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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
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PU Radiological and Environment - West Lafayette IN
Report Date 03/14/2023 14:46:00
Event Date 02/24/2023 0:00:00
EN Revision Imported Date: 10/23/2023
EN Revision Text: LOST SOURCE
The following is a summary of information provided by the licensee via phone:
On February 24, 2023, the Radiation Safety Officer (RSO) noticed a missing source during an annual radioactive material audit. The missing radioactive source is a Nano Tritium sealed source from City Labs (Model: P100a, S/N: 1020140018) containing 94 mCi of H-3. The RSO notified the principle investigator to begin a search for the sealed source, however, the source could not be located. The RSO believes the missing radioactive source may have been confused with an identical non-radioactive battery during previous audits, and the length of time the source has been missing is unknown.
The missing 94 mCi tritium sealed source was located in a test chamber in the lab where it was last suspected to have been used. Lab was not regularly utilized and was being organized as a corrective action from the lost source. No exposure caused by this incident.
Notified R3DO (Orth), NMSS (email), and ILTAB (email)
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Curtiss Wright Flow Control Co. - Cincinnati OH
Report Date 08/17/2023 13:17:00
Event Date 06/22/2023 0:00:00
EN Revision Imported Date: 10/6/2023
EN Revision Text: 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
The following information was provided by Curtiss Wright via email:
"The relay was subsequently returned to TYCO for their evaluation. TYCO tested the relay with and without the LL auxiliary switch option and could not duplicate the failure. In all tested conditions, the relay performed within manufacturer specifications, and with no contact binding.
"As the noted failure could not be reproduced by Curtiss-Wright or TYCO, there is no evidence of part malfunction and thus no further evaluation or notification applies."
Notified RDO2 (Miller) and Part 21/50.55 Reactors
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Paragon Energy Solutions, LLC - York SC
Report Date 09/06/2023 17:50:00
Event Date 09/05/2023 0:00:00
EN Revision Imported Date: 10/6/2023
EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS
The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.
On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.
Point of Contact: Richard Knott Vice President Quality Assurance Paragon Energy Solutions LLC 817-284-0077
Affected plants: Beaver Valley Limerick North Anna Sequoyah Susquehanna
* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *
The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:
Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.
Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.
Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.
To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.
These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.
Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors
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Texas Dept of State Health Services - Freeport TX
Report Date 09/24/2023 19:12:00
Event Date 09/23/2023 0:00:00
AGREEMENT STATE - STUCK SHUTTER
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On September 24, 2023, the Department was notified by the licensee that during a maintenance inspection, the shutter on a Ronan Engineering nuclear gauge failed to close. The gauge contains a 500 millicurie Cs-137 source. Open is the normal operating position for the gauge. The licensee stated that due to the location of the gauge it is not an exposure risk to any individual. The licensee is posting a sign at the access port to the vessel the gauge is attached to stating `NO ENTRY.' Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10054
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Georgia Radioactive Material Pgm - Savannah GA
Report Date 09/25/2023 9:04:00
Event Date 08/16/2023 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the Georgia Radioactive Materials Program via email:
"During a routine shutter check, it was discovered that a shutter was not working on an in service source device. This device is an Ohmart/Vega containing sealed source of 400 mCi cesium-137, serial number 65574, Model SHF2-45 K2 Chip Bin. The radiation safety officer (RSO) reported that the shutter had failed in the open position. The source was then barricaded from the area with appropriate signage. On August 21, 2023, a qualified technician from VEGA visited the site and repaired this shutter. The technician removed the old rotor and installed a new rotor on the source holder."
Georgia incident number: 70
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Stamford Hospital - Stamford CT
Report Date 09/26/2023 15:35:00
Event Date 09/21/2023 0:00:00
MEDICAL EVENT - DOSE TO UNINTENDED PART OF ORGAN
The following information is a summary of the information provided by the licensee via telephone:
On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed.
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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Utah Division of Radiation Control - Spanish Fork UT
Report Date 09/27/2023 18:23:00
Event Date 09/27/2023 14:00:00
AGREEMENT STATE - DAMAGED TROXLER GAUGE
The following information was provided by the Utah Division of Waste Management and Radiation Control via email:
"At approximately 1400 [CDT] on September 27, 2023, a Troxler 3440 portable gauge (serial number 37345) was run over by a water truck. The Troxler 3440 gauge has an 8 mCi Cs-137 source and a 40 mCi [Am-241/Be] source. The Utah radiation safety officer inspected the gauge at the job site and determined that the sources appeared to be undamaged and remained in the shielded position.
"The licensee took the gauge to another Utah licensee, Construction Materials Technologies (doing business as Precision Calibration) [with license number] UT1800143, for evaluation and repair."
Utah Event Report ID: UT23-0008
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Texas Dept of State Health Services - Odessa TX
Report Date 09/27/2023 18:40:00
Event Date 09/26/2023 10:00:00
AGREEMENT STATE - RADIOGRAPHY SOURCE DISCONNECTED
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 [CDT]. The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to [Radiation Emergency Assistance Center/Training Site] (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant.
"An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 [CDT] to discuss a dose estimate as well as get a narrative.
"The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the [NRC] Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300."
Texas Incident Number: I-10055 Texas NMED Number: TX230046
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident.
"It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive.
"The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot.
"Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event.
"Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv).
"This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report."
Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email.
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Utah Division of Radiation Control - Unknown UT
Report Date 09/27/2023 19:33:00
Event Date 05/08/2023 0:00:00
EN Revision Imported Date: 10/5/2023
EN Revision Text: AGREEMENT STATE - DAMAGED GAUGE
The following information was provided by the Utah Division of Waste Management and Radiation Control (the Division) via email:
"During a routine radioactive materials inspection on September 27, 2023, the Division was informed that a gauge was damaged by a piece of equipment which cracked the gauge's casing in May of 2023. The incident was not reported to the Division by the licensee as they believed the event was not reportable. The Division is waiting for additional information pertaining to the incident and will provide an update once the information is received."
Utah Event Report ID number: UT 230007
The following additional information was obtained from the Utah Division of Waste Management and Radiation Control in accordance with Headquarters Operations Officers Report Guidance:
The location is listed as 'Unknown' since the location where the portable gauge was in use when it was damaged is currently unknown but will be provided once that information is received.
The following information is a summary of an email provided by the Utah Division of Waste Management and Radiation Control (the Division):
After review of additional information provided to the Division by the licensee, it was determined that the gauge only received minor damage to the gauge casing. All equipment of the gauge necessary for safety worked as intended. Therefore the event was not reportable and requested by the Division to be withdrawn.
Notified R4DO (Kellar), NMSS Events (email).
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Marathon Pipe Line LLC - Indianapolis IN
Report Date 09/28/2023 13:35:00
Event Date 09/28/2023 0:00:00
NON-AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was provided by the licensee via phone:
On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.
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Kentucky Dept of Radiation Control - Lexington KY
Report Date 09/29/2023 10:55:00
Event Date 09/28/2023 9:30:00
AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION
The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on 9/29/2023, by a representative from the University of Kentucky that two patients were scheduled for treatment with Lu-177, one with commercially available Lu-177 dotatate (Lutathera) and one under a research protocol also using Lu-177 dotatate but distributed under an investigational new drug label. Both vials contained the same drug and differed only in their label for distribution / intended use. The nuclear medicine technologist prepared and administered Lu-177 dotatate from the vial labeled for research to the standard of care patient instead of the correct (commercial) vial. The patient received the correct amount of drug (prescribed activity), the correct chemical form (identical Lu-177 dotatate) by the correct route of administration as intended for their treatment. However, since the drug was dispensed from the vial distributed under the investigational new drug application intended for the research study patient, KY RHB considers this to meet the reporting requirements in Part 35 for a medical event.
"The physician was informed, the patient was informed, and no harm is anticipated as a result of this incident. Additional notifications have also been made as required considering the involvement of investigational drug product and the Institutional Review Board.
"The incident remains under evaluation and investigation for corrective actions."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
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Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 09/29/2023 14:55:00
Event Date 09/28/2023 0:00:00
EN Revision Imported Date: 10/16/2023
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported.
"The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available."
Illinois Item Number: IL230027
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On September 29, 2023, the Agency was contacted by Rush University Medical Center (IL-01766-01) to advise of a Y-90 Therasphere under dose that occurred the day before. The prescribed dose was 200 Gy and the prescribed activity was 45.92 mCi. The administered dose was 153.1 Gy with an administered activity of 35.15 mCi. This is a 23.5 percent deviation (under dose). The administration was determined to be clinically effective with no adverse patient impact reported. The patient and the referring physician were notified within 24 hours.
"Agency inspectors performed a reactionary inspection on October 3, 2023. The infusion of the Y-90 TheraSpheres went as intended with no identifiable irregularities. Post-admin calculations were performed which calculated that the dose delivered was 35.15 mCi. At this time the [accredited medical practitioner] (AMP) determined the dose delivered was 23.5 percent less than the written directive resulting in a potential medical event. The RSO interviewed all staff involved in the procedure and performed PET/CT imaging of the waste container (with dose vial, administration tubing kit, connector, extension tubing, microcatheter, forceps, etc.). This image was processed, and 3D volume renderings were utilized to identify where hot spots were located within the waste materials. Images of the waste container showed the highest activity was located in the dose vial. No additional apparent issues were discovered by the RSO. During an interview with the AMP, they stated that they tilted the dose vial back and forth to 90 degrees and tapped the vial on a hard surface. After the inspectors reviewed the procedures and through further questioning, they realized that the AMP was not tapping the vial sharply enough against a hard surface.
"Agency investigation findings identified the root cause of this event as inadequate agitation of the dose vial. Inspectors determined that the tapping process was not performed firmly enough against a hard surface to release the microspheres from the septum of the dose vial. This likely resulted in an increased number of microspheres remaining on the septum of the dose vial, and not released into the solution for administration to the patient. The RSO stated that they had begun the process of revising the checklist utilized during Y-90 TheraSphere procedures to better describe the dose vial preparation which includes the agitation process.
"Pending no further developments, this matter is considered closed."
Notified R3DO (Orth) and NMSS Events Notification (email).
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Virginia Rad Materials Program - Salem VA
Report Date 09/29/2023 18:43:00
Event Date 09/29/2023 9:30:00
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following report summary was received by email from Virginia Radioactive Materials Program (VRMP):
"On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr.
"According to the RSO, no public exposure occurred. The licensee has fitted a lead pig [lead shielded container] around the source for transport to a licensed nuclear gauge service company."
Virginia Event Report ID Number: VA230002
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Louisiana DEQ - St. Martin LA
Report Date 09/30/2023 15:18:00
Event Date 09/30/2023 0:00:00
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK UNSHIELDED AND RECOVERED
The following was received from the Louisiana Department of Environmental Quality (the Department) via email:
"On September 30, 2023, Acuren Inspection, Inc. notified the Department that an industrial radiography camera failed to retract the source after an exposure. The industrial radiography camera was a Century 330 QSA Cobalt camera. The serial number of the camera is P30078. The radiation source is a Cobalt-60 with an activity strength of 52.2 curie. The source serial number is 59740G. The source was cranked back out the end of the source guide tube with a collimator.
"The facility where this event occurred is in St. Martin, Louisiana. Only the two man radiography crew was present at the site during the event, which occurred between 0300 [CDT] and 0350. A source retrieval was performed, resulting with the source in a shielded condition in the radiography camera. The individual performing the source retrieval received only 1 millirem."
Louisiana Event Report ID No.: LA20230010
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Diablo Canyon - Avila Beach CA
Report Date 10/01/2023 3:02:00
Event Date 09/30/2023 20:14:00
MANUAL REACTOR TRIP
The following information was provided by the licensee via email:
"At 2014 [PDT] on 09/30/2023, with [Diablo Canyon] Unit 1 in Mode 1 at 11 percent reactor power in preparation for a pre-planned manual reactor trip into a scheduled refueling outage, the reactor was manually tripped due to a failed secondary system dump valve. Auxiliary feedwater was manually started in accordance with plant procedures.
"This event is being reported in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).
"There was no plant or public safety impact.
"The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Diablo Canyon Unit 2 was unaffected.
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PA Bureau of Radiation Protection - Pittsburgh PA
Report Date 10/02/2023 10:19:00
Event Date 09/28/2023 0:00:00
AGREEMENT STATE - I-125 SEED INADVERTENTLY TRANSECTED
The following information was provided by the Pennsylvania Bureau of Radiation Protection via email:
"On September 28, 2023, staff from Magee Pathology department called the [University of Pittsburgh] radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for [10 CFR] 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative."
PA event report ID: PA230028
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Louisiana DEQ - St. Gabriel LA
Report Date 10/02/2023 16:43:00
Event Date 10/02/2023 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following report was received from the Louisiana Department of Environmental Quality (the Department) via email:
"On October 2, 2023, Syngenta Crop Protection, LLC notified the Department that a nuclear level gauge shutter was broken. The shutter is stuck open at approximately 40 percent. The gauge manufacturer is Texas Nuclear, Model: 5182, serial number 149. The source is Cs-137 with 50 mCi activity, serial number: J34.
"BBP Sales has been contacted to come out to the facility to perform repairs on the nuclear gauge."
Louisiana Event Report ID No.: LA20230012
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Louisiana DEQ - Taft LA
Report Date 10/02/2023 17:09:00
Event Date 08/30/2023 9:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email:
"On August 30, 2023, at approximately 0900 [CDT], an Ohmart Model SH-F1-0 level/density gauge experienced a shutter malfunction during a routine semiannual shutter test. The gauge was installed on the Reactor 3, West Production vessel within the Poly Process Unit. The gauge possesses a nominal 500 millicurie sealed source of Cs-137. The above gauge was undergoing a routine semiannual shutter test when the malfunction was observed. The gauge sealed source serial number is: 1560CO. The device serial number has not been provided by the licensee. The gauge containing source number 1560CO, is mounted on the Reactor 3, West Production Chamber vessel in the polyethylene unit. On the above date, the Radiation Safety Officer (RSO) for Union Carbide Corporation contacted BBP Sales (BBP), radioactive material license LA-10799-L01. BBP arrived on site on that day to repair the stuck shutter. After several unsuccessful attempts to break the shutter free, the licensee and the BBP service engineer decided the best course of action would be to order a rotor replacement kit and the BBP service engineer should return on site to replace it. BBP is currently awaiting delivery of the new rotor kit.
"On October 2, 2023, at 0824, Union Carbide RSO notified the LDEQ concerning this equipment malfunction. According to RSO, the gauge rotor bracket broke due to corrosion, which prevented the gauge shutter from closing fully. The gauge is under the licensee's control. There were no exposures to members of the public approaching regulatory limits. Currently, the shutter on the gauge remains in the open position as the gauge source is needed to operate process control equipment. The gauge cannot be locked out in its current state. No entry to the vessel will be conducted until the gauge is repaired by BBP. The licensee will continue to monitor the gauge until repaired. The licensee stated they will keep the LDEQ updated on the progress of repairs."
Louisiana Event Report ID No.: LA230011
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New Mexico Rad Control Program - Loving NM
Report Date 10/03/2023 11:01:00
Event Date 10/02/2023 14:30:00
AGREEMENT STATE REPORT - DISCONNECTED RADIOGRAPHY SOURCE
The following information was provided by the New Mexico Radiation Control Bureau via phone:
On October 2, 2023, at 1430 MDT, a radiography camera source became disconnected from its cable while still inside the guide tube during operations at a fabrication facility in Loving, NM. The device was described as a QSA D880 Model A424-9 camera with a 79.7 Ci iridium-192 source, serial number: 76167M. The licensee reconnected the source and secured the source inside the device in the shielded position by 2100 MDT. There were no public or occupational overexposure related to the source being disconnected from its control cable.
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North Anna - Richmond VA
Report Date 10/03/2023 12:55:00
Event Date 10/03/2023 11:54:00
DEGRADED CONDITION The following information was provided by the licensee via email:
"At 1154 EDT on 10/03/23, investigation into a boric acid indication was determined to be through a leak on a weld-o-let upstream of a pressurizer level transmitter isolation valve. Unit 2 is currently in MODE 6 with reactor coolant system (RCS) operational leakage limits not applicable. The leak is not quantifiable as it only consists of a small amount of dry boric acid at the location. The failure constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI.
"Therefore, this is a degraded condition reportable under 10 CFR 50.72(b)(3)(ii)(A). This condition does not affect the health and safety of the public or station employees."
The Resident Inspector was notified.
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OR Dept of Health Rad Protection - Portland OR
Report Date 10/03/2023 16:42:00
Event Date 09/21/2023 10:00:00
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Oregon Department of Health Radiation Protection via email:
"At 1000 PDT on September 21, 2023, during an administration of a split-dose of Y-90 [yttrium] SirSpheres to the liver, the first dose was not completely delivered to the patient. The second dose, same lobe but a different site, was delivered completely. (First prescribed dose: 7.2mCi; First delivered dose: 5.614 mCi)
"The physician does not believe additional treatment will be needed but the case will be discussed by the licensee in a follow-up conference. The senior radiologist believes there was a `clump of spheres' remaining at the hub of the syringe for the first dose, resulting in under-dosing the patient by more than 20 percent.
"Corrective action is still to be determined."
Oregon Event Report Number: 23-0051
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
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Florida Bureau of Radiation Control - Plant City FL
Report Date 10/04/2023 14:37:00
Event Date 10/04/2023 0:00:00
AGREEMENT STATE REPORT - LOSS OF CONTROL
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau."
Florida Incident number - FL23-152
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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Colorado Dept of Health - Aurora CO
Report Date 10/05/2023 10:14:00
Event Date 10/04/2023 0:00:00
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Colorado Department of Public Health and Environment (the Agency) via email:
"On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation."
Event Report ID No.: CO2300034
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
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Texas Dept of State Health Services - Baytown TX
Report Date 10/05/2023 12:53:00
Event Date 09/26/2023 0:00:00
AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On October 5, 2023, Covestro LLC (the licensee) reported to the Agency that on September 26, 2023, during routine 6-month checks, the shutter on one of its VEGA SHLG-1 fixed nuclear gauges, containing 1.5 curies cesium-137, was found stuck in the open position. Open is the normal operating position for this gauge. There were no [personnel] exposures and none are anticipated as the gauge is mounted on the side of a vessel and secured from access. The licensee has contacted the manufacturer and is trying to make arrangements for repair or replacement. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 10056
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Vogtle 3/4 - Waynesboro GA
Report Date 10/05/2023 12:29:00
Event Date 08/07/2023 14:39:00
EN Revision Imported Date: 10/6/2023
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 1439 EDT on August 7, 2023, a spurious level spike on the unit 4 reactor coolant system (RCS) level instrument (4-RCS-LT160A, 'Hot Leg 1 Level') caused actuation of containment isolation, reactor trip, automatic depressurization system (ADS) stage 4, and in containment refueling water storage tank (IRWST) isolation signals. The spurious level changes caused an invalid signal based on the incidental response of the 4-RCS-LT160A instrumentation due to water spray that was being used for reactor vessel cleaning (being performed prior to initial fuel loading). The level fluctuations resulted in engineered safety features actuation signals (containment isolation, ADS stage 4, and IRWST isolation signals) and a reactor trip signal, with the reactor trip signal already present. Three containment isolation valves closed due to the containment isolation signal that was generated. These valves were: 4-CAS-V014, 'instrument air supply containment isolation, air-operated valve,' 4-SFS-V034, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve,' and 4-SFS-V035, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve.' The other automatic containment isolation valves were either already closed at the time of the event or properly removed from service. All affected equipment functioned properly. The other actuation signals that were observed during this event (ADS stage 4, IRWST isolation, and reactor trip) did not result in any equipment changing position or automatically operating (i.e., the actuation signals occurred while the systems were properly removed from service).
"Units 1, 2, and 3 were not affected. This event did not result in any adverse impact to the health and safety of the public."
The NRC Resident Inspector was notified.
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Maine Yankee - Wiscasset ME
Report Date 10/06/2023 13:00:00
Event Date 10/06/2023 10:25:00
OFFSITE NOTIFICATION
The following is a summary of information provided by the licensee via phone and email:
Two trespassers were observed by the central alarm station operator via site security cameras on the southeast end of the Maine Yankee property. Both trespassers observed to be carrying equipment to conduct manual digging for fish bait. Local law enforcement was called and responded to the Maine Yankee site. Law enforcement officers from Wiscasset Police and Lincoln County Sheriffs Department contacted both individuals and advised they had trespassed onto Maine Yankee property. Both trespassers apologized for their actions and were fully compliant with the officers. They were both advised and agreed to remain off Maine Yankee Property in the future. Their conduct was not deemed suspicious.
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Diablo Canyon - Avila Beach CA
Report Date 10/06/2023 18:12:00
Event Date 08/08/2023 11:07:00
60 DAY NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A)."
"On August 8, 2023, at 1107 hours pacific daylight time (PDT) with Unit 1 in Mode 1 at 100 percent power, an invalid actuation occurred when Unit 1 4-kV vital bus 'G' was automatically transferred from auxiliary power to startup power due to an invalid bus under voltage signal, which occurred during planned maintenance activities.
"As a result of the actuation signal, auxiliary salt water and containment fan cooling units transferred automatically and started as designed. Plant systems responded as expected. This event was entered into the Diablo Canyon Power Plant corrective action program for resolution.
"There was no plant or public safety impact.
"The NRC Senior Resident Inspector has been notified."
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NH Dept of Health & Human Services - Lebanon NH
Report Date 10/09/2023 14:32:00
Event Date 10/05/2023 0:00:00
AGREEMENT STATE - GREATER THAN ANTICIPATED DOSE TO NON-TARGET ORGAN
The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:
"Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR).
"During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive.
"The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive.
"The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days.
"Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated."
NMED Report Number: NH-23-0002
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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North Dakota Department of Health - Lakota ND
Report Date 10/09/2023 16:38:00
Event Date 10/09/2023 15:00:00
AGREEMENT STATE REPORT - MISSING SOURCE FOLLOWING VEHICLE ACCIDENT
The following information was provided by the North Dakota Department of Environmental Quality (DEQ), Radiation Control Program via phone and email:
The Radiation Safety Officer (RSO) for DMS Health Technologies Incorporated informed the North Dakota DEQ that a mobile nuclear medicine truck was involved in a vehicle accident around 1400 CDT, one to two miles east of Lakota, ND on Highway 2.
The RSO reported that a 10 mCi Co-57 sheet source was unaccounted for. One red ammo can containing a CS-137 and a Ba-133 source, as well as a 500 nanocurie rod source, were found undamaged at the scene.
North Dakota Highway Patrol is currently on the scene.
NMED Number: ND230002
National Response Center report number: 1381310.
The licensee's RSO contacted North Dakota DEQ to report that the missing Co-57 source had been located at the scene of the vehicle accident.
Notified R4DO (Kellar), NMSS, ILTAB, and CNSC (email).
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Farley - Ashford AL
Report Date 10/09/2023 21:52:00
Event Date 10/09/2023 19:10:00
FITNESS-FOR-DUTY VIOLATION
The following information was provided by the licensee via email:
A non-licensed employee 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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Palo Verde - Wintersburg AZ
Report Date 10/10/2023 0:38:00
Event Date 10/09/2023 15:07:00
REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED
The following information was provided by the licensee via email:
"On October 9, 2023, during the Palo Verde Nuclear Generating Station Unit 1 refueling outage, while performing a small nozzle inspection in support of boric acid walkdowns, boric acid leakage was found on the area of the weld of a pressurizer thermowell. At 1507 MST, non-destructive examination of the weld indicated leakage through the reactor coolant pressure boundary. The exam result constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(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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Cooper - Brownville NE
Report Date 10/10/2023 19:44:00
Event Date 10/10/2023 15:53:00
OFFSITE NOTIFICATION - SPURIOUS ALARM ACTUATION
The following information was provided by the licensee via fax:
"On October 10, 2023, at 1553 CDT, Cooper Nuclear Station (CNS) was notified of a spurious actuation of a single alert notification system siren in Nemaha, Nebraska. The CNS Emergency Alert System (EAS) was not activated. The actuation occurred during siren testing conducted at approximately 1545 CDT. No emergency conditions are present at Cooper Nuclear Station.
"A press release from Nebraska Public Power District is not planned at this time.
"This condition is reportable under 10CFR 50.72(b)(2)(xi) for any event or situation for which a news release is planned or notification to other government agencies has been or will be made which is related to heightened public or government concern.
"The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Offsite notification was to local Nemaha County Emergency Management.
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North Anna - Richmond VA
Report Date 10/11/2023 11:00:00
Event Date 06/18/2023 0:00:00
60 DAY NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation of the North Anna Power Station Unit 1 Emergency Core Cooling System (ECCS).
"On 6/18/2023, a comparator card power supply associated with 1-CH-PC-1121A, charging pressure low-standby pump start signal comparator, failed and caused the `A' and `B' charging pumps to auto-start and the previously running `C' charging pump to trip and lock-out.
"This event is considered an invalid system actuation because the actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. The ECCS pumps functioned as expected in response to the actuation. The `A' Charging pump was shut down in accordance with plant procedures following replacement of the comparator card. There was no impact on the health and safety of the public or plant personnel.
"The reportability requirement was determined beyond the 60-day notification requirement on 9/21/2023. The NRC Resident Inspector has been notified."
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Testing Technologies Inc - Woodbridge VA
Report Date 10/11/2023 16:23:00
Event Date 10/10/2023 10:00:00
NON-AGREEMENT STATE REPORT - DETACHED SOURCE
The following information was provided by the licensee via phone:
On October 10, 2023, at about 1000 EDT in College Park, Maryland, the licensee was performing industrial radiography on pipe welds in a ditch using a QSA Global 880 machine with a 54 curie Ir-192 source. The licensee, Testing Technologies Inc, is headquartered in Virginia but operates in Maryland under an NRC license.
While attempting to retract the source, it became detached from the drive cable. The licensee shielded the area until they eventually retrieved the source to its safe storage position later that afternoon. No exposure to workers or public occurred from this event. The source detachment was reported to the manufacturer and is under investigation.
The following is a synopsis of information provided by the license via email:
The radiography was being performed in a 14 foot deep trench. While conducting an exposure the crank moved only 1/2 turn, the radiographer attempted to retract the source but was unsuccessful. The area was secured, with boundaries at 2 millirem/hr. The Radiation Safety Officer (RSO) was contacted at 0940. He arrived approximately 30 minutes later. After assessing the situation, additional equipment and shielding were brought to the site. Six entries to the restricted area were made by the RSO with a total dose of: whole body =130 millirem, left hand = 205 millirem, right hand = 130 millirem. The RSO is the only individual who entered the area during the retrieval operation. No other employee or member of the public were exposed. The serial number of the unit is: 6011. TTI has also notified the State of VA Dept. of Health, State of Maryland Department of the Environment, QSA Global (the manufacturer), and the University of Maryland RSO.
Notified R1DO (Carfang) and NMSS Events Notification via email.
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DC COOK - Bridgman MI
Report Date 10/12/2023 12:17:00
Event Date 08/11/2023 0:00:00
PART 21 REPORT - EMERGENCY DIESEL GENERATOR DIGITAL REFERENCE UNIT PROBLEM
The following information was provided by the licensee via email:
"Donald C. Cook Nuclear Power Plant completed an internal Part 21 evaluation concerning an issue with an Emergency Diesel Generator (EDG) Digital Reference Unit (DRU) supplied by Engine Systems Incorporated (Appendix B Supplier for Woodward Governors). [On August 8, 2023,] a potential defect was identified [during a surveillance test] concerning a marginal solder joint on the DRU electronic circuit board that can result in a loss of continuity between the termination strip and the electronic board, causing a loss of setpoint output from the DRU to the Electronic Governor, and a subsequent loss of fuel to the EDG and inability to support any load. A formal failure analysis is ongoing at the time of this notification. A written notification will be provided within 30 days.
"Affected known plants include only Donald C. Cook Nuclear Power Plant Units 1 and 2 at the time of notification.
"The NRC Resident has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The EDG DRU was replaced after discovery of the potential defect and the EDG is currently operable.
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Ginna - Ontario NY
Report Date 10/12/2023 23:31:00
Event Date 10/12/2023 21:27:00
MANUAL REACTOR TRIP
The following information was provided by the licensee via email:
"On 10/12/23 at 2127 EDT, with the Unit 1 in Mode 1 at 100% Power, operators identified degrading condenser vacuum and manually tripped the reactor. All control rods inserted as expected. The trip was not complex, and all systems responded normally post-trip. The cause of the degraded condenser vacuum was an unexpected closure of the condenser air ejector regulator. The cause of the air ejector regulator going closed is not fully understood and is being investigated.
"Following the SCRAM, Operators responded and stabilized the plant. Decay heat is being removed by the Main Steam System through the Atmospheric Relief Valves (ARVs) and Auxiliary Feed Water (AFW) systems. Due to the Reactor Protection System (RPS) 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 a valid specified system actuation.
"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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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 10/13/2023 11:48:00
Event Date 10/12/2023 0:00:00
AGREEMENT STATE REPORT - MISSING RADIOPHARMACEUTICAL PACKAGE SHIPMENT
The following was reported by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified October 12, 2023, by GE Healthcare in Arlington Heights, IL to advise that a radiopharmaceutical package was missing [during shipment]. The last known location was a shipping facility in Fort Worth, TX when it was last scanned by shipping personnel on October 10, 2023, at 0035 CDT as 'arrived.' This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 cm cubed package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10 mL shielded vial. The activity of indium-111 was 1.535 mCi at the time of shipment but has since decayed to approximately 0.6 mCi. It was reportedly offered for shipment on October 9, 2023, for delivery to a customer in Carrollton, Texas on October 10, 2023. Upon failure to arrive, the licensee initiated a search, and after a review of online tracking data and conversations with shipping personnel, GE Healthcare logistics were informed that the shipping facility has initiated a search for the package and that it is currently unaccounted for in their system. The shipping facility's tracking system last showed the package as 'arrived' as of 0035 CDT on October 10, 2023."
Illinois Incident Number: Il230029
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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Maryland Dept of the Environment - College Park MD
Report Date 10/13/2023 12:06:00
Event Date 10/11/2023 0:00:00
AGREEMENT STATE REPORT - STUCK SOURCE The following information was provided by the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:
"On October 11, 2023 at 1558 EDT, the Maryland Department of the Environment Radiological Health Program was contacted via phone from the Radiation Safety Officer (RSO) of Testing Technologies, Inc. (TTI), and reported that a source disconnect had occurred on 10/10/2023, at about 1000 EDT while working at College Park, Maryland. TTI has an active authorization and reciprocity recognition to practice industrial radiography in Maryland with US NRC license (number 45-25007-01). TTI has a Virginia (Maryland reciprocity license number 94-031-01) and an NRC license; and they are also authorized to retrieve sources. The radiography device was QSA Global, Sentinel 880, device serial number D6011, which contains 50 Ci of Ir-192.
"The incident occurred when the TTI radiographer was taking images of a pipe in the well and while cranking back at finishing, the source became stuck at about the half-way position. The radiographer was aware that the source disconnection from the tube had happened and the source was lodged in a 14 feet deep hole. The radiographer later retrieved the source. The radiographer reported the incident to the TTI RSO.
"The RSO reported that there was no exposure to the public. A dose of 40 mrem was received by the radiographer.
"MDE/RHP will finalize a reactive investigation."
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Colorado Dept of Health - Parachute CO
Report Date 10/13/2023 16:04:00
Event Date 10/05/2023 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Hays Gulch Plant and several walkdowns of the facility, six exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number: SLX60 (7.5 Ci of H-3 each).
Event Report ID No.: CO230037
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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Colorado Dept of Health - Parachute CO
Report Date 10/13/2023 14:58:00
Event Date 10/05/2023 0:00:00
AGREEMENT STATE REPORT- LOST EXIT SIGN
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Crawford Trail and several walkdowns of the facility, one exit sign was reported as lost. The sign was manufactured by Isolite Corporation, model number 2000 (11.5 Ci of H-3).
Event Report ID No.: CO230036
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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Colorado Dept of Health - Parachute CO
Report Date 10/13/2023 14:53:00
Event Date 10/05/2023 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Parachute Creek Gas Plant and several walkdowns of the facility, eight exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number SLX60 (8.1 Ci of H-3 each).
Event Report ID No.: CO230038
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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Colorado Dept of Health - Carbondale CO
Report Date 10/13/2023 17:21:00
Event Date 09/08/2023 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On September 8, 2023, six exit signs were removed by a construction company and taken to an unknown location. The Carbondale Community School representative reported that they may have been taken to a landfill. The signs were manufactured by Self Powered Lighting, Inc., model number 700 Series (7.1 Ci of H-3 each).
Event Report ID No.: CO230039
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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Brunswick - Southport NC
Report Date 10/15/2023 23:30:00
Event Date 10/15/2023 22:56:00
UNUSUAL EVENT DUE TO FIRE NOT VERIFIED TO BE EXTINGUISHED WITHIN 15 MINUTES
The following information was provided by the licensee:
At 2256 EDT on October 15, 2023, Brunswick declared a Notification of Unusual Event due to a fire not extinguished within 15 minutes. The licensee received fire alarms and indication of a halon discharge in the basement of the emergency diesel generator building. Due to the delay in the entry into the area, the licensee was not able to verify that the fire was out within 15 minutes. Upon entry into the room, the licensee noted an acrid odor near a transformer, but there was not a fire in the room. The fire was declared out at 2310 EDT.
The licensee notified the NRC Resident Inspector.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
* * * UPDATE AT 0047 EDT ON 10/16/2023 FROM JOSEPH STRNAD TO BILL GOTT * * *
The following information was provided by the licensee via email:
"Termination of Unusual Event due to verification of no fire in the basement of the emergency diesel generator building."
The licensee terminated the Unusual Event at 0045 on 10/16/23.
The licensee notified the NRC Resident Inspector.
Notified R2DO (Miller), IR-MOC (Grant), NRR-EO (Felts), DHS-SWO, FEMA Ops Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
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Georgia Radioactive Material Pgm - Atlanta GA
Report Date 10/16/2023 13:14:00
Event Date 09/14/2023 0:00:00
AGREEMENT STATE REPORT - LOST SEED SOURCE
The following is a summary of information provided by the Georgia Radioactive Materials Program via email:
On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023.
Georgia NMED Incident Number: 71
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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Mercy Hospital South - St. Louis MO
Report Date 10/17/2023 15:46:00
Event Date 10/17/2023 11:00:00
SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE
The following is a synopsis of information provided by the licensee via phone and email:
On 10/17/23 around 1100 CDT, the licensee received two packages each containing technetium-99m. Swipe readings on the packages revealed gross counts of 19158 disintegrations per minute (DPM) for the first package and 6874 DPM for the second package. The licensee's radiation safety officer (RSO) and the supplier, Cardinal Health, were notified. The inside of the package was also wipe tested and was not contaminated. The nuclear medicine department was surveyed, including the hot lab and department hallway and no additional contamination was found. The licensee has placed the two cases in short term storage and intends to send them back to Cardinal Health when they are at background. The licensee also called and left a message with NRC Region 3 personnel.
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McGuire - Cornelius NC
Report Date 10/18/2023 15:18:00
Event Date 10/18/2023 11:16:00
AUTOMATIC ACTUATION OF AUXILIARY FEEDWATER SYSTEM
The following information was provided by the licensee via email:
"On October 18, 2023, at 1116 [EDT], with Unit 1 in Mode 5, an automatic actuation of the 1A auxiliary feedwater motor driven pump occurred when an incorrect action resulted in an automatic start signal. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the auxiliary feedwater system.
"Feedwater is not needed for plant conditions, and the 1A auxiliary feedwater pump did not feed the steam generators. 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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Prairie Island - Welch MN
Report Date 10/19/2023 15:15:00
Event Date 10/19/2023 11:10:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"On 10/19/2023, at approximately 1110 [CST], with Unit 1 in mode 1 at 100 percent power, the reactor automatically tripped. All control rods fully inserted into the core following the trip. All safety functions operated as designed. The cause of the trip is being investigated.
"Operations responded and stabilized the plant. Auxiliary feedwater actuated as expected. Decay heat is being removed by the steam generator through the steam generator power operated relief valve. The trip was complex as non-safety related power was lost to both Unit 1 and Unit 2. Unit 1 is currently in mode 3 and on natural recirculation as both reactor coolant pumps are without power. Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was lost for approximately 70 minutes. No impacts to the SFP temperature were observed.
"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 actuation of the auxiliary feedwater system following the reactor trip, this event is being reported as a specified system actuation in accordance with the reporting criteria of 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."
The second paragraph of the original report is amended as follows to correct information regarding the spent fuel pool for Unit 2:
"Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was maintained at all times with one train of SFP cooling. The second train lost power and was restarted approximately 70 minutes [after power was lost]. No impacts to the SFP temperature were observed."
Notified R3DO (Orth) and IR MOC (Crouch) and NRR EO (Felts) via email
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Prairie Island - Welch MN
Report Date 10/19/2023 19:58:00
Event Date 10/19/2023 11:10:00
LOSS OF SEISMIC MONITORING CAPABILITY
The following information was provided by the licensee via phone and email:
"Reporting due to loss of emergency preparedness capabilities. Seismic monitoring capability is non-functional due to loss of power. These monitors do not have a credited compensatory measure.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The NRC Resident Inspector has been notified. The licensee intends to notify state and local officials.
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Florida Bureau of Radiation Control - Orlando FL
Report Date 10/20/2023 12:44:00
Event Date 10/20/2023 0:00:00
AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted."
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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Maryland Dept of the Environment - Clarksburg MD
Report Date 10/20/2023 12:49:00
Event Date 08/31/2023 15:20:00
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the Maryland Department of the Environment (MDE) via email:
"At 1520 EDT on August 31, 2023 a troxler gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241 source was struck by a dump truck at a construction site in Clarksburg, Maryland. The gauge was licensed to, and being operated by, ECS Mid-Atlantic, LLC (MD-21-037-01). The display and source guide handle was damaged but the part of the gauge containing the sources was not. The sources' shielding was not damaged. The source rod was successfully retracted by the Radiation Safety Officer (RSO) and several surveys of the area were performed by the RSO confirming only background radiation levels. At the time, the gauge was returned to the licensee's storage facility and tested for source leakage. MDE was notified and requested that the gauge be tested for leakage and the RSO's dosimetry be read. Leak tests later showed no leakage of radioactive material and the RSO's dosimetry read a minimal dose. At this time, the gauge has been repaired by the manufacturer and returned to service.
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Texas Dept of State Health Services - Houston TX
Report Date 10/20/2023 16:52:00
Event Date 10/20/2023 0:00:00
AGREEMENT STATE REPORT - UNSHIELDED SOURCE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event."
Texas Incident Number: 10060 Texas NMED Number: TX230048
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Mistras Group - Heath OH
Report Date 10/20/2023 18:05:00
Event Date 06/10/2021 0:00:00
EN Revision Imported Date: 11/1/2023
EN Revision Text: PART 21 INTERIM REPORT - DEVIATION IN THE CALIBRATION CERTIFICATES FOR AN ACOUSTIC EMISSION INSTRUMENT
The following is a summary of information provided by the MISTRAS Group via fax:
On June 10, 2021, calibration certificates for an acoustic emission (AE) instrument were found to have been falsified (reference Notice of Violation 99902109/2023-201-02). The AE system was used for testing of lift rigs used for reactor head and internals. A 10 CFR Part 21 evaluation was initiated on June 15, 2021, and is now essentially complete. The final report will be made available by November 1, 2023.
The following reactor plants were affected: DC Cook, Kewaunee, Surry, Millstone, North Anna, Robinson, Oconee, Arkansas Nuclear One, Beaver Valley, Turkey Point, St. Lucie, Seabrook, Shearon Harris, Vogtle, Farley, Sequoyah, Watts Bar, and Prairie Island.
For questions, contact Donald D. Smith, Quality Assurance Director, MISTRAS Group, Inc., (630) 418-7301, donald.d.smith@mistrasgroup.com
Notified R1DO (Bickett), R2DO (Miller), R3DO (Ruiz), R4DO (Roldan-Otero), and via email: Part 21 Reactors.
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Watts Bar - Spring City TN
Report Date 10/21/2023 9:25:00
Event Date 10/21/2023 9:07:00
NOTIFICATION OF UNUSUAL EVENT DECLARED
The following information was provided by the licensee via fax and email:
"Fire potentially degrading the level of safety of the plant."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At 0907 EST, the licensee declared a notification of unusual event, under emergency action level HU.4, due to multiple fire alarms and CO2 discharge in the emergency diesel building. When the plant fire brigade entered the building, there was no indication of fire or damage to any plant equipment. The cause of the multiple alarms is under investigation.
State and local authorities were notified and no offsite assistance was requested. Both units remain at 100 percent power.
The NRC Resident Inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
* * * UPDATE FROM TYSON JONES TO KAREN COTTON AT 1007 EDT ON 10/21/23 * * *
At 1007 EDT, Watts Bar terminated the notification of unusual event. The basis for termination was that no fire or damaged plant equipment was found. The NRC Resident Inspector has been notified.
Notified R2DO (Miller), IR-MOC (Crouch), NRR-EO (Felts), DHS-SWO, FEMA Ops Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
"Watts Bar Nuclear Plant (WBN) is retracting Event Notice 56809, Notice of Unusual Event, based on the following additional information, not available at the time of the initial notification.
"Specifically, in accordance with the emergency preparedness implementing procedures, WBN reported a condition that was determined to meet emergency action level (EAL) HU4, Initiating criteria number 1, receipt of multiple (more than 1) fire alarms or indicators and the fire was within any Table H2 plant area, which includes the diesel generator building. It was further determined that multiple fire detection zones actuated (spurious and invalid) enabling the discharge of installed fire suppression (CO2) into the space. Upon entry by the site fire brigade, it was determined that no smoke or fire existed and reported to the Shift Manager at 0930 EDT. All fire alarms were reset. Troubleshooting activities are in progress to determine the cause. A fire watch has been established and CO2 has been isolated. The required compensatory measures for the affected areas will remain in place until completion of the investigation, and CO2 suppression is restored to functional."
Notified R2DO (Miller), IR-MOC (Crouch), NRR-EO (Felts), DHS-SWO (email), FEMA Ops Center (email), CISA Central (email), FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
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Nine Mile Point - Syracuse NY
Report Date 10/22/2023 1:43:00
Event Date 10/22/2023 20:48:00
AVERAGE POWER RANGE MONITORS DECLARED INOPERABLE
The following information was provided by the licensee via phone and email:
"On October 21, 2023, at 2048 EDT, reactor recirculation pump (RRP) 12 tripped. The cause for the trip is under investigation.
"Following the RRP trip, the average power range monitors (APRMs) flow bias trips were inoperable due to reverse flow through RRP 12. The APRMs were restored to operable on October 21, 2023, at 2058 EDT, when the RRP 12 discharge blocking valve was closed.
"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(v)(A) which states: "Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition."
"The NRC Resident Inspector has been notified."
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Cooper - Brownville NE
Report Date 10/22/2023 16:40:00
Event Date 10/22/2023 11:49:00
SECONDARY CONTAINMENT MOMENTARILY INOPERABLE
The following information was provided by the licensee via fax and phone:
"On October 22, 2023, at 1149 CDT, with the reactor at 100 percent core thermal power and steady state conditions, the Cooper Nuclear Station secondary containment differential pressure exceeded the Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.1.1 limit of -0.25 inches water gauge. The condition existed for approximately 80 seconds until the reactor building ventilation system responded to restore differential pressure to normal. Investigations identified a hinged duct access hatch found open. The hatch was closed and latched, and ventilation system parameters were returned to normal. There were no radiological releases associated with this event.
"Declaring secondary containment inoperable as a result of not meeting TS SR 3.6.4.1.1 is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material and mitigate the consequences of an accident.
"The NRC Senior Resident Inspector has been informed."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At the time the licensee notified the NRC Headquarters Operations Officer, the cause of the hinged access duct being open had not been determined. This event has been added to the licensee's corrective action program.
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California Radiation Control Prgm - San Diego CA
Report Date 10/24/2023 19:58:00
Event Date 10/24/2023 0:00:00
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following was received from the California Department of Public Health (CDPH) via email:
"On October 24, 2023, the Radiation Safety Officer (RSO) of Barnett Quality Control Services, contacted the California Department of Public Health (CDPH) regarding a moisture density gauge that was struck by a front loader at a construction site while the Cs-137 source was in the extended position. The gauge was a Troxler Model 3440, serial number 15052 (8 millicuries (nominal) Cs-137, 40 millicuries (nominal) Am:Be-241). The impact with the gauge resulted in the top section of the index rod breaking off. The source rod and the body of the gauge were intact (including the Am:Be-241 source). The RSO was contacted and responded to the scene of the incident. The RSO was able to place the Cs-137 source in the shielded position, but the section of the index rod that allowed the source rod to be locked in the shielded position was missing. The RSO was instructed by a CDPH inspector to secure the source with duct tape on the source handle and at the bottom opening to prevent the source from shifting from the shielded position. The RSO was also instructed to perform a radiation survey of the area of the incident after moving the gauge to ensure that the radioactive sources were not left behind. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."
There were no reports of contamination or exposure to personnel.
California Incident (5010) Number: 102423
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Turkey Point - Miami FL
Report Date 10/25/2023 1:12:00
Event Date 10/24/2023 21:59:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 2159 on 10/24/2023, with Unit 3 in Mode 1 at 100 percent power, the reactor was automatically tripped due to an actuation signal into the Unit 3 reactor protection system protection rack during maintenance. The trip was uncomplicated with all systems responding normally post trip. Decay heat is being removed via auxiliary feed water system and the steam dump system. Unit 4 is not affected.
"This event is being reported pursuant to 10CFR50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified.
"The cause of the automatic reactor trip will be investigated by the licensee."
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Curtiss Wright Flow Control Co. - Brea CA
Report Date 10/27/2023 20:57:00
Event Date 08/30/2023 0:00:00
EN Revision Imported Date: 10/31/2023
EN Revision Text: PART 21 - INCONSISTENT POTENTIOMETER RESISTANCE VALUES
The following is a synopsis of information that was provided by Curtiss-Wright via fax:
On August 30, 2023, Enertech (a division of Curtiss-Wright) determined a potential defect for potentiometer part number D2060S based on the inspection of a returned items from Korea Hydro and Electro Power in Korea. A number of returned potentiometers exhibited inconsistent resistance values at certain stroke positions. The potentiometers are used in modulating actuators.
A shorter wiper was used in the manufacture of the potentiometers that introduced the possibility of intermittent separation between the wiper (sliding contact) and the coil at certain stroke positions, resulting in momentary signal interruptions.
The evaluation at Enertech is also ongoing regarding the potential effects of wiper separation on the functionality of the modulating actuator and will not be completed within 60 days. The expected date of completion is December 20, 2023.
South Texas Project Electric Generating Station (Operator: STP Nuclear Operating Company) purchased defective modulating actuators on four occasions.
Questions should be directed to Loretta Anaya, Quality Assurance Manager, Enertech, at 714-982-1856.
Known potentially affected plant(s): South Texas Project
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FitzPatrick - Lycoming NY
Report Date 10/30/2023 17:06:00
Event Date 10/30/2023 12:00:00
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via phone call and email:
"A non-licensed supervisory employee had a confirmed positive test during a random fitness-for-duty test. The employee's access to the plant has been terminated."
The NRC Resident Inspector has been notified.
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