💾 Archived View for federal.cx › nukenews.gmi captured on 2024-06-16 at 12:15:36. Gemini links have been rewritten to link to archived content
⬅️ Previous capture (2024-05-10)
-=-=-=-=-=-=-
8b,dPPYba, ,adPPYba, 8b db d8 ,adPPYba, 88P' `"8a a8P_____88 `8b d88b d8' I8[ "" 88 88 8PP""""""" `8b d8'`8b d8' `"Y8ba, 88 88 "8b, ,aa `8bd8' `8bd8' aa ]8I 88 88 `"Ybbd8"' YP YP `"YbbdP"'
Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
--------------------
Ametek Solidstate Controls -
Report Date 02/09/2024 16:13:00
Event Date 12/13/2023 0:00:00
EN Revision Imported Date: 5/20/2024
EN Revision Text: PART 21 - INTERIM REPORT FOR OIL FILLED CAPACITORS
The following is a synopsis of information that was provided by AMETEK Solidstate Controls Inc. via email:
This component (07-020139-10) is a 13 micro-Farad AC oil filled capacitor. During operation in an inverter, oil may be visible on, around, or dripping from the capacitor or its mounting bracket or tray. If allowed sufficient time, enough oil will leak from the capacitor that it will short internally and fail. Time required for the failure could be greater than the recommended 10-year preventative maintenance cycle for this part.
AMETEK Solidstate Controls has not been able to determine a definitive cause of the failure, but is working to do so.
These capacitors are generally part of a larger capacitor bank. The failure would result in a reduction of output voltage that is directly proportional to the number of capacitors in the bank that fail. Any single capacitor failure would be less than a 3 volt decrease in output voltage.
Users of these capacitors should visually inspect any equipment containing the capacitor part number stated above for evidence of an oil leak. A review of the output voltage for the parent equipment for any consistent decrease in voltage of 0-3V may serve as an indication of capacitor failure. The user should notify AMETEK Solidstate Controls if any oil is observed during inspection.
Corrective actions should be established by May 2024.
Affected plants are not listed.
* * * UPDATE ON 05/17/24 AT 1305 EDT FROM ZACHARY RUMORA TO KAREN COTTON * * *
FINAL REPORT FOR OIL FILLED CAPACITORS
AMETEK Solidstate Controls Inc, (SCI) has completed their evaluation of the deviation described in their interim report submitted on February 9, 2024, and concluded that there was no way of recreating the potential defect and no evidence of a broad defect with the general design, manufacture, or use of the capacitor. However, they identified hypothesized causes of the failure and corrective actions to mitigate failure risks. AMETEK SCI also identified the end users that may be potentially affected.
The affected plants are Duke Energy; Oconee and Catawba, TVA; Browns Ferry and Watts Bar; Georgia Power, Vogtle 1 and 2; Dominion; Surry; and South Texas Nuclear Operating Company.
Notified R2DO(Miller), R4DO(Josey) and Part 21/50.55 Reactors (email)
--------------------
Paragon Energy Solutions - Fort Worth TX
Report Date 04/16/2024 23:29:00
Event Date 02/15/2024 0:00:00
EN Revision Imported Date: 6/3/2024
EN Revision Text: INITIAL PART 21 REPORT - POTENTIAL DEFECT WITH CIRCUIT BREAKER
The following information was provided by the licensee via email:
"Pursuant to 10CFR 21.21 (a)(2), Paragon Energy Solutions, LLC is providing this interim notification of ongoing analysis for Part 21 reportability of a potential defect with a Schneider Electric Medium Voltage VR Type Circuit Breaker Part Number V5D4133Y000.
"On February 15, 2024, Paragon completed initial documentation of a potential defect with the subject circuit breaker in which Duke-Oconee had identified failure to close on demand or delayed operation to close with extended application of the remote closing signal. Since the primary safety function of the circuit breaker is to close and maintain continuity of power to downstream loads, failure to close could potentially contribute to a substantial safety hazard.
"This is the first reported instance of this failure mode, and Paragon suspects the issue to be related to aging of the circuit breaker's lubrication. Paragon requires more time to complete testing and analysis to confirm the failure mode and determine reportability.
"Date when evaluation is expected to be complete: 5/03/2024."
Affected licensee: Oconee. Paragon is currently evaluating the extent of condition as it pertains to other plants and equipment that may utilize the same or similar circuit breakers.
Due to inconclusive results, the completion date of the testing is revised to 05/31/2024.
Notified R2DO (Miller) and Part 21/50.55 Reactors (email).
The following is a synopsis of the updated information received:
The only known affected licensee is Oconee. Paragon is evaluating if the issue pertains to other equipment or plants.
Paragon has conducted additional testing with the original equipment manufacturer, Schneider Electric, but will require more time to complete their evaluation. Evaluation is expected to be complete by 6/30/2024.
Other circuit breaker types that may be affected are: 5GSB2-250-1200 (uses KVR type element) 5GSB2-350-1200 (uses KVR type element) 5GSB3-350-1200 (uses KVR type element) 5GSB3-350-2000 (uses KVR type element)
Paragon recommends licensees with the breaker types listed above monitor for failure to close on demand or delayed. If any improper operation is found, report it to Paragon for evaluation.
Contact Information: Richard Knott Vice President Quality Assurance Paragon Energy Solutions 817-284-0077 rknott@paragones.com
Notified R2DO (Franke) and Part 21/50.55 Reactors (email).
--------------------
California Radiation Control Prgm - Redlands CA
Report Date 04/30/2024 15:54:00
Event Date 04/29/2024 0:00:00
AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE
The following was received from the California Department of Public Health (CDPH) via email:
"On Monday night, April 29, 2024, Converse Consultant's radiation safety officer (RSO) reported the loss of a Troxler moisture density gauge (model 3440, serial 31135) containing sealed sources of Cs-137 (8 mCi) and Am-241:Be (40 mCi). The loss was noticed by the authorized user (AU), after he returned to the Redlands office from a jobsite in Jarupa Valley. The AU admitted that he must have left the Troxler gauge on his tailgate when taking a phone call in the cab of his truck, then left the jobsite for the day and forgot to put the gauge back into its type A case before transport. The AU told the RSO he retraced his travel route but did not locate the gauge that night. The RSO notified the Riverside County Sheriff of the missing gauge and notified CDPH of the loss at 1843 [PDT]. Upon returning to the jobsite the next day, the construction workers found the gauge. Apparently, the gauge fell off the tailgate within the jobsite, and the construction workers found the gauge and held it in storage until the AU returned to the jobsite. The gauge handle was locked into the safe/shielded position when it fell off the tailgate, and the source rod remained in the shielded position after the fall. The gauge case and electronics sustained minor damage. The AU took the recovered gauge to a service provider (Maurer Technical Services) on April 30, 2024, for leak testing and damage assessment for the minor case/electronic damage. The licensee will report the leak test results to CDPH when they become available. The licensee will gather additional information for the follow up investigation and provide additional information to the CDPH as it becomes available."
California control number: 24-2488
--------------------
George Washington Hospital - District of Columbia DC
Report Date 04/30/2024 16:43:00
Event Date 04/15/2024 13:00:00
LOST IODINE-125 IMPLANT SEED
The following is a synopsis of information provided by the licensee via phone call:
On 4/15/24, a 145 microcurie iodine -125 implant seed was lost. The seed was one of four seeds to be implanted for mammography. During the exam, it was discovered that only three seeds were implanted. Licensee staff verified that the seed was not implanted in the patient. A thorough survey of the room, linens, and trash was performed and did not yield the seed. Licensee staff can not verify that the seed was present in the needle prior to the procedure.
The patient and the prescribing physician were made aware of the missing seed. No negative effect on the patient is expected.
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
--------------------
CARDINAL HEALTH - Indianapolis IN
Report Date 05/01/2024 10:37:00
Event Date 03/26/2024 8:00:00
UNPLANNED CONTAMINATION The following information was provided by the licensee via telephone: On March 26, 2024, at 0800 EDT, a spill occurred outside of the Cardinal Health facility's hot-cell. The spill was an aqueous thorium suspension containing 0.5 microcuries, Th-229 and 1.0 microcuries, Th-228. The spill was confined to the licensee's facility. On March 29, 2024, the licensee became aware of a potential airborne radioactivity hazard posed by the spill and directed personnel to wear respiratory protection in the area of the spill. Personnel dosimetry reports indicate that all external radiation exposures were below regulatory limits. Bioassay samples were taken and preliminary bioassay results were below the analytical minimum detectable concentration. Final bioassay results are pending more sensitive analysis.
Decontamination activities were completed on April 12, 2024.
--------------------
Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 05/01/2024 12:30:00
Event Date 04/30/2024 0:00:00
EN Revision Imported Date: 5/31/2024
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On April 30, 2024, the Agency was notified by Northwestern Memorial HealthCare's radiation safety officer of an yttrium-90 (Y-90) TheraSphere underdose. There were no adverse patient impacts reported, and the treatment is scheduled to be repeated the following week. The initial information indicated an underdose of Y-90 TheraSpheres of near 100 percent. Additional information is forthcoming, and Agency staff will be on-site to perform a reactive inspection on May 5, 2024. Updates will be made when available."
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"Based on the May 2, 2024, reactive investigation, agency inspectors determined that this case qualifies as a medical event under 335.1080(a)(1). The authorized user (AU) stated that no negative health effects were expected for the patient and that the patient will be retreated in the future. The patient and referring physician were notified of the event within 24 hours as required. Agency inspectors determined the potential root cause as the clumping of microspheres due to the overtightening of the tuohy luer lock. This matter may be considered closed pending further information."
Notified R3DO (Szwarc) and NMSS Events Notifications (Email).
IL Event Number: IL240009
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.
--------------------
Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 05/01/2024 14:14:00
Event Date 04/30/2024 0:00:00
EN Revision Imported Date: 5/13/2024
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE TO AN EMBRYO / FETUS
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on April 30, 2024, by Advocate Illinois Masonic Medical Center in Chicago, IL, to advise a patient was administered a therapeutic dose of iodine-131 on March 7, 2024, and was confirmed pregnant on April 29, 2024. The licensee estimates the pregnancy began 3-7 days after the iodine administration. Negative pregnancy test results were confirmed prior to the administration. Both the patient and the referring physician were notified on April 29, 2024. Using dose modeling [published by the International Commission on Radiological Protection] (ICRP-88) methodology, and assuming conception was 3 days post-administration, the Agency estimates dose to the embryo/fetus over the term of the pregnancy to be 19.8 rem. This is based on an effective half-life of 5.5 days over the 3 days from administration. The patient has had a thyroidectomy which complicates the use of available biokinetic models, but likely also alters the effective half-life. The licensee is researching to determine an appropriate value for the effective half-life (which may range down to 14.4 hours and result in a 900 mrem effective dose).
"Agency inspectors will conduct a reactionary inspection, and this report will be updated as additional information becomes available."
IL Report Number: IL240010
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"Agency inspectors performed a reactive inspection on 5/3/24. The licensee and involved physicians performed a detailed literature and patient review (remnant thyroid) and concluded 9.4 to 56.4 hours was the range of applicable effective half-lives. The licensee asserts, given the patient's sex, age, recombinant human thyroid stimulating hormone (rhTSH) treatment status, weight, renal function and disease burden; that 14.4 hours is the appropriate effective half-life to utilize. Empirical calculation using whole body counts was no longer viable due to decay/clearance. Based on a review of available literature and previous incidents, the Agency would concur that 14.4 hours is an appropriate value for a patient having undergone a thyroidectomy. Estimates on the date of conception relative to the date of administration were confirmed by the licensee and a range of 3/10/24 to 3/18/24 provided. The 3/10/24 date was utilized (as a means of conservation) which results in a 0.9 rem (9 mSv) dose to the embryo using the afore mentioned ICRP 88 methodology. The licensee submitted their written report and assessment on 5/10/24. The licensee consulted the I-131 package insert for tissue-specific dose conversion factors. Consistent with ICRP 88, the dose to the patient's uterus was used as representative of that to the embryo. While relying on dose conversion factors differing from those in ICRP 88, the licensee calculated a 5.19 mSv embryonic exposure. Notwithstanding the variation between the licensee's 5.2 mSv vs. the Agency's 9 mSv dose estimate; the dose falls beneath the reportable criteria."
Notified R3DO (Ruiz), NMSS Regional Coordinator (Riveria-Capella), and NMSS Events Notification via email.
--------------------
Reliable Testing Services - St Louis MO
Report Date 05/01/2024 16:58:00
Event Date 05/01/2024 12:00:00
RADIOGRAPHY SOURCE DISCONNECT
The following is a summary of information provided by the licensee via telephone:
On May 1, 2024, while conducting radiography on a weld using a QSA D880 with a 90 curie iridium-192 source, the source became disconnected from the cable when attempting retrieval. Surveys showed the source was still in the collimator. The radiation safety officer (RSO) set up boundaries and contacted the manufacturer for guidance. After about three hours, the RSO was able to return the source to its shielded container in the radiography camera. Pocket dosimetry indicated that the RSO received a dose of 178 mrem and the assistant RSO received a dose of 12 mrem. Film badge dosimeters will be read to confirm the exposures.
--------------------
WA Office of Radiation Protection - Seattle WA
Report Date 05/02/2024 16:16:00
Event Date 04/26/2024 0:00:00
AGREEMENT STATE REPORT - LEAKING ELECTRON CAPTURE DEVICE
The following was received from the Washington State Department of Health via email:
"The University of Washington has indication that an electron capture device (ECD) containing nickel-63 (Ni-63) is leaking.
"The ECD (G1223A, serial number F7283) had been removed from the gas chromatograph (Hewlett Packard 5890) for disposal. Previous leak testing had been performed with the ECD installed in the GC, and no contamination had been identified that required reporting. The ECD contains Ni-63 that is plated onto an inner surface of the cell body. The current activity is approximately 11.9 millicuries.
"On April 26, 2024, a health physicist performed a leak test by taking a wipe sample on the detector inlet. The wipe from the detector inlet showed contamination of 44,536 dpm using a machine calculated efficiency of approximately 72 percent. The detector inlet indicates a contamination level of 44,536 dpm or approximately 742 Bq (0.02 microcurie). This value exceeds the limit of 185 Bq (0.005 microcurie).
"The ECD will be returned for recycling/disposal of the source."
Washington Incident Report No.: WA-24-011
--------------------
Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 05/03/2024 10:27:00
Event Date 05/01/2024 0:00:00
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/2/24 to advise that a patient who was administered Y-90 TheraSpheres on 5/1/24 received an underdose of approximately 23.6 percent. Both the patient and the referring physician were notified. There is no anticipated adverse impact to the patient and retreatment will not be necessary. The root cause has yet to be identified, and Agency inspectors will perform a reactive inspection the week of 5/6/24. This report will be updated as additional information becomes available."
IL Event Number: IL240011
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.
--------------------
P4 Production, LLC - Soda Springs ID
Report Date 05/03/2024 11:49:00
Event Date 04/30/2024 10:00:00
STUCK SHUTTER
The following information was provided by the licensee via phone:
The radiation safety officer (RSO) attempted to actuate air to close the shutter on a 2003 Vega source holder, model SH-F2, serial number 2791CG, containing 500 mCi of Cs-137. The source turns into the source holder like it normally does, however, radiation levels are the same as when the shutter is open. The RSO is in contact with Vega to schedule a technician to service the shutter. The shutter is normally in the open position and there has been no additional exposure to personnel or the public due to the position of the shutter.
--------------------
Hope Creek - Hancocks Bridge NJ
Report Date 05/03/2024 11:56:00
Event Date 05/03/2024 4:11:00
PRIMARY CONTAINMENT DEGRADED
The following information was provided by the licensee via email:
"At 0411 EDT on 5/03/2024, it was determined that primary containment did not meet TS (Technical Specification) 4.6.1.2 [surveillance] requirement due to a primary containment leak rate test exceeding `La' [allowable leakage rate].
"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The final observed leak rate is still being calculated as the test is still within the stabilization period. Testing is allowed within the stabilization period for an unspecified amount of time. Short term corrective actions are to identify and repair any leak paths. No mode changes are required due to this event.
--------------------
Oconee - Seneca SC
Report Date 05/03/2024 16:18:00
Event Date 05/03/2024 7:50:00
CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA
The following information was provided by the licensee via email and phone call:
"At approximately 0750 EDT on 05/03/24, an employee discovered an unopened can of an alcoholic beverage inside a refrigerator located in a common break area inside the protected area. The container label indicates the beverage is 5.3 percent alcohol by volume. The employee immediately reported the discovery to their supervisor and site security. Security took possession of the container and is continuing the investigation.
"The Resident Inspector has been notified."
--------------------
Surry - Surry VA
Report Date 05/03/2024 17:16:00
Event Date 05/02/2024 15:05:00
EN Revision Imported Date: 5/7/2024
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"At 1630 EDT on 5/3/2024, the supervisor of nuclear site safety contacted the Area Director of OSHA to notify them of a worker's foot injury requiring removal of a toe to the first joint.
"This was a 24 hour notification in accordance with 29 CFR 1904.39.
"The NRC Residents have been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The individual was not contaminated or working in a radiological area at the time of injury.
--------------------
SC Dept of Health & Env Control - Cheraw SC
Report Date 05/03/2024 17:21:00
Event Date 04/15/2024 0:00:00
EN Revision Imported Date: 5/29/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST NUCLEAR GAUGES
The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via phone and email:
"The Department was notified via telephone on 5/3/2024, that four fixed gauging devices were unaccounted for by the general licensee. The general licensee is reporting that four Industrial Dynamics fixed gauging devices (model number FT 50) containing 100 mCi (3.7 GBq) of americium-241 each, for a total of 400 mCi (14.8 GBq), were sent to a recycling facility on 3/8/2024. The serial numbers for the four fixed gauging devices were as follows: 112531, 112532, 112533, 112534. The general licensee is reporting no immediate health and safety concerns, or ongoing emergencies. Department inspectors will be dispatched. This event is still under investigation by the Department. No internal event identification number has been assigned to this event."
"Department inspectors were dispatched to the recycling facility on 05/08/24, but were unable to locate the missing fixed gauging devices. The general licensee submitted a 30-day written report on 05/24/24. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
The internal event number is SC 240002
Notified R1DO (DeFrancisco) and NMSS Events (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
--------------------
Braidwood - Braceville IL
Report Date 05/05/2024 8:11:00
Event Date 05/05/2024 3:38:00
AUTOMATIC REACTOR TRIP DUE TO LOWERING STEAM GENERATOR WATER LEVEL
The following information was provided by the licensee via email and phone:
"At 0338 CDT, with the unit 1 in mode 1 at 6 percent power, the reactor automatically tripped due to lowering steam generator water level. The trip was uncomplicated with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for an actuation of the auxiliary feedwater system.
"Operations responded using procedure 1BwEP-0 and stabilized the plant in mode 3. Decay heat is removed by steam dumps via the main condenser. 1A and 1B auxiliary feedwater pumps were actuated manually prior to the reactor trip in an attempt to restore steam generator water level. Unit 2 is not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
--------------------
Arkansas Department of Health - Ashdown Mill AR
Report Date 05/06/2024 12:49:00
Event Date 04/25/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTERS
The following information was provided by the Arkansas Department of Health, Radiation Control Section (ADH) via email:
"On 4/25/2024, [the licensee] notified ADH by phone that, during semi-annual routine inspection, five Berthold process nuclear gauges were either stuck/seized or difficult to operate. All affected gauges were stuck in the open/operate position. A representative from Berthold reported to the site on 4/30/2024 and successfully cleaned/lubricated all shutter/operating mechanisms restoring normal operation to the affected gauges.
"The following gauges were affected: "Berthold Model LB 7440-D-CR:
SN 37624-12090:
Cs-137
50 mci:
(Unknown License) "Berthold Model LB 330:
SN 2868-11-89:
Cs-137
24 mci:
(Unknown License)
"Berthold Model LB 300L:
SN 6001:
Co-60
4.1, 0.7, 0.2 mci:
(General License) "Berthold Model LB 300:
SN 7687:
Co-60
1.8, 0.5, 0.2 mci:
(Specific License) "Berthold Model LB 300L:
SN 17729-1396-10023:
Cs-137
24 mci:
(General License)
"Licensee corrective actions included flagging the gauges locally, involving management, notifying their safety department, and suspending any activity that would require access to the gauges until they were repaired.
"The licensee is evaluating disposal of the gauges and possible replacement.
"The licensee confirmed at 1020 CDT on 5/06/2024, that one LB 300 gauge shown above is a specific license gauge.
"The investigation is ongoing, and reporting will proceed in accordance with SA-300."
Arkansas Event Number: AR-2024-003
--------------------
REC Silicon - Butte MT
Report Date 05/07/2024 10:29:00
Event Date 05/07/2024 0:00:00
LOST TRITIUM EXIT SIGNS
The following information was provided by the licensee via telephone:
During an inspection in early March 2024, the licensee could not locate ten tritium exit signs. On May 7, 2024, after searching for the signs, the licensee declared the signs lost. The licensee does not know when the signs were lost. The total activity was 118.7 curies.
The licensee notified the NRC Region 4 inspectors.
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
--------------------
Saint Francis Medical Center - Cape Girardeau MO
Report Date 05/07/2024 14:56:00
Event Date 05/06/2024 11:00:00
MEDICAL EVENT - Y-90 OVERDOSE
The following information was provided by the licensee via telephone:
A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem.
The patient and referring physician were informed. No health effect or permanent functional damage is expected.
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.
--------------------
Texas Dept of State Health Services - Corpus Christi TX
Report Date 05/07/2024 15:50:00
Event Date 05/01/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SOURCE
The following was received from the Texas Department of State Health Services (the Department) via email:
"On May 7, 2024, the Department was notified by the licensee that on May 1, 2024, one of its radiography crews was unable to fully retract a 82.92 curie iridium-192 source into a QSA 880D exposure device. The radiographers had cranked the source out to test a weld, but when they tried to retract the source back to the fully shielded position they could not. The radiographers immediately notified the licensee's site radiation safety officer (SRSO), set up new barriers, and warned other individuals in the area. After a licensee manager arrived at the location, it was determined that a bend in the guide tube was too sharp to allow the source to be retracted. Using a set of 6.5 foot tongs, the SRSO repositioned the guide tube, and a radiographer was able to return the source to the fully shielded position. No individual received an exposure that exceeded 100 millirem. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10104 Texas NMED Number: TX240014
--------------------
Oregon State University (OREG) - Corvallis OR
Report Date 05/08/2024 14:30:00
Event Date 05/07/2024 14:28:00
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via phone:
Per the licensee's Technical Specifications (TS) 6.1.3.a, "The minimum staffing when the reactor is not secured shall be: . A reactor operator or the senior reactor operator on duty in the control room."
On May 7, 2024, following the reactor shutdown, there was an indication that one control rod was not fully inserted. Both the reactor operator and reactor engineer left the control room to investigate and discovered that one control rod was not fully inserted. The reactor operator leaving the control room violated the minimum control room staffing requirements of TS 6.1.3.a.
On May 8, 2024, the licensee determined that the cause for the control rod not being fully inserted was a dislodged plastic buffer at the bottom of the control rod barrel.
The NRC Project Manager has been notified.
--------------------
Illinois Emergency Mgmt. Agency - Evanston IL
Report Date 05/08/2024 17:00:00
Event Date 05/07/2024 0:00:00
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The radiation safety officer for Endeavor Health Clinical Operations (IL-01248-02) contacted the Agency at 1115 CDT on 5/8/2024 to report a medical underdose. The patient had been prescribed two administrations of Y-90 TheraSpheres. The first administration was completed without incident. The second administration (a separate written directive) resulted in only 14 percent of the dose being delivered (17.1 Gy of 122.14 Gy prescribed). The administering physician reported initial resistance due to a kinked catheter at the distal end. Both the patient and the referring physician were notified. The licensee met the reporting requirements. A reactive inspection is scheduled to be performed on 5/16/2024."
IL Event Number: IL240012
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.
--------------------
Beaver Valley - Shippingport PA
Report Date 05/09/2024 11:48:00
Event Date 05/09/2024 8:00:00
CONTAINMENT BYPASS CONDITION DUE TO DEGRADED RIVER WATER PIPING
The following information was provided by the licensee via phone and email:
"At 0800 EDT on May 9, 2024, it was identified during leak rate testing that through-wall flaws existed on 'reactor plant river water' piping inside the containment building. This determination resulted in a containment bypass condition such that a gaseous release could have occurred at a location not analyzed for a release in the loss of coolant accident dose consequence analysis. This condition is not bounded by existing design and licensing documents. Evaluation of the condition of the piping is ongoing to support repair prior to startup.
"With the plant currently in cold shutdown, the containment, as specified in Technical Specification 3.6.1, is not required to be operable. There was no impact on the health and safety of the public or plant personnel.
"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A), 10 CFR 50.72(b)(3)(ii)(B), and 10 CFR 50.72(b)(3)(v)(C).
"The NRC Resident Inspector has been notified."
--------------------
Framatome ANP Richland - Richland WA
Report Date 05/09/2024 12:57:00
Event Date 05/07/2024 10:15:00
CONCURRENT REPORT FOR OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"In accordance with 10 CFR 70, Appendix A(c) concurrent reporting, this notification is being made because a plant condition required reporting to the Washington State Department of Health (WDOH). At approximately 1015 PDT on 5/7/2024, three items were found in a storage area.
"Those items were: 1. A metal table that had been used in contaminated areas. 2. A cart that had been used in contaminated areas to transport material, with an additional weight standard stored on it. 3. An out-of-service overpack, designed to transport pellet sintering boats between buildings.
"The items were removed and sent to an outside waste area for gamma spectrometry measurement. The gamma spectrometry results at 1445 PDT on 5/7/2024, indicated that less than 8 grams of uranium were present in the transfer vault. This is more than the annual portion quantity of the building containing the storage area. The limit per stack license for Emission Unit 1511 is 1 gram of uranium.
"The other items were found to not be contaminated. There was no removable contamination on the items as measured by health and safety technicians."
--------------------
Engine Systems, Inc. - Rocky Mount NC
Report Date 05/09/2024 14:42:00
Event Date 02/22/2024 0:00:00
PART 21 - EMERGENCY DIESEL GENERATOR CYLINDER LINER LEAK
The following is a synopsis of information provided by Engine Systems, Inc. (ESI) via fax and email:
On February 22, 2024, an EMD brand cylinder liner developed a jacket water leak following installation on an emergency diesel generator set. The leak occurred at a brazed joint and was detected after post-installation engine testing. Had the leak gone undetected, jacket water may have accumulated in the combustion chamber or airbox and potentially contaminated the engine's lubricating oil. Jacket water intrusion into any of these areas is undesirable and could lead to failure of the diesel engine and therefore failure of the emergency diesel generator set.
The extent of condition is a single cylinder liner, P/N 9318833, S/N 20D6294 used in the power assembly shown below. Customer: Constellation - Fitzpatrick Customer PO: 703, release 13498 ESI Sales Order: 3021545 Part Number Ordered: 40124898 (Blade Power Pack) Serial Number: 20L0603 ESI C-of-C Date: April 1, 2021
The corrective action: For Fitzpatrick: No action required; the power assembly has been returned to ESI for replacement. For ESI: ESI will revise the dedication package to include additional verifications to prevent reoccurrence. The revision will be implemented within 30 days.
Name and contact information: Dan Roberts, Quality Manager Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804
John Kriesel, Engineering Manager Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804
--------------------
New Mexico Rad Control Program - Eunice NM
Report Date 05/09/2024 17:21:00
Event Date 05/09/2024 12:30:00
AGREEMENT STATE REPORT - LOST CAMERA
The following synopsis was received via phone and email from the New Mexico Radiation Control Bureau:
At 1230 MDT on 05/09/2024, a Delta 880 industrial radiography camera containing an activity of 74 curies of iridium (Ir-192) has been determined to be lost on a closed non-public road on an oil field lease. The camera serial number is D15729. The sealed source serial number is 93189M.
Local law enforcement has been informed, details to follow.
NM Event number: ENTS 18002
Notified the following external agencies: DHS Senior Watch Officer, FEMA Operations Center, USDA Operations Center, HHS Operations Center, DOE Operations Center, CISA Central, EPA Emergency Operations Center, FDA Emergency Operations Center, Nuclear SSA (email), FEMA National Watch Center (email), CWMD Watch Desk (email)
The following is a summary of information received from the New Mexico Radiation Control Bureau via phone and email:
The Delta 880 camera has been found by a member of the public and is in process of being transferred to a representative of the Department of Energy (DOE) Radiological Assistance Program for inspection and transfer to a DOE facility. The device has an automatic locking mechanism and there is no indication of public exposure at this time.
Notified R4DO (Josey), NMSS Regional Coordinator (Williams), IRMOC (Grant), ILTAB (MacDonald), INES National Officer (email), NMSS Events Notification (email), NMSS INES Coordinator (email).
Notified the following external agencies: DHS Senior Watch Officer, FEMA Operations Center, USDA Operations Center, HHS Operations Center, DOE Operations Center, CISA Central, EPA Emergency Operations Center, FDA Emergency Operations Center (email), Nuclear SSA (email), FEMA National Watch Center (email), CWMD Watch Desk (email), CNSNS-Mexico (email).
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
--------------------
WA Office of Radiation Protection - Anacortes WA
Report Date 05/09/2024 19:45:00
Event Date 05/07/2024 10:26:00
AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE
The following is information received from the Washington State Department of Health via email:
"On 05/07/2024, three radiographers started work around 1000 [PDT] and were in the process of completing a second shot about 12-feet off the floor when the collimator attached to the source fell to the ground. This caused a bend/crimp in the guide tube preventing the radiographers from retracting the source back into its shielded position within the exposure device. After several attempts at retracting the source, the radiographers contacted the radiation safety officer (RSO) at 1026 PDT. The boundaries were expanded and the workers guarded the area. No other workers or contractors were present at the time.
"At 1130 PDT, the RSO arrived with additional shielding (lead shot bags) and tools. The RSO made a first approach to the source and observed that the collimator was facing northwest. The RSO, using a long reaching tool to manipulate the collimator, turned it to face the ground. No change in activity was recorded and it was determined that the source was not within the collimator. The RSO placed a 25-pound bag of lead shot on the guide tube just below the collimator. No change in activity was observed. The team then retreated. The technician approached the source and placed a second bag further down the guide tube. Survey meters read a substantial decline in activity. The RSO then returned to the source and placed several more bags on the source location. After the source was shielded, the RSO inspected the guide tube and located a slight pinch in the tube. The RSO then used a tool to partially remove an irregularity from the guide tube and requested the technician to crank the source back into the camera. The source was returned to the camera successfully. The RSO removed the damaged guide tube from service.
"The total exposure to the lead radiographer was 10.75mR. The first assistant radiographer exposure was 3.9mR. The second assistant radiographer exposure was 3.6mR. The RSO had an exposure of 20mR on their arm and 4.3mR on their trunk.
"The camera is a Sentinel model 880 with an Ir-192 source of 38.7 Ci."
Washington Incident No.: WA-24-013
--------------------
FitzPatrick - Lycoming NY
Report Date 05/09/2024 21:10:00
Event Date 05/09/2024 16:29:00
HIGH PRESSURE COOLANT INJECTION INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1629 EDT on 05/09/2024, the high pressure coolant injection (HPCI) system was declared inoperable due to a pinhole through-wall leak identified on the seal drain line for 23HOV-1 (HPCI trip throttle valve) downstream of the restricting orifice 23RO-137A. The location of the defect is in the class 2 safety related piping. HPCI is a single train safety system and this notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D).
"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:
This pinhole leak was discovered during normal operator rounds. Although HPCI is inoperable and in a 14 day limited condition of operation, the system function remains available. In addition, all other ECCS systems are currently operable. Compensatory measures (walkdowns) have been implemented to ensure the leak rate does not significantly increase.
--------------------
Screaming Eagle Coal - Bickmoore WV
Report Date 05/10/2024 8:15:00
Event Date 05/09/2024 12:00:00
DAMAGED GAUGE
The following synopsis of the event was provided by the licensee via phone:
On the afternoon of May 9, 2024, during a leak test, the licensee identified a damaged shutter on a gauge (Serial Number - SH-F180) with a cesium (Cs-137) source of 100 millicuries at their facility. The licensee determined that no exposures or injuries occurred as a result of the damaged shutter since the gauge is located twenty feet off the ground in a primarily inaccessible location. No surveys are known to have been performed at this time. The shutter was determined to be unworkable, and is scheduled to be replaced at a later date.
Notified R1DO (Young) and NMSS Events via email.
--------------------
Waterford - Killona LA
Report Date 05/11/2024 22:49:00
Event Date 05/11/2024 16:55:00
ACTUATION OF REACTOR PROTECTION SYSTEM and EMERGENCY FEEDWATER SYSTEM
The following information was provided by the licensee via phone and email:
"At 1655 CDT, Waterford Steam Electric Station, Unit 3 was in Mode 3 with all control rod element assemblies (CEA) fully inserted with reactor trip circuit breakers closed and individual CEA disconnects open for plant startup. During the performance of emergency feedwater surveillance testing, reactor protection system (RPS) trip set point and emergency feedwater actuation system (EFAS) initiation set point for steam generator level low was exceeded for steam generator 1.
"Preliminary evaluation indicates that all plant systems functioned normally. The unit is currently stable in Mode 3. All control rods remain fully inserted.
"This event is being reported as a eight-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the RPS and emergency feedwater systems. The NRC Resident Inspector has been notified."
--------------------
Arkansas Nuclear - Russellville AR
Report Date 05/12/2024 0:09:00
Event Date 05/11/2024 20:30:00
OFFSITE NOTIFICATION
The following information was provided by the licensee via fax, email, and phone:
"At 2030 CDT on May 11, 2024, Arkansas Nuclear One, Unit 1 (ANO-1) determined that the State of Arkansas should be notified after greater than 100 gallons of refueling canal water overflowed from the borated water storage tank (BWST) onto the ground inside the protected area outside the ANO-1 Auxiliary Building. The activity for transferring water from the ANO-1 refueling canal to the BWST was stopped and the tank level was lowered to stop the overflow. None of the spilled liquid was introduced into a storm drain or other pathway to Lake Dardanelle. This condition did not exceed any NRC regulations or reporting criteria.
"Arkansas Nuclear One, Unit 2 (ANO-2) was unaffected by this event.
"This notification is being made as a four-hour, non-emergency notification for a notification of other government agency in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers report guidance: The area where the liquid spill occurred is being controlled and a spill remediation plan is in progress.
--------------------
South Texas - Wadsworth TX
Report Date 05/12/2024 20:46:00
Event Date 05/12/2024 16:41:00
EN Revision Imported Date: 5/23/2024
EN Revision Text: AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email and phone:
"At 1641 CDT on May 12, 2024, with Unit 2 in Mode 1 at 15 percent power, the reactor automatically tripped due to a unit auxiliary transformer lockout. During the trip, all control rods fully inserted. The cause of the transformer lockout is currently unknown. Emergency diesel generator (EDG) 21 and 23 actuated and all three engineered safety feature (ESF) busses were energized.
"All equipment responded as expected except for steam generator power operated relief valve (PORV) 2C which failed to open when required in automatic, and the load center (LC) E2A output breaker which failed to close automatically but was closed manually. Steam generator PORV 2C did open when placed in manual, although it subsequently failed to full open and was then closed. Primary system temperature and pressure are currently being maintained at 567 degrees/2235 psig following start of reactor coolant pumps 2A and 2D.
"Due to the reactor protection system actuation (RPS) 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 per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the emergency diesel generators. There was no impact to 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:
South Texas Project Unit 2 was in Mode 1 at 15 percent power due to performance of testing and analysis on the main turbine prior to the RPS actuation.
* * * UPDATE FROM ROBERT DEWOODY TO BRIAN P. SMITH ON MAY 22, 2024 AT 1805 EDT * * *
The following information was provided by the licensee via email and phone:
"South Texas Project is submitting the following correction to the event notification:
"The steam generator (SG) power operated relief valve (PORV) '2C' did not fail to open automatically. System pressure during this event did not reach the automatic setpoint for the PORV (1225 psi), and there was no demand for it to open automatically. During the event, SG PORV '2C' was taken to manual and it went full open when the 'up' button was pushed slightly. It went closed when the 'down' button was pressed to close it manually. In addition, the load center 'E2A' output breaker initially failed to close automatically, however, after operations placed it in 'pull-to-lock' and returned the hand switch to automatic, it closed automatically."
Notified R4DO (Dixon).
--------------------
Univ Of Missouri-Columbia (MISC) - Columbia MO
Report Date 05/13/2024 14:21:00
Event Date 05/10/2024 0:00:00
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via phone and email:
"During a routine source check on 5/10/2024, it was noted that three of the six iodine-131 processing hot cell radiation monitors were located incorrectly. Upon investigation, it was discovered that on 4/19/2024 the filter banks were switched between bank 'A' and bank 'B'. During this filter bank switch, the detectors monitoring the filter banks were also not changed. This led to processing iodine three times between 4/19/2024 and 5/10/2024 without meeting the conditions of Technical Specification 3.10.c regarding monitoring requirements. The event was corrected on 5/10/2024.
"Several detectors were monitoring the suite during the period from 4/19/2024 and 5/10/2024, including the off-gas (stack) radiation monitor per Technical Specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room DAC monitors, and the remaining three iodine-131 processing hot cell radiation monitors. No in-service monitors indicated abnormal rises in iodine levels.
"After the detectors were returned to service in the correct location, it was noted that the readings on the filter banks were very low. These readings provide supporting evidence that they were not being loaded while the detectors were incorrectly located."
--------------------
Watts Bar - Spring City TN
Report Date 05/13/2024 16:40:00
Event Date 05/13/2024 9:17:00
INOPERABILITY OF BOTH TRAINS OF UNIT 2 LOW HEAD SAFETY INJECTION
The following information was provided by the licensee via phone and email:
"At 0917 EDT on May 13, 2024, a control room operator erroneously rendered the `B' train of the Unit 2 residual heat removal (RHR) system inoperable. This occurred while the `A' train of the Unit 2 RHR system was out of service for preplanned maintenance. RHR serves as the low head safety injection (LHSI) subsystem for the emergency core cooling system (ECCS) and because of this, Unit 2 was without a required train of ECCS from 0917 EDT to 0921 EDT.
"No other equipment issues were identified.
"The LHSI subsystem is credited by the analysis for a large break loss of coolant accident at full power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC resident inspector has been notified.
"There is no release of radioactive material associated with this event."
--------------------
Illinois Emergency Mgmt. Agency - Carol Stream IL
Report Date 05/14/2024 12:05:00
Event Date 05/13/2024 0:00:00
EN Revision Imported Date: 5/23/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/13/24 concerning one lost iodine-125 brachytherapy seed with an activity of approximately 0.267 millicuries. On 5/13/24, Bard Brachytherapy received a package from Northside Hospital - Gwinnett (Lawrenceville, GA), and initially identified a total of seven of the nineteen iodine-125 brachytherapy seeds were missing. Five seeds were found shortly thereafter in the packing material. The common carrier was called to return to the Bard facility and an additional seed was located within the delivery vehicle. Additional searches of the local Schaumburg, IL [common carrier] hub and O'Hare airport facility were unsuccessful in locating the final seed. The Agency was notified that the final seed was considered lost. The package is reported as having left Lawrenceville, GA and then Norcross, GA before arriving at the Schaumburg, IL facility. Reportedly, the package had no indication of damage from transit. The cause of the loss seed appears to be inadequate packaging when shipped."
Illinois event number: IL240013.
"The licensee's written report was received 5/22/23 and provided no additional information. Exposures to the carrier and other members of the public are not expected to exceed reportable limits. Due to the small size and the proximity required to accumulate a reportable exposure, this incident is not expected to result in public exposures exceeding regulatory limits. The Illinois licensee followed reporting timelines and package receipt procedures. Provided no new information becomes available that would allow identification of the seed, reasonable search efforts have been undertaken and this matter is considered closed."
Notified R3DO (Ziolkowski), R1DO (Carfang), NMSS Events Notification (email), 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
--------------------
Cook - Bridgman MI
Report Date 05/15/2024 5:50:00
Event Date 05/15/2024 4:27:00
UNIT 2 MANUAL REACTOR TRIP
The following information was provided by the licensee via email:
"On May 15, 2024 at 0427 EDT, DC Cook's Unit 2 reactor was manually tripped due to difficulty maintaining steam generator water levels.
"DC Cook Unit 2 had removed the main turbine from service at approximately 0354 EDT during a planned down-power to repair a steam leak on the high pressure turbine right outer steam/stop control valve upstream drip pot. Stable steam generator water levels were unable to be maintained. As a result, DC Cook Unit 2 was manually tripped with reactor power stabilizing at approximately 20 percent.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'Reactor Protection System' actuation as a four hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the 'Auxiliary Feedwater System', as an eight hour report.
"The reactor trip was not complicated and all plant systems functioned normally. The DC Cook NRC Resident Inspector was notified."
--------------------
Perry - Perry OH
Report Date 05/16/2024 20:53:00
Event Date 05/16/2024 8:40:00
REACTOR WATER CLEANUP SYSTEM ISOLATION CHANNEL INOPERABLE
The following information was provided by the licensee via email:
"On May 16, 2024 at 0840 EDT, operations declared the reactor water cleanup (RWCU) leak detection instruments related to the high differential flow signal inoperable. Technical specification (TS) 3.3.6.1, primary containment and drywell isolation instrumentation, conditions `A' and `B' were entered as one required channel of instrumentation was inoperable, and an automatic function with isolation capability was not maintained. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C) and 10 CFR 50.72(b)(3)(v)(D). All other RWCU primary containment isolation instrumentation functions remained operable.
"At 1210 EDT, the affected leak detection instruments were declared operable, and the TS limiting condition for operation 3.3.6.1 was declared met.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
--------------------
Beaver Valley - Shippingport PA
Report Date 05/19/2024 1:21:00
Event Date 05/19/2024 0:30:00
MANUAL REACTOR TRIP
The following information was provided by the licensee via email:
"At 0030 [EDT] on 5/19/24, with Beaver Valley Unit 1 in mode 1 at 14 percent power, the reactor was manually tripped due to inability to control the 'A' steam generator water level. The trip was not complex, with all systems responding normally post-trip. The turbine driven auxiliary feedwater pump automatically started on a valid actuation signal. All control rods inserted into the core. Operations responded and stabilized the plant. Decay heat is being removed by the feedwater system and the main condenser. Beaver Valley Unit 2 is unaffected.
"Due to the reactor protection system system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the emergency safety feature system actuation (automatic start of the turbine driven auxiliary feedwater pump) while critical, this event is being reported as an eight-hour, non-emergency notification per 10CFR 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 verbally notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Unit 1 is stable on off-site power, normal configuration. All emergency systems are available.
--------------------
North Dakota Department of Health - ND
Report Date 05/20/2024 14:18:00
Event Date 05/17/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by North Dakota Department of Health via email:
"At 0955 CDT, Monday, May 20, 2024, the North Dakota Department of Health received a call from the Corporate, Radiation Safety Officer (RSO) of Braun Intertec Corporation (Braun). Braun's North Dakota [state] RSO received a phone call on Friday, May 17, 2024, at 0941 from a Braun radiographer on site indicating a 40.5 curie Iridium-192 source (QSA Model 424-9, S/N 91621M) was unable to be returned into the radiographic device (QSA Model 880 Delta S/N D15651). The radiographer had initiated a crank out of the source and immediately was aware something was not working properly. Attempts to return the source to the locked position failed. The RSO indicated that the source may not have been fully out of the radiographic device and inside the guide tube, but may have been out of the locked position yet still inside the radiographic device.
"The North Dakota RSO arrived on site at 1205 to perform the source retrieval. The Iridium-192 source was retracted into the radiographic device at 1315.
"Initial investigation indicates no dose exceedances/overexposures occurred during the retrieval process, and a faulty control assembly is the cause of the misconnect event. The control assembly has been removed from service."
North Dakota's reference number: ND240002.
--------------------
Louisiana Radiation Protection Div - St Rose LA
Report Date 05/20/2024 17:05:00
Event Date 05/20/2024 0:00:00
AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE
The following information was provided by the Louisiana Radiation Protection Division via email:
"The Louisiana Radiation Protection Division was notified on May 20, 2024, by the Radiation Safety Officer (RSO) for SPEC, that an employee had a 10.695 REM exposure on the Lanadauer badge for the month of April 2024. The employee works in shipping. The licensee does not know if it was an actual overexposure or not. The licensee will be speaking with the employee on 5/21/2024."
Event Report ID No.: LA 20240006
--------------------
Karmanos Cancer Institute - Detroit MI
Report Date 05/22/2024 14:33:00
Event Date 05/22/2024 9:30:00
LOST LUTETIUM-177 SOURCE
The following synopsis was provided by the licensee via phone:
On 5/21/24, a 200 millicurie lutetium-177 (Lu-177) source was delivered to the Karmonas Cancer Institute and was placed in a clean hot laboratory. A physics resident cleaning the hot laboratory placed the box containing the source outside the hot lab on a trash can. A custodian threw the box in the trash at the end of the day. The licensee notified the trash management company and the facility security department. No threat to public health is expected based on source packaging.
The NRC Region 3 inspector was also notified.
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
--------------------
Perry - Perry OH
Report Date 05/23/2024 4:25:00
Event Date 05/23/2024 4:00:00
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
The following information was provided by the licensee via email:
"At 0400 EDT on May 23, 2024, a technical specification required shutdown was initiated at Perry. Technical specification action 3.4.5 condition B [unidentified reactor coolant system leakage exceeds 5 gallons per minute] was entered on May 23, 2024 at 0000 with a required action to reduce leakage to within limits within 4 hours, due by 0400 on May 23, 2024. This required action was not completed within the completion time, therefore, a technical specification required shutdown was initiated, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i).
"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 reactor coolant leakage was stable at approximately 6 gallons per minute.
--------------------
Arkansas Nuclear - Russellville AR
Report Date 05/23/2024 11:24:00
Event Date 05/23/2024 7:51:00
FITNESS FOR DUTY PROGRAMMATIC FAILURE
The following information was provided by the licensee via email:
"During a security inspection, it was determined that some past events at Entergy sites that were not reported may have met the reporting criterion of 10 CFR 26.719(b)(4). As a result, the following events at Arkansas Nuclear One, Units 1 and 2 are now being conservatively reported: On February 2, 2023, a condition report was written to document that an individual who should have been placed in a follow-up fitness for duty (FFD) program was not tested according to this program. On September 6, 2023, a subsequent condition report was written to document that a different individual who should have been placed in a follow-up FFD program was not tested according to this program. The resident inspector has been notified."
--------------------
Grand Gulf - Port Gibson MS
Report Date 05/23/2024 11:24:00
Event Date 05/23/2024 7:51:00
FITNESS FOR DUTY PROGRAMMATIC FAILURE
The following information was provided by the licensee via email:
"During a security inspection, it was determined that some past events at Entergy sites that were not reported may have met the reporting criterion of 10 CFR 26.719(b)(4). As a result, the following event at Grand Gulf, Unit 1 is now being conservatively reported: On May 11, 2023, a condition report was written to document that an individual who should have been placed in a follow-up fitness for duty program was not tested according to this program. The resident inspector has been notified."
--------------------
River Bend - St Francisville LA
Report Date 05/23/2024 11:24:00
Event Date 05/23/2024 7:51:00
FITNESS FOR DUTY PROGRAMMATIC FAILURE
The following information was provided by the licensee via email:
"During a security inspection, it was determined that some past events at Entergy sites that were not reported may have met the reporting criterion of 10 CFR 26.719(b)(4). As a result, the following events at River Bend Station, Unit 1 are now being conservatively reported: On March 21, 2023, a condition report was written to document that an individual who should have been placed in a follow-up fitness for duty (FFD) program was not tested according to this program. On May 11, 2023, a subsequent condition report was written to document that a different individual who should have been placed in a follow-up FFD program was not tested according to this program. The resident inspector has been notified."
--------------------
Waterford - Killona LA
Report Date 05/23/2024 11:24:00
Event Date 05/23/2024 7:51:00
FITNESS FOR DUTY PROGRAMMATIC FAILURE
The following information was provided by the licensee via email:
"During a security inspection, it was determined that some past events at Entergy sites that were not reported may have met the reporting criterion of 10 CFR 26.719(b)(4). As a result, the following event at Waterford Steam Electric Station, Unit 3 is now being conservatively reported: On May 15, 2023, a condition report was written to document that an individual who should have been placed in a follow-up fitness for duty program was not tested according to this program. The individual was no longer badged at Waterford 3 but is currently badged at another Entergy site. The resident inspector has been notified."
--------------------
Quad Cities - Cordova IL
Report Date 05/24/2024 2:08:00
Event Date 05/23/2024 11:46:00
AUTOMATIC SCRAM DUE TO TURBINE TRIP SIGNAL
The following information was provided by the licensee via email:
"At 2223 CDT on May 23, 2024, with Quad Cities Unit 2 at 38 percent power, the reactor automatically tripped due to a turbine trip signal resulting in main stop valve closure, creating a valid reactor protection system signal. Reactor vessel level reached the low-level set-point following the scram, resulting in valid Group II and Group III containment actuation signals. The trip was not complex with all systems responding as expected post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group II and Group III isolation.
"Operations responded using their emergency operating procedures and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.
"Unit 1 remains at 100 percent power.
"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:
Unit 2 was at a reduced power for maintenance.
--------------------
Paragon Energy Solutions - Bridgman MI
Report Date 05/24/2024 15:47:00
Event Date 05/09/2024 0:00:00
PART 21 - DEFECT WITH EMERGENCY DIESEL GENERATOR VOLTAGE REGULATOR
The following information was provided by Paragon Energy Solutions, LLC via email:
"Paragon has identified a defect in one voltage regulator supplied to AEP DC Cook with serial number NLI-3S7950GR751A1-1007.
"Pursuant to 10CFR Part 21 21.21(d)(3)(i), Paragon is providing initial notification of a defect associated with the emergency diesel generator (EDG) voltage regulator. The voltage regulator was refurbished under the client purchase order 01600229, project number 351030025. Part of the refurbishment involved complete replacement of the units wiring, physical inspection and testing of the unit to Paragon approved acceptance testing instructions. The refurbished unit was supplied to the customer in December 2023. Prior to installation (March 2024), the unit successfully passed bench testing at the plant. During post installation testing, the EDG was started, and the output voltage pegged high and was not controllable. DC Cook subsequently removed the voltage regulator and documented the non-conformance. DC Cook troubleshooting determined the unit was mis-wired. The unit [voltage regulator] was returned to Paragon, and inspection confirmed the plant's diagnosis. The identified mis-wire affects the system circuitry by placing silicon controlled rectifier 5CD in a reverse biased position. The reversed biased rectifier blocks the flow of current which creates an open circuit condition. This open circuit condition causes the output voltage to max out, and does not allow the output voltage to be adjusted. This condition, if left uncorrected, could contribute to a substantial safety hazard and is reportable in accordance with 10CFR Part 21.
"Date of Discovery: May 9, 2024
"Reportability Determined: May 23, 2024
"Paragon has entered this condition in our corrective action program, and we have custody of the effected unit. The extent of condition is limited to this unit supplied to DC Cook. Paragon has determined there is no action necessary for DC Cook at this time."
Affected plant: DC Cook
--------------------
Arizona Department of Health Services - Phoenix AZ
Report Date 05/24/2024 16:39:00
Event Date 05/22/2024 0:00:00
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:
"On May 23, 2024, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on May 22, 2024. A patient was prescribed a dose of 1.304 GBq but was delivered 0.931 GBq, a percent dose delivered of 71.4 percent. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona incident number: 24-007
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.
--------------------
Millstone - Waterford CT
Report Date 05/25/2024 15:26:00
Event Date 05/25/2024 4:00:00
CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA
The following information was provided by the licensee by phone and email:
"A 50 ml bottle of vodka was found in the Unit 3 debris basket on the exterior of the intake structure. The bottle likely came from the ultimate heat sink (Niantic Bay) during normal backwash operations by the system that collects debris.
"Security has discarded the contraband. 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 bottle was found unsealed.
--------------------
South Texas - Wadsworth TX
Report Date 05/26/2024 13:52:00
Event Date 05/26/2024 7:20:00
EN Revision Imported Date: 6/14/2024
EN Revision Text: TWO OF THREE ESSENTIAL CHILLED WATER TRAINS DECLARED INOPERABLE
The following information was provided by the licensee by phone and email:
"At 0210 CDT 5/24/24, essential chiller 'A' train and cascading equipment was declared inoperable for maintenance to correct a temperature control malfunction.
"At 0720 CDT 5/26/24, essential cooling water 'B' train and cascading equipment (including 'B' train essential chiller) was declared inoperable due to a through wall leak discovered on the essential cooling water return header temperature element thermal well.
"This condition resulted in an inoperable condition on two out of three safety trains for the accident mitigating function, including the train 'A' and train 'B' high head safety injection, low head safety injection, containment spray, electrical auxiliary building heating ventilation and air conditioning (HVAC), and essential chilled water. All 'C' train safety related equipment remains operable.
"This was determined to be reportable within 8 hours as required by 10CFR50.72(b)(3)(v)(D).
"NRC Resident Inspector has been notified."
The following information was provided by the licensee by phone and email:
"This is a communication to retract the 8-hour notification Event Notification (EN) 57146 reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) on 05/26/2024. Based on a subsequent engineering review of the conditions that existed at the time of discovery, it was determined that:
"1) The maximum postulated leak rate, conservatively estimated, from the 'B' Train essential cooling water return piping thermowell in the mechanical auxiliary building sump room would have been less than the administrative allowable limit for leakage in this room during a design basis accident, "2) No adjacent safety related components or functions would have been adversely affected, and "3) the return line leakage represented a negligible impact regarding essential cooling water system inventory and the system ability to cool required components.
"Therefore, it was recommended that the 'B' Train essential cooling water system with the as-found leakage condition be considered operable. Therefore, this event notification is being retracted.
"The NRC Resident Inspector has been notified."
Notified R4DO (Taylor)
--------------------
North Anna - Richmond VA
Report Date 05/29/2024 8:50:00
Event Date 05/29/2024 6:24:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email and phone:
"On May 29, 2024, at 0624 EDT, Unit 1 automatically tripped from 100 percent power due to a negative rate trip. The unit has been stabilized in mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The auxiliary feedwater pumps actuated as designed because of the reactor trip and is reportable per 10 CFR 50.72(b)(3)(iv)(A) for a valid engineered safety feature (ESF) actuation. Decay heat is being removed by the condenser steam dump system and Unit 1 is in a normal shutdown electrical lineup. Unit 2 was not affected by this event."
The NRC Resident has been notified.
--------------------
Westinghouse Electric Corporation - Columbia SC
Report Date 05/30/2024 17:07:00
Event Date 05/30/2024 4:30:00
MEDICAL TRANSPORT WITH CONTAMINATION
The following information was provided by the licensee via email:
"At approximately 0430 [EDT] on May 30, 2024, conversion operators were performing a deionized (DI) water flush on the conversion line 3 decanter following completion of the acid wash. The DI water valve required closing on the conversion line 3 decanter platform to complete the evolution. In the process of completing this step on the decanter platform, an operator inadvertently stepped on a catch pan containing a small quantity of nitric acid. When the operator stepped on the pan, it flipped over causing nitric acid to splash onto the operator's leg. The nitric acid is added either manually to a bucket or by connecting a hose to the decanter system to perform the acid wash step. The nitric acid supply line for acid wash additions is isolated by a spring-loaded valve, and a catch pan is located underneath this segment of nitric acid piping to collect residual liquid drips and protect the decanter platform floor from corrosion.
"The operator was wearing the required personal protective equipment for the DI water flushing evolution.
"The operator immediately reported the exposure to a nearby coworker and was instructed to rinse the exposed skin. The skin area was rinsed for approximately twenty minutes.
"The incident commander and medical first responders from the Columbia Fuel Fabrication Facility (CFFF) emergency brigade provided initial medical treatment. Health physics (HP) surveys detected contamination on the exposed area of the employee's skin. Direct survey results were 2700 dpm/100 cm squared alpha for the inner right thigh/knee area, 2000 dpm/100 cm squared for the inner right ankle and 800 dpm/100 cm squared alpha for the left hand. All smear survey results of the exposed skin area were below clean area limits (less than 200 dpm/100 cm squared). As a precaution to ensure comprehensive evaluation and treatment for nitric acid exposure to the skin, the operator was transported by ambulance to an offsite medical facility. Per procedure the employee's leg was wrapped in plastic, and the employee was accompanied by a CFFF HP technician for evaluation. Contamination surveys were performed in the ambulance and at the offsite medical facility and all results were below clean area limits indicating no spread of contamination during care for the employee. All potentially contaminated materials associated with the transport were collected and returned to the CFFF for disposal.
"All Conversion lines were inspected for extent of condition with pans or pales containing nitric acid. Containers with acid were emptied and valves in the vicinity of each decanter in conversion were inspected for leaks.
"The event did not exceed the performance requirements of 10 CFR 70.61 as analyzed in the integrated safety analysis.
"This event did not impact safety equipment.
"A causal analysis and corrective actions will be documented in the corrective action program.
NRC Regional staff was notified.
--------------------
South Texas - Wadsworth TX
Report Date 05/30/2024 17:43:00
Event Date 05/30/2024 12:00:00
EN Revision Imported Date: 6/10/2024
EN Revision Text: FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the licensee via email and phone:
"On May 30, 2024, at 1200 CDT, South Texas Project (STP) FFD management identified from industry operating experience (OE) a programmatic failure, degradation, or discovered a vulnerability of the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program. A review of the personnel in-processed and placed into the follow-up program by STP and external utilities since the implementation of the Illuminate software (07/31/2023) was completed. The issue affecting individuals placed into the follow-up program by external utilities was bound to in-processing of individuals [between] 02/22/2024 and 04/09/2024. One other individual processed in November of 2023, was also affected by this event. This event did not impact STP personnel that were either placed or had an existing record in the follow-up program. Compensatory measures were implemented and an extent of condition review was completed.
"This is a 24-hour reportable event per 10 CFR 26.719(b)(4)."
The NRC Resident Inspector has been notified.
--------------------
Harris - Raleigh NC
Report Date 05/30/2024 22:52:00
Event Date 05/30/2024 19:49:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email and phone:
"On May 30, 2024, at 1949 EDT, Unit 1 automatically tripped from 100 percent power due to an electrical fault on the 'B' unit auxiliary transformer. The unit has been stabilized in mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). Decay heat is being removed by the condenser steam dump system and Unit 1 is in a normal shutdown electrical lineup. There was no impact on the health and safety of the public or personnel."
The NRC Resident Inspector has been notified.
--------------------