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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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West Virginia University Hospital - Morgantown WV
Report Date 08/21/2023 15:16:00
Event Date 08/17/2023 0:00:00
EN Revision Imported Date: 11/8/2023
EN Revision Text: 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.
It was determined that the dose of yttrium-90 Thera Spheres was not delivered according to the written directive due to an emergent patient condition. Therefore, the incident does not qualify as a reportable medical event.
The patient's blood formed a clot within the microcatheter which prevented the passage of Y-90 microspheres. At the onset of administration, the Authorized User (AU) encountered significant resistance in the microcatheter, and they could not flush forward. When troubleshooting the delivery set, the AU visually identified the blood clot within the microcatheter. After several unsuccessful attempts to clear the blood clot, and in consultation with representatives from Boston Scientific, the AU decided to terminate the procedure. On September 1st, the Y-90 prescribed activity, as stated on the written directive, was successfully administered to the patient's hepatic artery. There were no adverse effects to the patient because of the underdose incident. The details of this incident were discussed with NRC inspectors who were on site for a reactive inspection. During those discussions it was concluded that since the patient's blood clotted within the microcatheter, the inability to complete the administration was due to an emergent patient condition.
The blood clot within the microcatheter was confirmed by an analysis of the delivery set performed by Boston Scientific's Product Analysis Team.
Notified: R1DO (Elise), NMSS Events Notification (E-mail)
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Flowserve - Lynchburg VA
Report Date 09/29/2023 8:36:00
Event Date 09/29/2023 0:00:00
EN Revision Imported Date: 11/20/2023
EN Revision Text: PART 21 INTERIM REPORT - DEVIATION ASSOCIATED WITH AN SMB-1 GEARED LIMIT SWITCH ASSEMBLY
The following information was provided by Flowserve via phone and email:
"The purpose of this letter is to provide written notification of an evaluation of a deviation in a basic component in accordance with 10 CFR21.21(a)(2). This interim report pertains to actuator geared limit switch assemblies contained in SMB-1 actuators supplied to Bopp & Reuther Valves for use in safety related applications at Bruce Nuclear Generating Station.
"Flowserve - Limitorque was contacted by Bruce Power who reported a malfunction of an actuator geared limit switch (GLS) assembly which occurred while attempting to set the valve travel position limits prior to placing the actuator into service. Site inspections of the GLS assembly revealed damage to the GLS drive pinion which engages with the actuator drive train. Site photos and dimensional measurements of the drive pinion requested by Flowserve indicate that the GLS was assembled with an incorrect drive pinion resulting in the malfunction. Use of an incorrect subcomponent in the assembly constitutes the deviation to the design being evaluated. The actuator GLS assembly is a safety related component. A malfunction of the GLS in service has the potential to affect the safety function of the actuator.
"The assembly containing the deviation is a 4-train geared limit switch (GLS) assembly part number 10168 supplied in SMB-1 actuators manufactured on Flowserve order 175377.001 Three actuators (serial numbers L1226986, L1226987, & L1226988) were shipped to Bopp & Reuther Valves on 2/4/2020.
"Flowserve's evaluation of this issue is ongoing and will not be completed within 60 days. The evaluation is expected to be completed by 11/17/2023 pending return of the affected components to Flowserve for inspection. Questions concerning this notification can be directed to Chris Shaffer, Quality Manager."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
This issue was identified at a Canadian reactor plant owned by Bruce Power. The Quality Manager at Flowserve is not currently aware of any affected US reactor plants.
Flowserve Quality Assurance Manager submitted the Final Part 21 Report pertaining to a deviation in a basic component in accordance with 10 CFR 21.21(a)(2). The report concluded that the evaluated deviation constitutes a reportable defect affecting three actuators listed in the final report.
Notified R1DO (Defrancisco), R2DO (Miller), R3DO (Feliz-Adorno), R4DO (Vossmar), and Part 21 Reactors (email).
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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: 11/13/2023
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
The following information was provided by the licensee via phone: The final report will be delayed. The final report will be made by November 10, 2023, instead of the original date of November 1, 2023.
Notified R1DO (Bickett), R2DO (Miller), R3DO (Ruiz), R4DO (Roldan-Otero), and via email: Part 21 Reactors.
MISTRAS Group Quality Assurance Director submitted evaluation of nonconformance report.
Notified R1DO (Eve), R2DO (Miller), R3DO (Ruiz), R4DO (Warnick), and Part 21 Reactors (email).
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Illinois Emergency Mgmt. Agency - Woodstock IL
Report Date 10/25/2023 14:52:00
Event Date 09/01/2023 0:00:00
AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE SOURCE
The following was received from the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS)) via email:
"IEMA-OHS was contacted the morning of October 25, 2023, by GE Precision Healthcare (a Wisconsin-licensed service provider) to advise of a Ge-68 source that had been improperly shipped to Illinois. Reportedly, a positron emission tomography-computed tomography (PET/CT) unit, still containing the Ge-68 source, was removed from a medical facility in Washington state and shipped to an unlicensed Illinois facility (MAK Healthcare). The parties involved are seeking the proper removal and return of the source to the Washington licensee. It is our understanding that GE Healthcare intends to send a technician to the Illinois facility on Friday, October 27 to remove or retrieve the sources under reciprocity. Thereafter, the source will be packaged and returned to the licensee in Washington state.
"Illinois staff contacted Washington staff and advised them of the available details. In accordance with SA-300, section 5.6.2, this report is being filed with the Nuclear Regulatory Commission as a 'found source'. The matter may also be reportable under the Illinois equivalent of 10 CFR 20.2203(a)(3)(ii). IEMA-OHS staff will monitor the activities in Illinois to verify source integrity and proper return to appropriately licensed individuals.
"This report will be updated as details become available. At this time, the Ge-68 sealed source is estimated to have a maximum activity of 11 mCi and is either an IPL-model number HEGL-0132 or 0019 or 0020."
Illinois report number: IL230031
See NRC Event Notification number 56818 for a parallel report made by Washington.
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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Pilgrim - Plymouth MA
Report Date 10/25/2023 15:09:00
Event Date 07/06/2022 0:00:00
LOST SEALED SOURCES
The following information was provided by the licensee via phone and email:
"This is a non-emergency 30-day notification for missing licensed material. This event is reportable in accordance with 10 CFR 20.2201(a)(1)(ii). On September 25, 2023, while performing the required semi-annual source leak check and inventory, radiation protection personnel could not locate seven sealed radioactive sources. Five of the sources exceed the reporting threshold of ten times the activity listed in 10 CFR 20 Appendix C. Of the five sources, four were Ni-63 sources previously utilized in security bomb detection equipment with a current source radioactivity of between 7.1 and 8.7 mCi. The fifth sealed source exceeding the reporting threshold is an Am-241 former lab calibration standard with a source radioactivity of 0.97 microcuries. These sources were last accounted for on July 6, 2022. Pilgrim's accountability process does not require leak checks or physical inventory of sources that are out of service. A search was conducted for the missing sources; however, they could not be located.
"These sealed sources are classified as Category 5 radioactive sources in accordance with the International Atomic Energy Agency (IAEA) Safety Guide No. RS-G-1.9. Sources that are less than Category 3 (Cat 4 and 5 sources) are very unlikely to cause permanent injury to individuals.
"Based on the activity of Ni-63 and Am-241 present in the sources, this 30-day phone notification to NRC is provided pursuant to 10CFR20.2201(a)(1)(ii). The required written report pursuant to 10CFR20.2201(b)(1) will be provided to NRC within 30 days. The Resident Inspector has been notified. The licensee will notify State and local authorities."
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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Kentucky Dept of Radiation Control - Lexington KY
Report Date 10/25/2023 16:16:00
Event Date 10/23/2023 0:00:00
EN Revision Imported Date: 12/7/2023
EN Revision Text: AGREEMENT STATE REPORT - POSSIBLE DOSE 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 10/25/23 by the radiation safety officer (RSO) of University of Kentucky (UK) Broad Scope medical license, of an incident which occurred at the UK Chandler Medical Center on October 23, 2023.
"[The UK] RSO reports, 'During a high dose rate (HDR) treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user (AU) directed that the transfer tubing be replaced and treatment completed. The tubing used to complete the cycle was not the correct length, resulting in approximately 10 seconds of source exposure at the wrong dwell position(s). The source was outside of the body during this exposure period, therefore, there is uncertainty in the dose estimates to patient skin. Likely exposure in the treatment position (legs apart) is likely below the reporting thresholds in 10 CFR 35, while conservative estimates (assuming patient's legs were closed) lead to doses above reporting thresholds. Since the exact positioning is indeterminant, the licensee did not report a dose from this incident at this time. Upper bound worse case estimates place the skin dose below the level where patient harm is expected by the treating oncologist and no changes in plan of care are anticipated from this event. This incident remains under investigation.'
"RHB is following up with the RSO for additional information not included in the initial report."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The intended organ to be dosed was the cervix/uterus. Dose estimates were not available at the time the report was received from KY RHB.
"On 10/25/2023 the University of Kentucky (UK) reported a possible dose misadministration that occurred at the UK Chandler Medical Center on 10/23/2023. During a high dose rate (HDR) cervix/uterus treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user directed that the transfer tubing be replaced, and treatment completed. The tubing used to complete the cycle was not cut to the correct length. This resulted in the source being 12cm out of position for the 10 seconds remaining in the planned treatment. The source was outside of the patient's body during that exposure period, causing a potential radiation exposure to the skin of the thigh in excess of reporting requirements. The worst-case assessment assumes that the patient's thigh was in direct contact with the applicator for the full 10 seconds, resulting in a localized skin dose of 300 cGy. In the judgment of treating physician, the dose is below the level likely to cause injury. However, the dose is above the reporting threshold for a Medical Event. In the most likely scenario, the patient's thigh was at least 8 mm away, resulting in a significantly lower dose of less than 50 cGy. The patient and referring physician were informed in a timely manner.
"Corrective Actions:
"1) A leak mitigation countermeasure is being trialed in an effort to prevent fluid from leaking down the catheter and potentially causing this issue in the future.
"2) Current procedures are very specific about verification of transfer catheter length before starting a treatment. However, they have not until now directly addressed a process for interruption of a procedure to make adjustments to the patient set up. These procedures have been updated and training / education is being performed on the updated processes.
"Based on the investigation by the [Kentucky Department for Public Health and Safety] Radiation Health Branch in collaboration with the University of Kentucky, we find the corrective actions to be sufficient and consider this incident closed."
NMED Item Number: 230461
Notified R1DO (Werkheiser), NMSS Division Director (Williams), and NMSS Event Notifications (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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Tennessee Div of Rad Health - Kingsport TN
Report Date 10/25/2023 17:38:00
Event Date 10/25/2023 0:00:00
AGREEMENT STATE - STUCK OPEN SHUTTER
The following information was provided by the Tennessee Division of Radiological Health via email:
"During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was a normal operating position. A VEGA field technician has been scheduled to arrive onsite on November 7, 2023, to service the gauge.
"Manufacturer: Ohmart/VEGA "Source holder model: SHLM-CR "Source serial number: 4259CO "Isotope: Cs-137, 37 mCi
"Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days."
Tennessee Event Report ID Number: TN-23-079
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WA Office of Radiation Protection - Woodstock IL
Report Date 10/25/2023 20:24:00
Event Date 09/01/2023 0:00:00
AGREEMENT STATE - LOST AND FOUND RADIOACTIVE SOURCE
The following information was provided by the Washington State Department of Health via email:
"A positron emission tomography-computed tomography (PET/CT) unit with a Ge-68 sealed source (11 millicurie) was removed improperly from a medical facility in WA (Radia Imaging Center) and shipped to an unlicensed facility (MAK Heathcare in Woodstock, IL). Leak tests are in process to verify no spread of contamination. Currently, the plan is to ship the PET/CT scanner back to source manufacturer, Eckhert & Ziegler, in Burbank, CA on Friday, 10/27/2023."
WA Incident Report Number: WA-23-028
See NRC Event Notification number 56814 for a parallel report made by Illinois.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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North Dakota DEQ - Fargo ND
Report Date 10/27/2023 10:02:00
Event Date 10/25/2023 0:00:00
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the North Dakota (ND) Department of Environmental Quality (DEQ) via telephone and email:
"The ND DEQ received a call from Innovis Health, LLC, Fargo, North Dakota, (ND License No. 33-02604-01) at 0945 CDT on October 26, 2023, informing the ND DEQ of a possible medical event (10 CFR 35.3045(a)(1)) which occurred on October 25, 2023. The event involved a patient scheduled to receive a prescribed therapy dose of 120 Gy of yttrium-90 Theraspheres microspheres. During the line check while attempting to administer the microspheres, the licensee experienced some difficulties, stopped the procedure, and noticed a higher-than-normal radiation reading of the delivery system and associated materials. After measuring these materials, it appeared the patient received 41.7 Gy to the target site (liver). Initial imaging of the patient directly following the procedure did not show activity around the target area and surface radiation readings of the patient in this area was 0.06 mR/hr. At this time, the licensee was questioning if any of the dose was administered. The licensee contacted the manufacturer the same day regarding the event.
"The licensee also noted increased radiation activity in other materials used in the procedure. The radiation survey reading of these materials was 140 mR/hr. The license was researching a way to calculate the amount of activity that may have been in these additional materials.
"Further viewing of the images of the upper abdomen of the patient by the Interventional Radiologist (IR) demonstrated a very faint outline of the right lobe of the liver (the intended treatment area). This indicated a very small amount of the dose was delivered. The IR discussed everything with the patient before the patient had left the recovery area. There were no immediate adverse health effects, and the IR would monitor the patient for the next two weeks (about five half-lives)."
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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Ohio Bureau of Radiation Protection - Dayton OH
Report Date 10/27/2023 13:31:00
Event Date 10/26/2023 0:00:00
AGREEMENT STATE - LOST CATEGORY 4 SOURCE
The following information was provided by the Ohio Department of Health (ODH) via email:
"ODH received a notification last night [on 26 October, 2023], that NDC Technologies, Inc. (NDC) discovered a 25 mCi Americium-241 (Am-241) source was missing from their inventory. NDC is located in Dayton.
"The licensee has conducted three inventories of all sources, reviewed all shipping logs, and have searched (both visually and with a survey meter) areas, floors, and drawers where devices are built and stored.
"The source may have mistakenly been put into a trashcan or sent, still mounted in the sodium iodine crystal, for disposal. The last disposal was on July 12, 2023, and the licensee has contacted the disposal company and will speak with them further today.
"ODH will be sending an inspector to further investigate."
NMED report number: OH230010
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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Wisconsin Radiation Protection - Waukesha WI
Report Date 10/30/2023 21:10:00
Event Date 10/30/2023 14:35:00
AGREEMENT STATE - STOLEN SOURCE
The following information was provided by the Wisconsin Department of Health Services (the Department) via email and telephone:
"On October 30, 2023, at 1830 CDT, the Department received a notification from the licensee that a CPN MC1DRP gauge containing up to 10 mCi of Cesium-137 and 50 mCi of Americium-241 had been out of their control since 1435 CDT when the vehicle containing the gauge was stolen. Local law enforcement has been notified. The Department will monitor and update."
Event Report Number: WI230019
"The missing gauge was recovered around 0800 [CDT] on October 31, 2023 and is now in the custody of the licensee. The gauge had no visual damage. The Department will follow up with the licensee."
Notified R3DO (Dickson), ILTAB and NMSS Events notification by 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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Texas Dept of State Health Services - Cotulla TX
Report Date 10/31/2023 10:45:00
Event Date 10/27/2023 0:00:00
AGREEMENT STATE REPORT - BROKEN CABLE ON EXPOSURE DEVICE
The following information was provided by the Texas Department of State Health Services via email:
"On October 30, 2023, the licensee reported that on October 27, 2023, they had an industrial radiography source disconnect when the drive cable broke at the connector while the crew was working at a temporary job site. The exposure device was an INC IR-100 [containing a 92.1 curie Iridium-192 source]. The source was retrieved and secured in the exposure device by trained personnel. Self reading pocket dosimeters for the radiographers and retriever involved indicate there were no overexposures as a result of this event. Dosimetry badges are being sent for processing. The licensee is re-inspecting and re-servicing all of its crank and cable assemblies. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 10063 Texas NMED Number: TX230049
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River Bend - St Francisville LA
Report Date 10/31/2023 14:20:00
Event Date 10/31/2023 8:00:00
EN Revision Imported Date: 11/3/2023
EN Revision Text: FALSE NEGATIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via phone call and email:
"On October 31, 2023, at 0800 CDT, River Bend Station discovered that the results of a blind performance sample provided to an Health and Human Services (HHS)-certified testing facility were inaccurate (false negative). This report is being made in accordance with 10 CFR 26.719(c)(3). The HHS-certified testing facility has been informed of the error."
The licensee notified the NRC resident inspector.
"On November 1, 2023, River Bend Station personnel were informed by the HHS-certified testing facility that the cut-off levels used for analysis of the performance testing sample in question were the correct (higher) cut-off levels currently being used by the licensee. This resulted in a correct negative test.
"The performance testing sample sent to the HHS-certified testing facility was purchased for use based on the new lower cut-off levels in accordance with the new fit for duty (FFD) rule being implemented by the licensee on November 6, 2023. Because the higher confirmatory cut-off levels were used at the HHS-certified testing facility, the results provided were correct.
"The NRC Resident Inspector has been notified."
Notified R1DO (Eve) and FFD Group (email)
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Hatch - Baxley GA
Report Date 11/01/2023 9:38:00
Event Date 11/01/2023 6:48:00
MANUAL REACTOR TRIP DUE TO TRIP OF REACTOR FEED PUMP
The following information was provided by the licensee via email:
"At 0648 EDT on 11/1/23, with Unit 2 in MODE 1 at 56 percent power, the reactor was manually tripped due to a trip of the 'B' reactor feed pump (RFP). The 'A' RFP had been previously isolated due to a leak. Closure of containment isolation valves (CIVs) in multiple systems and the actuation of high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) occurred as a result of reaching the actuation setpoint on reactor water level as designed. The trip was not complex, with all safety systems responding normally post-trip.
"Operations responded and stabilized the plant. Reactor water level is being maintained with RCIC. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 was not affected.
"Due to the emergency core cooling system (ECCS) discharging into the reactor this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). Also, the reactor protection system actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, it is reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of CIVs, RCIC and HPCI.
"There was no impact on the health and safety of the public or plant personnel."
The Resident Inspector was notified.
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Prairie Island - Welch MN
Report Date 11/01/2023 16:52:00
Event Date 11/01/2023 16:52:00
CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA
The following information was provided by the licensee via email:
"On October 31 at 1856 CDT, Prairie Island Nuclear Generating Plant personnel identified a prohibited item (alcohol) in a kitchen area located within the protected area. An 'Extent of Condition' search was performed of all other protected area kitchen areas, no additional prohibited items were found.
"The NRC Resident has been notified."
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WA Office of Radiation Protection - Auburn WA
Report Date 11/02/2023 11:03:00
Event Date 10/31/2023 9:00:00
EN Revision Imported Date: 11/16/2023
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES
The following information was received from the Washington State Department of Health via email:
"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.
"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."
Washington Incident Number: WA-23-029
The following information was received from the Washington State Department of Health via email: "Attached is the final report for the reported medical event # WA-23-029. "We are also reviewing the event closely and are available to provide further information if needed."
Notified R4DO (Vossmar) and NMSS Events via 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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Point Beach - Two Rivers WI
Report Date 11/02/2023 16:41:00
Event Date 11/02/2023 7:15:00
FALSE NEGATIVE AND POSITIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via email:
"On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines.
"Investigation is ongoing to determine if the results are accurate.
"This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).
"The NRC Resident Inspector has been notified by the licensee."
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Oconee - Seneca SC
Report Date 11/03/2023 15:27:00
Event Date 11/03/2023 15:30:00
OFFSITE NOTIFICATION - PRESS RELEASE
The following information was provided by the licensee via email:
"A press conference is being held by the Oconee County Sheriff's office today at 1530 EDT in which Duke Energy will be present and may participate regarding the facts pertaining to an event that occurred outside the Oconee Nuclear Power Plant.
"The NRC Resident Inspector was notified.
"This is a four-hour report per 10 CFR 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 event is not significant with respect to the health and safety of the public."
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California Radiation Control Prgm - Pasadena CA
Report Date 11/03/2023 19:01:00
Event Date 11/02/2023 0:00:00
AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following information was received via email:
"The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90.
"Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event."
CA event ID number: 110323
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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Comanche Peak - Glen Rose TX
Report Date 11/04/2023 1:11:00
Event Date 11/03/2023 22:31:00
CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA
The following information was provided by the licensee via email:
"On 11/03/2023 at 2231 CDT, a security officer found 2 bottles of vanilla extract in the protected area. One bottle was a 1.5 ounce size with a trace amount of vanilla in the bottle, the other bottle was a 4.5 ounce size with approximately 1 ounce of vanilla. Alcohol was identified as an ingredient on the label. It was determined the vanilla extract is 35 percent alcohol by volume (ABV), above the 0.5 percent ABV considered low alcohol content. Security personnel took custody of the bottles of vanilla extract."
The NRC Resident Inspector has been notified.
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Texas Dept of State Health Services - Katy TX
Report Date 11/04/2023 23:16:00
Event Date 11/04/2023 0:00:00
AGREEMENT STATE - LOST TROXLER GAUGE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 4, 2023, the Department was notified by the licensee that one of its technicians had lost a Troxler 3430 moisture/density gauge. The gauge contains one 40 millicurie Am-241 source and one 8 millicurie Cs-137 source. The licensee reported that a technician was waiting in their truck to perform a test at a temporary job site when they were told by the job supervisor that the work was done for the day. The technician drove home and when they reached their home, realized they had left the gauge, which was inside its transportation box, sitting on the tailgate of the truck and it was now missing. The licensee did not know if the cesium source rod or transport case was locked. The technician retraced their route twice, but it was already dark, and they did not see the gauge. The technician notified his radiation safety officer that they had lost the gauge. The licensee will notify local law enforcement of the event. The licensee stated they will begin searching for the gauge as soon as it is light out. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10064
Texas NMED Number: TX230050
"On November 5, 2023, the Department contacted the licensee and requested the status of the gauge. The licensee stated that they had performed additional searches for the gauge this morning but did not find the gauge. The licensee stated they had contacted the Harris County, Texas, Sheriff's Department. The licensee stated they would offer a reward for the gauges return. The licensee was advised to contact local pawn shops and watch social media platforms like eBay and Craig's List. The licensee was advised to contact local fire departments about the gauge and provide its contact information. The licensee stated the gauge was labeled with its contact information. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Roldan-Otero), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Waterford - Killona LA
Report Date 11/05/2023 17:52:00
Event Date 11/05/2023 10:33:00
DEGRADED CONDITION - TWO STEAM GENERATOR TUBE FAILURES IDENTIFIED
The following information was provided by the licensee via email:
"At 1033 CST on November 5, 2023, while in a refueling outage, it was determined that Waterford Steam Electric Station, Unit 3, did not meet the performance criteria for steam generator structural integrity in accordance with Technical Specification 6.5.9.b.1, Steam Generator Program, due to two tube failures in the number 1 steam generator. The condition was identified during performance of in-situ pressure testing.
"The affected tubes will be plugged.
"The plant is currently stable with all fuel in the spent fuel pool. Decay heat is being removed by normal spent fuel cooling system operation.
"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A) as a degraded condition.
"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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Wisconsin Radiation Protection - La Crosse WI
Report Date 11/06/2023 16:19:00
Event Date 11/06/2023 14:08:00
AGREEMENT STATE REPORT - LOST NUCLEAR GAUGE
The following information was received from the Wisconsin Department of Health Services (the Department) via email:
"On November 06, 2023, at 1408 CST, the Department received a notification from the licensee that a Peco Controls Corporation gauge (serial number 5450LA) containing 100 mCi of Am-241 had been determined to be missing while conducting inventory of gauges in storage. This is all the information that is known at this time. The Department will follow up and provide additional information as it becomes available."
Wisconsin Event Report ID No.: WI230021
The following update was received from the Wisconsin Department of Health Services (the Department) via phone and email:
"On November 10, 2023, the licensee determined that an additional four Peco Controls Gamma 101P gauges were missing (serial numbers 0550LX, 9145LV, 9142LV, and 9580LV). Each gauge contained 300 millicuries of Americium-241. Department inspectors were onsite and physically verified the remainder of the licensee's inventory.
"In addition, the model number of the gauge declared missing on November 6, 2023 was confirmed to be a Gamma 101P."
Notified R3DO (Ruiz), NMSS Event Notifications, ILTAB, and CNSC via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Colorado Dept of Health - Lakewood CO
Report Date 11/07/2023 10:16:00
Event Date 10/30/2023 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a synopsis of information provided by the Colorado Department of Public Health and Environment via email:
On 10/30/23, the licensee discovered that 11 tritium exit signs were not able to be located. The exit signs were SRB Technologies (model number BX-10-BK) signs each containing 10 Ci of tritium (H-3). This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).
Event Report ID No.: CO230040
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Florida Bureau of Radiation Control - Fort Myers FL
Report Date 11/07/2023 12:46:00
Event Date 11/07/2023 11:30:00
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
A Radiation Safety Officer (RSO) with Environmental Safety Consultant (ESC) Florida, LLC called BRC in Orlando on November 7, 2023, at 1150 EST to report a soil moisture density gauge (Model: Instro Tek Xplorer 3500, 8 mCi Cs-137, 40 mCi Am-241:Be) was run over on a job site around 1130 this morning. The RSO indicated that the source rod was retracted when the incident occurred. An inspector was sent to investigate.
Florida Event Number: FL23-161
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Seabrook - Manchester NH
Report Date 11/07/2023 18:18:00
Event Date 11/07/2023 12:00:00
EN Revision Imported Date: 11/9/2023
EN Revision Text: AUXILIARY FEEDWATER SYSTEM INOPERABLE
The following information was provided by the licensee via email:
"On November 07, 2023 at 1200 EST, it was discovered that all pumps in the Auxiliary Feedwater system were inoperable due to the loss of control power to the 'B' train Emergency Feedwater (EFW) flow control valve which supplies the 'D' steam generator. The redundant 'A' train EFW control valve for the 'D' steam generator remains functional, as well as the capability of the Auxiliary Feedwater system to supply all steam generators.
"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B).
"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 'A' and 'B' EFW Flow Control Valves are arranged in a series configuration for each Steam Generator. Failure of any of the 8 EFW Flow Control Valves to meet its Surveillance Requirements will render all EFW Pumps inoperable per tech specs."
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Calvert Cliffs - Lusby MD
Report Date 11/07/2023 18:42:00
Event Date 11/07/2023 16:17:00
REACTOR TRIP DUE TO NON-SAFETY RELATED BUS UNDER VOLTAGE
The following information was provided by the licensee via email:
"At 1617 on 11/7/2023, Calvert Cliffs Unit 2 experienced an automatic trip from a Reactor Protection System (RPS) based on reactor trip bus under voltage (UV). At that time a loss of U-4000-22 caused a loss of 22, 23, and 24 4kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV condition. The loss of 22 and 23 4kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.
"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4-hour report.
"ESFAS actuation (2B DG start on UV) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report.
"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report.
"Site Senior NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Unit 1 was unaffected. Estimation of duration of shutdown is 24 hours.
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Louisiana Energy Services - Eunice NM
Report Date 11/08/2023 5:59:00
Event Date 11/08/2023 3:37:00
ALERT - SEISMIC EVENT FELT ONSITE
The following information was provided by the licensee via fax and phone call:
"An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility and felt inside the control room. A release of hazardous material has not occurred."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On 11/08/2023 at 0337 MST, Urenco USA declared an Alert (EAL 5.1A) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 0559 EST (0359 MST). No radioactive release has occurred. A 5.2 magnitude earthquake occurred in western Texas with an epicenter 36.7 km west-southwest of Mentone, Texas. Plant personnel are conducting walkdowns of the site.
The State and local authorities have been notified.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)
TERMINATION OF SEISMIC EVENT ALERT
The following information was provided by the licensee via fax and phone call:
"The earthquake of 5.2 magnitude in western Texas was felt in the control room. No release of UF6 was detected. Building inspections have been completed with no damage identified. This event has been terminated at 0937 MST and has entered into the recovery process. The State and local authorities have been notified."
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), NMSS (Brenneman), IRMOC (Grant), OPA (Burnell).
The following additional information was obtained in accordance with Headquarters Operations Officers Report Guidance: US Geological Survey (USGS) updated the seismic event to 5.3 magnitude at 10:27 on 11/08/23.
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Calvert Cliffs - Lusby MD
Report Date 11/08/2023 13:27:00
Event Date 11/08/2023 6:45:00
MANUAL ACTUATION OF AUXILIARY FEEDWATER SYSTEM (AFW)
The following information was provided by the licensee via phone and email:
"At 0645 EST, on November 8, 2023, with Unit 2 in Mode 3 at zero percent power, a manual actuation of the auxiliary feedwater system (AFW) occurred during a planned plant cooldown. The reason for the AFW manual-start was a trip of the 22 steam generator feed pump due to a high casing level. The 23 AFW motor driven pump was manually started in accordance with implementation of AOP-3G, Malfunction of Main Feedwater System to restore steam generator levels.
"There was no impact to Unit 1. 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 AFW system. There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
No other systems were affected. No other compensatory or mitigation strategies implemented. Plant cooldown was the only significant evolution in progress. No impact to other technical specifications or limiting conditions for operation. All systems functioned as required. The electric plant is being supplied by offsite power with all diesel generators available. No significant increase in plant risk. There was nothing unusual or not understood.
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Colorado Dept of Health - Lamar CO
Report Date 11/08/2023 16:01:00
Event Date 11/08/2023 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following information was obtained and summarized from the Colorado Department of Public Health and Environment in accordance with Headquarters Operations Officers Report Guidance:
On November 8, 2023, Five Rivers Cattle Feeding (Lamar) reported to the Colorado Department of Public Health and Environment one lost exit sign (Manufacturer: Isolite Corporation; Model #: SLX60; Isotope & activity: H-3, 6.2 Ci).
Event Report ID No.: CO230041
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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Texas Dept of State Health Services - Abilene TX
Report Date 11/09/2023 13:45:00
Event Date 11/08/2023 0:00:00
AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number 10065
Texas NMED Number: TX230051
The following update was provided by the Texas Department of State Health Services via email:
"On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location."
Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Sequoyah - Soddy-Daisy TN
Report Date 11/09/2023 15:55:00
Event Date 11/09/2023 11:36:00
FITNESS-FOR-DUTY REPORT
The following is a summary of information provided by the licensee via email:
A controlled substance was found in the protected area. The NRC Resident Inspector has been notified.
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Susquehanna - Allentown PA
Report Date 11/10/2023 3:14:00
Event Date 11/10/2023 3:14:00
MANUAL REACTOR SCRAM
The following information was provided by the licensee via email:
"At 0118 EST, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually scrammed due to degrading main condenser vacuum. The scram was not complex, with all systems responding normally post-scram. The main turbine bypass valves opened automatically to maintain reactor pressure.
"Operations responded and stabilized the plant. Reactor water level is being maintained via feedwater pumps. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not impacted.
"Due to Reactor Protection System actuation while critical, this event is being reported as a four-hour and eight-hour non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).
"Unit 1 reactor is currently stable in mode 3. An investigation is in progress into the cause of the degrading condenser vacuum. 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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SC Dept of Health & Env Control - Charleston SC
Report Date 11/10/2023 10:02:00
Event Date 11/09/2023 17:00:00
AGREEMENT STATE REPORT - PATIENT RECEIVED 45 PERCENT UNDERDOSE
The following was received from the South Carolina Department of Health and Environmental Control (Department) via phone and email:
"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 0930 EST on 11/10/23 that a medical event had been discovered by the licensee on 11/09/23 at approximately 1700 EST. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 45 percent of the prescribed 500 Gray (Gy) dose. MUSC estimates that the patient received 276 Gy of the intended 500 Gy dose. The licensee reported that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more.
"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
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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South Texas - Wadsworth TX
Report Date 11/10/2023 22:52:00
Event Date 11/10/2023 14:13:00
ESSENTIAL CHILLER TRAINS INOPERABLE
The following information was provided by the licensee via email:
"On 11/10/23 at 0642 CST, essential chiller 'B' train and cascading equipment was declared inoperable due to chill water temperature exceeding limits.
"At 1413 CST, essential chiller 'C' train and cascading equipment was declared inoperable due to discharge pressure exceeding limits.
"This condition resulted in an inoperable condition on two out of the three safety trains for the accident mitigating function including the 'B' and 'C' train high head safety injection, low head safety injection, containment spray, electrical auxiliary building HVAC, control room envelope HVAC, and essential chill water. All 'A' train equipment remained operable.
"This was determined to be reportable within 8 hours as required by 10 CFR 50.72(b)(3)(v)(D)."
The NRC Resident Inspector has been notified.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Plant is in a 72 hour limiting condition for operation per technical specification 3.7.7. Restoration of 'B' train anticipated on 11/11/23 mid day.
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Waterford - Killona LA
Report Date 11/11/2023 0:23:00
Event Date 11/10/2023 15:45:00
UNANALYZED CONDITION
The following information was provided by the licensee via email:
"At 1545 CST on November 10, 2023, personnel at Waterford Steam Electric Station Unit 3 determined that 19 conduits in the engineered safety features actuation system (ESFAS) auxiliary relay cabinets A and B did not have the required fire seals for bay separation. This condition meets the criteria involving an unanalyzed condition that significantly affects plant safety.
"The plant is currently defueled. Decay heat is being removed by normal spent fuel cooling system operations. ESFAS is not required to be operable in the current plant mode.
"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC Region 4 Branch Chief [Dixon] has been notified."
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Watts Bar - Spring City TN
Report Date 11/12/2023 22:02:00
Event Date 11/12/2023 3:00:00
EN Revision Imported Date: 11/14/2023
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by the licensee via email:
"On November 12, 2023, at 0300 EST, a Watts Bar contractor was transported offsite for medical treatment due to a work-related injury. Upon arrival at an offsite medical facility, medical personnel determined the injury required the individual to be admitted into the hospital and will be kept overnight. The individual was inside of the Radiological Controlled Area, however was free released with no contamination.
"The injury and hospitalization were reported to the Occupational Safety and Health Administration (OSHA) under 29 CFR 1904.39(a)(2). The contracting agency informed OSHA at 1319 EST. Watt Bar Operations personnel were officially notified by the contracting agency of the report made to OSHA at 1945 EST.
"This is a four-hour notification, non-emergency for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"The NRC Resident Inspector has been notified."
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Framatome ANP Richland - Richland WA
Report Date 11/13/2023 15:13:00
Event Date 11/02/2023 10:45:00
CONCURRENT REPORT FOR DEGRADED CONNECTOR
The following information was provided by the licensee via phone and email:
"Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report:
"On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter.
"On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, [November 13, 2023]."
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Farley - Ashford AL
Report Date 11/14/2023 14:36:00
Event Date 11/14/2023 10:41:00
MANUAL REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 1041 CST on 11/14/23 with Farley Unit 2 in Mode 1 at 10 percent power, the reactor was manually tripped due to rising steam generator levels. The trip was not complex, with all systems responding normally post-trip.
"Operations responded and stabilized the plant. Auxiliary feedwater (AFW) was manually initiated in accordance with plant procedures and is feeding the steam generators. Heat removal is being provided via the atmospheric relief valves. 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). 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 results 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."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All rods fully inserted. The licensee attempted to take manual control of the feedwater control valves to lower steam generator level but, due to reaching a steam generator level that requires a manual trip, the licensee manually tripped the reactor.
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Florida Bureau of Radiation Control - Tampa FL
Report Date 11/14/2023 16:54:00
Event Date 11/14/2023 12:11:00
DOSE GREATER THAN PRESCRIBED
The following information was provided by the Florida Department of Health via email:
"On 11/14/2023, a patient arrived in the nuclear medicine department for administration of their fourth cycle of Lutathera, a Lu-177 labeled radiopharmaceutical. The standard prescription of Lutathera for patients is 200 mCi in accordance with manufacturer's instructions for use and industry standard. The technologist assayed the vial and went through pre-administration procedures including a pre-treatment time out. 202 mCi of Lutathera was administered via IV in the right upper forearm over the course of thirty minutes. Start time of 1211 [EST] with an end time of 1241.
"Upon completion of the procedure, the technologist noticed that the patient had been prescribed a reduced activity of 150 mCi as opposed to the standard prescription of 200 mCi. Realizing this was a medical event, the technologist notified the radiation safety officer (RSO) at approximately 1330. The technologist also informed the nuclear medicine department supervisor. The RSO proceeded to inform the Authorized User (AU)/prescribing physician.
"The AU spoke with the patient explaining that the activity administered exceeded the prescribed amount. The physician explained that he did not expect any adverse effects from the higher than prescribed activity as the patient had received the standard activity of 200 mCi. The reduced activity of 150 mCi had been decided by the prescribing physician due to borderline renal function and the patient had tolerated all previous three administrations. Since the patient's renal function was not affected by the three previous administrations, the prescribing physician explained that the patient could have received the 200 mCi. The patient did not express concern upon being informed of this event.
"The AU also informed the referring physician.
"An initial report was made to [Florida] via telephone at 1529 in accordance with 64E-5.345(4)(a)."
Florida Incident Number: FL23-164
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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Wisconsin Radiation Protection - Wausau WI
Report Date 11/15/2023 14:19:00
Event Date 11/08/2023 0:00:00
AGREEMENT STATE - DOOR INTERLOCK FAILURE
The following information was provided by the Wisconsin Department of Health Services (the Department) email:
"On Wednesday, November 8, 2023, the licensee was treating an individual in their high dose rate (HDR) suite. During the treatment, while the Ir-192 source was exposed, it was noticed that the door to the suite was ajar. The treatment was immediately paused, and the physicist confirmed that the door was open and that the door interlock was not functioning as required. The staff closed the door, put up caution tape, and maintained constant visual surveillance to ensure no one entered. Treatment was reinitiated and completed according to the written directive.
"On Friday, November 10, 2023, the interlock had not yet been repaired, and the licensee performed another HDR treatment utilizing caution tape and constant surveillance.
"The licensee reported the event to the Department by phone on November 14, 2023.
"The licensee performed an event reconstruction and surveyed at the open door with the Ir-192 source exposed. The highest dose rate of 0.3 mR/hr indicates that no member of the public would have received a dose exceeding public dose limits from this event.
"The patients were unaffected.
"The Department will be performing a reactive inspection on November 20, 2023."
WI Event Report ID Number: WI230022
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Texas Dept of State Health Services - Dallas TX
Report Date 11/15/2023 16:40:00
Event Date 11/14/2023 0:00:00
AGREEMENT STATE - LOST TROXLER GAUGE
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On November 15, 2023, the Department was notified by the licensee that a Troxler model 3440 moisture/density gauge had been lost. The gauge contains one 8 millicurie Cs-137 source and one 40 millicurie Am-241 source.
"The radiation safety officer (RSO) stated that on November 14, 2023, a licensee technician was performing work at a temporary job site where testing was being performed periodically. While sitting in their truck with the gauge on the tailgate of the truck, the technician realized they needed to go to a second job site about 20 minutes from where he was. When they reached the second job site, the technician realized they had left the gauge on the tailgate.
"The technician notified the licensee's RSO and the licensee conducted multiple searches for the gauge but did not locate the gauge. The RSO was advised to contact local law enforcement about the event. The RSO was advised to check local pawn shops and internet sites such as eBay and Craig's List to watch for the gauge. The RSO does not believe the gauge possesses an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10066
NMED Number: TX230052
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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Calvert Cliffs - Lusby MD
Report Date 11/16/2023 5:15:00
Event Date 11/16/2023 2:27:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 0227 EST on 11/16/23, Calvert Cliffs Unit 2 experienced an automatic trip from the reactor protection system (RPS) based on reactor trip bus undervoltage (UV). At that time, a loss of U-4000-22 (13 kV to 4 kV transformer) caused a loss of 22, 23, and 24 4 kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV. The loss of 22 and 23 4 kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4 kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.
"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4 hour report "ESFAS (engineering safety features actuation system) actuation (2B DG start on UV) is reportable under 10 CFR 50.72(b)(3)(iv)(A) - 8 hour report "AFW operation is reportable under 10 CFR 50.73(a)(2)(iv)(A) - 60 day report
"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:
All rods fully inserted. There was no impact on Unit 1 operations. Unit 2 is stable in mode 3.
"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8 hour report"
Notified R1DO (Defrancisco).
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Patriot Engineering - Evansville IN
Report Date 11/16/2023 8:11:00
Event Date 11/15/2023 17:35:00
EN Revision Imported Date: 12/12/2023
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST TROXLER GAUGE
The following information was provided by the licensee via phone conservation:
An NRC licensee lost a portable moisture density gauge while in transit to a testing site. The licensee inadvertently drove to the work location with a Troxler gauge on the work vehicle tailgate. The gauge was last known to be in possession by the licensee at the intersection of Kentucky and Diamond Avenues in Evansville, Indiana. The Troxler Model 3400, SN 20494, contained 9 mCi, Cs-137 and 1320 mCi, Am-241/Be.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The site radiation safety officer received a call on Friday, November 17, 2023, from the job site informing them that the gauge was returned. The licensee returned to the job site, retrieved the gauge, performed leak tests, and notified the NRC Region III Office (Jason Draper).
Notified R3DO (McCraw), NMSS Events, and ILTAB via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Brunswick - Southport NC
Report Date 11/16/2023 12:12:00
Event Date 11/16/2023 9:06:00
FAILED FITNESS FOR DUTY TEST
The following information was provided by the licensee via phone and email:
"At 0906 Eastern Standard Time (EST) on November 16, 2023, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness for Duty (FFD) testing program. The individual's authorization for site access has been removed.
"The NRC Resident Inspector has been notified."
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Cleveland Cliffs Steel Corporation - Dearborn MI
Report Date 11/16/2023 15:20:00
Event Date 11/16/2023 8:00:00
NON-AGREEMENT STATE REPORT - FAILED INDICATING LIGHT
The following information was provided by the licensee via phone and in accordance with Headquarters Operations Officers Report Guidance:
On November 11, 2023, at about 1330 EST, at the Cleveland Cliffs Steel Corporation in Dearborn Michigan, the licensee staff noted that the indicating light for a 1 curie Am-241 thickness gauge shutter position was malfunctioning. The light indicated open continuously even though the shutter was closing normally. Operation of the plant continued and the shutter remained in its normally open position measuring the product steel thickness. Shutter position was subsequently checked by radiation measurements to confirm that the indicating light was not indicating correctly. No abnormal exposure resulted and the vendor will troubleshoot and repair. The location of the gauge is not normally manned.
* * * UPDATE ON 11/18/23 AT 1509 EST FROM WAYNE LANGDON TO IAN HOWARD * * *
The following update was received from the licensee via email:
"Today, a Thermo Fisher Scientific technician came on site to diagnose the shutter position indicator light issue. It was found that the shutter arm flag was bad. The technician replaced the shutter arm flag with a new one and verified that the unit was properly working. No Cleveland Cliffs employees nor the Thermo Fisher Scientific technician were exposed at any time during the event."
Notified R3DO (Feliz-Adorno) and NMSS Event Notifications (E-mail).
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California Radiation Control Prgm - Duarte CA
Report Date 11/16/2023 20:05:00
Event Date 11/15/2023 0:00:00
AGREEMENT STATE REPORT - IODINE-131 OVERDOSE
The following information was provided by the California Department of Public Health (CDPH) via email:
"On November 15, 2023, at 2107 PST, [DELETED], the radiation safety officer (RSO) at City of Hope, reported by email that a patient scheduled to receive an oral administration of 100 mCi (millicuries) of iodine-131 (I-131) was instead orally administered 160 mCi of I-131, an excess of 60 mCi. On November 16, 2023, the RSO calculated that the difference in the prescribed dose to the thyroid (target organ) was 488 rem, and that the difference in the prescribed dose to the whole body effective-dose-equivalent was 62 rem. The licensee will be submitting a 15-day written report with additional details."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No patient intervention was reported immediately but may be reported in the 15-day report. The excess activity of 60 mCi and dose of 488 rem will result in a dose to the patient that exceeds the original prescribed dose by more than 50 percent.
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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South Texas - Wadsworth TX
Report Date 11/16/2023 21:30:00
Event Date 11/16/2023 15:41:00
ESSENTIAL CHILLER TRAINS INOPERABLE
The following information was provided by the licensee via phone and email:
"11/05/23, 2200 CST: Essential Chiller 'B' train and associated cascading equipment were declared INOPERABLE for planned maintenance. Unit 2 entered the Configuration Risk Management Program as required by Technical Specifications on 11/12/23 at 2200.
"11/16/23, 1541: Essential Chiller 'C' train and associated cascading equipment were declared INOPERABLE due to an unexpected material condition causing the Essential Chiller to trip. The most limiting [Limiting Condition of Operability] LCO is 3.7.7, Action c.
"This condition resulted in the INOPERABILITY of two of the three safety trains required for the accident mitigating function including: High Head Safety Injection, Low Head Safety Injection, Containment Spray, Electrical Auxiliary Building HVAC, Control Room Envelope HVAC, Essential Chilled Water.
"This is an 8 hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident.
"A risk analysis was performed for the equipment INOPERABILITY and mitigating actions have been taken per site procedures. All 'A' train equipment remains operable."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The 'B' train Emergency Diesel Generator was also inoperable due to planned maintenance and continues to be inoperable. It was considered in the Configuration Risk Management Program and it was determined this condition could be maintained. LCO 3.7.7, Action c requires reactor shutdown within 72 hours.
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UP Health Systems Marquette - Marquette MI
Report Date 11/17/2023 15:44:00
Event Date 11/17/2023 11:00:00
MEDICAL EVENT - Y-90 POTENTIAL UNDERDOSE
The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone in accordance with Headquarters Operations Officers Report Guidance:
On 11/17/23 at 1100 EST at UP Health System Marquette, the radiation safety officer (RSO) determined that a patient received a dose that differed from the prescribed dose by more than 20 percent. The patient was prescribed a dose of 11.34 mCi of Y-90. The target organ was a tumor located in the patient's liver. The dose was administered to the target organ as expected, however, calculations on the remaining radioactivity left over from the administration estimated that the patient received a dose of only 2.82 mCi (24.9 percent of the prescribed dose). The RSO notified the referring physician, and the referring physician will notify the patient. The RSO is currently investigating the cause of the underdose and will submit a 15-day written report to follow up once the investigation is complete.
The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone:
The initial dose estimate was based on incorrect measurements and has been revaluated and the dose was in the acceptable range.
Notified R3DO (Feliz-Adorno) and NMSS Events Notification (via 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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River Bend - St Francisville LA
Report Date 11/18/2023 2:51:00
Event Date 11/17/2023 23:55:00
MANUAL REACTOR SCRAM
The following information was provided by the licensee via phone and email:
"On November 17, 2023, at 2215 CST, River Bend Station (RBS) was operating at 30 percent reactor power performing plant startup activities when an isolation of low-pressure feedwater string `A' occurred. The team entered applicable alternate operating procedures and inserted control rods to exit the restricted region of the power to flow map. Feedwater temperature continued to lower until it challenged the prohibited region of the AOP-0007 graph requiring a reactor scram. The team inserted a manual reactor scram at 2355 from 24 percent reactor power. All control rods fully inserted and there were no complications. All systems responded as designed. Currently RBS Unit 1 is stable with reactor level being maintained 10 to 51 inches with feed and condensate, and pressure being maintained 500 to 1090 psig using steam drains.
"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the Reactor Protection System (RPS) when the reactor is critical and 10 CFR 50.72(b)(3)(iv)(A) Specified System Actuation as result of Group 3 isolations.
"The NRC Senior Resident inspector has been notified.
"No radiological releases have occurred due to this event from the unit."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The electric plant is in a normal lineup for current plant conditions with all emergency diesel generators available. The cause of the initial isolation of low-pressure feedwater string "A" is still under investigation.
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Harris - Raleigh NC
Report Date 11/19/2023 0:53:00
Event Date 11/18/2023 21:38:00
OFFSITE NOTIFICATION - REPORT TO ANOTHER GOVERNMENT AGENCY
The following information was provided by the licensee via phone and email:
"At 2138 EST on November 18, 2023, Harris Nuclear Plant notified the National Response Center of a biodegradable oil leak that entered the Harris Lake. The North Carolina Department of Environmental Quality will also be notified of this condition on November 19, 2023. The oil leak was less than one gallon and came from a temporary pump. The leak has stopped, and spill cleanup is underway. This condition did not violate any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a notification to another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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Quad Cities - Cordova IL
Report Date 11/19/2023 14:44:00
Event Date 11/18/2023 20:20:00
FITNESS FOR DUTY REPORT
The following information was provided by the licensee via phone and fax:
"On November 18, 2023, the presence of alcohol was discovered inside the protected area. In accordance with the Constellation Fitness For Duty (FFD) Program, the individual has been escorted offsite and access to the plant denied pending the results of an investigation.
"This event is being reported under 10 CFR 26.719(b)(1) as it represents a significant FFD violation.
"The NRC Resident Inspector has been notified."
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Dresden - Morris IL
Report Date 11/20/2023 17:53:00
Event Date 11/20/2023 9:56:00
HPCI DECLARED INOPERABLE
The following information was provided by the licensee via email:
"At 0956 [CST] on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.
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Texas Dept of State Health Services - Houston TX
Report Date 11/21/2023 13:40:00
Event Date 11/20/2023 0:00:00
AGREEMENT STATE REPORT - EQUIPMENT FAILURE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300.
"Device Information: Best Vascular Novoste IVB model A1000
"Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries."
Texas Incident Number: 10067
Texas NMED Number: TX230053
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Texas Dept of State Health Services - Helotes TX
Report Date 11/21/2023 21:20:00
Event Date 11/21/2023 0:00:00
AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 21, 2023, the licensee's radiation safety officer (RSO) advised the Department that one of its technicians had lost a Humboldt 5001EZ moisture density gauge [which contains a nominal activity of 40 mCi of Am-241:Be and 10 mCi of Cs-137]. The technician had finished testing at a temporary job site and then took a phone call. After completing the call, he left the job site with the moisture density gauge sitting on the tailgate. When he realized what had happened, he called the project supervisor who sent workers out to search the testing area and surrounding areas. The technician notified the RSO and started driving back to the site while looking for the gauge. The RSO sent more technicians out to assist in the search and he also notified the local police department. The RSO reported the trigger lock was not on the insertion rod and it was only the gauge that was lost. It was not inside the transport case at the time. Search of the driving route will resume after daylight and the RSO will be checking with other construction workers at this and nearby sites. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 10069
Texas NMED Number: TX230054
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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New York State Dept. of Health - Grand Island NY
Report Date 11/22/2023 12:17:00
Event Date 11/19/2023 0:00:00
AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE The following information was provided by the New York State Department of Health (the Department) via email:
"New York State (NYS) Department of Heath received an email from the radiation safety officer (RSO) of NRD, LLC regarding an employee entering a restricted zone (Silver Recovery) without use of proper personal protective equipment (PPE) and respiratory protection on Sunday, November 19, 2023. Staff at NRD were made aware of this on November 20, 2023, at 1145 EST. The individual entered the restricted area to conduct non-authorized work, which was performed for 20 minutes in a 12 DAC-hr environment based on continual air monitor (CAM) readings at this time. The individual did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a PPE requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work that was being conducted is unknown by the Department at this time.
"As the individual did not perform nasal swabs or have personnel air monitoring estimated doses were assumed using the 12 derived air concentration-hour (DAC-hr) environments based on the CAM. The assumptions in preliminary calculations assume a 2-hour working time to be conservative, which shows 24 DAC Hours (2 percent) of intake for the most limiting isotope (Am-241). Individual has been placed on bioassay urine collection and has had authorizations and security removed. NRD will be notifying the Department of these results and more information as it becomes available. This worker has received one bioassay for urinalysis and has been terminated from employment by NRD, LLC.
"NRD, LLC contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) regarding this event as a precaution to inquire on the potential supply of Diethylenetriamine pentaacetate (DTPA) for chelation therapy. The affected individual involved in this event has apparently refused to cooperate with REAC/TS. The results of this bioassay will be used to determine if an overexposure event has occurred for this individual where possible."
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Iowa Department of Public Health - Ames IA
Report Date 11/22/2023 16:14:00
Event Date 11/22/2023 8:15:00
AGREEMENT STATE REPORT - BROKEN GAUGE SHUTTER
The following information was provided by the Iowa Department of Health and Human Services (HHS) via email:
"3M Company in Ames, Iowa, possesses NDC Technologies fixed nuclear gauges for material thickness measurements on their production line. It is being reported that on the morning of November 22, 2023, when beginning production at 0815 CST, a web from the line caught the shutter of an NDC model 103X fixed nuclear gauge, containing 150 millicuries of americium-141, and bent the shutter away from the closed position impacting the function [of the] shutter and not allowing it to fully shield the beam as intended. This was immediately identified by staff and the line was shut down and the radiation safety officer (RSO) was notified. The affected device is installed behind guarding and nobody had access to the beam until the RSO came onsite at 0920 to evaluate the situation. Iowa HHS was notified at 0945. Under the direct supervision and instruction of the RSO, using a radiation survey meter, the licensee (3M Company) fixed the shutter and 3M Corporate Health Physics was notified that the device had been fixed at 1130.
"No overexposures, release, or contamination of radioactive material has occurred because of this incident and Iowa HHS will update this reportable event as more information (cause, corrective actions, radiation doses) becomes available."
NMED item number: IA230003
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Illinois Emergency Mgmt. Agency - Memphis TN
Report Date 11/22/2023 16:41:00
Event Date 11/21/2023 0:00:00
EN Revision Imported Date: 12/6/2023
EN Revision Text: AGREEMENT STATE - LOST PACKAGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On November 22, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN [common carrier] hub where it was scanned on November 21, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 10 milli-Liters shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.56 millicuries. It was offered for shipment on November 17, 2023, for delivery to a customer in Ontario, Canada on November 20, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Tennessee program officials were notified, and the matter was reported to the HOO [NRC Headquarters Operations Officer]. This report will be updated with any available information."
Illinois Item Number: IL230033
"On 12/5/23, the licensee advised that the package was delivered undamaged to the client site. This matter is considered closed."
Notified R1DO (Werkheiser), R3DO (Szwarc), NMSS 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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Indian Point - Buchanan NY
Report Date 11/29/2023 17:02:00
Event Date 11/29/2023 15:00:00
EN Revision Imported Date: 12/1/2023
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by the licensee via email:
"This notification is being made per 10 CFR 50.72(b)(2)(xi), as a result of notifications made to State and local government agencies for the discovery of an oil sheen in the discharge canal outside Unit 3. The New York State Department of Environmental Conservation and Westchester County Department of Health were notified. No sheen was observed in the river or at the southern end of the discharge canal near the outfall gates. Clean up efforts are underway.
"The licensee will notify the NRC Project Manager."
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