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Licensee Name

Site Name - City Name State Cd

Report Date Notification Dt Notification Time

Event Date Event Dt Event Time

Event Text

--------------------

Detroit Edison Co.

Fermi - Newport MI

Report Date 06/13/2023 6:02:00

Event Date 06/12/2023 23:33:00

EN Revision Imported Date: 8/4/2023

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."

* * RETRACTION AT 1540 EDT ON 8/8/2023 FROM WHITNEY HEMINGWAY TO BILL GOTT * * *

"The purpose of this notification is to retract a previous event notification (EN) 56570 reported on June 13, 2023, at 0602 EDT.

"The cause of the fan trip was a failed vibration switch. At 0429 EDT on June 14, 2023, the vibration switch was replaced, the MDCT fan "D" was tested satisfactory for operability, and the UHS, emergency diesel generator 13/14, and MDCT were declared operable.

"Following the initial EN, further analysis of the condition was performed utilizing a previously performed gothic analysis model (to perform HPCI room heat-up calculations) which bounded this condition. Based on the initial conditions at the time of the indication loss, specifically HPCI room and suppression pool temperature, it was determined that the resulting worst case post-accident room temperature was sufficiently low enough to provide margin to HPCI operability without the room cooler in service for the required mission time.

"No other concerns were noted during the event. HPCI remained operable and there was no loss of safety function. The fan trip did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).

"Therefore, the NRC non-emergency 10CFR50.72(b)(3)(v)(D) report was not required and the NRC report 56570 can be retracted, and no licensee event report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Nguyen)

--------------------

New Indy Containerboard

SC Dept of Health & Env Control - Catawba SC

Report Date 07/21/2023 11:38:00

Event Date 07/20/2023 15:07:00

EN Revision Imported Date: 8/24/2023

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE HANDLE The following information was provided by the South Carolina Department of Health and Environment (the Department) via email: "On July 20, 2023, at 1507 EDT, the Department was notified by the licensee that while performing semi-annual shutter checks the licensee discovered that the handle on a Berthold LB7440D had broken off which prevented the shutter from being locked. The licensee cordoned off the area and was able to rotate the shutter to the closed and shielded position. The gauge is a Berthold Model LB7440D s/n FT314 and contains a 30 mCi Cesium-137 source. On July 21, 2023, BRH [Bureau of Radiological Health] on-call duty officer met licensee's RSO at 0800, to perform a visual inspection and radiation survey of the gauge. The highest radiation measured was 0.2 mR/hr. The licensee has contacted a licensed vendor to schedule the repair of the handle. "

* * UPDATE FROM ANDREW ROXBURGH TO DONALD NORWOOD AT 1132 EDT ON 8/23/2023 * * *

The following information was provided by the Department via email:

On July 28, 2023, the licensed vendor was on site to repair the damaged shutter handle. The handle and shutter were replaced, and the gauge was placed back into service. This incident is considered closed.

Notified R1DO (Gray) and NMSS Events Notification email group.

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Cardinal Health Nuclear Pharmacy

OR Dept of Health Rad Protection - Portland OR

Report Date 07/24/2023 0:28:00

Event Date 07/24/2023 18:45:00

EN Revision Imported Date: 8/24/2023

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL (LOST THEN FOUND) OF RADIOACTIVE MATERIAL

The following is a synopsis of information received from Oregon Health Authority, Radiation Protection Services (RPS):

At 1845 PDT this evening a caller contacted the Oregon Emergency Response System (OERS) to report a yellow package with a radioactive placard that was found in a parking lot at their location.

RPS followed up on the OERS report (Incident Number: 2023-1825) and it appears that an employee from Weston Solutions, an EPA contractor, discovered a box with a Yellow II DOT label in the middle of a parking lot outside of their warehouse in Portland. The box appeared structurally sound and intact.

The caller had a survey meter on-site (a Ludlum 2241 with pancake probe) and measured approximately 11,000 cpm at 1 inch away from the package. The employee called 911 and the police notified the National Response Center and sent officers to respond.

The police inspected the package and discovered it belonged to Cardinal Health. Cardinal Health Nuclear Pharmacy, a licensee, shares a parking lot and occupies an adjacent warehouse to Weston Solutions. The police then hand-carried the box to the Cardinal Health building. A representative from Cardinal Health (police verified credentials) accepted the package and took it inside their facility.

RPS called Cardinal Health Nuclear Pharmacy Services and spoke with the on-call pharmacist / RSO of the facility. At the time of the call she was on-site at the pharmacy to investigate the situation after being contacted by the employee that accepted the package from the police.

The pharmacist / RSO explained that she had immediately leak tested the package and the readings were typical. The box was labeled as containing I-131. There was no sign of a breach or disturbance to the package. The package was then transported to a locked storage vestibule and the pharmacist / RSO then notified the courier of the misplaced material.

The courier used to transport the radionuclides to the nuclear pharmacy was PNW Trade Winds. RPS called and spoke with the lead courier to gather more information about the circumstances that could have led to losing the package.

The lead courier had spoken with the driver involved and their best guess is that while the driver was segregating packages for the different delivery locations at his vehicle, he must have dropped a box and it landed underneath the vehicle. All the material that was supposed to arrive at Cardinal Health was accounted for, so the driver was not aware of the missing package. The driver most likely would not have realized it was lost until performing a physical inventory at a subsequent location.

As far as timing, the lead courier explained that the driver had left Cardinal Health at approximately 1800 PDT and the package was discovered by Weston Solutions at 1820 PDT. When talking with the Weston Solutions employee, he had mentioned that they were in the parking lot area at 1745 PDT and did not see the package at that time, confirming the timeline. Therefore the material was in the parking lot for only about 20 minutes before it was discovered.

RPS Incident Number: 23-0035

* * UPDATE FROM TOM PFAHLER TO DONALD NORWOOD AT1334 EDT ON 8/23/2023 * * *

The following information was received from RPS via email:

"This letter [from Cardinal Health to RPS] serves as the written report concerning an incident involving the loss of radioactive material as it relates to Oregon radioactive materials license ORE-90509, pursuant to OAR 333-102-0350(3)(b).

"On July 23, 2023 at 1845 PDT, a caller contacted the state emergency response system to report a package was discovered in their parking lot with a radioactive material label in Portland, OR. The package was labeled Cardinal Health. Cardinal Health's Portland nuclear pharmacy (ORE-90509) shares a parking lot with the location that reported the package. The police delivered the package to Cardinal Health, where it was then secured by a Cardinal Health employee. The package was inspected and wipe tested by the site radiation safety officer, with no contamination, damage, or breach found.

"The package contained 1 mCi worth of I-131 capsules that had been packaged for delivery to a separate Cardinal Health location in Seattle, WA. The package was transferred to PNW Trade Winds, a contract courier, upon receipt at the airport for transportation to Cardinal Health's Seattle location. PNW Trade Winds reported that the package was likely dropped when segregating packages for different delivery locations. The driver reportedly left the licensee at approximately 6:00 pm, the package was discovered at 1820 PDT. With this timeline the package was left unattended for approximately 20 minutes before it was discovered.

"In response to this event Cardinal Health has inquired with PNW Trade Winds to review the corrective actions taken on their part. PNW Trade Winds reported that the driver has reviewed their triple check policy and has been placed on three months' probation. During the first month of their probation they are required to call their manager at each stop to review the delivery and verify the remaining packages in the vehicle."

Notified R4DO (Dixon) and the NMSS Events Notification and ILTAB email groups.

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Canyon Fuel Company LLC-Sufco Mine

Utah Division of Radiation Control - Salina UT

Report Date 07/25/2023 11:04:00

Event Date 07/16/2023 9:00:00

AGREEMENT STATE REPORT - DAMAGED ASH/MOISTURE GAUGE

The following information was provided by the Utah Division of Radiation Control (the Division) via email:

"There was a partial roof collapse in a coal mine, resulting in a damaged, beyond repair AshScan coal analyzer. The Division was notified of the incident by voicemail the afternoon of July 24, 2023 (State of Utah Holiday). The Division contacted the licensee's radiation safety officer (RSO) at 0630 [MDT] on July 25, 2023 after listening to the voicemail.

"Received from the licensee (by the Division):

"The device referenced was an AshScan serial number AS16-157, utilizing 300 mCi of Am241 and 5 mCi of Cs137. The roof fall occurred on the morning of July 16, 2023. After notification of the incident, the licensee began the process of developing a plan and getting an approval from the Mine Safety Health Administration (MSHA) to begin the work of removing rubble and uncovering the belt and device. The approval allowed the licensee to work their way through approximately 150 feet of rubble, removing rubble and bolting the roof every 5 to 6 feet according to the roof control plan. The area was pre-shifted twice a day with the pre-shifter using a radiation detector to ensure that there was no errant radiation.

"The RSO was notified on July 19, 2023, that the device was visible but not yet accessible due to the roof not being bolted. That morning, the licensee had a brow collapse in the same area, effectively setting them back to where they started. The process of mucking and bolting the brow took priority until the morning of July 24, 2023 when they were able to safely access the gauge. Once they were able to access the gauge and assess its condition, the licensee determined that the gauge was not repairable and would need to be decommissioned. The licensee moved the gauge with a scoop into Crosscut 38 which is about 100 feet away from the original position of the gauge. It was filled with rock on one end. The licensee taped off the other end and placed radiation warning signs to keep personnel from entering the area. The licensee is arranging for a technician to come and decommission the device and will then forward the appropriate paperwork once that work is completed.

"The Division will investigate this matter and update the record upon completion of the investigation."

Utah Event Report Number: UT23-0006

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Christiana Care Health System

Christiana Care Health System - Newark DE

Report Date 07/25/2023 16:23:00

Event Date 07/24/2023 11:00:00

EN Revision Imported Date: 8/10/2023

EN Revision Text: MEDICAL EVENT - DOSE TO UNINTENDED ORGAN

The following is a summary of information provided by the licensee via telephone:

A patient was prescribed Y-90 microsphere implants to the liver. The procedure occurred on 4/20/23 with no abnormal outcomes reported. The patient returned to the hospital on 7/24/23 reporting stomach pain which was diagnosed as an ulcer. A biopsy of the ulcer revealed microspheres. Due to the tissue damage, it was assessed that the dose to the stomach lining exceeded 50 Rem. This event is being reported per 10 CFR 35.3045(a)(3).

* * * RETRACTION ON 8/9/23 AT 1405 EDT FROM CHRISTIANA CARE HEALTH SYSTEM TO KAREN COTTON * * * The following information was provided by the licensee via telephone: The Radiation Safety Officer called the NRC Headquarters Center at 1405 EDT to retract Event 56638. NRC and Christiana, the licensee, assessed the event, and determined that it was due to shunting, and thus did not meet the criteria of a medical event.

Notified R1DO (Dimitriadis) and NMSS Events Notification (email)

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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Sisters of Charity Hospital

New York State Dept. of Health - Buffalo NY

Report Date 07/25/2023 16:23:00

Event Date 07/03/2023 0:00:00

AGREEMENT STATE REPORT - LOST SEED

The following information was provided by the New York Department of Health via email:

"A patient at Sisters of Charity Hospital in Buffalo, RAM license 2911, was implanted with a Best Medical International model 2301, serial no. 56305C, I-125 localization seed (108.76 microcurie) on 6/23/23 for a surgical removal scheduled on 6/26/23. The seed was in the breast specimen when it arrived in pathology on 6/26/23 (Activity was 105.08 microcurie) and was supposedly removed, bagged, and stored in the proper storage area. Personnel from nuclear medicine retrieved the seeds from the pathology storage unit on 7/3/23 and filled out the log sheet and the chain of custody paperwork. While bringing the seeds to the nuclear medicine decay closet, a nuclear medical technician (NMT) noticed that one of the bags with seeds in it (they retrieved 4 seeds that day from pathology) had a seed that seemed thicker than the others. Upon further investigation, it was noted that there was a clip and not an I-125 seed in the one bag. NMT staff Immediately went and monitored all areas in pathology (floor, work areas, sharp containers, garbage of the remaining specimen and the patient slides). No activity was noted. Staff contacted the boiler house, and no radioactive waste has been discovered leaving the premises. The licensee believes that the seed possibly went down the drain in the pathology lab. As a precaution, the licensee plans to set up a dedicated area to survey the biohazard bag with the seed in it and the sink drain will be covered during dissection. This seed is considered lost with no reasonable probability of recapture."

New York State Event Report Number: NY-23-06

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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Tesla

New York State Dept. of Health - Buffalo NY

Report Date 07/25/2023 16:40:00

Event Date 07/12/2023 0:00:00

AGREEMENT STATE REPORT - MISSING STATIC ELIMINATOR

The following information was provided by the New York Department of Health via email:

"Tesla reported that one of their Polonium-210 static eliminators is missing. The device is a NRD model P-2021-Z705, s/n A2ME848. The device was shipped to Tesla on 2/23/21. The device has been through more than six half-lives so the activity at this point should be below 0.1 millicurie."

New York State Event Report Number: NY-23-07

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

Geotech Environmental Equimnt, Inc.

Colorado Dept of Health - Denver CO

Report Date 07/26/2023 18:22:00

Event Date 07/19/2023 0:00:00

AGREEMENT STATE REPORT - LOST GAUGE

The following information was provided by the Colorado Department of Health (the Department) via email:

"On July 19, 2023, Geotech Environmental Equipment, Inc. informed the Department that they rented a generally licensed Viken PB200i XRF device (SN: 1015) containing a 5 millicurie, cobalt-57 sealed source to Hi-Tech Environmental located in Brooklyn, New York on July 7, 2021. Geotech Environmental Equipment, Inc. stated that as of October 25, 2022, Hi-Tech Environmental stopped replying to emails, stopped paying their rental balance, and was not providing information for returning the device. Geotech Environmental Equipment also stated that as of June 26, 2023, they made the decision to report the XRF device as a transferred device on their 2023 general radioactive material license registration inventory.

"Based on the description of the event, the device was not transferred and as of July 19, 2023 the Department has determined that Geotech Environmental Equipment, Inc. lost the generally licensed Viken PB200i XRF device (SN: 1015)."

Colorado Event Report ID Number: CO230022

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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City Of Great Falls

City Of Great Falls - Great Falls MT

Report Date 07/31/2023 12:01:00

Event Date 07/31/2023 7:30:00

TROXLER MOISTURE DENSITY GAUGE INADVERTENTLY BUMPED BY TRUCK

The following summary information was provided by the licensee via telephone:

On 7/31/2023 at about 0730 MDT, employees of the City of Great Falls were standardizing a Troxler moisture density gauge (contained 9 millicuries of cesium-137 and 44 millicuries of americium-241) with the gauge on an asphalt lot and the source in its cage; as per standard practice. A loader truck inadvertently hit the gauge but was halted before it ran over the gauge. Some plastic on the gauge was damaged. The licensee halted operations and restricted access. Subsequently, radiation levels of 0.294 millirem per hour at 1 foot and 0.004 millirem per hour at 4 feet were measured, which were essentially background levels. No overexposure or other personnel injury were reported.

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American Centrifuge Operating, LLC

American Centrifuge Plant - Piketon OH

Report Date 08/01/2023 10:50:00

Event Date 08/01/2023 9:06:00

PREPLANNED OUTAGE OF A REQUIRED SAFETY MONITORING SYSTEM

The following information was provided by the licensee via email:

"The American Centrifuge Plant (ACP) criticality accident and alarm system (CAAS) is designed to detect a nuclear criticality accident and provide audible and visual alarms that alert personnel to evacuate the immediate area, as required by 10 CFR 70.24, criticality accident requirements.

"The CAAS will be temporarily disabled (declared inoperable in accordance with approved plant procedures) to perform periodic CAAS testing activities. The planned CAAS outage is expected to last for approximately 48 hours, commencing at approximately 0800 EDT, on Wednesday, August 2, 2023. The planned maintenance activities will affect the CAAS in X-3001 North.

"Essential personnel will be present inside the controlled access area during the maintenance activities. Compensatory measures will be implemented in accordance with section 5.4.4 of the license application for the ACP. These measures include the following: evacuation of non-essential personnel from the area of concern and the immediate evacuation zone (IEZ) before removing CAAS equipment from service; limiting access into the area; restricting fissile material movement; and the use of personal alarming dosimeters for personnel that must access the area during the CAAS outage. These measures will be implemented until CAAS coverage is verified to be operational, and the CAAS is declared operable in accordance with approved plant procedures.

"American Centrifuge Operating, LLC will notify the NRC when CAAS coverage is returned to normal operation.

"The licensee has notified the NRC Project Manager."

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Southern Nuclear Operating Company

Vogtle 3/4 - Waynesboro GA

Report Date 08/01/2023 11:48:00

Event Date 07/31/2023 15:06:00

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

"At 1506 EDT on July 31, 2023, it was determined that a contractor supervisor failed a test specified by the fitness for duty testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."

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Georgia-Pacific Toledo LLC

OR Dept of Health Rad Protection - Toledo OR

Report Date 08/01/2023 14:30:00

Event Date 08/01/2023 8:30:00

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK SHUT

The following is a summary of the information provided by the Oregon Health Authority via email:

At 0830 PDT on August 1, 2023, during the 6-month shutter check and 3-year wipe test on the number 1 digestor level source, the licensee discovered a corroded shear pin that allowed the lever to detach from the source, leaving the source in the closed position. The current state of the source was verified closed with a survey meter. The licensee repaired the sheer pin and tested the mechanism. The source was working correctly and returned to service by 0922 PDT.

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Detroit Edison Co.

Fermi - Newport MI

Report Date 08/01/2023 15:53:00

Event Date 08/01/2023 9:55:00

ACTIVE SEISMIC MONITORING SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"On 08/01/2023 at 0955 EDT, the Fermi 2 active seismic monitoring system provided indication of a potential seismic activity event. Plant abnormal procedures were entered, and compensatory measure were met and remain in place. Neither the [United States Geological Survey] (USGS) nor the next closest nuclear power plant could confirm or validate the readings obtained at Fermi. The seismic monitoring system was declared nonfunctional to validate the calibration of the system. Femi 2 has two active seismic monitors: one on the reactor pressure vessel pedestal and one in the high-pressure core injection (HPCI) room. Only the HPCI room accelerometer was declared inoperable. The HPCI accelerometer is the sole 'trigger' for the seismic recording system, which outputs peak accelerations experienced during a seismic event. This is used in assessment of the magnitude of an earthquake for EAL HU 2.1.

"The loss of the active seismic monitoring system is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).

"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.

"The NRC Resident Inspector has been notified."

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Elkhart Clinic

Elkhart Clinic - Elkhart IN

Report Date 08/02/2023 14:14:00

Event Date 08/02/2023 14:00:00

RADIOACTIVE SOURCE LOST IN TRANSIT

The following information was received from Elkhart Clinic via telephone:

A 300 micro-curie germanium-68 (Ge-68) phantom source was sent from Elkhart Clinic of Elkhart, Indiana, in Siemens Medical Solutions in Knoxville, Tennessee, via [common carrier] on November 22, 2022. The radioactive source never arrived at its destination and was subsequently declared lost by [common carrier]. Ge-68 is used as a quality control source for positron emission tomography (PET) studies.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Constellation Nuclear

Nine Mile Point - Syracuse NY

Report Date 08/03/2023 16:58:00

Event Date 08/03/2023 10:03:00

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

A licensed employee 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 Senior Resident Inspector was notified.

--------------------

Paragon Energy Solutions -

Report Date 08/03/2023 17:05:00

Event Date 08/03/2023 0:00:00

EN Revision Imported Date: 8/28/2023

EN Revision Text: INITIAL PART 21 REPORT - DEFECT WITH EATON/CUTLER HAMMER SIZE 4 AND 5 FREEDOM SERIES CONTACTORS

The following information was provided by Paragon Energy Solutions, LLC via email:

"Pursuant to 10 CFR 21.21(d)(3)(i), Paragon Energy Solutions, LLC is providing this initial notification of a potential defect with Eaton/Cutler Hammer size 4 and 5 freedom series contactors that have been modified to include either a special coil and/or to improve the securing of shading coils. These contactors may have been supplied integral to a motor control center (MCC) cubicle or as spare parts. This condition, if left uncorrected, could potentially cause a substantial safety hazard.

"Paragon completed an initial evaluation of a failure of a size 4 freedom series contactor (PN: NLI-CN15NN3A-T16-MOD-M) supplied to Perry Nuclear Power Plant. The reported failure occurred 26 days following installation into its associated MCC Cubicle. Perry identified the screws holding the contact bar to the push bars had fallen out and were laying in the bottom of the molded base. This allowed the movable contact bar to sit on the stationary contacts and significantly degrade due to arcing and then fail in the energized position. This condition could prevent the contactor from performing its safety function to either energize or de-energize the attached load.

"The loose hardware is most likely a workmanship error since the contactor must be disassembled to complete the special coil and RTV modifications to the shading coils. In the fully re-assembled condition, inspection of this hardware for tightness is not possible."

Affected plants: North Anna, Turkey Point, Harris, and Perry.

* * UPDATE ON 08/25/23 AT 1448 EDT FROM RICHARD KNOTT TO ERNEST WEST * * *

Paragon Energy Solutions submitted their final report in accordance with 10 CFR 21.21(d)(4).

Paragon reported completion of corrective actions including revising the test inspection procedure to ensure hardware tightness during contactor reassembly, identifying all projects containing the affected contactors and verifying appropriate inspections have been completed, restricted use of test inspection procedures issued prior to 8/2/2023 until a formal review is completed, and issued a technical bulletin (TB-Starter-2023-01 Rev 0) for use by affected clients.

Paragon recommends affected licensees perform the steps contained in Technical Bulletin TB-Starter-2023-01 Rev 0 to verify this condition is not present as part of their next routine maintenance outage associated with the affected in use equipment, and at the earliest opportunity for stock spares.

Affected plants: North Anna, Turkey Point, Harris, and Perry.

Notified R2DO ( Miller), R3DO (Skokowski), and Part 21/50.55 Group via email.

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BP Products North America, Inc.

WA Office of Radiation Protection - Blaine WA

Report Date 08/03/2023 19:19:00

Event Date 07/06/2023 0:00:00

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER STUCK IN THE ON POSITION

The following information was provided by the Washington State Office of Radiation Protection via email:

"During the semi-annual routine shutter tests on a fixed gauge, the gauge was found to be stuck in the 'ON' position. This malfunction did not pose any additional risk to personnel in the 'ON' position; it only inhibited the ability to lock the gauge in the 'OFF' position for maintenance. The gauge manufacturer was contacted, and a service engineer was able to move the source tube assembly to the 'OFF' position by applying lubricant to the handle rod and gently twisting and pulling on it. This event appears to have occurred due to a lack of lubricant on the handle rod, or from the dust conditions that the gauge is located in, resulting in the source tube assembly becoming stuck inside the source housing. Going forward, a few drops of lubricant will be added during the semi-annual shutter checks to prevent the source tube assembly from becoming stuck again."

There were no personnel overexposures due to this event.

Device/Source Details: VEGA Americas, Inc., model number: HLG-2, serial number: 13570676, containing a 2 Ci (original activity) Cs-137 source.

Reference Document Number: WA-23-013.

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B. Hillebrandt Soils Testing, Inc.

California Radiation Control Prgm - Alamo CA

Report Date 08/03/2023 20:09:00

Event Date 08/01/2023 0:00:00

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received by the California Department of Public Health , Radiation Health Branch (RHB) via email:

"On 08/01/23, a portable moisture density gauge containing radioactive materials (Humboldt Model 5001C082, Serial number HIS 1767, containing 10 mCi Cs-137 and 40 mCi Am-241/Be) was run over by a piece of heavy equipment, on a construction site. The licensee cordoned off the area where the gauge was damaged and contacted Pacific Nuclear Technology (PNT) for assistance. The top shell of the gauge was crushed and found in several pieces, the source rod was bent, and there was no damage to the area where the Cs-137 source was contained. PNT was able to place the rod containing Cs-137 into its original shielding position. The Am-241/Be source was found undamaged in its original position attached to the base. PNT had surveyed the area using a Ludlum model 3, 44-9 detector, and no radiation levels above background were detected. The gauge was placed in the undamaged transit case (transportation index measured 0.2 mR/hr) and transported to the PNT facility where the gauge was leak tested. The leak test performed on the damaged gauge did not indicate any contamination. Currently, the gauge is in storage awaiting approval for disposal.

"RHB will be following up on this investigation."

California incident number: 080123

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Grandont Golf Corporation

Colorado Dept of Health - La Veta CO

Report Date 08/04/2023 14:07:00

Event Date 07/10/2023 0:00:00

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

The licensee reported three lost exit signs, each containing 9.21 Ci of tritium.

Colorado Event Report ID Number: CO230025

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Nylon Corporation of America

NH Dept of Health & Human Services - Manchester NH

Report Date 08/04/2023 14:32:00

Event Date 08/02/2023 0:00:00

AGREEMENT STATE - REMOTE SHUTTER INDICATION FAILURE

The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:

"On August 2, 2023, Nylon Corporation of America (NYCOA) reported that a specifically-licensed fixed level gauge (Berthold, Serial No. 175-02-07) installed on the `Capro Recovery Unit' apparently failed a semi-annual detector test. The detector provides a remote indication of tank level and shutter position. In the absence of remote indication, shutter position can be noted visually. The gauge shutter is manually operated and performs as designed. Additional testing performed on August 3, 2023, verified the detector failure. NYCOA formally reported their findings to the NHRHS via email on August 3, 2023 at 1316 [EDT].

"The fixed gauge (Berthold Model LB-300L) houses a 32.9 MBq (0.89 mCi) Co-60 source assayed on January 1, 2006. The current activity is calculated as 3.3 MBq (0.088 mCi). The gauge is affixed to a tank that is suspended about 9 feet above the process room floor. The location cannot be accessed without a ladder. The surrounding area contains process piping and is not normally occupied.

"On August 4, 2023, at 0930, NHRHS inspectors arrived to perform a reactive inspection. As found, the level gauge shutter was closed and appropriately locked-out/tagged-out of service. The highest measured exposure rate was 0.327 mR/hour in contact with the gauge housing (shutter closed). At head height, below the gauge, the exposure rate was 0.010 mR/hr, which approximates normal background. A Ludlum 9DP ion chamber was utilized for these measurements.

"There is no indication of personnel overexposure.

"NYCOA stated that the Capro Recovery Unit has been offline for about five years and there are no near-term plans to bring it back online. NYCOA will investigate removal and disposal of the level gauge rather than repair the detector."

NMED Report Number: NH-23-0001

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Florida Power And Light

Turkey Point - Miami FL

Report Date 08/04/2023 15:30:00

Event Date 08/04/2023 13:20:00

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 1320 [EDT] on 08/04/2023, with the Unit 3 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering level in the 3C steam generator. The trip was uncomplicated with all systems responding normally post-trip.

"Decay heat is being removed via the auxiliary feed water system and the atmospheric steam dumps.

"Unit 4 is not affected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A). 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 cause of lowering level in the 3C steam generator was unknown at the time of the notification and will be investigated by the licensee.

--------------------

Anbessaw Consulting, Inc.

California Radiation Control Prgm - Pomona CA

Report Date 08/04/2023 19:17:00

Event Date 08/04/2023 6:00:00

AGREEMENT STATE - STOLEN MOISTURE-DENSITY GAUGE

The following information was provided by the California Department of Public Health via email:

"On August 4, 2023, the Radiation Safety Officer for Anbessaw Consulting, Inc. contacted Los Angeles County Radiation Management to report a stolen moisture density gauge. After receiving the report, the information was forwarded to the California Department of Public Health. The gauge was a CPN International model MC-3, Serial Number M320500859 [10 mCi Cs-137 (nominal), 50 mCi Am-241:Be (nominal)].

"The gauge was stolen from a 20 foot [long] Container Express (CONEX) box stored at a fenced in and secured construction site with security guards. The gauge was placed in storage around 1700 [PDT] on August 3, 2023, and discovered to be missing around 0600-0615 on August 4, 2023. The lock on the CONEX box had been cut and the transport case containing the gauge was removed from the CONEX box. No other items were stolen from the CONEX box. The transport box was secured with a lock, and a lock was placed on the trigger of the gauge.

"After a search of the area near the CONEX box was conducted without finding the gauge, the Los Angeles Police Department was contacted, and a burglary report was filed. After the report was filed, a further search of the construction site and the area surrounding the site was made without finding the gauge or its transport case. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Tennessee Valley Authority

Watts Bar - Spring City TN

Report Date 08/04/2023 20:51:00

Event Date 08/04/2023 17:46:00

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via phone and email:

"At 1746 EDT on 08/04/2023, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to number 2 steam generator low low level. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by 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 number 2 steam generator low low level is being investigated."

--------------------

University of Pennsylvania

PA Bureau of Radiation Protection - Philadephia PA

Report Date 08/05/2023 11:07:00

Event Date 08/05/2023 11:07:00

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the PA Bureau of Radiation Protection (the Department) via email:

"On August 4, 2023, the licensee, University of Pennsylvania, informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. The event is reportable per 10 CFR 35.3045(a)(1).

"On August 3, 2023, it was determined that 71.0 percent of the prescribed dose to the target tissue was delivered for the above treatment. The only information relayed to the Department so far was that there were no spills or leaks in the system. The DEP [Department of Environmental Protection] is currently in contact with the licensee and will update this event as soon as more information is provided.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

Event Report ID No: PA230021

* * UPDATE ON 08/07/2023 AT 1207 EDT FROM JOHN CHIPPO TO ERNEST WEST * * *

"An administration of Y-90 TheraSpheres occurred with no apparent difficulties. No leaks or spills were identified, as corroborated by post administration monitoring which identified no contamination. However, when the waste was measured it was determined that less than 80 percent (72.6 percent) of the prescribed activity was administered. It is estimated that 21.18 mCi of the 29.18 mCi prescribed dose was administered. The patient and prescribing physician have been informed. No adverse effects to the patient are present nor are any anticipated."

Notified R1DO (Dimitriadis) and NMSS (Email).

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.

--------------------

Southwest Medical Imaging, LLC

Arizona Dept of Health Services - Scottsdale AZ

Report Date 08/06/2023 18:38:00

Event Date 08/04/2023 0:00:00

AGREEMENT STATE REPORT - FOUND MEDICAL SEED

The following information was provided by the Arizona Department of Health Services (The Department) via email:

"The Department was notified by the licensee that on 8/4/2023, a person walked into their facility to report a box with a radioactive material label was sitting on top of a trash can outside of their facility with their name on it. The licensee determined that the box contained (1) Isoaid I-125 seed (0.150 mCi) that had been picked up by [Common Carrier] the day before (8/3) at 4:09pm. The licensee inspected the package and determined that the package was still sealed and intact. The Department has requested additional information and continues to investigate the event."

Arizona Event No.: 23-014

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Helmut, LLC

Helmut, LLC - Alexandria SD

Report Date 08/07/2023 15:13:00

Event Date 11/01/2022 0:00:00

NON-AGREEMENT STATE REPORT - LOST SOURCE

The following is a synopsis of information was provided by Helmuth, LLC via phone call:

During a relocation of Helmuth to a new facility in November 2022, the static removing air nozzle was mistakenly disposed of in the municipal trash. The mistake was not noticed until a new unit was delivered to the new location.

Manufacturer: AMSTAT Industries Model : P-2021-8101 Serial Number: A2MR173

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Activity of the nozzle is 10 mCi ( 370 MBq) of Po-210.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Defense Health Agency

Defense Health Agency - Biloxi MS

Report Date 08/07/2023 17:50:00

Event Date 08/07/2023 9:00:00

NON-AGREEMENT STATE REPORT - EXTERNALLY CONTAMINATED PACKAGE

The following information was provided by the Defense Health Agency via email:

The licensee made a 10 CFR 20.1906 report of receipt of a shipment of Tc-99m with external contamination present on the "high-tech solution bag." The licensee reported this event due to contamination levels potentially exceeding regulatory limits prior to receipt during transit.

At approximately 0900 (CDT) IonSouth delivered a package to the licensee's facility at Keesler Air Force Base Medical Center's hotlab. The licensee identified that the bag had external contamination present. The licensee performed 300 square centimeter wipes at approximately 1130 (CDT) resulting in 50544 disintegrations per minute (dpm) inside the package and 5920 dpm outside the package. The Radiation Safety Officer (RSO) projected that the contamination level outside the bag was 7917.5 dpm at time of delivery. The package was placed in a plastic bag and secured for decay.

The licensee notified IonSouth to inform them of the contaminated package. The RSO is awaiting additional information from the vendor.

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Henry Ford Health

Henry Ford Health - Detroit MI

Report Date 08/08/2023 15:44:00

Event Date 08/08/2023 0:00:00

MEDICAL EVENT - UNDERDOSE

The following is a summary of information provided by the licensee via telephone:

During post procedure processing of a Y-90 treatment to a liver, it was realized that only 78.5 percent (0.77 Giga-Becquerel) of the prescribed dose (0.99 Giga-Becquerel), was delivered to the target organ. The remainder of the dose was still in the delivery vial. All of the administered dose was delivered to the target organ. The prescribing physician has been informed. A written report will be forwarded when complete.

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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Entergy Nuclear

FitzPatrick - Lycoming NY

Report Date 08/08/2023 17:03:00

Event Date 08/08/2023 0:00:00

FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

"A licensed (non-active) individual failed to comply with fitness for duty testing policies. The individual's unescorted access was terminated."

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BRASKEM AMERICA INC

Texas Dept of State Health Services - Freeport TX

Report Date 08/08/2023 19:04:00

Event Date 08/08/2023 0:00:00

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On August 8, 2023, the Agency was notified by the licensee's service provider that the shutter on a Vega America SH-F2 nuclear gauge would not close. Open is the normal position for the gauge. The gauge contains a sixty millicurie (original activity) Cs-137 source. The source is mounted in an elevated location that prevents exposures to any personnel. The service provider stated the licensee had just completed maintenance in the vessel where the gauge was mounted and was opening the shutter when they began to feel resistance to movement. The licensee continued to open the shutter and as they reached the open position the screws holding the operating arm in place broke. The operating arm no longer operates the shutter. The licensee will contact a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 10044

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Aurora Health Care Central, Inc

Wisconsin Radiation Protection - Sheboygan WI

Report Date 08/09/2023 11:38:00

Event Date 07/13/2023 0:00:00

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Wisconsin Department of Health Services (the Department) via email:

"On August 9, 2023, the Department was notified by the licensee of a yttrium-90 (Y-90) TheraSphere medical event that had occurred on July 13, 2023. The licensee's radiation safety officer performed a records review on August 2, 2023, and identified a written directive indicating a potential underdose to the patient. After confirming that the documentation was correct on August 8, 2023, the licensee determined that a reportable event had occurred.

"The prescribed activity to the patient was 1.07 GBq. The licensee initially calculated a delivered activity of .86 GBq based on pre- and post-administration surveys. The radiation safety officer was not able to replicate this calculation and determined that the delivered activity was approximately .781 GBq. This is a delivered activity of 72.99 percent. Utilizing the TheraSphere worksheet, the licensee calculated that the patient received 73.4 percent of the prescribed dose.

"The licensee will be notifying the patient. There is no anticipated harm to the patient, or exposure to any additional individuals."

Event Report ID No.: WI230006

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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Louisiana Energy Services, Llc

Louisiana Energy Services - Eunice NM

Report Date 08/09/2023 16:26:00

Event Date 08/08/2023 14:22:00

UNANALYZED CONDITION

The following information was provided by the licensee via mail:

"It was determined that the Urenco United States of America (UUSA) safety analysis did not analyze for stacked, criticality safe (CSA) containers when not in an engineered storage array. This potentially results in an inadequate analysis.

"Urenco USA stores CSA containers in isolation on the floor and spaces them 60 centimeters apart, prior to performing IROFS [Items Relied on For Safety] 58a mass determination and placing a container in an array. However, an analysis has not determined whether dropping a container, or stacking a container, onto another container stored in this way, could result in exceeding the Code of Federal Regulations Title 10 Part 70.61 requirements. Currently, there are no containers stacked in this way.

"Urenco USA has stopped all work regarding moving the containers in areas affected by accident sequence DS1-9. The plant is in a safe and stable condition."

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Mayo Clinic

Florida Bureau of Radiation Control - Jacksonville FL

Report Date 08/09/2023 16:32:00

Event Date 08/09/2023 0:00:00

AGREEMENT STATE REPORT - LOST SHIPMENT

The following information was provided by the Florida Bureau of Radiation Control via email:

"The Texas DSHS [Department of State Health Services], called to report a lost shipment of Y-90, with a final delivery of Mayo Clinic, Jacksonville. The original supplier was Boston Scientific (Storage) [the Y-90 was, however, ordered by Boston Scientific and shipped from a Texas location] . The product was shipped by MNX Global Logistics Grp, Texas License #07144-000. The location of the product is unknown at this time.

"An investigation is in progress."

FL Incident Number FL23-124

This event was also reported by Texas under EN 56672.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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MNX Global Logistics Corp.

Texas Dept of State Health Services - Grapevine TX

Report Date 08/09/2023 17:42:00

Event Date 07/28/2023 0:00:00

AGREEMENT STATE REPORT - LOST SHIPMENT

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On August 9, 2023, the Department was notified by a licensee of radioactive material lost in shipment. The material was 1.82 GBq (49 mCi) of Y-90 Theraspheres which is greater than 1000 times the Appendix C value for Y-90 (10 microcuries). The owner of the material is the manufacturer of the microspheres. The manufacturer ships the material to the Texas licensee who is located near a major airline hub. The Texas licensee then stores the material until the owner sends an order for rapid shipping to a medical facility. At which point, the Texas licensee ships the material via a common carrier to the address on the order. The manufacturer is responsible for confirming the facility receiving the package has a radioactive material license.

"On July 27, 2023 the Texas licensee received an order from the manufacturer to ship four sets of Theraspheres to a licensee in Florida. The four sets were each in separate type A packages. The Texas licensee has closed circuit television of the common carrier picking up the four packages which were sent 'Priority Overnight'. On July 28, 2023, three of the packages arrived at the Florida licensee. The Texas licensee contacted the common carrier asking about the fourth package which has a tracking number of [deleted]. After some investigation, the common carrier reported that the package had not left their Irving, TX facility near the Dallas Fort Worth airport. Three of the packages had scans leaving that facility but not the fourth and missing package. A transit facility in Greensboro, NC reported that they did not have the package. They reported scanning three packages on the way to the Florida licensee.

"On August 3, 2023, the common carrier advised the Texas licensee that they had closed the lost claim and were no longer looking for the package.

"The Department has asked the Texas licensee to contact the dangerous goods section of the common carrier and request their assistance. This Department has also notified the Florida Radiation Control program of the incident. This Department is waiting for contact information for the radiation safety officer of the manufacturer and owner of the material. Once obtained the Department will notify the appropriate state agency. Further information will be provided per SA-300."

Texas Incident number: 10045 Texas NMED number TX230037

This event was also reported by the State of Florida under EN 56671.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Firstenergy Nuclear Operating Company

Perry - Perry OH

Report Date 08/10/2023 4:03:00

Event Date 08/10/2023 0:39:00

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0039 [EDT] on 8/10/23, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped during a reactor protection system (RPS) bus shift. All systems responding normally post-trip. There was no equipment inoperable at the time of the trip. Operations responded and stabilized the plant. Reactor water level being maintained via feedwater. Decay heat is being removed by cycling safety relief valves.

"An actuation of high-pressure core spray, division 3 diesel generator, and reactor core isolation cooling occurred during the scram and main steam line isolation closure. The reason for the auto-start was reaching Level 2 (130 inches in the reactor pressure vessel) during the transient. The systems automatically started as designed and injected to the reactor vessel when the Level 2 signal was received.

"The RPS actuation is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The emergency core cooling system (ECCS) injection is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). The ECCS actuation is being reported as a eight-hour, non-emergency notification per 10 CFR 50.72(b)(2)(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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Tesla

California Radiation Control Prgm - San Rafael CA

Report Date 08/10/2023 15:31:00

Event Date 07/12/2023 0:00:00

AGREEMENT STATE REPORT - LOST RADIOACTIVE SOURCE

The following information was provided by the California Radiation Control Program (RHB) via email:

"On 7/12/23, Tesla, San Rafael facility contacted RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, Model P-2021-Z705, serial number A2LZ130 (air-gun), originally shipped to the facility by NRD, LLC on 5/8/2020, (based on this information, current activity is approximately 26 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. Facility will be transitioning to an anti-static tool that does not utilize a radioactive source."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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PFNW Waste Processing

WA Office of Radiation Protection - Richland WA

Report Date 08/10/2023 22:17:00

Event Date 08/04/2023 0:00:00

AGREEMENT STATE - SHIPPING INCIDENT

The following information was provided by the Washington State Department of Health via email:

"A low specific activity (LSA)-2 excepted package arrived at [the licensee's] facility with a wet corner and a minor liquid drip. The package contained resin for Cr-51 with total activity of between 5 to 7 mCi of U-233, U-234, and U-236 isotopes. No contamination [was detected].

"The incident is currently being investigated. The shipper was suspended. The shipper will be required to submit a root cause analysis and corrective actions."

Washington incident number: WMS-DOT-23-05

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Exelon Nuclear Co.

Quad Cities - Cordova IL

Report Date 08/11/2023 8:03:00

Event Date 08/11/2023 3:29:00

AUTOMATIC REACTOR SCRAM

The following information was provided by the licensee via phone and email:

"At 0329 [CDT] on August 11, 2023, with Unit 2 in Mode 1 at 90 percent power, the reactor automatically tripped due to a turbine trip. The trip was uncomplicated with all systems responding normally post-trip. The cause and details of the event are under investigation. Containment isolation valves actuated closed in multiple systems on a valid Group II signal.

"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), and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group II isolation.

"Operations responded using the emergency operating procedure and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected.

"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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Defense Health Agency

Defense Health Agency - San Antonio TX

Report Date 08/11/2023 20:33:00

Event Date 08/10/2023 14:28:00

NON-AGREEMENT STATE REPORT - LOSS OF RADIOACTIVE SEEDS The following information was provided by the Defense Health Agency via email:

"The discovery of the loss of 10 radioactive (0.300 mCi each, I-125; total of 3 mCi) seeds used for localization of non-palpable breast lesions occurred on August 10, 2023, when mammography reported a Pyxis inventory discrepancy to health physics (HP). The seeds were likely lost between August 3, 2023, and August 10, 2023.

"The Brooke Army Medical Center (BAMC) breast imaging (mammography) section is missing 10 radioactive seeds from the mammography Pyxis. The loss of 10 radioactive (0.300 mCi each, I-125; total of 3 mCi) seeds used for localization of non-palpable breast lesions occurred on August 10, 2023 (batch number 56406). This batch of 10 seeds was received from the nuclear medicine pharmacist and logged into the BAMC health physics radiological science lab (RSL) seed tracking log on May 11, 2023. A second batch of 10 seeds (batch number 56668) was retrieved by mammography personnel from nuclear medicine and logged in to the BAMC health physics RSL seed tracking log on June 15, 2023. As of June 15, 2023, the mammography Pyxis had 20 radioactive seeds present.

"The first procedure, using radioactive seeds from either batch, was August 3, 2023. When the mammography nurse went to log the seed used on August 3, 2023, into the tracking log (seed number 56668-1), she noticed that no seeds from the number 56406 batch had been used. This is atypical because they are always used in sequential order. At this time, she also noticed that the number 56406 batch (received on May 11, 2023) was physically placed behind the number 56668 batch (received June 15, 2023) in the designated Pyxis bin. This is also atypical, as seeds are used in sequential order from oldest batch to newest batch.

"Following the August 3, 2023, procedure, the seed count, post procedure, was 19 radioactive seeds (9 in batch number 56668 and 10 in batch number 56406). The next radioactive seed was placed on August 10, 2023 (seed number 56668-2) giving a radioactive seed count of 8 in batch number 56668. At this time, it was discovered that the entire batch of number 56406, seeds 1-10, was missing from the Pyxis. Health physics confirmed today, August 11, 2023, that missing batch number 56406, seeds 1-10, is not currently expired, and should not have been removed from the Pyxis.

"The current seed receipt and exchange process is once the seeds are received in mammography from nuclear medicine they are placed in the Pyxis. A note is left in the Pyxis for the logistics technician to only update the count in the Pyxis. The established procedure is that the logistics personnel are not to remove any seeds from the Pyxis whether they are expired or not, and to only to update the count. When seeds expire, they are retrieved by health physics after notification by mammography staff.

"The process for removing expired seeds in the Pyxis is to bundle them and label them as expired. Health physics is contacted for pick up. Seed packaging information is copied and signed by health physics. Health Physics takes a copy, and a copy of the transfer is retained by mammography team. BAMC has transitioned 90 percent of radioactive seed utilization to magseeds.

"On Friday morning, August 11, 2023, HP met with logistics and mammography personnel. The seeds were searched for by multiple representatives from HP, mammography and logistics personnel. The Pyxis system in mammography was thoroughly searched along with logistics areas that expired products are routed through to include sharps containers and mammography work areas. Due to the seeds being shielded, the RAM waste alarm log was not reviewed. If logistics accidentally removed the seeds from the Pyxis for disposal, the seeds would show up on a transfer receipt before being packaged for waste disposal to the landfill. At 1500 on August 11, 2023, BAMC HP declared the seeds lost. HP requested that all Pyxis systems on the 1st floor be searched for the seeds in case they were inadvertently placed there during inventories.

"There was no mission impact to healthcare. This is an NRC reportable event.

"The corrective actions taken were to immediately remove the remaining 8 seeds from the Pyxis and currently store them in the radioactive material (RAM) waste shed until one is required for a procedure. Mammography was informed of the new procedure in which they will contact HP the day before a scheduled procedure to coordinate the delivery of a seed from HP. This action ensures that only HP has possession of seeds until one is needed.

"All RSL seeds will be in possession of HP and locked in the storage shed until mammography needs one for a procedure. The chain of custody starts and ends with HP, thus preventing logistics from mistakenly removing them from the Pyxis system."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Nine Dragons Paper

Maine Radiation Control Program - Rumford ME

Report Date 08/15/2023 11:35:00

Event Date 08/14/2023 11:35:00

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following is a synopsis of information received from Maine Radiation Control Program via telephone:

The licensee was in the process of shutting down the plant when it was discovered that 4 level gauges on one tank have stuck open shutters. The model and activity are not available at this time. Due to the location of the gauges, no exposures were recorded nor are any expected. This investigation for the stuck open shutters is on going.

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Cooper Nuclear Power Plant

Cooper Nuclear Power Plant - Brownville NE

Report Date 08/15/2023 13:20:00

Event Date 07/05/2023 0:00:00

PART 21 REPORT - RELAY MECHANICAL PROBLEM

The following information is a synopsis provided by the licensee via facsimile:

Cooper Nuclear Station completed an internal Part 21 evaluation concerning a batch of relays procured under the same purchase order from General Electric Hitachi. Following the failure of a relay, an independent laboratory identified a mechanical problem with the hinged armature, resulting in the relay potentially failing to return to its de-energized state. The relays are not currently installed in a safety related application. The NRC Resident has been notified. A written notification will be provided within 30 days.

Affected known plants include only Cooper at the time of the notification.

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Hartford Hospital

Hartford Hospital - Hartford CT

Report Date 08/15/2023 15:00:00

Event Date 08/14/2023 17:00:00

MEDICAL EVENT - PATIENT UNDERDOSE

The following is a summary of information provided by the licensee via phone:

A patient underwent an eye plaque procedure where they were to receive 85 Gy of Iodine-125 over a seven day period. The patient received an estimated dose of 57 Gy. The total dose delivered differs from the prescribed dose by greater than 20 percent. The licensee believed the seed could have shifted during the 7 days. A written report will be forwarded when complete.

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.

--------------------

Non-licensee

NJ Rad Prot And Rel Prevention Pgm - Hillsborough NJ

Report Date 08/16/2023 15:16:00

Event Date 08/15/2023 0:00:00

AGREEMENT STATE REPORT - CONTAMINATION EVENT

The following information was received via email from the New Jersey Department (NJDEP) Bureau of Environmental Radiation:

"On 6/28/2023, NJDEP Bureau of Environmental Radiation (BER) was notified by its NRC Regional State Agreements Officer of an allegation made by a concerned citizen regarding a powder being sold by an online marketplace. The company address is in New Jersey. The citizen believed the powder contained Thorium-232 (Th-232). BER subsequently followed up with a site investigation and confirmed that Th-232 was present. The individual on-site stated that the powder had been mixed into paint, which was used to paint the walls in his basement and bathroom. The investigation is ongoing.

"On 7/8/2023, BER staff visited the seller's residence to perform an interview and contamination survey. The survey confirmed the presence of alpha and beta contamination in the residence. A sample of the powder was also collected and sent for gamma spectrometry analysis by a certified laboratory. Results of the analysis were received on 8/14/2023, and indicated concentrations of Th-232 as 14,800 pCi/g. On 8/15/2023, an estimate on the total activity present was made, and it was determined that this was a reportable event."

New Jersey Event Report Number: Not yet assigned

--------------------

G.E. Healthcare DBA

Illinois Emergency Mgmt. Agency - Arlington Heights IL

Report Date 08/17/2023 12:15:00

Event Date 08/12/2023 0:00:00

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

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Curtiss Wright Flow Control Co.

Curtiss Wright Flow Control Co. - Cincinnati OH

Report Date 08/17/2023 13:17:00

Event Date 06/22/2023 0:00:00

PART 21 INTERIM REPORT - FAILURE OF CURTISS WRIGHT SUPPLIED SAFETY RELATED RELAY

The following is a summary of the Part 21 report provided by Curtiss Wright:

On June 20, 2023, Duke Energy sent a letter to Curtiss Wright (CW) to formally notify them that a Tyco (Agastat) relay had failed. Duke Energy had identified certain contacts that were found sticking in the open position.

The relay was returned to CW for evaluation; however, CW could not duplicate the failure. As the relay is questionable for reliable service, CW is having the relay returned to Tyco for their evaluation. Once the evaluation is complete, the current report will be updated. CW anticipates an update to the notification with final results by October 15th.

Affected plant: Catawba

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Ohio State University

Ohio Bureau of Radiation Protection - Columbus OH

Report Date 08/17/2023 15:25:00

Event Date 07/28/2023 0:00:00

AGREEMENT STATE REPORT - TREATMENT TO WRONG SIDE OF ORGAN

The following report was received via email by the Ohio Bureau of Radiation Protection:

"On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive."

Ohio Event Number: OH230009

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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Detroit Edison Co.

Fermi - Newport MI

Report Date 08/20/2023 18:30:00

Event Date 08/20/2023 16:00:00

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

The following information was provided by the licensee via email:

"On 8/20/2023 at 1600 EDT, during plant walkdowns in the drywell while in mode 3 to identify a cause of increasing unidentified leakage rate, reactor coolant system pressure boundary leakage (approximately 2 gpm) was identified on the reactor recirculation sample line between the reactor recirculation sample line inboard isolation valve (B3100F019) and where the sample line taps off the B reactor recirculation jet pump riser. This requires entry into technical specification 3.4.4 condition C, identification of pressure boundary leakage with a required action to be in mode 3 in 12 hours and mode 4 in 36 hours. At 1630 EDT, a technical specification required shutdown to mode 4, cold shutdown, was initiated.

"A press release by DTE is anticipated. This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i), a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(xi), and an eight-hour, non-emergency notification 10 CFR 50.72(b)(3)(ii)(A) for the degraded condition of the pressure boundary.

"Investigation into the cause of the reactor coolant system pressure boundary leakage is still ongoing.

"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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West Virginia University Hospital

West Virginia University Hospital - Morgantown WV

Report Date 08/21/2023 15:16:00

Event Date 08/17/2023 0:00:00

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by West Virginia University Hospital via telephone and email:

"It was determined on 8/21/2023, that during a Y-90 (Yttrium-90) Thera Sphere treatment performed on 8/17/2023, the delivered dose differed from the prescribed dose by more than 20 percent. The prescribed activity was 101.5 mCi and the administered activity was 3.4 mCi.

"At the start of the infusion the authorized user (AU) was unable to deliver the microspheres due to a blood clot in the microcatheter. The AU then decided to abort the infusion and reschedule instead of chancing potential contamination that could occur by changing out the microcatheter.

"The AU had completed the pre-treatment safety checklist with no issues. The AU has made the notification to the referring physician."

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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Blue Marlin Engineering

Florida Bureau of Radiation Control - Orlando FL

Report Date 08/21/2023 18:49:00

Event Date 08/21/2023 17:51:00

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:

"On 8/21/23 at 1751 EDT, BRC received notification from the Blue Marlin Engineering radiation safety officer (RSO) that a Troxler 3430 Gauge (serial number 76 464, Cs-137 77-17679, Am/Be 78-12867) was reported stolen from a work site in Apopka, FL. The RSO does not know when the loss of control occurred. The device was last used at approximately 1100 EDT on 8/21/23 prior to the authorized user (AU) traveling for lunch. Upon returning from lunch, the AU noticed the device was no longer under his control.

"An initial incident report [is planned] to be submitted by the Florida Department of Health on 8/22/23."

* * UPDATE ON 8/22/23 AT 0814 EDT FROM MONROE COOPER TO ADAM KOZIOL * * *

"RSO believes device was likely stolen, but states there is a possibility it has been filled into a ditch on the work site. Orange County Police Report: 23-51399."

Florida Incident Number: FL23-128

Notified: R1DO (Gray), NMSS (email), ILTAB (email)

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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University of Louisville (brdscope)

Kentucky Dept of Radiation Control - Louisville KY

Report Date 08/22/2023 13:00:00

Event Date 10/04/2022 0:00:00

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via email from the Kentucky Department for Public Health:

"Kentucky Radiation Health Branch (KY RHB) was notified on 8/22/2023 by a representative from University of Louisville Hospital, of an I-125 radioactive seed localization that was implanted on 10/4/2022. The patient went to surgery on 10/5/2022 to have the tissue resected and the seed removed. The physician resected the tissue along with removing what he thought was the seed.

"When the patient came back yesterday (8/21/2023), they found that the seed was still there. The physician had removed a clip (a non-radioactive small metallic object that somewhat resembles a seed). The patient will be having the seed removed due to needing other tissue removed at a future date to be determined.

"Based on a dose calculation, the [Radiation Safety Officer] RSO has calculated the radiation dose as 74 cGy (rad) dose to the breast tissue. With the medical event requirements being over 50 rem to an organ or tissue, this makes it a medical event.

"The RSO will write up a report and mail to KY RHB within 15 days."

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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Allegheny Health Network, Pittsburgh, PA

PA Bureau of Radiation Protection - Pittsburgh PA

Report Date 08/22/2023 13:37:00

Event Date 08/21/2023 0:00:00

AGREEMENT STATE REPORT - MEDICAL EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):

"On August 21, 2023 the licensee informed the Department of a medical event where the equipment failed to function as designed. This is reportable under 10 CFR 30.50(b)(2).

"A patient was scheduled for an intravascular brachytherapy (IVBT) patient treatment using a Beta-Cath Strontium 90 device (s/n 91273) and upon source retraction the source failed to return to the transfer device due to a kink in the catheter. An emergency 'bailout' procedure was performed, with the cardiologist removing the delivery catheter and guidewire from the patient. The delivery catheter was left attached to the transfer device and placed it into the temporary plexiglas 'bailout' box. The patient was surveyed to confirm the source had been removed. The 'bailout' box was visually inspected and surveyed to confirm the source was in the catheter in the box. This box was then transferred to the radiation oncology secure storage area. The device will be returned to the manufacturer for inspection. No overexposures were reported.

"The cause of the event is unknown at this time.

"The Department will perform a reactive inspection. More information will be provided as received."

PA Event Report ID Number: PA230022

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD AT 1357 EDT ON 8/23/2023 * * *

The following information was received via email from the Department.

"The event type has been changed from a medical event to a Part 30 equipment event.

"The Department has learned that the authorized user said that treatment was complete and the source did not enter the device within 3 seconds so they started emergency removal of catheter from the patient and placed it in the 'bailout' box; total time from end of treatment to the catheter/device in the emergency box was approximately 10 seconds. The kink in the catheter was noted after it and the source were approximately 15 cm from where it entered the patient thus no overexposure or unintended dose.

"Device make, model, serial number: Best Vascular, Inc, A1000 Series Models, Transfer Device s/n 91273. "Radionuclide: Sr-90; Jacketed Radiation Source Train s/n ZB948 (60 mm source train) (24 sources). "Source strength(s): 3.13 Gbq (84.6 mCi) total; [3.52 mCi/source * 24 sources]; Assay date 12/3/2003; Activity as of August 21, 2023 = 1.92 Gbq (51.9 mCi) total. "Dose patient received:18.4 Gray @ 2 mm; (vessel 3.0 mm). "Dose patient prescribed:18.4 Gray @ 2mm (vessel 3.0 mm)."

Notified R1DO (Gray) and NMSS Events Notification email group.

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Combined Metals of Chicago, LLC

Illinois Emergency Mgmt. Agency - Elgin IL

Report Date 08/22/2023 14:41:00

Event Date 08/22/2023 0:00:00

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received via email from the Illinois Emergency Management Agency (the Agency):

"The Agency was contacted on August 22, 2023, by Combined Metals of Chicago, LLC in Elgin IL to advise of a stuck open shutter on a 100 mCi Sr-90 fixed gauge. The reportable equipment failure was discovered by the maintenance team during the morning hours on August 22, 2023. The Radiation Safety Officer [RSO] was promptly advised and took appropriate steps to ensure adequate control of the gauge and area until the shutter is repaired. 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 combined reactionary/routine inspection next week to review the event and confirm that appropriate corrective actions were taken.

"Details: Radioactive Materials Staff were contacted via email at 0955 EDT on August 22, 2023 by the RSO at Combined Metals of Chicago, LLC (IL-02397-01) regarding a reportable equipment failure. The stuck open shutter on a Radiometrie thickness gauge containing 100 mCi of Sr-90 was identified by the maintenance team during typical operations early this same morning. The RSO confirmed that the gauge will remain in its mounted condition and that a 1 inch Lexon polycarbonate shield/guard (used during typical running operations) was placed on the gauge. Exposure readings reported during a 2019 inspection by the Agency reported a maximum exposure rate of 600 microrem/hr at contact with the gauge (shutter open). Operators/maintenance staff were immediately advised of the inoperable shutter and per the RSO remained at least 6 feet from the gauge during typical operations. Currently no product is running through the affected line. Agency staff will verify reported actions taken by the RSO during a reactionary/routine inspection to be performed next week. The manufacturer was notified and is scheduled to be on site Thursday, August 24, 2023 to repair the shutter. No personnel exposures were reported and actions taken by the RSO appear adequate to ensure the safety of plant personnel pending repair of the shutter."

Illinois Item Number: IL230020

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ECS, Limited

NC Div of Radiation Protection - Dunn NC

Report Date 08/22/2023 16:53:00

Event Date 08/22/2023 0:00:00

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received via email from the North Carolina Radioactive Material Branch:

"The Licensee Authorized User was on a construction site in Dunn performing compaction testing with the referenced nuclear gauge. The area was an open fill section with dump trucks back dumping upon arrival. The contractor requested a test for the current fill layer and the field technician randomly picked a location. There were no dump trucks onsite at the time of the testing. After taking the density test with Gauge 1029, the field technician properly placed the source rod back in the safe position prior to the incident. The technician turned to tell the contractor the test results, then took a few steps (about 12 feet) away from the gauge due to the equipment noise. When he turned around to get the gauge, a dump truck was about twenty feet away heading towards the gauge. The technician immediately started flagging and yelling for the truck to stop due to the proximity of the work area. The driver's attention was in another direction, so he didn't hear or see the field technician's efforts to prevent the accident. The driver ran over the gauge and stopped to see what happened. After a brief conversation, the truck driver left the site. The field technician notified the local Radiation Safety Officer (RSO) and Office Manager of the incident. The RSO instructed the employee to secure the area and to prevent access until he could get there. The local RSO, Office Manager, and Director of Subsidiary Safety responded and arrived at the incident location within 1 hour of the notification. ECS called the North Carolina Emergency Management telephone number and informed them that a nuclear moisture - density gauge had been run over by construction equipment, that the source rod had come out of the gauge but had been placed back into the shielded position.

"Upon arrival, the field technician and grading contractor employees were interviewed by the RSO. The gauge and test location were surveyed using a calibrated survey meter (Model Radalert, Serial No.: 7326, last calibrated March 26, 2023) by the RSO while approaching the gauge to ensure that the source was in the shielded position and that the transport index was within the acceptable range. The source rod was bent about 6 inches up and the guide rod was broken. The source was confirmed to be in the secured safe position and after the survey was placed in the transport case. Due to the bend handle, the case lid would not close fully on the gauge transport case, so it was pulled tightly to within 2 inches of closing and secured with a python cable and locked.

"A nuclear safety stand down occurred with all parties involved in the incident upon securing the gauge. The field technician was immediately reinstructed in proper gauge handling requirements. The licensee also scheduled a formal retraining session for the field technician for the following day.

"All ECS Authorized Users at the licensee's other North Carolina location will receive retraining in gauge security and situational awareness within the next 2 weeks.

"A leak test was performed on gauge 1029 and the test specimen was transported to Instrotek. No leakage was detected.

"Gauge Manufacturer: Instrotek Model Number: 3500 Serial Number: 1029

"Cs-137 Source Manufacturer: Eckert and Ziegler Model Number: Cs-137 Serial Number: cz-2185 Activity: 10 mCi

"Am-241 Source Manufacturer: Eckert and Ziegler Model Number: AmBe-241 Serial Number: 127/09 Activity: 40 mCi"

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Southern Nuclear Operating Company

Vogtle 1/2 - Waynesboro GA

Report Date 08/22/2023 21:05:00

Event Date 08/22/2023 17:24:00

MANUAL REACTOR TRIP AND AUTOMATIC ACTUATION OF AUXILIARY FEEDWATER SYSTEM

The following information was provided by the licensee via email:

"At 1724 EDT, on August 22, 2023, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to a failure of the non-safety heater drain pump 'B' and the failure of the non-safety condensate pump 'A' to automatically or manually start. At 1735 EDT, a fire was identified on heater drain pump 'B' and was extinguished by the onsite fire brigade at 1807 EDT. Operations responded and stabilized the plant. The trip was not complex, with all safety systems responding normally post-trip. Decay heat is being removed by the main steam system to the main condenser using the steam dumps. There was no impact to Units 2, 3, or 4.

"An automatic actuation of the auxiliary feedwater system (AFW) also occurred, as expected, due to lo-lo steam generator levels resulting from the reactor trip. AFW is currently controlling all steam generator levels at their normal levels. 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). Due to the notification of another government agency, the Burke County Fire Department, this event is being reported as a four-hour, non-emergency notification under 10 CFR 50.72(b)(2)(xi). The Burke County Fire Department was not needed to extinguish the fire. This event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the auxiliary feedwater system.

"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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Alliance Healthcare Services

Alliance Healthcare Services - MI

Report Date 08/23/2023 9:30:00

Event Date 08/21/2023 7:00:00

EN Revision Imported Date: 9/6/2023

EN Revision Text: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE

The following is a summary of information provided by the licensee via phone and email:

The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.

* * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *

"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."

Notified R3DO Skokowski, NMSS Events Notification, and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Southern Nuclear Operating Company

Vogtle 1/2 - Waynesboro GA

Report Date 08/24/2023 8:24:00

Event Date 08/23/2023 9:39:00

FITNESS FOR DUTY (FFD) REPORT

The following information was provided by the licensee via email:

A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated.

The NRC Resident Inspectors have been notified

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UPMC Horizon, Greenville, PA

PA Bureau of Radiation Protection - Greenville PA

Report Date 08/24/2023 13:03:00

Event Date 08/23/2023 0:00:00

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):

"On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1).

"On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator.

"Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID No.: PA230023.

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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Entergy Nuclear

Grand Gulf - Port Gibson MS

Report Date 08/24/2023 21:30:00

Event Date 08/23/2023 21:00:00

FITNESS FOR DUTY (FFD) REPORT - NON-LICENSED SUPERVISOR VIOLATED FFD POLICY

The following information was provided by the licensee via email:

"On August 23, 2023 at 2100 CDT, Grand Gulf Nuclear Station was notified that a non-licensed supervisor violated the station's Fitness for Duty policy. The employee's unescorted access at Grand Gulf Nuclear Station has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."

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Exelon Nuclear Co.

Byron - Byron IL

Report Date 08/25/2023 23:39:00

Event Date 08/25/2023 16:00:00

LOSS OF EMERGENCY ASSESSMENT CAPABILITY

The following information was provided by the licensee via email:

"At approximately 1600 CDT on 8/25/2023, a partial loss of the commercial phone communications system occurred that affects the emergency notification system (ENS) and the functionality of an emergency response facility.

"This is an eight-hour, non-emergency notification of a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii).

"Communications via alternate methods were subsequently established. The telecommunications provider has not provided an estimated repair time.

"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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Txu Generation Company Lp

Comanche Peak - Glen Rose TX

Report Date 08/30/2023 14:57:00

Event Date 07/05/2023 1:30:00

NOTICE OF MISSED 24-HOUR NOTIFICATION PER 10 CFR 26.719(b)(1)

The following information was provided by the licensee via email:

"On 07/05/2023, at 0130 hours, a security officer found a 1 ounce bottle of vanilla extract in the protected area. Alcohol was identified as an ingredient on the ingredients label. It was determined the alcohol by volume (ABV) for vanilla extract is 35 percent ABV, above the 0.5 percent ABV considered low alcohol content. Vanilla extract is not listed as a prohibited item within Comanche Peak procedures.

"The initial reporting assessment of not reportable has been questioned during an in-process security access inspection and reassessed as a reportable condition. Emergency Notification System notification should have been made by 0130 CDT on 07/06/2023. This report restores compliance."

The NRC Resident will be notified.

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