Event Notification Report for September 26, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/25/2023 - 09/26/2023
Agreement State
Event Number: 56682
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Licensee: G.E. Healthcare DBA
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Notification Date: 08/17/2023
Notification Time: 12:15 [ET]
Event Date: 08/12/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Notification Time: 12:15 [ET]
Event Date: 08/12/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/26/2023
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT
The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:
"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:
"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
"The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed."
Illinois Event Number: IL230018
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 - LOST SOURCES MISSING IN TRANSIT
The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:
"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:
"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
"The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed."
Illinois Event Number: IL230018
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: 56697
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Notification Date: 08/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/26/2023
EN Revision Text: AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE
The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed.
Illinois Item Number: IL230021
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 - LOST LESS THAN CAT 3 SOURCE
The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed.
Illinois Item Number: IL230021
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: 56744
Rep Org: California Radiation Control Prgm
Licensee: Tesla (Non-Licensee), San Rafael
Region: 4
City: Santa Anna State: CA
County:
License #: GL - N/A
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Kerby Scales
Licensee: Tesla (Non-Licensee), San Rafael
Region: 4
City: Santa Anna State: CA
County:
License #: GL - N/A
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Kerby Scales
Notification Date: 09/18/2023
Notification Time: 17:53 [ET]
Event Date: 09/13/2023
Event Time: 00:00 [PDT]
Last Update Date: 09/18/2023
Notification Time: 17:53 [ET]
Event Date: 09/13/2023
Event Time: 00:00 [PDT]
Last Update Date: 09/18/2023
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)
CNSNS (Mexico), - (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST GENERALLY LICENSED SOURCE
The following information was received from the California Department of Public Health via email:
"On 09/13/23, Tesla Corporation contacted [Radiation Health Branch] RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source."
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 California Department of Public Health via email:
"On 09/13/23, Tesla Corporation contacted [Radiation Health Branch] RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source."
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: 56746
Rep Org: Colorado Dept of Health
Licensee: North Colorado Medical Center
Region: 4
City: Greeley State: CO
County:
License #: CO 263-01
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: John Russell
Licensee: North Colorado Medical Center
Region: 4
City: Greeley State: CO
County:
License #: CO 263-01
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: John Russell
Notification Date: 09/19/2023
Notification Time: 13:03 [ET]
Event Date: 09/18/2023
Event Time: 10:00 [MDT]
Last Update Date: 09/19/2023
Notification Time: 13:03 [ET]
Event Date: 09/18/2023
Event Time: 10:00 [MDT]
Last Update Date: 09/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE
The following information was received from the Colorado Department of Public Health and Environment via email:
"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."
Colorado Event Report ID: CO 230032
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 received from the Colorado Department of Public Health and Environment via email:
"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."
Colorado Event Report ID: CO 230032
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: 56748
Rep Org: Texas Dept of State Health Services
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Notification Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
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 - LOST SOURCE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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 provided by the Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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
Power Reactor
Event Number: 56637
Facility: Millstone
Region: 1 State: CT
Unit: [2] [] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: Jason Parr
HQ OPS Officer: Thomas Herrity
Region: 1 State: CT
Unit: [2] [] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: Jason Parr
HQ OPS Officer: Thomas Herrity
Notification Date: 07/25/2023
Notification Time: 16:06 [ET]
Event Date: 07/25/2023
Event Time: 09:24 [EDT]
Last Update Date: 09/26/2023
Notification Time: 16:06 [ET]
Event Date: 07/25/2023
Event Time: 09:24 [EDT]
Last Update Date: 09/26/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Bickett, Carey (R1DO)
Bickett, Carey (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 86 | Power Operation | 86 | Power Operation |
EN Revision Imported Date: 9/27/2023
EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE
The following information was provided by the licensee via email:
"At 0924 [EDT] on July 25, 2023, it was discovered that both trains of control room air conditioning system were simultaneously inoperable due to an inoperable control room envelope boundary. The boundary was restored at 0925 [EDT] on July 25, 2023. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified.
"There has been no impact to Unit 3 which remains at 100% power."
* * * RETRACTION ON 09/26//23 AT 1305 EDT FROM PATRICK SIKORSKY TO JOHN RUSSELL * * *
The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that the access hatch being open did not have an adverse impact upon the control room emergency ventilation system and the control room envelopes boundary's ability to perform their safety function including:
Radiation dose to the occupants did not exceed the licensing basis, design basis accident calculated value.
Protection of control room occupants from hazardous chemicals and smoke.
Therefore, this condition is not reportable and NRC Event EN56637 is being retracted. The basis for this conclusion has been provided to the NRC Resident Inspector.
Notified R1DO (Lally)
EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE
The following information was provided by the licensee via email:
"At 0924 [EDT] on July 25, 2023, it was discovered that both trains of control room air conditioning system were simultaneously inoperable due to an inoperable control room envelope boundary. The boundary was restored at 0925 [EDT] on July 25, 2023. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified.
"There has been no impact to Unit 3 which remains at 100% power."
* * * RETRACTION ON 09/26//23 AT 1305 EDT FROM PATRICK SIKORSKY TO JOHN RUSSELL * * *
The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that the access hatch being open did not have an adverse impact upon the control room emergency ventilation system and the control room envelopes boundary's ability to perform their safety function including:
Radiation dose to the occupants did not exceed the licensing basis, design basis accident calculated value.
Protection of control room occupants from hazardous chemicals and smoke.
Therefore, this condition is not reportable and NRC Event EN56637 is being retracted. The basis for this conclusion has been provided to the NRC Resident Inspector.
Notified R1DO (Lally)
Agreement State
Event Number: 56749
Rep Org: PA Bureau of Radiation Protection
Licensee: Earth Engineering, Inc
Region: 1
City: East Norriton State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: Benjamin Seiber
HQ OPS Officer: John Russell
Licensee: Earth Engineering, Inc
Region: 1
City: East Norriton State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: Benjamin Seiber
HQ OPS Officer: John Russell
Notification Date: 09/20/2023
Notification Time: 12:21 [ET]
Event Date: 09/19/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2023
Notification Time: 12:21 [ET]
Event Date: 09/19/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2023
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)
Grant, Jeffery (IR)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Grant, Jeffery (IR)
AGREEMENT STATE - LOST THEN FOUND NUCLEAR DENSITY GAUGE
The following information was provided by the Pennsylvania Bureau of Radiation Protection (DEP):
"On September 19, 2023, a licensee vehicle was involved in an automobile accident during which a nuclear density gauge ejected from the vehicle. State Police recovered the device. The licensee reported to the scene and recovered the device. There was no damage to the gauge itself. The only damage incurred was to the transportation box. The side handle was ripped off as a result of the accident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.
"Troxler Model Number: 3440
Serial Number: 35195
Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries"
Pennsylvania Report Number: PA230025
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 provided by the Pennsylvania Bureau of Radiation Protection (DEP):
"On September 19, 2023, a licensee vehicle was involved in an automobile accident during which a nuclear density gauge ejected from the vehicle. State Police recovered the device. The licensee reported to the scene and recovered the device. There was no damage to the gauge itself. The only damage incurred was to the transportation box. The side handle was ripped off as a result of the accident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.
"Troxler Model Number: 3440
Serial Number: 35195
Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries"
Pennsylvania Report Number: PA230025
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: 56750
Rep Org: Texas Dept of State Health Services
Licensee: Texas Instruments
Region: 4
City: Dallas State: TX
County:
License #: L05048
Agreement: Y
Docket:
NRC Notified By: Marvin Earles
HQ OPS Officer: Lawrence Criscione
Licensee: Texas Instruments
Region: 4
City: Dallas State: TX
County:
License #: L05048
Agreement: Y
Docket:
NRC Notified By: Marvin Earles
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/20/2023
Notification Time: 16:14 [ET]
Event Date: 08/15/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/20/2023
Notification Time: 16:14 [ET]
Event Date: 08/15/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/20/2023
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), - (FAX)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (FAX)
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following was received from the Texas Department of State Health Services (the Department) via email:
"On September 6, 2023, the Department was notified of a lost exit sign but did not get detailed information regarding the lost source until September 19, 2023. The licensee reported a tritium exit sign was removed to accommodate a facility renovation, placed in a construction staging area for later disposition, and subsequently was unable to be located on August 15, 2023. The licensee conducted an internal investigation which concluded on September 6, 2023, at which point the Radiation Safety Officer declared that the tritium exit sign was lost. The sign was purchased in 1998 with an initial activity of 25 curies. It is a Betalux, Model SRB S/N 237918. The licensee reported that the integrity of the sign was not compromised and that there is no exposure risk. The Department has requested additional information from the licensee. The investigation into this event is on-going. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10051
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 received from the Texas Department of State Health Services (the Department) via email:
"On September 6, 2023, the Department was notified of a lost exit sign but did not get detailed information regarding the lost source until September 19, 2023. The licensee reported a tritium exit sign was removed to accommodate a facility renovation, placed in a construction staging area for later disposition, and subsequently was unable to be located on August 15, 2023. The licensee conducted an internal investigation which concluded on September 6, 2023, at which point the Radiation Safety Officer declared that the tritium exit sign was lost. The sign was purchased in 1998 with an initial activity of 25 curies. It is a Betalux, Model SRB S/N 237918. The licensee reported that the integrity of the sign was not compromised and that there is no exposure risk. The Department has requested additional information from the licensee. The investigation into this event is on-going. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10051
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: 56751
Rep Org: Maryland Dept of the Environment
Licensee: Tesla
Region: 1
City: Owing Mills State: MD
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Atnatiwos Meshesha
HQ OPS Officer: Lawrence Criscione
Licensee: Tesla
Region: 1
City: Owing Mills State: MD
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Atnatiwos Meshesha
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/20/2023
Notification Time: 17:38 [ET]
Event Date: 07/12/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2023
Notification Time: 17:38 [ET]
Event Date: 07/12/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2023
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 - LOST RADIOACTIVE MATERIAL
The following information was provided by the Maryland Department of the Environment via email:
"On July 12, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via email from a Tesla employee who reported the loss of a device with NRD model number P-2021 Z705 from a Tesla Body and Paint facility located in Maryland.
"The lost device is manufactured by NRD, LLC with model number P-2021-Z705, serial number A2MF439. The device contains 10 mCi of Polonium-210. No reference date is associated with it, but the device was shipped to Tesla, Inc. on March 16, 2021. These devices are generally-licensed and sold to Tesla by NRD, LLC. Tesla, Inc. Maryland Site, NA-US-MD-Owings Mills-Body is located at 9430 Reisterstown Road, Owings Mills, Maryland 21117.
"On July 14, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) investigation showed that the Po-210 radioactive material is used for alpha ionizer applications at the Tesla paint and body shop to stop dust from clinging to the body panels prior to painting. As per the company's procedure, when the device is no longer in use, the radioactive 'barrel' cartridges will be returned to NRD (or suitable disposer). The device had the 'gun' separated from the 'barrel' cartridge. The 'barrel' cartridge was returned to NRD as per procedure and the non-radioactive 'gun' part was lost or misplaced. In this process, the Po-210 source was not accounted for by NRD, LLC and reported as lost.
"This information is not conclusive as a lost source and needs to be further confirmed. Information on the current activity is required. MDE/RHP will finalize a reactive investigation."
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 provided by the Maryland Department of the Environment via email:
"On July 12, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via email from a Tesla employee who reported the loss of a device with NRD model number P-2021 Z705 from a Tesla Body and Paint facility located in Maryland.
"The lost device is manufactured by NRD, LLC with model number P-2021-Z705, serial number A2MF439. The device contains 10 mCi of Polonium-210. No reference date is associated with it, but the device was shipped to Tesla, Inc. on March 16, 2021. These devices are generally-licensed and sold to Tesla by NRD, LLC. Tesla, Inc. Maryland Site, NA-US-MD-Owings Mills-Body is located at 9430 Reisterstown Road, Owings Mills, Maryland 21117.
"On July 14, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) investigation showed that the Po-210 radioactive material is used for alpha ionizer applications at the Tesla paint and body shop to stop dust from clinging to the body panels prior to painting. As per the company's procedure, when the device is no longer in use, the radioactive 'barrel' cartridges will be returned to NRD (or suitable disposer). The device had the 'gun' separated from the 'barrel' cartridge. The 'barrel' cartridge was returned to NRD as per procedure and the non-radioactive 'gun' part was lost or misplaced. In this process, the Po-210 source was not accounted for by NRD, LLC and reported as lost.
"This information is not conclusive as a lost source and needs to be further confirmed. Information on the current activity is required. MDE/RHP will finalize a reactive investigation."
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: 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