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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
--------------------
Comanche Peak - Glen Rose TX
Report Date 04/20/2023 13:29:00
Event Date 04/18/2023 16:30:00
EN Revision Imported Date: 6/8/2023
EN Revision Text: SAFE SHUTDOWN CAPABILITY AND ACCIDENT MITIGATION
The following information was provided by the licensee via email:
"Notification per 10 CFR 50.72 (b)(3)(v)(A) and (v)(D)
"At time 1630 CDT on 4/18/23, Comanche Peak Unit 1 entered TS (Technical Specification) 3.0.3 for 11 minutes due to declaring Train A component cooling water (CCW) inoperable in conjunction with a Train B centrifugal charging pump (CCP) inoperable for scheduled maintenance. This resulted in an event or condition that could have prevented fulfillment of a safety function, high head injection of the emergency core cooling system.
"CCP 1-02 and fan cooler were tagged out of service at 0400 CDT on 4/18/23 due to scheduled maintenance activities. Containment spray (CT) pump 1-03 seal oil cooler CCW leak was found by a watchstander at 0930 CDT on 4/18/23. Engineering determined that leakage was CCW from a pipe flange weld after insulation removal and could not [determine] operability and notified control room at 1630 CDT on 4/18/23. This placed unit 1 in a TS 3.0.3 condition from 1630 to 1641 CDT for approximately 11 minutes until CCP 1-02 was restored back to operable status. CCW was declared operable at 1912 after CT pump 1-03 seal oil cooler was isolated. CT pump 1-03 remained inoperable until weld repair completed. Train A CT pump 1-03 declared operable at 1211 CDT 4/19/23.
"ENS notification should have been made by 0030 CDT on 4/19/23. This report restores compliance."
The NRC Resident Inspector has been notified.
The following information was provided by the licensee via phone and email:
"Although Comanche Peak Unit 1 conservatively entered a limiting condition for operation action statement and performed repairs immediately, further engineering inspection and evaluation concluded that the CCW system was fully able to provide the needed flow to the 1-03 CT pump seal coolers from the time of discovery (0930 CDT) until which time the piping was isolated for repairs. During this period, structural integrity of the joint was maintained, CCW inventory loss remained within acceptable limits, and CCW could perform its intended design and safety functions.
"Based on this revised operability determination, train A CCW was always operable, and TS 3.0.3 did not apply.
"Therefore, reportability requirements per 10 CFR 50.72 (b)(3)(v)(A) and (v)(D) did not apply, and a 60 day LER will not be submitted."
The licensee notified the NRC Resident Inspector.
Notified R4DO (Young)
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Palisades - Covert MI
Report Date 05/02/2023 22:41:00
Event Date 05/02/2023 15:00:00
EN Revision Imported Date: 6/23/2023
EN Revision Text: LOSS OF COMMUNICATIONS
The following information was provided by the licensee via email:
"At approximately 1500 [EDT] on 5/2/2023, it was determined that the commercial telecommunications capacity was lost to the Palisades Nuclear Plant (PNP) control room and technical support center due to an issue with the telecommunications provider. After discovery of the condition it was discovered that this loss also included the emergency notification system (ENS). Communications link via the satellite phone was tested satisfactorly. In addition, if needed, the satellite phone would be used to initiate call-out of the emergency response organization. The condition did not affect the ENS or commercial telecommunications capabilities at the offsite Emergency Operations Facility. The telecommunications provider has not provided an estimated repair time."
PNP will be notifying the NRC resident inspector.
* * * RETRACTION ON 06/22/23 AT 1358 EDT FROM J. LEWIS TO T. HERRITY * * *
The following information was provided by the licensee via email:
"This notification is being made to retract event EN 56501 that was reported on May 02, 2023. Based on further investigation, the Emergency Plan and Emergency Implementing Procedures provide an acceptable alternative routine communication system, which is satellite phones, for communicating with Federal, State, and local offsite agencies, that are in addition to the primary commercial telephone system. It was determined that no actual or potential loss of offsite communications capability existed per 10 CFR 50.72(b)(3)(xiii). This is consistent with NUREG 1022, Revision 3, Supplement 1, 'Event Report Guidelines 10 CFR 50.72(b)(3)(xiii),' and NEI 13-01, Revision 0, 'Reportable Action Levels for Loss of Emergency Preparedness Capabilities.'
"The NRC Decommissioning Inspector has been notified of the retraction.
"Commercial telecommunications to the plant were restored at approximately 0600 EDT on 5/3/2023."
Notified R3DO (Orlikowski)
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Wolf Creek - Burlington KS
Report Date 05/16/2023 17:20:00
Event Date 05/16/2023 11:27:00
EN Revision Imported Date: 6/6/2023
EN Revision Text: EMERGENCY EXHAUST INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1127 CDT on 5/16/2023, during the reperformance of test procedure 'STS PE-006, Charcoal Adsorber In-Place Leak Test' due to a failure from the previous day, both trains of emergency exhaust were rendered inoperable due to incorrect performance of the procedure. Performers incorrectly de-energized the humidity control heating coil for the unit not under test, rendering it inoperable. This issue was identified and rectified at 1138 CDT on 5/16/2023, exiting the LCO [limiting condition of operation] for both trains inoperable at that time. There was no impact to the health and safety of the public."
"The initial failure of the STS PE-006 test was caused by a malfunction of the test equipment which initially injected excessive amounts of tracer gas and caused saturation of the charcoal. Using test equipment sourced from Callaway, and following guidance from the vendor, STS PE-006 test was successfully passed on 5/17/2023. No maintenance or intrusive testing was performed on the unit between initial test failure and satisfactory completion of the test. Because this train of emergency exhaust was not actually inoperable at the time the second train was rendered inoperable due to incorrect procedure performance, there was no loss of safety function. Therefore, this event notification is being retracted."
The licensee has notified the NRC Resident Inspector. Notified R4DO (Gepford).
--------------------
Colorado Dept of Health - Aurora CO
Report Date 05/25/2023 16:40:00
Event Date 05/24/2023 13:00:00
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Colorado Department of Health via email:
"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."
Event Report ID No.: CO230014
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.
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Florida Bureau of Radiation Control - Orlando FL
Report Date 05/31/2023 10:36:00
Event Date 05/31/2023 0:00:00
AGREEMENT STATE - DAMAGED TROXLER GAUGE
The following information was provided by the Florida Department of Health Bureau of Radiation Control (BRC) via email:
"Universal Engineering Sciences Corporate Radiation Safety Officer (RSO) called the BRC Orlando [office] this morning to report one of their Troxler gauges was run over on a job site this morning. He stated the source rod was in the retracted and shielded position at the time of the accident. Unit apparently sustained housing damage. Local RSO was enroute with a radiation meter. A BRC inspector is also enroute."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The Troxler gauge involved contains nominal activity of 40 mCi of Am-241:Be and 8 mCi of Cs-137.
FL incident number: FL23-081
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Florida Bureau of Radiation Control - Milton FL
Report Date 05/31/2023 11:22:00
Event Date 05/28/2023 0:00:00
AGREEMENT STATE REPORT - MEDICAL EVENT - INCORRECT TARGET ORGAN
The following information was provided by the Florida Department of Health Bureau of Radiation Control (BRC) via email:
"The Radiation Safety Officer (RSO) for Santa Rosa Medical Center, called the BRC to report an incident which occurred on Sunday 5/28/23. A technician was performing a lung scan on a patient and accidentally grabbed the wrong dose. The patient received 4 mCi of Tc-99 before the technician realized her mistake; whole dose would have been 10 mCi. The radiologist and the patient were both made aware of the incident.
"Licensing and technology is being asked to further investigate this incident."
The following additional information was obtained from the RSO:
The prescribed dose was 10 mCi of Tc-99 tagged for lung scan while the administered dose of Tc-99 was tagged for the liver. The total body effective dose equivalent to the patient was 80 mrem.
Florida Incident Number: FL23-082
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.
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Florida Bureau of Radiation Control - Tallahassee FL
Report Date 05/31/2023 11:26:00
Event Date 05/18/2023 0:00:00
AGREEMENT STATE REPORT - MATERIAL IDENTIFIED IN INVENTORY NOT ON LICENSE
The following report was received by the Florida Bureau of Radiation Control (BRC):
"FSU [Florida State University] contacted BRC Radioactive Materials Licensing via written letter dated May 18th, 2023 regarding a request to add [Uranium] U-233, any form except aerosols, to their license #0032-10. BRC Tallahassee called BRC Orlando this morning at 0900 [EDT] to notify. During a recent inventory close-out process, they found approximately 1.71 mCi of U-233. After checking the U-233 against their license, it was noticed that the U-233 is currently not listed on their current license. After additional review of archival records, it was found that the listing of U-233 was a remnant of their license #0032-18. License #0032-18 was terminated in 2012. The material has not been used in decades. The U-233 will stay in their radioactive materials storage vault and will not be used for any research. The plan moving forward is to eventually transfer the U-233 to a new research laboratory at the Colorado School of Mines. An amendment to current license to add U-233 is needed for this transfer."
Florida Event Number: FL23-080
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North Carolina Department of Health - Greensboro NC
Report Date 06/01/2023 12:56:00
Event Date 05/09/2023 0:00:00
AGREEMENT STATE REPORT - LOST MEDICAL SOURCE
The following is a summary of an email received from the North Carolina Department of Health and Human Services:
The Breast Center of Greensboro reported one lost brachytherapy seed (Iodine-125 in a preloaded 7 cm syringe, initial activity 255 microcuries, final activity 176 microcuries, order number 202385558, lot number 85558, satisfactory leak test on April 4, 2023) to the North Carolina Department of Health and Human Services on May 12, 2023. The lost source was identified during an inventory performed on May 9, 2023. An extensive search was performed but the seed was not located. The seed was most likely thrown away in a sharps container and is not believed to be stolen. Each medical procedure performed with this specific seed lot was audited with no abnormalities noted. Corrective actions include identifying each seed with a unique tracking number, updating use procedures, designating waste containers for seed use only, daily seed tracking when seeds are used, and retraining for all seed technicians.
North Carolina Event Number: NC230009
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
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Minnesota Department of Health - St. Paul MN
Report Date 06/01/2023 15:34:00
Event Date 05/23/2023 0:00:00
AGREEMENT STATE REPORT - LOST IODINE LOCALIZATION SEED
The following was received by email from the Minnesota Department of Health:
"An Iodine-125 localization seed (approximately 270 microcuries) was lost following removal from the specimen. The seed is suspected to have been placed on a surgical towel and never put into the source vial. Prior to discovery of the missing seed, the pathology department linens were taken to a laundry facility where the towel was washed. The licensee surveyed the pathology department and the laundry facility and were not able to find the seed."
State event report number: MN230003
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
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Louisiana Energy Services - Eunice NM
Report Date 06/01/2023 20:16:00
Event Date 06/01/2023 2:39:00
PARTIAL LOSS OF CRITICALITY ACCIDENT ALARM SYSTEM
The following information was provided by the licensee via email:
"On June 1, 2023, during inclement weather, a Phase 2 CAAS [Criticality Accident Alarm System] detector fault was received. Troubleshooting efforts indicated two CAAS nodes are impacted and SBM1005 [Process Services Corridor] was evacuated. The affected detectors are located in the north end of the SBM1005 Process Services Corridor. Compensatory measures are implemented in the affected area to support maintenance troubleshooting efforts.
"UUSA is reporting this event per 10 CFR 70.50(b)(2)."
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Palo Verde - Wintersburg AZ
Report Date 06/02/2023 10:44:00
Event Date 06/02/2023 4:05:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS [Emergency Notification System] or under the reporting requirements of 10 CFR 50.73.
"At 0405 MDT on June 2, 2023, the Unit 2 reactor automatically tripped on low steam generator water levels due to degraded flow from the A main feedwater pump. Steam generator water levels reached the automatic Auxiliary Feedwater Actuation System (AFAS) setpoint resulting in automatic AFAS-1 and AFAS-2 actuations and subsequent start of both class auxiliary feedwater pumps.
"Steam Generator water levels are being restored to normal band with the class 1E powered motor driven auxiliary feedwater pump.
"Following the reactor trip, all control element assemblies inserted fully into the core. No emergency plan classification was required per the Emergency Plan. Safety related buses remained powered from offsite power during the event and the offsite power grid is stable. Both emergency diesel generators automatically started on the AFAS-1 and AFAS-2 actuations as designed and are currently running unloaded. This event is being reported as a reactor protection system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and a specified system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Senior Resident Inspector has been informed. Unit 1 and 3 are in Mode 1 at 100 percent power."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Decay heat is being removed to main condenser via automatic steam bypass and B auxiliary feedwater pump.
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SC Dept of Health & Env Control - Charleston SC
Report Date 06/02/2023 11:39:00
Event Date 04/21/2023 0:00:00
EN Revision Imported Date: 6/22/2023
EN Revision Text: AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for.
"Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
SC internal ID number is: SC230011
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):
"A 30-day written report was submitted to the Department on 05/15/23 and a revised 30-day written report was submitted to the Department on 05/17/23. The licensee reported no exposure above background to individuals. The lot number of the manual brachytherapy sealed sources involved in the procedure is BBHQ0080, last leak tested 03/21/23. The licensee has also revised and adopted, or plan to adopt new procedures related to manual brachytherapy implant procedures. This event is considered closed."
Notified R1DO (Eve), ILTAB, and NMSS Notifications via 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
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North Carolina State University (NCSU) - Raleigh NC
Report Date 06/02/2023 13:17:00
Event Date 06/02/2023 8:18:00
UNSCHEDULED SHUTDOWN
The following information was provided by the licensee via fax or email:
"An unscheduled shutdown of the reactor occurred on 6/2/23 at 0818 EDT due to an abnormal response of the Safety Power Level channel during the approach to power of 1 MW at 150 kW. The Reactor Operator observed a discrepancy in power indications by the Linear Power Level and Safety Power Level channels and took immediate actions required by procedure NRP-OP-105, Response to SCRAMS, Alarms, and Abnormal Conditions. The reactor was shut down and secured immediately. The Designated Senior Reactor Operator was immediately notified.
"The Safety Power Level channel is required to be operable per Technical Specification 3.3.b Table 3.3-1 while the reactor is being operated. During the startup checklist, the channel performed satisfactorily. The Safety Power Level channel is part of the reactor safety system and has two automatic shutdowns (SCRAMs) associated with it. Reactor power was correctly monitored by all other operable power monitoring channels which have redundant SCRAM capabilities. No SCRAM occurred or was needed due to the power level of the reactor. Following the reactor shutdown, the reactor staff investigated and determined that the high voltage power supply in the Safety Power channel was faulty. The power supply was replaced and a channel calibration of the Safety Power channel will be performed using procedure PS 1-05-03A:S1 to verify the channel is operable. Maintenance Log #0888 has been opened. There was no safety issue with this event. Procedures were followed during reactor operation, shutdown, and the investigation.
"This unscheduled shutdown is a reportable event per TS 6.7.1 based on the circumstances and as defined in the facility Technical Specification (TS 1.2.24.d) for reportable events from operation in violation of Limiting Conditions for Operation (LCO) established in TS. TS 1.2.24.d, does not allow for an exception for taking prompt remedial action.
"A report to the NRC is required within one working day and will be made by 1700 EDT by phone on 6/2/23, as required by TS 6.7.1. Also as required by TS 6.7.1, a written report to the NRC is due in 14 days (6/16/23)."
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PA Bureau of Radiation Protection - King of Prussia PA
Report Date 06/05/2023 11:17:00
Event Date 06/01/2023 0:00:00
AGREEMENT STATE REPORT - STOLEN/FOUND SOURCE
The following information was provided by the Pennsylvania Department of Radiation Protection (DEP) via email:
"On June 1, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. The vehicle was located and returned to the employee within a few hours. The gauge was still properly stored in the trunk and untouched with no evidence that the trunk lock, gauge chain, chain lock, or gauge case had been tampered with. The DEP has been in contact with the licensee and will update this event as soon as more information is provided. "Troxler Model Number: 3430 "Serial Number: 29846 "Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries"
Event Report ID No: 230017
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
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Florida Bureau of Radiation Control - Tampa FL
Report Date 06/05/2023 11:42:00
Event Date 06/05/2023 0:00:00
AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE
The following was received by email from the Florida Department of Health, Bureau of Radiation Control (BRC):
"BRC received a call at 1045 EDT from the radiation safety officer of ECS Florida LLC. The caller stated that an Instrotek 3500 (#4012, AmBe K893/19, Cs137 BG1008) moisture density gauge was stolen from the back of a pickup truck on its way to a job site. The vehicle made several stops on the way and they do not know at which location it was stolen."
Florida Incident Number: FL23-085
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
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Seabrook - Manchester NH
Report Date 06/05/2023 17:26:00
Event Date 06/02/2023 14:30:00
EN Revision Imported Date: 6/23/2023
EN Revision Text: FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"On June 2, 2023, a blind specimen provided to a laboratory did not analyze as expected. The specimen reported a false negative for amphetamines and a false positive for opiates.
"This event is being reported pursuant to 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).
"The NRC Resident Inspector has been notified."
"Follow-up investigation by an independent Health and Human Services laboratory confirmed that the blind specimen in question was analyzed correctly. The error is thought to have occurred during the preparation of the blind specimen, prior to delivery to the site.
"The NRC Resident Inspector has been notified."
Notified R1DO (Eve) and FFD Group (email)
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Paragon Energy Solutions - York SC
Report Date 06/05/2023 18:25:00
Event Date 04/05/2023 0:00:00
EN Revision Imported Date: 6/7/2023
EN Revision Text: PART 21 - RELAY CARD POTENTIAL DEFECT
The following information summary was provided by the licensee via email:
On April 5th, 2023, Duke Catawba Nuclear Station informed Paragon of a failure of a Trane External Auto/Stop and Emergency Stop relay card (Part Number: X13650728-06) in a chiller control system. Analysis of the failed relay card identified minor delamination and water intrusion of the microcontroller chip. Ongoing evaluation is expected to be completed by 7/15/23.
Potential plants affected: Nine Mile Point, Catawba, River Bend, McGuire.
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Texas Dept of State Health Services - Cibolo TX
Report Date 06/05/2023 21:20:00
Event Date 06/01/2023 0:00:00
AGREEMENT STATE - FOUND DENSITY GAUGE
The following was received by email from the Texas Department of State Health Services [the Agency]:
"On June 1, 2023, a steel mill notified the Agency that a load of scrap coming into their facility set off the radiation alarm. The source was identified as an inline-type density gauge and it was secured at their facility until more information could be identified on the device to determine the owner. On June 5, 2023, the facility found a phone number on the gauge that stated to call Schlumberger if the gauge was found. Schlumberger was contacted and stated the gauge had been sold to Liberty Oilfield Services INC. The Agency and steel mill contacted the licensee which picked up the gauge the same day. The gauge was a Thermo-Fisher model 5192, Serial # B7615 containing 200 mCi (7.4 GBq) of Cesium-137. An investigation is ongoing into how the licensee lost possession of the gauge."
Texas Incident number: 10024. NMED National Event number: TX230026.
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
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Ginna - Ontario NY
Report Date 06/05/2023 21:58:00
Event Date 06/05/2023 18:23:00
OFFSITE NOTIFICATION
The following information was provided by the licensee via email:
"At 1823 EDT, the shift manager was notified that one siren, part of the public notification system (siren number 10), spuriously activated for approximately one minute. Monroe County agencies were notified regarding the actuation. The cause of the actuation is being investigated and the ability for the siren to actuate has been removed until the cause is determined. There is no impact to the emergency planning zone.
"This event is a four-hour, non-emergency report for notification to other government agencies in accordance with 10 CFR 50.72(b)(2)(xi)."
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Three Mile Island - Middletown PA
Report Date 06/06/2023 13:19:00
Event Date 06/06/2023 9:37:00
OFFSITE NOTIFICATION DUE TO ON-SITE FATALITY
The following information was provided by the licensee via email:
"At 0937 EDT on June 6, 2023, it was discovered that a site employee suffered a non-work-related fatality. The individual was found non-responsive outside the Radiological Controlled Area. This is a four-hour, non-emergency notification for which a notification to other government agencies has been made. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Region I inspector has been notified."
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Callaway - Fulton MO
Report Date 06/07/2023 11:00:00
Event Date 06/06/2023 12:33:00
FITNESS-FOR-DUTY REPORT
The following information is summary provided by the licensee via email:
A non-licensed supervisor was found to have falsified fitness for duty reports for a period of two months. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
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New York State Dept. of Health - New Hyde Park NY
Report Date 06/07/2023 12:29:00
Event Date 06/07/2023 6:30:00
EN Revision Imported Date: 7/21/2023
EN Revision Text: AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE
The following information was provided by the New York State Department of Health (the Department) via fax:
"The licensee reported to the Department that a portable moisture density gauge had been stolen (Humboldt Scientific, Inc., model 5001 EZ, S/N 9909, Isotope: Am-241/Be (S/N: K833-19) & Cs-137 (S/N: Q1676), activity (when new): Am-241/Be 44mCi & Cs-137 11 mCi).
"An authorized user working under the license removed the gauge from the permanent storage location on June 6, 2023, with the intent to store it in a company van overnight to deliver it to a temporary jobsite in the morning of June 7, 2023. At around 0600-0700 [EDT] on June 7, 2023, the authorized user looked outside and did not see the van, so they contacted the New York Police Department and the Radiation Safety Officer. The Radiation Safety Officer indicated that the gauge was stored in the back of the van overnight. The gauge case was locked, and was secured to the floor of the van by chain, so it was stolen along with the van.
"Currently, the location and status of the gauge is unknown. Any updates to this event will be provided as soon as possible."
New York Event number: NY-23-05
"The Department was notified at 1206 EDT that the vehicle had been located at an auto shop. The Radiation Safety Officer (RSO) was onsite and had to wait for the NYPD to get access to the site and vehicle. At 1445 EDT, the RSO notified the Department that the gauge was found in the vehicle and had not been damaged. It is now in the possession of the licensee and is being returned to the permanent storage location. This incident can be closed."
Notified R1DO (Carfang), NMSS Events, ILTAB, and CNSC (Canada) via 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
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Oregon Health Authority - Tigard OR
Report Date 06/07/2023 16:47:00
Event Date 06/06/2023 0:00:00
AGREEMENT STATE REPORT - STOLEN AND RECOVERED MOISTURE DENSITY GAUGE
The following is a summary of information provided by Oregon Health Authority via phone and email:
On the evening of 6/6/23, a licensee's vehicle containing a Troxler moisture density gauge (44 mCi Am/Be, 9 mCi Cs-137) was stolen. The vehicle was equipped with a GPS location device which allowed Oregon State Police to recover the vehicle and the moisture density gauge within two hours. The gauge was returned to the licensee undamaged. There was no exposure to the public.
Oregon event number: RPS 23-0023
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
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Seabrook - Manchester NH
Report Date 06/08/2023 9:37:00
Event Date 04/12/2023 11:07:00
AUTOMATIC ACTUATION OF "B" EMERGENCY DIESEL GENERATOR EMERGENCY POWER SEQUENCER
The following information was provided by the licensee via email:
"On April 12, 2023, with Seabrook Station Unit 1 in Mode 6 at zero percent power, a valid actuation of the 'B' emergency diesel generator (EDG) emergency power sequencer occurred due to a loss of power to the 'B' train emergency bus. The 'B' EDG was removed from service for scheduled maintenance during this time.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) for a valid actuation of the 'B' EDG emergency power sequencer.
"The NRC Resident Inspector has been notified."
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Seabrook - Manchester NH
Report Date 06/08/2023 9:37:00
Event Date 05/06/2023 15:52:00
ACTUATIONS OF REACTOR PROTECTION SYSTEM
The following information was provided by the licensee via email:
"On 05/06/2023, at 1552 [EDT] with Seabrook Unit 1 in Mode 3 at zero percent power, while performing digital rod position indication system surveillance testing, shutdown bank 'E' stopped withdrawing. In response, the reactor trip breakers were manually opened, initiating a valid actuation of the reactor protection system (RPS).
"Subsequently, at 2253 while continuing to perform digital rod position indication system surveillance testing, shutdown bank 'C 'stopped inserting. Reactor trip breakers were manually opened, initiating a valid actuation of the RPS.
"The RPS responded as designed during both events, and both actuations are being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."
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Mistras Group, Inc. - Burr Ridge IL
Report Date 06/08/2023 14:14:00
Event Date 06/07/2023 0:00:00
TEMPORARY LOSS OF CONTROL OF RADIOGRAPHY EXPOSURE DEVICE
The following is a summary of information provided by the licensee via phone and email:
On 6/7/23 at 1040 ADT, the licensee (Mistras Group, Inc.) was providing gamma radiography services in Prudhoe Bay, Alaska when an industrial radiography source (QSA 880 Delta, SN 73648M, Ir-192, 115.6 Ci) cable failed to retract. The device was moved safely to a location where repairs were made to the cable. No overexposures were associated with this event or during recovery operations. No radiation exposure was received by the general public.
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Illinois Emergency Mgmt. Agency - Gurnee IL
Report Date 06/08/2023 15:33:00
Event Date 06/08/2023 0:00:00
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following is a summary provided by the Illinois Emergency Management Agency (the Agency) via email:
On June 8, 2023 at 0920 CDT, the licensee (Roquette America Inc.) in Gurnee, IL, advised the Agency of a stuck open shutter (Ohmart fixed gage, 15 mCi, Cs-137). The reportable equipment failure was discovered during a routine shutter check. The Radiation Safety Officer confirmed that the gauge will remain in its mounted condition attached to a small sectional tank and that operators were immediately advised of the inoperable shutter. The manufacturer was notified and confirmation for a site visit to repair the shutter is pending. No personnel exposures occurred as a result. The incident was reported to the Agency within 24 hours as required under 32 Ill. Adm. Code 340.1220(c)(2). Agency staff will perform a reactionary inspection to ensure adequate control of the gauge and area until the shutter is repaired.
Illinois event number: IL230012
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Illinois Emergency Mgmt. Agency - Mt. Zion IL
Report Date 06/08/2023 16:20:00
Event Date 06/08/2023 0:00:00
AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE
The following is a summary of information provided by the Illinois Emergency Management Agency (the Agency) via email:
On 6/8/23, the licensee (SKS Engineers) was transporting a moisture density gauge (Troxler Model 3440, serial number 30126, 40 mCi Am-241/Be, 8 mCi Cs-137), and it fell out of the truck. The truck bed door was found down upon arrival at the work location. The licensee was transporting the device within its case from Decatur, IL to a work location in Mt. Zion, IL which represented a 9.4-mile path.
Illinois event number: IL230013
The following information was provided by the Agency via email and phone:
"The gauge has been located and returned to safe storage. A member of the public located the gauge and facilitated its return to the licensee. The gauge was undamaged and still contained within the locked case."
Notified R3DO (Nguyen), NMSS (email), and ILTAB (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
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Beaver Valley - Shippingport PA
Report Date 06/11/2023 9:02:00
Event Date 06/11/2023 1:30:00
UNANALYZED CONDITION
The following information was provided by the licensee via email:
"At 0130 EDT on June 11, 2023, it was discovered that the Beaver Valley Power Station, Unit No. 2 auxiliary building door A-35-5A, credited for tornado missile protection of the primary component cooling water system, was open and unlatched. Upon discovery, the door was shut and latched. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(B). There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
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Fermi - Newport MI
Report Date 06/13/2023 6:02:00
Event Date 06/12/2023 23:33:00
EN Revision Imported Date: 6/15/2023
EN Revision Text: ACCIDENT MITIGATION - HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE
The following information was provided by the licensee via email:
"At 2333 EDT on June 12, 2023, the division 2 Mechanical Draft Cooling Tower (MDCT) Fan `D' was declared inoperable due to a trip of the fan while running in high speed. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components, including the High-Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI room cooler. The cause of MDCT Fan `D' trip is currently unknown with trouble shooting being developed for remediation of the condition. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"The NRC Senior Resident Inspector has been notified."
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Colorado Dept of Health - Lone Tree CO
Report Date 06/13/2023 13:00:00
Event Date 06/12/2023 11:00:00
AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was provided by the the Colorado Department of Health via email:
"On June 12, 2023, as the semi-annual leak tests/inventory were being performed at Sky Ridge Medical Center (RAML 1053-01), a leaking Co-57 Benchmark mini flood source (SN BM552021321103) was found. The exact timing of when the source started leaking is unknown. The source was last inventoried in December 2022, and was at background. [A staff member] from the Colorado Associates in Medical Physics (CAMP) found the source had 185 Bq (0.005 micro-Ci) or more removable contamination in excess of the regulatory limits. The initial removable contamination resulted in a wipe count of 3835 cpm (0.00525 micro-Ci) of removable contamination. The source was cleaned with paper towels and dish soap and when re-wiped had a lower count (1900 cpm), but remained above background even after additional wipes. All paper towels used for cleaning surveyed at background (0.03 mR/hr) and were disposed of in the hot trash in the hot lab.
"The source was wrapped in a thick trash bag, secured with tape and was placed in the shielded decay cabinet. The activity of the source on 6/12/2023 was 5.02 milli-Ci. The storage container, the cardiac single-photon emission computed tomography camera, and the hot lab counters were all wiped and surveyed, and all readings were at background (0.03 mR/hr).
"The source did not appear damaged or broken. CAMP will dispose of the source, and they have initiated a disposal inquiry. In the meantime, the source will remain in the shielded decay cabinet."
Colorado event report ID number: CO230016
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Columbia Generating Station - Richland WA
Report Date 06/13/2023 23:53:00
Event Date 06/13/2023 18:42:00
OFFSITE NOTIFICATION - OIL RELEASE
The following information was provided by the licensee via email:
"On 6/13/23 at approximately 1030 PDT, testing was being conducted on a lubricating oil system which interfaces with a cooling water system that has a pathway to the Columbia River. Due to an equipment failure, an indeterminate amount of oil leaked into the cooling water system, with a maximum potential loss of 300 gallons of oil. At 1230 PDT, an oil sheen was identified on the water basin which is the suction and discharge for this cooling system. The discharge pathway to the river was isolated at 1235 PDT. Investigation at the Columbia River showed no signs of oil sheen. This is being reported to offsite agencies under the Columbia Generating Station NPDES [National Pollutant Discharge Elimination System] Permit section S3.E.b. l and RCW [Revised Code of Washington] 90.56.280 due to the discharge of oil which has the potential to cause a sheen on the surface of the river.
"This condition is being reported pursuant to 10CFR50.72(b)(2)(xi) for news release or notification of other government agencies related to health and safety of the public or protection of the environment. Notifications to off-site agencies were performed at 1842 PDT on 6/13/2023.
"United States Coast Guard National Response Center Incident Report# 1369989.
"Washington State Emergency Management Division Report# 23-2245.
"Discharge pathway will remain secured until on-site cooling water system has been remediated.
"The NRC resident has been informed."
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Reid Health - Richmond IN
Report Date 06/14/2023 10:12:00
Event Date 06/14/2023 7:00:00
NON-AGREEMENT STATE - SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE
The following is a summary of information provided by the licensee via telephone:
On 6/14/23 around 0700 EDT, the licensee received three packages containing F-18 sources. Swipe readings on the packages revealed 42333 counts per minute (cpm), 12857 cpm, and 267 cpm. The packages had slightly elevated radiation readings. The radiation safety officer (RSO) and supplier were notified. There was no contamination found inside of the packaging, and the F-18 doses were double sealed without damage. Swipe readings were taken along the delivery path, but no spread of contamination to public spaces was detected. The affected packages were placed in a radiation storage area pending disposal.
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Illinois Emergency Mgmt. Agency - Springfield IL
Report Date 06/14/2023 15:32:00
Event Date 03/02/2023 0:00:00
AGREEMENT STATE REPORT - LOST/ABANDONED SOURCE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On March 2, 2023, staff with the Illinois Emergency Management Agency and Office of Homeland Security responded to a load of scrap metal that tripped portal monitors in Indiana and was returned under DOT SP-IN-IL-23-001.The load of scrap originated at B.L. Duke in Forest View, IL. Within that load, a small unidentified radium-226 source was identified. It was estimated to contain approximately 150 microcuries of activity. On June 14, 2023, the licensing division learned of the recovery and began an investigation into the applicability of reporting requirements. There are no discernable markings or serial/model numbers. Activity estimates (based on dose rate) would place the source at approximately 150 microcuries. Aside from this source having significantly less activity, this appears to be a Ra-226 radiography source from the early 30's/40's. As this source does not appear to be exempt, it is likely byproduct material as a discrete source of radium and subject to specific licensure. Therefore, it is being reported as a lost/missing source. The source has been placed into the Agency's orphan source collection program and will be disposed of as low level radioactive waste." Illinois report number: IL230015
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
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Georgia Radioactive Material Pgm - Augusta GA
Report Date 06/15/2023 9:10:00
Event Date 06/15/2023 9:10:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the Georgia Department of Natural Resources (the State) via email:
"On June 12, 2023, [the licensee] notified the State that they had discovered a stuck shutter on one of their fixed gauges [Ohmart Corp 4/2000 containing 100 mCi of Cs-137] that morning. The [licensee] had a service vendor repairing the handle of the gauge, and when they went to shut the shutter it wouldn't shut. They attempted to lubricate the shutter to get it to move, but it still would not close. It was determined that the issue will not cause undue exposure or risk to personnel. The vendor is sourcing the parts required for repair. As soon as the part is delivered, they will return to the site and replace the mechanism. Until then, the gauge will remain on the pipe with a notice attached to it, informing personnel of the issue to not interact with the gauge."
Georgia Incident Number: 66
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Byron - Byron IL
Report Date 06/15/2023 9:35:00
Event Date 06/14/2023 9:26:00
FITNESS-FOR-DUTY REPORT
The following is a summary of information provided by the licensee via email:
A non-licensed, non-supervisory employee was identified bringing a prohibited item into the protected area. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
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WA Office of Radiation Protection - Spokane WA
Report Date 06/15/2023 19:53:00
Event Date 06/14/2023 0:00:00
AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was provided by the Washington State Office of Radiation Protection via email:
"On 6/14/2023, a dose misadministration occurred during high dose rate brachytherapy at the Sacred Heart (SH) Radiotherapy Department. The authorized user (AU) intended for 15 Gy to be delivered in three [separate] 5 Gy fractions, but it was planned and delivered in a single 15 Gy treatment. The incident was discovered around 1630 [PDT] the same day. The AU has informed the patient and the referring physician.
"The SH medical physicist noted that 13 Gy in a single fraction is an effective treatment for the patient's condition (keloids on and around both ears). The 15 Gy was delivered to the keloid surface, and skin tolerance in a single fraction is greater than 25 Gy.
"Follow up with the patient will be perform in the next few days and ongoing. No other exposure to staff is reported."
WA incident number: WA-23-009
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.
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Texas Dept of State Health Services - Bishop TX
Report Date 06/15/2023 20:38:00
Event Date 06/15/2023 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTERS
The following information was provided by the Texas Department of Health Services (the Agency) via email:
"On June 15, 2023, the Agency was notified by the licensee that during routine shutter checks, the shutters on two Berthold model LB7442 nuclear gauges were stuck in the open position. The gauges both contain a 20 millicurie (original activity) cesium - 137 source. Open is the normal operating position of the gauges. There is no risk of additional radiation exposure to members of the general public or radiation workers due to this failure. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300."
TX incident number: I-10026
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Oregon State University (OREG) - Corvallis OR
Report Date 06/16/2023 13:25:00
Event Date 05/31/2023 9:30:00
TECHNICAL SPECIFICATIONS POWER LIMIT VIOLATION
The following information was provided by the licensee via phone and email:
"[Oregon State University Radiation Center is] providing this information as a follow-up with the phone call to the Headquarters Operations Center made today at 1325 EDT (EN-56579). On the morning of 5/31/2023, a senior reactor operator and a trainee operator were performing a square-wave operation to raise power from 100 W to 1 MW. After firing the transient rod, the reactor immediately scrammed on both safety and percent power channels. Review of the chart recorder shows that reactor power likely reached 1.45 MW. This is potentially a violation of Technical Specification 3.1.1 which limits power to 1.1 MW during steady-state operations.
"Reviewing the power chart recorder, it appears that two immediately adjacent steps required for the square-wave operation were performed inadvertently out of order. The chart's sample rate is 1 Hz, so the resolution on the data is limited. Within 10 seconds, the final procedure steps for square-wave operation were performed (with the mode switch in square-wave mode). Once the transient rod air actuation button was pushed, starting the square-wave, the safety channel shortly thereafter (approximately 1 second) went from 0.02 percent to 145.91 percent of 1 MW. The reactor immediately scrammed and shut down the reactor as the safety and percent power channels exceeded their scram setpoints of 106 percent of 1 MW, which were checked on the daily startup checklist. The cause of the event was that two steps in the procedure were performed out of order, causing the regulating rod to withdraw to match demand power as the transient rod withdrew. As a result, this caused an additional 18 cents of reactivity to be inserted above the planned reactivity insertion of 80 cents.
"[Oregon State University Radiation Center plans] on following this up with a more thorough report within 14 days."
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Comanche Peak - Glen Rose TX
Report Date 06/16/2023 22:16:00
Event Date 06/16/2023 18:32:00
AUTOMATIC REACTOR TRIP DUE TO LO-LO STEAM GENERATOR LEVEL
The following information was provided by the licensee via email:
"[On June 16, 2023,] at 1832 CDT, Unit 1 reactor automatically tripped on lo-lo level in the '1-04' steam generator (SG). Prior to the trip, the 1B [main feedwater pump] (MFP) tripped due to speed oscillations and a runback to 700MW was in progress. Both motor driven auxiliary feedwater pumps started due to the lo-lo level in SG '1-04'.
"Unit 1 is being maintained in hot standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007A. The Emergency Response Guideline network has been exited. Decay heat is being rejected to the main condenser via the steam dump valves."
The licensee notified the NRC Resident Inspector.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Unit 1 is in a normal post-trip electrical line-up. There was no effect on Unit 2 due to the Unit 1 trip.
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California Radiation Control Prgm - Sacramento CA
Report Date 06/19/2023 18:32:00
Event Date 06/19/2023 1:00:00
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following report was received by the California Department of Public Health (the Department) via email:
"On June 19, 2023, the licensee notified the Department that at 0100 [PDT] one nuclear gauge (Troxler 3430, SN 19706) containing 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen from a locked vehicle that was parked in an apartment complex. The gauge was stored in its case that was chained and locked to the pick up truck bed. The gauge was not visible as the bed of the truck was fitted with a locking cover. The cover had been broken open and the locks securing the gauge were cut. Sacramento Police were notified and an electronic report was filed.
"The Department will investigate."
California Event Number: 061923
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
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Arkansas Department of Health - Pine Bluff AR
Report Date 06/20/2023 10:41:00
Event Date 06/19/2023 10:30:00
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Arkansas Department of Health via email:
"On June 19, 2023, at approximately 1300 CDT, the licensee contacted the Arkansas Department of Health to report a medical event from Jefferson Regional Medical Center, Pine Bluff, Arkansas. The Radiation Safety Officer, Imaging Services Compliance Specialist, called to report a mishap with their first procedures with Y-90. It appears that their patient was to have received 19.8 Gray. However, due to equipment or patient issues the patient received only 6% (i.e. 2.6 Gray). The original injection was to have been 68.5 mCi.
"The report from the licensee is as follows: This is a termination of the Y-90 therapy due to stasis of the administration. 'Based on dosimeter readings of the Y-90 vial, and Geiger-Mueller meter measurements of the equipment, the microspheres were blocked in a tubing connector and did not fully reach the patient and/or organ. There was no spillage or contamination of microspheres from the Y-90 dose. The tubing and catheter were placed in appropriate shielding for long term decay in storage. Below and attached are the calculations we received from the lead Nuclear Medicine technologist and Therasphere representative.'
"Written Directive: 68.6 mCi
"Administration: 64.9 mCi at 1030 [CDT]
"Start: 1138 [CDT]
"Stasis Termination: 1209 [CDT]
"Dose to patient: 3.6 mCi"
AR event number: ARK-2023-004
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.
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Illinois Emergency Mgmt. Agency - Des Plaines IL
Report Date 06/21/2023 15:28:00
Event Date 06/20/2023 0:00:00
AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL RECOVERED AT A SCRAPYARD
The following information was received from the Illinois Emergency Management Agency (Agency) via email:
"Agency staff responded to a radiation monitor trip at a scrap metal recycling facility (SIMS Metal Management in Chicago) on 6/20/23 and identified an activated component from a high energy therapy device. The component is estimated to contain less than 1 microcurie of Co-60 and had an exposure rate of 100 microrem/hour on contact. The device originated from Varian Medical Systems and was decommissioned and transported by Legacy Transportation Services. Legacy is an Illinois radioactive materials licensee (IL-02445-01) that receives decommissioned Varian (and other low/high energy) devices and sorts the equipment for recoverable materials versus scrap. Radioactive components are to be identified and returned to Varian. This piece reportedly circumvented their radiation screening process. The licensee was contacted by the Agency and their staff promptly recovered the piece today (6/21/23). An assessment of contamination was performed and none identified. This incident did not result in members of the public receiving exposures in excess of (Illinois) Part 340 limits. Pending appropriate enforcement action and the licensee's written report; this matter is considered closed. Root cause and the adequacy of corrective action will be assessed in the licensee's response."
Illinois Item Number: IL230016
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
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Monticello - Monticello MN
Report Date 06/22/2023 9:44:00
Event Date 04/28/2023 4:02:00
60 DAY NOTIFICATION FOR AN INVALID ACTUATION OF PRIMARY CONTAINMENT ISOLATION LOGIC
The following information was provided by the licensee email:
"This telephone notification is provided in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to report an invalid actuation of Division 2 Primary Containment Isolation logic at the Monticello Nuclear Generating Plant (MNGP) that occurred while in a refueling outage.
"At approximately 0402 Central Daylight Time (CDT) on April 28, 2023 and at approximately 1611 and 2143 CDT on May 4, 2023, momentary losses of 'Y80 Division 2 Uninterruptible 120VAC Class 1E Distribution Panel', which provides power to Division 2 Primary Containment Isolation logic, resulted in a partial Primary Containment Group 2 Isolation (gas systems), initiation of the Standby Gas Treatment system, and the shift of Control Room ventilation to the high radiation mode. The momentary losses of 'Y80' were due to an intermittent, age-related degradation issue with the 'Uninterruptible Power Supply Y81, Division 2 120VAC Class 1E Inverter', which resulted in a temporary loss of output plus a lack of static switch transfer from the inverter supply to the alternate source as designed.
"The actuations were not initiated in response to actual plant conditions, these were not intentional manual initiations, and there were no parameters satisfying the requirements for initiation. Therefore, these events have been determined to be invalid actuations that were attributed to the same cause.
"All systems responded as designed to the actuation signal. Operations reset the partial Primary Containment Group 2 Isolation signal, shutdown the Standby Gas Treatment system, and restored Control Room ventilation per the procedure. There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
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Robinson - Hartsville SC
Report Date 06/22/2023 13:50:00
Event Date 06/22/2023 10:35:00
EN Revision Imported Date: 6/27/2023
EN Revision Text: AUTOMATIC REACTOR TRIP OCCURRED DURING PROTECTION SYSTEM TESTING
The following information was provided by the licensee via email:
"At 1035, on June 22, 2023, with Unit 2 in Mode 1 at 100% power, the reactor automatically tripped due to `A' train reactor trip breaker and `B' train reactor trip bypass breaker opening during testing. The trip was not complex, with all systems responding normally post-trip. MST-021 (Reactor Protection Logic Train `B' At Power) testing was in progress at the time of trip.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"As a result of the reactor trip, emergency feedwater actuated; therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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Honeywell International, Inc. - Metropolis IL
Report Date 06/22/2023 14:01:00
Event Date 06/21/2023 15:30:00
FUEL FACILITY - SAFETY EQUIPMENT FAILED TO FUNCTION
The following information was provided by the licensee via email:
"On the first floor of the Feed Materials Building at approximately 1530 CDT on 06/21/2023 while performing cylinder filling operations, a visual indicator of material was identified and operators initiated mitigating actions in accordance with site operating procedures. It was determined that a remotely operated valve closing mechanism at the number 4 fill spot failed to close a UF6 cylinder valve. The cylinder valve was then closed manually by operations personnel. Based on preliminary observations, the licensee does not believe that regulatory limits were exceeded."
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SC Dept of Health & Env Control - Columbia SC
Report Date 06/22/2023 16:36:00
Event Date 06/22/2023 16:40:00
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by the South Carolina Department of Health and Environmental Control [the Department] via email:
"The South Carolina Department of Health and Environmental Control was notified via telephone at 1515 EDT on 06/22/23, that during the commissioning of a new device [at their Gaston S.C. facility] the strip source of the fixed gauging device was stuck between the source housing and dip-tube. The licensee is reporting that the fixed gauge is a Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device, housing a Cs-137 Berthold Technologies USA, LLC., sealed source Model BT-MPLM. The licensee is reporting that no immediate health and safety concerns have been identified. The licensee is reporting that a consultant has been contacted to perform the repair. A department inspector will be dispatched to the facility to conduct an on-site investigation. This event is still under investigation by the Department."
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Perry - Perry OH
Report Date 06/23/2023 17:04:00
Event Date 06/23/2023 15:21:00
OFFSITE NOTIFICATION - ENVIRONMENTAL
The following information was provided by the licensee via email:
"At 1521 EDT on 6/23/2023, Perry Nuclear Power Plant reported elevated levels of tritium in the underdrain system to the State of Ohio as a non-voluntary reporting of tritium. An investigation is currently ongoing to identify the cause of the elevated tritium levels. The tritium levels did not exceed any NRC regulations or reporting criteria. Tritium has not been detected in any other locations and is not expected to impact groundwater or exceed any limits in the Off Site Dose Calculation Manual (ODCM).
"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The following agencies were notified by licensee: Lake County Emergency Management Agency (EMA) Ashtabula County EMA Geauga County Department of Emergency Services Ohio EMA Radiological Branch
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WA Office of Radiation Protection - Bellingham WA
Report Date 06/23/2023 19:53:00
Event Date 06/22/2023 14:19:00
AGREEMENT STATE REPORT - SOURCE RECOVERY MALFUNCTION
The following is a summary of the information provided by the Washington State Office of Radiation Protection via email:
On 6/22/23 at 1419 PDT, the licensee identified that a 56.4 Ci Ir-192 radiography source could not be retracted into the exposure device (QSA Model 880D) due to a crank malfunction. The radiographer immediately contacted the Radiation Safety Officer who provided source recovery/retrieval actions along with crank mechanism fixes. The radiographer secured the source in the exposure device at 1422 PDT. The problem with the retrieval was identified as a loose securing nut that caused the crank to spin freely and the drive cable to come out of the crank conduit.
During the incident, the radiographer's survey meter read 20 mr/hr at the crank location. A radiographer assistant expanded the boundaries and ensured the general public was not affected. The radiographer's total direct dosimeter reading after 6 normal radiography exposures and the source recovery actions were complete was 3 mRem. The incident took place at a temporary job site in Anacortes, WA. There were no overexposures or spread of contamination.
WA Incident Number: WA-23-010
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Sequoyah - Soddy-Daisy TN
Report Date 06/27/2023 11:52:00
Event Date 06/27/2023 8:31:00
EN Revision Imported Date: 6/29/2023
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"At 0831 [EDT] on June 27, 2023, Sequoyah Nuclear Plant reported an oil discharge into the plant intake located on the Tennessee River to the [Department of Transportation] National Response Center (report number 1371356). The source of oil was from a broken hydraulic hose from equipment in use on the intake. This oil spill is minor and did not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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Watts Bar - Spring City TN
Report Date 06/27/2023 19:04:00
Event Date 06/27/2023 16:26:00
EN Revision Imported Date: 6/29/2023
EN Revision Text: AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 1626 EDT, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The [reactor] trip was not complex with all systems responding normally post-trip.
"Operations responded and stabilized the plant. Decay heat is being removed using the auxiliary feedwater and steam dump systems. Unit 1 is not affected.
"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"All control rods are fully inserted. The cause of the turbine trip is being investigated."
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Texas A&M University (TAMN) - College Station TX
Report Date 06/29/2023 10:20:00
Event Date 06/28/2023 13:15:00
TECHNICAL SPECIFICATIONS DEVIATION - DEGRADED FUEL PIN
The following information was provided by the Texas A&M University (TAMN) via phone and email:
"At approximately 1315 CDT on Wednesday, June 28, 2023, during routine fuel inspections required under Technical Specification (TS) 4.1.5 ['Reactor Fuel Elements'], a fuel pin (serial number 11394) did not pass the test criteria. The pin was bloated enough to not fit in the bend test rig. 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, TAMN notified the NRC Headquarters Operations Officer within one working day.
"Visual inspection of the pin did not indicate any obvious degradation that would be exceptional for a pin with sixteen years of burnup history, other than a slight bloat in the middle of the pin.
"There have been no indications of cladding failure on routine primary coolant analyses.
"As required by TS 4.1.5.2, TAMN is initiating an inspection of the entire core fuel inventory once TAMN finishes the regularly scheduled fuel inspections for the year. TAMN informed the NRC Project Manager."
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Grand Gulf - Port Gibson MS
Report Date 06/29/2023 15:41:00
Event Date 06/29/2023 8:07:00
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via email:
"A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
"The NRC Resident Inspector has been notified."
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