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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
--------------------
Peach Bottom - Philadelphia PA
Report Date 11/14/2021 8:50:00
Event Date 11/14/2021 5:25:00
EN Revision Imported Date: 1/31/2024
EN Revision Text: MANUAL TRIP DUE TO LOWERING MAIN CONDENSER VACUUM At 0525 EST, November 14, 2021, "Unit 2 was manually scammed by operations due to lowering main condenser vacuum. This resulted in PCIS (primary containment Isolation system) Group II/III isolation signals. All control rods inserted, and all systems operated as designed."
Unit 3 is unaffected and remains at 100 percent power in Mode 1.
The Resident Inspector was notified.
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Kentucky Dept of Radiation Control - Lexington KY
Report Date 08/31/2023 8:22:00
Event Date 08/30/2023 10:00:00
EN Revision Imported Date: 1/3/2024
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
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 8/30/2023, at 1700 CDT, by a representative from University of Kentucky Broadscope Medical, of an underdose of a patient during a lutetium 177 (Lu-177) treatment. The underdosing was due to a leakage in the administration line.
"The underdosing was considered more than 20 percent. There was no harm to the patient. A separate report will be submitted once all the facts are gathered."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following summary of information was provided by the Kentucky Department of Public Health and Safety, Radiation Health Branch (KY RHB) via email and phone:
Further pertinent information regarding the medical event on Wednesday, August 30, 2023 at Chandler Hospital was identified per KY RHB's 15 day report. The event involved an administration of 200 mCi of Lutathera (Lu-177) via syringe pump where a leak was identified during the infusion. At approximately 20 minutes into the infusion the patient reported a wet feeling on their hand. The infusion was halted immediately. It was identified that a small volume of radioactive liquid was present on the patient's hand having dripped down onto it. The site of the leak was identified to be the connection between the syringe pump apparatus and the patient. Bedding and materials adjacent to the patient were found to have absorbed the majority of the leaked material, though some had also leaked onto the floor coverings. Spill response procedures were immediately initiated as well as notification to the authorized user (AU). Approximately 1/3 of the prescribed activity remained in the syringe. The AU elected to have a new connection established and administer the remainder to the patient.
The licensee estimated the administered activity based on volume of the drug administered, measurements of the contaminated bedding materials, and patient dose rate measurements post infusion (corrected for BMI). These estimates all suggest that this incident resulted in an underdose of approximately 25 percent to 30 percent due to the lost material from the leak. The skin dose to the patient's hand was estimated to conservatively be less than 10 rem (100 mSv). This is well below the level at which any tissue reaction is expected to occur.
Notified R1DO (Bickett), NMSS (Rivera-Capella), NMSS Events Notification (email)
NMED Event Number: 230360
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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
EN Revision Imported Date: 1/26/2024
EN Revision Text: 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."
* * * RETRACTION ON 1/25/24 AT 1139 EST FROM REX GUNDERSON TO THOMAS HERRITY * * *
"Follow-up investigation by an independent Health and Human Services laboratory confirmed that the blind specimen in question was analyzed correctly. The error is thought to have occurred during the preparation of the blind specimen, prior to delivery to the site.
"The NRC Resident Inspector has been notified by the licensee."
Notified R3DO (Orlikowski) and FFD Group (email).
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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
EN Revision Imported Date: 1/8/2024
EN Revision Text: 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
"On January 4, 2024, the Department was notified by the licensee that a Troxler gauge identical to the one they had lost was on the Facebook Marketplace website. The Department contacted the Federal Bureau of Investigation Special Agent (FBISA) it has worked with previously and shared the information. On January 5, 2024, the FBISA worked with the licensee and was able to set up a meeting with the seller and was able to recover the gauge. [The FBISA confirmed by serial number it was the gauge that was stolen]. The licensee returned the gauge to its secured storage location and will perform radiation and leak test on the gauge. The individual who had the gauge stated they did not know it contained radioactive material. They also stated they never manipulated the source rod. Additional information will be provided as it is received in accordance with SA300."
Notified R4DO (Drake), 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 11/11/2023 0:23:00
Event Date 11/10/2023 15:45:00
EN Revision Imported Date: 1/9/2024
EN Revision Text: 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."
"On November 10, 2023, Waterford Steam Electric Station Unit 3 reported in EN 56849 that 19 conduits in engineered safety features actuation system (ESFAS) auxiliary relay cabinets A and B did not have the required fire seals for bay separation. This condition met the criteria involving an unanalyzed condition that significantly affects plant safety.
"Waterford 3 has determined that the ESFAS auxiliary relay cabinets A and B jumper conduits do not require fire seals based on review of an engineering specification that specifies the size and length of conduits which require fire seals to be installed. None of the nineteen affected conduits meet the size and length criteria that would necessitate installation of a fire seal. Based on this, the condition described in EN 56849 is not considered to be an unanalyzed condition that significantly affects plant safety as described in 10 CFR 50.72(b)(3)(ii)(B) and therefore is not reportable.
"The licensee notified the NRC Resident Inspector."
Notified R4DO (Gaddy)
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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
EN Revision Imported Date: 1/31/2024
EN Revision Text: 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
The following updated information was provided by the Texas Department of State Health Services (the Department) via email:
"On January 22, 2024, the Department received information from a steel mill in Texas that it had discovered a radioactive source in a load of scrap metal from San Antonio. The investigation revealed the source to be the 40 millicurie Americium-241 source from the licensee's lost device. The source was still in its holder and secured to the device's structure, on which the device serial number was stamped. The cover, electronics, and the Cesium-137 source and source rod were not attached or located. The load of scrap the mill found the source in has been fully processed and none of their other radiation detectors indicated the presence of the Cesium source. The scrap yard is surveying the areas at their facility. The steel mill noted radiation readings of 400 microR/hr on contact. They have secured the source at their facility and the licensee is making arrangements for retrieval/disposal of it. There is no information or indication of any exposure exceeding regulatory limits. More information will be provided as it is obtained in accordance with SA-300."
Notified R4DO (Agrawal), NMSS Events Notification (Email), ILTAB (Email), CNSNS (Mexico).
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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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 12/15/2023 10:09:00
Event Date 12/14/2023 0:00:00
EN Revision Imported Date: 1/22/2024
EN Revision Text: AGREEMENT STATE - LOST PACKAGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On December 14, 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 December 12, 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 3 mL shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.154 millicuries. It was offered for shipment on December 8, 2023, for delivery to a customer in Clovis, CA on December 11, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for."
Item Number: IL230035
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
"As of 1/11/2024, the package is now back at the pharmacy and in storage for decay. The package did eventually arrive at its intended location but was then sent back to the pharmacy. The inner packaging was damaged but the vial containing radioactive material was undamaged. This matter is now considered closed."
Notified R3DO (Orlikowski), and NMSS via email.
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JAN X-Ray Services, Inc. - Parma MI
Report Date 12/15/2023 16:16:00
Event Date 12/15/2023 6:52:00
EN Revision Imported Date: 1/16/2024
EN Revision Text: NON-AGREEMENT STATE - POSSIBLE EXPOSURE ABOVE LIMIT (TEDE > 5 rem)
The following is a synopsis of information provided by the licensee via phone call:
On December 15, 2023, at 0652 EST, JAN X-ray Services received notification from the laboratory performing regularly scheduled analysis of their employee's thermoluminescent dosimeters (TLDs) that one of the units is indicating an employee received a dose of 5.729 rem. The limit is 5.0 rem. The worker is not normally involved in radiography. The licensee is investigating how the employee received the indicated dose.
* * * RETRACTION ON 01/12/24 AT 0934 EST FROM JAMES MARAMBA TO KERBY SCALES * * *
The following retraction is a summary of information provided by the licensee via email:
JAN X-Ray Services requested the event be retracted based on findings that indicated that the exposure was to whole-body monitoring badge and not the individual.
Notified R3DO (Szwarc) and NMSS Event Notifications via email.
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Illinois Emergency Mgmt. Agency - Gurnee IL
Report Date 12/17/2023 21:31:00
Event Date 12/16/2023 23:00:00
EN Revision Imported Date: 1/29/2024
EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE RACK
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:
"The IEMA-OHS Operations Center was contacted at 1712 CDT on December 17, 2023, by the radiation safety officer for Sterigenics to report a stuck source rack. The rack reportedly became stuck around 2300 on December 16, 2023, with approximately 10 percent of the sources above the pool level. The area was isolated with an additional restricted area established to maintain occupational exposures within limits. At this time, no public or occupational exposures above regulatory limits have been reported. This matter has a 24-hour reporting requirement under 32 Ill. Adm. Code 346.830 which was met by the licensee. IEMA-OHS inspectors will arrive at the facility on 12/18 to evaluate timelines for corrective action and the efficacy of safety systems. Staff will also evaluate the site and review staff dosimetry, potential impacts to source capsule integrity, any anticipated heat impacts, and plans for quality assurance of the impacted system(s)."
Source type: sealed source irradiator Radionuclide: Co-60 Activity: 24 MCi (888 PBq) Model no.: C-188
Illinois report no.: IL230036
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:
"Agency staff arrived at the site on 12/18/23 and surveys indicate no public or occupational exposure levels above normal operation. The source rack is still stuck in the unshielded position. The Agency continues to monitor the situation and will update when additional information is available."
Notified R3DO (Edwards), NMSS (via email).
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:
"The Licensee reports 18 modules (3 rows), constituting 626,000 curies of Co-60, in the B/C cell remain stuck in the unshielded position due to product carts impeding travel of the rack. The sources are below the point of product cart impact. A second IEMA-OHS inspection was conducted to increase coordination on response activities and obtain additional data on the following: security requirements (all operational), radiation levels (700 microR/hour maximum reading), dosimetry procedures (transitioned to digital dosimetry which is read daily and employed at a 40 mrem/day investigational level), total occupational doses to date (20 mrem), exposure rate maps including access points used for radiation hardened cameras, personnel access, pool conductivity (within specifications), updated operations and emergency procedures (confirmed), on site staff and safety culture (satisfactory, additional manufacturer health physics staff brought in to assist), fire hazards (none at this time), status of deionizer (satisfactory), and mitigation planning.
"The Licensee is awaiting cameras and remote vehicles capable of withstanding radiation levels and manipulating product totes. The facility was confirmed to be in a safe and stable condition and ongoing response operations will be coordinated with IEMA-OHS. IEMA-OHS has now transitioned to weekly inspections until the incident is remedied.
"Updates will be provided as they become available."
Notified R3DO (Stoedter), NMSS (via email).
The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:
"The source rack was successfully returned to the shielded position. Sterigenics staff employed engineered tooling to access the stuck rack through roof projections on the evening of 1/25/24. IEMA-OHS staff were on site to observe setup and operations throughout the week. A review of digital dosimetry in use for all phases of the operations indicates there were no occupational exposures in excess of regulatory limits.
"Full report and root cause analysis pending. This report will be updated."
Notified R3DO (Orlikowski), NMSS (via email).
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Paragon Energy Solutions - Fort Worth TX
Report Date 12/19/2023 17:34:00
Event Date 12/18/2023 0:00:00
EN Revision Imported Date: 1/18/2024
EN Revision Text: INITIAL PART 21 REPORT - DEFICIENT FUEL INJECTORS
The following is a synopsis of information was provided by the licensee via phone and email:
Pursuant to 10 CFR 21.21(d)(3)(i), Paragon provided initial notification of a defect associated with the auxiliary feedwater pump diesel engine fuel injectors supplied to Constellation. The injectors were provided to Paragon for refurbishment. Constellation provided Paragon with root cause report # 4703982 on November 12, 2023. The associated failure analysis report documented potential defects with some fuel injectors supplied to Braidwood. These reported deficiencies allowed excessive fuel oil leakage which resulted in diesel lubricating oil system contamination above specified limits. Paragon concluded their evaluation on December 18, 2023, which determined that this condition, if left uncorrected, could contribute to a substantial safety hazard and is reportable in accordance with 10 CFR Part 21.
The extent of condition is limited to the Constellation Braidwood and Byron plants.
Paragon has entered this condition in their corrective action program. Affected injectors at Braidwood have been removed from service and returned to Paragon. Paragon is coordinating with Byron on recommended actions and will follow up with a final notification on or before 1/17/2024.
Paragon Energy Solutions submitted a final report for this event.
Notified R3DO (Orlikowski), R4DO (Josey), and Part 21 (email).
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Rock Island Arsenal - Rock Island IL
Report Date 12/28/2023 12:20:00
Event Date 11/28/2023 0:00:00
FOUND DEPLETED URANIUM PROJECTILE
The following information was provided by the licensee via email:
"In accordance with 10 CFR 20.2201 (a)(1)(ii), the US Army is (telephone) reporting the recovery of a 120 mm depleted uranium (DU) projectile from a landfill in York, PA. [10 CFR 20.2201(a)(1)(ii) - Within 30 days after the occurrence of any lost, stolen, or missing licensed material becomes known to the licensee, all licensed material in a quantity greater than 10 times the quantity specified in appendix C to Part 20 that is still missing at this time.]
"An M829 120 mm DU projectile has 4000 grams of DU, which equates to approximately 1,520 microcuries of U-238. The M829 DU projectile was manufactured in the 1970's - 1980's.
"The Part 20 App C limit for U-238 is 100 microcuries. 100 microcuries times 10 equals 1,000 microcuries.
"The specifics on retrieving the 120 mm DU projectile are as follows:
1. A military explosive ordnance disposal (EOD) team was contacted (Nov 28) and requested to respond to a possible unexploded ordnance (UXO) device at the York County Resource Recovery Center, York, Pennsylvania. 2. The EOD team arrived (Nov 28) and identified the UXO as a 120 mm DU projectile (projectile with tailfin, no propellant, no cartridge case, no explosives, no tracer). 3. EOD placed the item in an ammo storage container and transported the item to Joint Base McGuire-Dix-Lakehurst, New Jersey for safe storage. 4. US Army Joint Munitions Command DoD Low Level Radioactive Waste (LLRW) Lead Agent was notified on or about December 1. 5. A member of the LLRW team is at Joint Base McGuire-Dix-Lakehurst on December 27-28 to package and ship the DU projectile to our Morris Consolidation Facility (NRC License 12-00722-15), Rock Island Arsenal, Rock Island, IL, for safe storage and eventual disposal. 6. At this time, we have no further information or evidence to determine how the item arrived at the Pennsylvania landfill. 7. There are no clear identification markings that we have viewed on pictures (so far) that will help us to determine where the device was stored or possessed. We will conduct a more thorough visual exam once we have the item in our possession at our Rock Island Arsenal facility (Morris Consolidation Facility).
"In accordance with 10 CFR 20.2201 (b), a written report will be provided to the NRC within 30 days after making the telephone report."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Swipe test of the ordinance revealed no loose contamination. Dose rate on contact is 1-2 mrem/hr, so exposure exceeding limits to public is unlikely.
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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Watts Bar - Spring City TN
Report Date 12/28/2023 18:55:00
Event Date 12/28/2023 11:29:00
EN Revision Imported Date: 1/5/2024
EN Revision Text: UNANALYZED CONDITION
The following information was provided by the licensee via email:
"Plant alignment caused an unanalyzed condition regarding unit 1 and unit 2 Appendix R procedures.
"[Watts Bar Nuclear] (WBN) unit 1 and unit 2 Appendix R procedures require manual operator action times including [volume control tank] (VCT) isolation. They are calculated with an assumed hydrogen cover gas constant at 20 psig. This is to preclude hydrogen ingestion into the charging pumps with an operator action time of 70 minutes. Due to recent lower hydrogen concentration in the [reactor coolant system] (RCS), [unit 2] VCT hydrogen regulator set point was increased to 28 psig. This increased pressure set point invalidated the initial assumptions made in the Appendix R calculations for manual operator action times.
"WBN unit 1 VCT hydrogen regulator was also verified high out of band at 22 psig.
"WBN has restored unit 1 and unit 2 VCT hydrogen regulators to the required specification.
"The NRC Resident Inspector has been notified of this condition."
The following information was provided by the licensee via email:
"In accordance with NUREG-1022, Section 2.8 and Section 4.2.3, WBN is retracting the previous report in EN 56910 pursuant to 10 CFR 50.72(b)(3)(ii)(B). An analysis of the postulated Appendix R Fires that could cause ingestion of cover gas into the charging pumps would be mitigated through current plant processes and procedures and therefore does not present a significant threat to fire safe shutdown. Based on sufficient margin and existing operator actions, the event does not represent a condition that significantly degrades plant safety under 10 CFR 50.72(b)(3)(ii)(B). Therefore EN 56910 is being retracted.
"The NRC Resident Inspector has been notified of this retraction."
Notified R2DO (Miller).
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Illinois Emergency Mgmt. Agency - Park Ridge IL
Report Date 12/29/2023 18:53:00
Event Date 12/29/2023 0:00:00
AGREEMENT STATE REPORT - UNDERDOSE
The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) via email:
"A medical administration of Y-90 microspheres that took place on 12/29/23. Advocate General Hospital in Park Ridge, IL, failed to deliver nearly 100 percent of the intended dose. There was no patient impact and the treatment will be rescheduled.
"The radiation safety officer (RSO) for Advocate General Hospital, contacted the IEMA-OHS Operations Center on 12/29/23, to report the above described medical underdose. The patient had been prescribed two administrations of Theraspheres Y-90 microspheres. The first administration went without issue. The second administration (from a separate written directive) called for 3.5 GBq to segment 8 of the liver. Post-administration surveys indicated that nearly 100 percent of the microspheres were still contained within the delivery tubing. The patient and referring physician were immediately notified. The RSO and the authorized user (AU) believed that the time between dose preparation and delivery may have been a contributing issue, but the investigation is ongoing. This matter is reportable by the next calendar day. The licensee met reporting requirements. Inspectors will not be dispatched until next week as there is no immediate radiation safety concern. This report will be updated as additional information becomes available."
Illinois Event Number: IL230037
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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Saint Lucie - Ft. Pierce FL
Report Date 01/03/2024 15:38:00
Event Date 01/03/2024 12:57:00
PRESSURE BOUNDARY DEGRADED / BOTH TRAINS OF HIGH PRESSURE SAFETY INJECTION INOPERABLE
"At 1257 EST on January 3, 2024, it was determined that a class 1 system barrier had a through wall flaw with leakage. The leakage renders both trains of high pressure safety injection inoperable. The unit is being cooled down to cold shutdown to comply with technical specifications.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A) and 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 Officer Report Guidance:
At the time of the discovery, the unit was shutdown in mode 3. The unit was experiencing signs of reactor coolant system leakage and a shutdown was initiated in order to search for possible sources. The unit is currently cooling down and proceeding to mode 5, where the safety function is not required.
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Engine Systems, Inc. - Rocky Mountain NC
Report Date 01/04/2024 16:00:00
Event Date 11/27/2023 0:00:00
EN Revision Imported Date: 1/18/2024
EN Revision Text: PART 21 - EMD CYLINDER LINER WITH BORE DEFICIENCY
The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:
An edge or lip in the bore of an EMD (Brand name: Electro-Motive Diesel) cylinder liner prevented successful installation of the corresponding power assembly on an emergency diesel generator set. The lip is located axially at the bottom of the inlet ports and is present around the circumference of the bore. The EMD model 645E4 is a 2-stroke engine with air inlet ports in the wall of the cylinder liner. As the piston travels below the inlet ports, air box pressure scavenges and replenishes air to the power assembly.
Installation of the power assembly requires lowering the piston through the liner in order to secure the connecting rod to the crankshaft. During this process the piston could not be lowered below the inlet ports due to the piston rings catching on the lip. The power assembly was not installed and therefore there was no safety hazard; however, if the defect had gone undetected there was the potential to damage engine components and possibly reduce load carrying capacity of the engine.
The extent of the condition is this single cylinder liner, P/N 9318833, S/N 20M0938 used in the power assembly at Tennessee Valley Authority (TVA) - Sequoyah Nuclear Plant, Serial Number: 23H1306.
Corrective Actions: For TVA-Sequoyah: No action required; the power assembly has been returned to ESI. For ESI: To prevent reoccurrence, ESI has revised the dedication package to include verification that bore machining is continuous along the entire length and no edges or lips are present. The revision was implemented on December 6, 2023.
Engine Systems, Inc. sent a revision to change the date of defect identification to November 27, 2023.
Notified R2DO (Miller), Part 21 Group (email)
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Perry - Perry OH
Report Date 01/05/2024 15:56:00
Event Date 01/05/2024 15:52:00
EN Revision Imported Date: 1/9/2024
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"At 1552 [EST] on 01/05/2024, Perry Nuclear Power Plant reported elevated levels of tritium in the underdrain system to the state of Ohio as a non-voluntary reporting of tritium. An investigation is currently ongoing to identify the cause of the elevated tritium levels. The tritium levels in this location do not exceed any NRC regulations or reporting criteria.
"This notification is being made solely as a four-hour, non-emergency notification for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
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Davis Besse - Oak Harbor OH
Report Date 01/05/2024 18:18:00
Event Date 01/05/2024 10:40:00
EN Revision Imported Date: 1/18/2024
EN Revision Text: EMERGENCY VENTILATION SYSTEMS INOPERABLE
The following information was provided by the licensee via phone and email:
"At approximately 1111 EST on 01/05/2024, a mechanical penetration room door was discovered unlatched. Based on security badge history, the door was last opened at 1040 EST. The unlatched door resulted in both trains of the station emergency ventilation system being inoperable due to being unable to maintain the shield building negative pressure area. With both trains simultaneously inoperable, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The door was closed and verified latched upon discovery to restore the systems to an operable status.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"The station emergency ventilation system (EVS) was tested with the mechanical penetration room door unlatched. The test results showed that the station EVS attained the required negative pressure in the shield building within the time required by the Technical Specifications. Therefore, the station EVS remained operable with the door unlatched, and this issue did not prevent the system from fulfilling its safety function to control the release of radioactive material and mitigate the consequences of an accident.
"The NRC Resident Inspector has been notified."
Notified R3DO (Orlikowski)
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St Luke's Regional Medical Center - Boise ID
Report Date 01/09/2024 13:18:00
Event Date 01/08/2024 0:00:00
MEDICAL EVENT - Y-90 UNDERDOSE
The following information was provided by St. Luke's Regional Medical Center via email:
"The authorized user was performing a yttrium-90 (Y-90) procedure on January 8, 2024. The prescribed activity to be administered was 3.9 GBq, per the written directive. During the procedure, the authorized user paused the administration when they thought that there may have been a leak in one of the connection points. After verifying that there was no leakage occurring, administration resumed as normal. The post-procedure assay of tubing and vial showed that only 3.1 GBq was delivered. There was no spill involved and all remaining activity was contained within the delivery tube.
"Actual dose to the target volume was still at an appropriate range, per the provider. It is not expected that an additional delivery of Y-90 will be scheduled at this time.
"A representative from TheraSphere has been contacted for post-administration inspection of procedure and equipment."
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.
"After further review of the administration records, patient and organ doses, and administered activities, along with a better understanding of the Y-90 Licensing Guidance, we are requesting that this event notification be withdrawn."
Notified R4DO (Gaddy), NMSS Events (email).
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Texas Dept of State Health Services - Seadrift TX
Report Date 01/09/2024 17:10:00
Event Date 01/09/2024 0:00:00
AGREEMENT STATE - SHUTTER STUCK IN OPEN POSITION
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On January 9, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that during routine checks, the shutters on three Vega America SH-F2 source holder failed to close. Open is the normal operating position for the gauges. Each gauge contains a 200 millicurie cesium-137 source. The gauges do not create an exposure risk to any individual. The RSO stated they have contacted a service provider for repairs to the gauges. Additional information will be provided as it is received in accordance with SA300."
Texas Incident Number: I-10076
NMED Number: TX240001
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California Radiation Control Prgm - Lake Forest CA
Report Date 01/09/2024 20:10:00
Event Date 01/08/2024 0:00:00
AGREEMENT STATE - STOLEN GAUGE
The following information was provided by the California Department of Public Health, Radiation Health Branch via email:
"On January 8, 2024, the licensee's radiation safety officer contacted the California Office of Emergency Services to report a moisture/density gauge was stolen from a vehicle (Honda Pilot SUV) that was parked at the operator's residence. The gauge transport case was locked, as was the gauge inside the case, and the case was secured to the frame of the locked vehicle with a lock and chain. The gauge was a CPN model MC-3, serial number M339028680 containing 10 mCi Cs-137 (nominal) and 50 mCi Am:Be-241 (nominal). A police report was submitted to the Orange County Sherriff's Department. An advertisement has been submitted to the Orange County Register with a reward for return of the gauge. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
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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V. C. Summer - Jenkinsville SC
Report Date 01/10/2024 8:18:00
Event Date 11/12/2021 0:00:00
EN Revision Imported Date: 1/18/2024
EN Revision Text: PART 21 - EATON-CUTLER HAMMER RELAY ON EMERGENCY DIESEL FAILED
The following information was provided by the licensee via email and phone call:
"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a control power circuit monitor (CP1) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.
"On November 12, 2021, the 'B' EDG was rendered inoperable when its CP1 relay de-energized due to mechanical binding of the magnet carrier assembly. The binding was caused by a manufacturing defect that allowed heat-induced shrinkage to reduce the clearance between the magnet carrier and adjacent coil housing and base, preventing it from moving freely. VCSNS replaced the affected relay and restored operability of its 'B' EDG.
"Manufacturer/Model: Eaton-Cutler Hammer D26MRD30A1
"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. 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:
The plant has notified the manufacturer. It is not known if any other plants are affected by this defect.
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V. C. Summer - Jenkinsville SC
Report Date 01/10/2024 8:18:00
Event Date 05/05/2021 0:00:00
EN Revision Imported Date: 1/18/2024
EN Revision Text: PART 21 - GOULD FIELD FLASH RELAY ON EMERGENCY DIESEL FAILED
The following information was provided by the licensee via email and phone call:
"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a field flash contactor (K2) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.
"During testing on May 5, 2021, the 'B' EDG was rendered inoperable when its K2 relay coil switch exhibited intermittent binding due to insufficient clearances of the switch actuator from the protective case and plastic switch molding. The inadequate clearances resulted in accelerated loss of graphite lubrication at these locations, which led to mechanical binding. VCSNS replaced the affected relay and restored operability of its 'B' EDG.
"Manufacturer/Model: Gould F10NOCLD1 DC coil switch
"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. 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:
The licensee did not notify the intellectual property owner because the manufacturer is no longer operating or in business. They are not aware of other plants that utilize this coil switch.
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WA Office of Radiation Protection - Richland WA
Report Date 01/10/2024 13:13:00
Event Date 12/20/2023 0:00:00
AGREEMENT STATE REPORT - IMPROPER SHIPMENT HANDLING
The following is a summary of information provided by the Washington State Department of Health via email:
A shipment from Environmental Management and Controls, Inc. (EMC) to a commercial low-level radioactive waste (LLRW) disposal site near Richland, Washington, was identified as violating Department of Transportation regulations, Washington administrative code, and the LLRW disposal site license. Specific violations were (1) improper transportation vehicle utilized for a shipment with surface radiation greater than 200 mrem/hr, (2) two containers arrived with higher than manifested surface radiation levels, and (3) one container arrived with lower than manifested radiation levels.
The Washington Department of Health issued a notice of violation to the licensee which detailed required remediation including root cause analysis, corrective action plan, and a quality assurance plan in a written response. The licensee use of the LLRW disposal site was also suspended pending a passing inspection by the state of Washington. This incident was not a contamination event and is under investigation.
Washington Incident Number: WMS-DOT-23-07
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Texas Dept of State Health Services - Alvin TX
Report Date 01/11/2024 13:32:00
Event Date 01/11/2024 0:00:00
AGREEMENT STATE REPORT - SOURCE STUCK IN UNSHIELDED POSITION
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On January 11, 2024, the licensee's service company reported to the Department that when the licensee's radiation safety officer was verifying a lock-out on an Ohmart SHLM-BR-2 fixed gauge, containing a 1,000 millicurie cesium-137 source, he found that the source had separated from the insertion rod and therefore could not be returned to the fully shielded position. The gauge operates by rod insertion of the source into a housing that is inside the reactor unit. The licensee has contacted the manufacturer to get the gauge repaired. There have been no exposures as a result of this event, and none are expected due to the location of the gauge. The intended work on the unit has been postponed until the gauge is repaired and the source can be returned to the fully shielded position. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident #: 10079 Texas NMED # TX240002
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Illinois Emergency Mgmt. Agency - Romeoville IL
Report Date 01/12/2024 11:12:00
Event Date 12/11/2023 0:00:00
EN Revision Imported Date: 1/25/2024
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was received from the Illinois Emergency Management Agency (the Agency) via email.
"On Thursday, January 11, 2024, the Agency received written notification from the radiation safety officer (RSO) at a nuclear pharmacy of an elevated dosimetry badge report for a worker in Romeoville, IL. The whole body dose reported would exceed the occupational limits in 32 Ill. Adm. Code 340.210. The information provided indicates the worker received 162,926 mrem during the week of December 11, 2023, which exceeds the annual limit of 5,000 mrem. This is a reportable incident under 32 Ill. Adm. Code 340.1230, and will be reported to NRC and NMED. While an investigation is underway to determine the cause of this overexposure, after speaking with the RSO, it is likely the result of a spill/splash event. If this spill resulted in an occupational exposure in excess of the limits, it is also reportable under 32 Ill. Adm. Code 340.1220(b) and will be reported to the NRC today. In the next week, Agency inspectors will perform a reactionary inspection to inspect the adequacy of the licensee's investigation, compliance with the Agency's regulations, and determine the root cause."
NMED Item Number: IL240002
"A reactive inspection was conducted on 1/19/24. Reportedly on 12/11/2023, the technician noted a pressure issue within an F-18 synthesis cell. While containing approximately 9.9 Ci of F-18, the technician opened the synthesis cell to diagnose the issue. The magnitude of the resulting whole-body exposure is an unknown component of the reported 162 rem. Extremity badges reported only 447 mrem for this wear period. Movement of the synthesis tubing resulted in an undetermined quantity of F-18 contaminating the upper chest, neck and underarm of the technician.
"The technician reports feeling `wetness' as a result of the contamination event. Licensee staff estimated 3-5 minutes passed before decontamination efforts were initiated. Initial survey readings on the technician were 12 mR/hour from the neck and chest after shirt and lab coat were removed. No assessment of uptake/intake was performed, nor were any bioassays performed. No medical assessment was performed for blood changes or impacts to the skin. The corporate Radiation Safety Officer (RSO) was not notified until the dosimetry report was returned nearly 30 days later. At the time of the inspection, no medical conditions had emerged that were indicative of radiation exposure. The technician's badge was not evaluated for contamination, simply assumed to be contaminated and sent for reading. The badge did not show evidence of contamination when received by the dosimetry processor - however, that may have been due to decay.
"The licensee did not cease or limit any work with radioactive materials assigned to the individual. The employee has continued work in 2024, as the elevated exposure was attributed to the 2023 annual limit. Inspectors believe there is some portion of the exposure recorded on the optically stimulated luminescence (OSL) [dosimeter] that was not a true whole-body exposure (resulting from contamination and storage in the bunker). However, the lack of adequate records or timely assessment makes any quantification impossible. While an undetermined fraction of the recorded 162 rem was likely not a whole-body dose to the technician; there are certainly exposure avenues which could have led to at least 5 rem whole body. Until data is presented which indicates otherwise, this matter is being treated as an occupational exposure in excess of the 5 rem limit. While 16 mL containing 9.9 Ci of F-18 was in the synthesis cell, there is no accurate account on the amount of activity deposited on the technician's skin/clothing. (The syringe containing the F-18 was not used and allowed to decay within the cell. No volume or activity assessment performed). The only data allowing an estimate is the initial 12 mR/hour exposure rate, which would be close to 13 microcuries of activity incident to the detector active surface area. I.e., if the badge was surveying 12 mR/hour at one inch, that would equate to approximately 13 microcuries of F-18 incident to the probe. The exposure to the OSL over the mean life of this F-18 is estimated at 20 Rem.
"No data is available to estimate committed dose. While a VARSKIN+ analysis is pending, initial estimates indicate skin dose is likely less than 10 percent of the occupational limit. If the entirety of the 162-rem exposure was suspected to have come from contamination, the initial contamination of the badge would have needed to exceed 100 microcuries. This would have an exposure rate in excess of 100 mR/hour - inconsistent with the recorded exposure rates. Occupational whole body dose year to date, prior to this incident, was recorded at 974 mrem. Average weekly whole-body dose was 19 mrem.
"The area was isolated due to the spill and this incident is likely also reportable under 32 Ill. Adm. Code 340.1220(b), equivalent to 10 CFR 20.2202(b). The investigation is still in process."
Notified R3DO (Orlikowski), NMSS Event Notifications (Email), and NMSS/MSST Division Director (Williams)
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Minnesota Department of Health - Bovey MN
Report Date 01/12/2024 14:28:00
Event Date 01/12/2024 0:00:00
AGREEMENT STATE REPORT - LOST FIXED GAUGE
The following information was provided by the Minnesota Department of Health (MDH) via email:
"The MDH was notified on 1/12/2024, by PPL Group LLC, a representative for ERP Iron Ore, LLC Plant 2, of a missing/lost fixed gauge from the licensee's location listed above. PPL Group LLC contracted a waste broker to dispose of the registered generally licensed devices located at the plant. The completed inventory indicates that one device is missing. The missing device is a Berthold model LB74400-CR, serial number 0240/12 containing a 50 mCi Cs-137 source (assay date of 3/20/2014).
"MDH will do an inspection next week and will continue to keep the NRC informed of the status of our investigation."
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Arizona Dept of Health Services - Tucson AZ
Report Date 01/12/2024 19:18:00
Event Date 12/14/2022 0:00:00
AGREEMENT STATE REPORT - LOST CARBON-14 RADIOACTIVE MATERIAL
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On January 12, 2024, the Department received notification from the licensee that 568 millicuries of C-14 was found to be missing on December 14, 2023. The licensee stated that the radioactive material was last seen sometime in July of 2023 during their last manufacturing run. The Department has requested additional information and continues to investigate the event."
Arizona Incident: 24-001
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Louisiana Radiation Protection Div - New Orleans LA
Report Date 01/14/2024 19:21:00
Event Date 01/12/2024 0:00:00
AGREEMENT STATE REPORT - Y-90 INCOMPLETE DOSE
The following information was provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:
"This medical event was reported [to the LA DEQ] on January 13, 2024, at 2259 [CST]. On January 12, 2024, the licensee was performing a Y-90 brachytherapy medical procedure. A tubing failure (catheter) resulted in an incomplete dosing of the patient. The catheter became blocked up with the undelivered radiopharmaceutical Y-90. The Y-90 was contained within the administrating device's tubing. There was no spill involved. The Y-90 being used was TheraSphere from Boston Scientific.
"Approximately 23 percent of the radiopharmaceutical Y-90 was delivered to the patient. No effect on the individual was determined. The remainder of the prescribed dose will be administered to the patient at a later date."
LA DEQ Event Report ID: LA20240001
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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Univ Of New Mexico (NEWM) - Albuquerque NM
Report Date 01/17/2024 19:20:00
Event Date 01/17/2024 16:16:00
NON-POWER REACTOR - ADMINISTRATIVE TECH SPEC VIOLATION
The following is a synopsis of information provided by the licensee via email and phone call:
On January 17th, at 1616 MST, the Reactor Supervisor violated Technical Specification (TS) 6.1.12.a. During an NRC exam, a trainee was operating the reactor under the supervision of the reactor supervisor. The doorbell rang, and the supervisor requested that the reactor be scrammed and the console power be turned off, which was accomplished. The supervisor then stepped out of the reactor room, but the key remained in the console, thus the reactor was unsecured. TS 6.1.12.a requires one reactor operator or reactor supervisor to be in the room when the reactor is not secured.
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Columbia Generating Station - Richland WA
Report Date 01/18/2024 21:38:00
Event Date 01/18/2024 12:04:00
RESIDUAL HEAT REMOVAL DEGRADED DUE TO SERVICE WATER LEAKAGE
The following information was provided by the licensee via email:
"On January 18, 2024, at 0030 PST, diesel generator 2 (DG2) was shut down following a monthly surveillance run. Subsequently, a leak was discovered in the DG2 building. Service water pump '1B' was secured at 0117, effectively stopping the leak. The leak was determined to be service water coming from a diesel generator mixed air cooling coil. Service water system 'B' and DG2 were subsequently declared inoperable at 0135. After discussion with engineering, it was identified that the amount of service water leakage from the cooling coil was assumed to be greater than the leakage allowed by the calculation to assure adequate water in the ultimate heat sink to meet the required mission time of 30 days.
"At 1204, it was determined that entry into Technical Specification 3.7.1 condition D was warranted since the assumed leakage from the cooling coil could exceed the calculated allowed value. At 1238, the control power fuses for service water pump '1B' were removed. DG2 and service water system 'B' were declared unavailable, and the technical specification condition for the inoperable ultimate heat sink was exited. With the control power fuses removed, the pump is kept from auto starting, effectively preventing the leak and ensuring the safety function of the ultimate heat sink is maintained while the cooling coil is repaired or replaced.
"Due to the leakage assumed greater than the calculated allowable value this condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition and per 10 CFR 50.72(b)(3)(v)(B) as an event or condition that could have prevented fulfillment of the safety function of structures or systems that are needed to remove residual heat.
"There was no impact to the health and safety of the public."
The NRC Resident has been notified.
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Maine Radiation Control Program - Windsor ME
Report Date 01/19/2024 12:53:00
Event Date 12/22/2023 0:00:00
AGREEMENT STATE REPORT - LOST SOURCE
The following report in part was received via email from the Maine Radiological Control Program [MRCP]:
"The licensee service manager contacted MRCP by phone on December 22, 2023, to report that a source could not be accounted for during a monthly source inventory. The service manager reported that the missing source had been observed in the service area of the licensee's facility in Windsor, ME, approximately two weeks before the inventory identified it as missing. The missing source had been removed from a customer's machine and replaced with a new source. The missing source is an 8 mCi Ni-63 source with serial number 09-6700 from Isotope Products Laboratories, Valencia, CA. The source was still in its sealed form inside the detector housing which is assembled with tamper-proof screws. Once the source was determined unaccounted for in the monthly inventory, a team of licensee employees searched the entire facility, spending in excess of 20 man-hours trying to locate it. The licensee's best assumption is that the missing source may have been accidentally disposed of during a recent shop cleaning. MRCP conducted a site inspection on January 2, 2024, to gather information regarding the incident. A licensee service technician was able to trace the waste stream which is routinely deposited in a dumpster and is then transported to the Waterville, ME, transfer station. As of January 19, 2024, the missing Ni-63 source remains lost."
Maine Event Report Number: ME 2023-002
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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WA Office of Radiation Protection - Seattle WA
Report Date 01/22/2024 18:11:00
Event Date 01/19/2024 12:00:00
EN Revision Imported Date: 2/1/2024
EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MISADMINISTRATION
The following is a summary of information received via email from the Washington Office of Radiation Protection:
On the afternoon of Friday, January 19th, a Pluvicto (radiopharmaceutical) dose was not administered properly. A typical administered dose may have up to 2 to 4 mCi of residual activity after a 200 mCi administration. However, for this administration there was 43 mCi of residual activity and only 149 mCi of calculated administered activity for a 200 mCi prescribed dose. Pluvicto is a six fraction, six administration regimen with about six weeks between each administration, and this was the patient's fourth fractional dose. Treated as a single administration treatment, this constitutes a medical event as the dose administered activity of 149 mCi is more than 20% less than the 200 mCi prescribed dose. The final report will be sent in 15 days.
Washington Event Number: WA-24-003
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.
A lutetium 177 (drug name: Pluvicto) dose was prescribed to be 200 mCi. The calculated dose administered to the patient was about 149 mCi, based upon the measured residual. The underdosing occurred due to a method of folding and crimping the intravenous tube with a hemostat and gauze instead of utilizing the kit provided clamp. The hospital supply chain of the intravenous kit was recently changed and the needed clamp was thought to be missing. To prevent future crimping of the intravenous tube, the use of hemostat and gauze will no longer be used.
This dose was the fourth dose of six prescribed to the patient, with six weeks between each administration. There is no expected change in the patient's treatment or prognosis based on the underdosing of the fourth fraction of six and no additional actions are required.
Final report will be sent in 15 days.
Washington Event Number: WA-24-003
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.
Notified R4DO (Agrawal) and NMSS (email).
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Louisiana Radiation Protection Div - Gibson LA
Report Date 01/23/2024 18:07:00
Event Date 01/22/2024 14:00:00
TWO SUSPECTED ORPHAN GAUGES FOUND
The following information was provided by the Louisiana Department of Environmental Quality (LDEQ) via email:
"On January 22, 2024, at approximately 1400, Central Standard Time (CST), an unidentified nuclear gauge of roughly cylindrical dimensions and less than 30 cm in length and 12 cm in width was detected by the entrance gate radiation monitor at the Louisiana Scrap Metal facility (LA Scrap) located in Gibson, LA in Terrebonne Parish. Facility scrap surveyors were immediately dispatched to more close survey the suspected gauge using Ludlum Model 3 survey instruments with external probes. During this time an additional suspected nuclear gauge, similar in design and overall dimensions to the first, was discovered by the facility's scrap surveyors. Surface radiation readings of approximately 0.9 to 1.2 mR/hr were observed at the surface of both devices. No identifying markings, labels or tags were noted on the gauges' surfaces, and both devices appeared to have sustained significant corrosion to their housings, which nonetheless appeared intact. The devices were believed by the reporting party to have originated with scrap from the disassembly of a 220-foot marine vessel purchased by LA Scrap from a Florida scrap broker. The above incident was reported via the LDEQ Radiation Hotline at approximately 1335 CST on January 23, 2024. The facility is awaiting identification of the devices' isotope(s) (to be provided by the LDEQ) prior to contracting with BBP Sales, Louisiana Radioactive Material License, LA-10799-L01, for inspection, leak testing, packaging, and disposal of the devices.
"The facility environmental health and safety (EHS) manager, stated that the gauges have been enclosed in a bucket of moist dirt and secured within an area on site with restricted access. Facility workers were advised by the EHS manager to stay clear of the area in the meantime."
LA Event Report ID: LA240002
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California Radiation Control Prgm - Santa Clara CA
Report Date 01/23/2024 20:20:00
Event Date 01/22/2024 22:00:00
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE The following information was provided by the California Department of Public Health Radiologic Health Branch (RHB) via email:
"On 1/23/24, California Governor's Office of Emergency Services (CAL OES), contacted RHB to report a stolen moisture density gauge. Per the CAL OES report, at around 2200 PST on 01/22/24, a portable gauge was stolen from the bed of a parked truck belonging to the reporting party.
"On 1/23/24, RHB contacted the reporting party (gauge user) and learned the following:
"The stolen gauge is a CPN Model 131, serial number, MD 00705803, containing 10 mCi of Cs-137 and 50 mCi of Am-241. On 1/22/24, around 2030 PST, the gauge user was feeling ill and was not able to return the gauge to the storage unit and decided to leave it in his work truck parked at his residence. On the next day morning (1/23/24) at around 0700, the user drove his truck to a job site in Palo Alto, CA, opened the cover of the bed of the truck and discovered that the gauge was stolen from the vehicle. There were no signs of a break-in, so the truck bed may have been left unlocked. The gauge storage box was chained through two handles and was attached to the bed of the truck. On 1/23/24, at around 1400 PST, the gauge user notified the Daily City Police Department of the stolen gauge (Report No. T24000071).
"RHB will be following up on this investigation."
CAL OES Report CENTRL No.: 24-0397
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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Watts Bar - Spring City TN
Report Date 01/27/2024 23:39:00
Event Date 01/27/2024 21:41:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 2141 EDT, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The trip was not complex, with all systems responding normally post-trip.
"Operations responded and stabilized the plant. Decay heat is being removed using the auxiliary feedwater and steam dump systems. Unit 1 is not affected.
"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"All control rods are fully inserted. The cause of the turbine trip is being investigated."
The licensee notified the NRC Resident Inspector.
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Peach Bottom - Philadelphia PA
Report Date 01/29/2024 13:32:00
Event Date 01/29/2024 12:02:00
EN Revision Imported Date: 2/1/2024
EN Revision Text: AUTOMATIC REACTOR SCRAM
The following information was provided by the licensee via email:
"At approximately 1202 EST on 01/29/24, unit 2 experienced a reactor scram caused by a main turbine trip. Investigation is still ongoing."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All control rods were fully inserted. The licensee indicated that the turbine trip may have been caused by a power load imbalance, however the cause of the incident is under investigation. The scram was not complex.
Decay heat is currently being removed thru bypass valves dumping to the main condenser. Initially unit 2 lost the use of the bypass valves due to lack of condenser vacuum. Unit 2 used the high pressure coolant injection (HPCI) system in the condenser storage tank (CST) to CST mode to remove decay heat. Residual heat removal was used to keep the torus cool. Condenser vacuum was regained and unit 2 is back to removing decay heat with the turbine bypass valves.
There was no impact to unit 3.
The licensee confirmed there was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
The following information was provided by the licensee via email:
Licensee adds 8-hour non-emergency 10 CFR 50.72(b)(3)(iv)(A) specified system actuation report to original 4-hour non-emergency 10 CFR 50.72(b)(2)(iv)(B) RPS Actuation report. "At approximately 1202 EST on 01/29/24, unit 2 experienced a reactor scram by a main turbine trip. All control rods inserted. Reactor core isolation cooling system (RCIC) was manually initiated for level control. HPCI was manually initiated for pressure control. Primary containment isolation system (PCIS) Group II and III isolations occurred [specified system actuation]. Investigation is ongoing."
The NRC Resident Inspector has been notified.
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Grand Gulf - Port Gibson MS
Report Date 01/29/2024 16:56:00
Event Date 01/29/2024 10:05:00
HIGH PRESSURE CORE SPRAY FAILURE The following information was provided by the licensee via email: "At 1005 CST on January 29, 2024, Grand Gulf Nuclear Station was conducting surveillance testing on the high pressure core spray system. During testing, the 1E22F012 minimum flow valve failed to return to the full closed position. The valve went from full open indication to dual indication.
"The event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition which could have prevented the fulfillment of a safety function.
"Troubleshooting is in progress.
"The NRC Senior Resident has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All off-site power is available. No other systems are out of service and there are no compensatory measures taken. There is no increase to plant risk.
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Limerick - Philadelphia PA
Report Date 01/30/2024 18:56:00
Event Date 01/30/2024 9:37:00
FITNESS FOR DUTY
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On January 30, 2024, a non-licensed employee supervisor, after investigation, was determined to be in involved with a controlled substance. The employee's access to the site has been placed on administrative hold, pending further investigation.
The NRC Resident Inspector has been notified.
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