2021
Event Time: 01:49 [CDT]
Last Update Date: 08/18/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (EMAIL)
DEESE, RICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (EMAIL)
EN Revision Imported Date: 8/26/2021
EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was received from the state of Texas (the Agency) via email:
"On August 18, 2021, the Agency was notified by the licensee that a Troxler model 3430 moisture density gauge was stolen from the back of an employee's truck. The employee's truck was parked at their apartment overnight. The licensee stated that the apartment complex security camera system showed the theft occurred at about 0149 CDT on August 18, 2021. The gauge contains a 40 milliCurie Americium - 241 source and an 8 milliCurie Cesium - 137 source. The licensee stated the gauge was locked using chains in the back of the pickup truck. The licensee reported local law enforcement has been notified of the theft. The Agency requested additional information from the licensee. Additional information will be provided in accordance with SA-300."
TX Incident #: 9877
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 MOISTURE DENSITY GAUGE
The following information was received from the state of Texas (the Agency) via email:
"On August 18, 2021, the Agency was notified by the licensee that a Troxler model 3430 moisture density gauge was stolen from the back of an employee's truck. The employee's truck was parked at their apartment overnight. The licensee stated that the apartment complex security camera system showed the theft occurred at about 0149 CDT on August 18, 2021. The gauge contains a 40 milliCurie Americium - 241 source and an 8 milliCurie Cesium - 137 source. The licensee stated the gauge was locked using chains in the back of the pickup truck. The licensee reported local law enforcement has been notified of the theft. The Agency requested additional information from the licensee. Additional information will be provided in accordance with SA-300."
TX Incident #: 9877
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: 55417
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendorf State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Randal Dahlin
HQ OPS Officer: Howie Crouch
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendorf State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Randal Dahlin
HQ OPS Officer: Howie Crouch
Notification Date: 08/19/2021
Notification Time: 07:19 [ET]
Event Date: 08/18/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2021
Notification Time: 07:19 [ET]
Event Date: 08/18/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/27/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER
The following information was obtained from the state of Iowa via email:
"On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan."
The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241.
NMED Number: IA210003
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER
The following information was obtained from the state of Iowa via email:
"On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan."
The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241.
NMED Number: IA210003
Power Reactor
Event Number: 55427
Facility: FitzPatrick
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Andrew Weaver
HQ OPS Officer: Brian P. Smith
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Andrew Weaver
HQ OPS Officer: Brian P. Smith
Notification Date: 08/24/2021
Notification Time: 16:51 [ET]
Event Date: 08/24/2021
Event Time: 14:06 [EDT]
Last Update Date: 08/24/2021
Notification Time: 16:51 [ET]
Event Date: 08/24/2021
Event Time: 14:06 [EDT]
Last Update Date: 08/24/2021
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):
GREIVES, JONATHAN (R1)
GREIVES, JONATHAN (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 8/26/2021
EN Revision Text: APPENDIX R HOT SHORT UNANALYZED CONDITION
"During an extent of condition review of DC control circuits, it was identified there are additional unprotected DC control circuits which are routed between separate Appendix R fire areas. A postulated fire in one area can cause a short circuit and potentially result in secondary fires or cable fires in other fire areas where the cables are routed. The secondary fires or cable failures degrade the degree of separation for redundant safe shutdown trains and are outside the assumptions of the 10 CFR 50 Appendix R Safe Shutdown Analysis. This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B).
"Compensatory actions for affected fire areas have been implemented. Design modifications in the affected control circuits are being developed and will be scheduled to correct this condition."
EN Revision Text: APPENDIX R HOT SHORT UNANALYZED CONDITION
"During an extent of condition review of DC control circuits, it was identified there are additional unprotected DC control circuits which are routed between separate Appendix R fire areas. A postulated fire in one area can cause a short circuit and potentially result in secondary fires or cable fires in other fire areas where the cables are routed. The secondary fires or cable failures degrade the degree of separation for redundant safe shutdown trains and are outside the assumptions of the 10 CFR 50 Appendix R Safe Shutdown Analysis. This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B).
"Compensatory actions for affected fire areas have been implemented. Design modifications in the affected control circuits are being developed and will be scheduled to correct this condition."
Fuel Cycle Facility
Event Number: 55431
Facility: NUCLEAR FUELS SERVICES
Region: 2 State: TN
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Danielle Rogers
HQ OPS Officer: Thomas Kendzia
Region: 2 State: TN
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Danielle Rogers
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/25/2021
Notification Time: 14:43 [ET]
Event Date: 03/30/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/26/2021
Notification Time: 14:43 [ET]
Event Date: 03/30/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/26/2021
Emergency Class: Non Emergency
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
10 CFR Section:
20.1906(d)(1) - Surface Contam Levels > Limits
Person (Organization):
MILLER, MARK (R2DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Rivera-Ortiz, Joel (EMAIL)
MILLER, MARK (R2DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Rivera-Ortiz, Joel (EMAIL)
EN Revision Imported Date: 8/27/2021
EN Revision Text: CONTAMINATED ITEMS DISCOVERED AT WAREHOUSE
The following was received from the Nuclear Fuels Services, Inc. (NFS) Nuclear Safety & Licensing Manager via email:
"This event was reported previously as an amendment to EN55161 on March 31, 2021 The purpose of this report is to establish a new Event Number containing only the transportation related notification and to ensure severance from of all security related information. A 30-day written report was provided to the NRC on April 28, 2021 (Reference NFS Document Number 21G-21-0076). The 30-day written report will be revised to redact all security related information and resubmitted following this telephone notification.
"On March 30, 2021, NFS identified legacy equipment that contained contaminated items at an NFS owned offsite warehouse. This equipment was transported on public roads to this facility during/prior to 2016.
"There were no actual or potential safety consequences to workers, the public, or the environment.
"The licensee notified the NRC Resident Inspector 3/31/2021 at 1350 hours EDT."
NFS Event (PIRCS) Number: 83261
EN Revision Text: CONTAMINATED ITEMS DISCOVERED AT WAREHOUSE
The following was received from the Nuclear Fuels Services, Inc. (NFS) Nuclear Safety & Licensing Manager via email:
"This event was reported previously as an amendment to EN55161 on March 31, 2021 The purpose of this report is to establish a new Event Number containing only the transportation related notification and to ensure severance from of all security related information. A 30-day written report was provided to the NRC on April 28, 2021 (Reference NFS Document Number 21G-21-0076). The 30-day written report will be revised to redact all security related information and resubmitted following this telephone notification.
"On March 30, 2021, NFS identified legacy equipment that contained contaminated items at an NFS owned offsite warehouse. This equipment was transported on public roads to this facility during/prior to 2016.
"There were no actual or potential safety consequences to workers, the public, or the environment.
"The licensee notified the NRC Resident Inspector 3/31/2021 at 1350 hours EDT."
NFS Event (PIRCS) Number: 83261
Agreement State
Event Number: 55419
Rep Org: NORTH CAROLINA DIV OF RAD PROTECTIO
Licensee: Moses Cone Health System
Region: 1
City: Greensboro State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Howie Crouch
Licensee: Moses Cone Health System
Region: 1
City: Greensboro State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Howie Crouch
Notification Date: 08/20/2021
Notification Time: 10:05 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/20/2021
Notification Time: 10:05 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
EN Revision Imported Date: 8/27/2021
EN Revision Text: AGREEMENT STATE REPORT - UNINTENDED DOSE TO AN ORGAN
The following information was received from the state of North Carolina via email:
"A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate.
"An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated.
"Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures."
NMED Report No.: NC210014
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.
EN Revision Text: AGREEMENT STATE REPORT - UNINTENDED DOSE TO AN ORGAN
The following information was received from the state of North Carolina via email:
"A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate.
"An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated.
"Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures."
NMED Report No.: NC210014
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: 55422
Rep Org: ALABAMA RADIATION CONTROL
Licensee: Applied Technical Services
Region: 1
City: Mobile State: AL
County:
License #: 1454
Agreement: Y
Docket:
NRC Notified By: Carson Coan
HQ OPS Officer: Thomas Kendzia
Licensee: Applied Technical Services
Region: 1
City: Mobile State: AL
County:
License #: 1454
Agreement: Y
Docket:
NRC Notified By: Carson Coan
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/20/2021
Notification Time: 17:59 [ET]
Event Date: 08/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2021
Notification Time: 17:59 [ET]
Event Date: 08/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF PROTECTIVE COVER OVER LOCKING MECHANISM
The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:
"During the Agency's inspection on 8/12/2021, of licensee Applied Technical Services, license no. 1454, the representative stated that a technician lost the protective cover over the locking mechanism on a QSA 880D exposure device. The representative stated that the metal lanyard connecting the cover to the device housing snapped, and the cover fell between metal grating. The representative did not remember the date of this occurrence. The representative stated that no exposures to personnel or members of the public resulted from the lost cover. The Agency has followed up with Applied Technical Services for more information, with no more information at this time. The Agency is continuing to investigate.
"Device QSA 880-Delta, Ir-192 source, source activity and device serial number is not available at this time."
Alabama Event 21-28
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF PROTECTIVE COVER OVER LOCKING MECHANISM
The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:
"During the Agency's inspection on 8/12/2021, of licensee Applied Technical Services, license no. 1454, the representative stated that a technician lost the protective cover over the locking mechanism on a QSA 880D exposure device. The representative stated that the metal lanyard connecting the cover to the device housing snapped, and the cover fell between metal grating. The representative did not remember the date of this occurrence. The representative stated that no exposures to personnel or members of the public resulted from the lost cover. The Agency has followed up with Applied Technical Services for more information, with no more information at this time. The Agency is continuing to investigate.
"Device QSA 880-Delta, Ir-192 source, source activity and device serial number is not available at this time."
Alabama Event 21-28