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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
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Cleveland Cliffs Steel Corporation - Dearborn MI
Report Date 11/16/2023 15:20:00
Event Date 11/16/2023 8:00:00
EN Revision Imported Date: 7/16/2024
EN Revision Text: NON-AGREEMENT STATE REPORT - FAILED INDICATING LIGHT
The following information was provided by the licensee via phone and in accordance with Headquarters Operations Officers Report Guidance:
On November 11, 2023, at about 1330 EST, at the Cleveland Cliffs Steel Corporation in Dearborn Michigan, the licensee staff noted that the indicating light for a 1 curie Am-241 thickness gauge shutter position was malfunctioning. The light indicated open continuously even though the shutter was closing normally. Operation of the plant continued and the shutter remained in its normally open position measuring the product steel thickness. Shutter position was subsequently checked by radiation measurements to confirm that the indicating light was not indicating correctly. No abnormal exposure resulted and the vendor will troubleshoot and repair. The location of the gauge is not normally manned.
* * * UPDATE ON 11/18/23 AT 1509 EST FROM WAYNE LANGDON TO IAN HOWARD * * *
The following update was received from the licensee via email:
"Today, a Thermo Fisher Scientific technician came on site to diagnose the shutter position indicator light issue. It was found that the shutter arm flag was bad. The technician replaced the shutter arm flag with a new one and verified that the unit was properly working. No Cleveland Cliffs employees nor the Thermo Fisher Scientific technician were exposed at any time during the event."
Notified R3DO (Feliz-Adorno) and NMSS Event Notifications (E-mail).
The following is a summary of information provided by the licensee via phone and email:
The licensee is withdrawing the event following further analysis. The failure only affected the indicator light, and all safety devices (the shutter) continued to function normally. There was no exposure to personnel.
Notified R3DO (Nguyen) and NMSS Events Notification via email.
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Curium US LLC - Maryland Heights MO
Report Date 03/06/2024 17:05:00
Event Date 03/06/2024 6:00:00
EN Revision Imported Date: 7/16/2024
EN Revision Text: CONTAMINATION IN RESTRICTED AREA
The following is a summary of information provided by the licensee via telephone:
On March 6, 2024, around 0600 CST, a technician found loose molybdenum (Mo-99) / technetium (Tc-99m) contamination inside a restricted area. Prior to the discovery, a production hot cell inside the restricted area had been deep cleaned as part of the regular maintenance program.
A thorough investigation of the area was conducted which revealed additional loose contamination on the lab floor. Surveys of surrounding areas did not reveal any spread of contamination outside of the restricted lab area.
Due to (1) the existing access controls, (2) personal protective equipment requirements for lab access, and (3) the absence of contamination identified by body scans of personnel exiting the lab; the licensee does not suspect any spread of contamination outside of the restricted area or personnel intake. Biological samples will be collected to confirm that no intake occurred.
The highest contamination level identified was 260 mrem/hr on contact and 2.3 mrem/hr at 1 foot. The contamination has been remediated to below licensee action levels. Overall, 2.4 mCi of Mo-99 was identified outside of the production hot cell. The 10 CFR 20 Appendix B limit for Mo-99 is 1 mCi. The licensee is investigating the root cause of this event.
The following retraction is a summary of information provided by the licensee via telephone:
Due to performing additional air samples and biological assays, the licensee determined that they did not exceed any thresholds, and the event is not reportable.
Notified R3DO (Nguyen) and NMSS Events Notification via email.
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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: 7/29/2024
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).
The following is a synopsis of the updated information received:
Paragon Energy Solutions has provided a new expected date for completion of their evaluation: 7/28/2024. The only known affected licensee remains Oconee.
Notified R2DO (Suggs) and Part 21/50.55 Reactors (email).
The following is an excerpt from a Part 21 final update received via email:
"Paragon has been working closely with OEM (Schneider Electric) to conduct the failure analysis. After extensive inspection and testing by Schneider Electric, the condition has not been able to be recreated following cleaning and relubrication activities, nor has any non-conformances with breaker parts and materials been identified that would cause delayed closing of the breaker mechanism. Paragon has reviewed the final OEM analysis report and concludes the issue exhibited with this breaker is related to lubrication maintenance and not the result of any defect in design or manufacturing. Paragon will be updating instruction manuals associated with this breaker element for all clients recommending more frequent cleaning, relubricating, and cycling frequencies.
"Based on the evaluation conducted, Paragon has concluded the deviation discussed above is not reportable per 10CFR Part 21."
Notified R2DO (Coovert) and Part 21/50.55 Reactors (email).
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Braidwood - Braceville IL
Report Date 05/05/2024 8:11:00
Event Date 05/05/2024 3:38:00
EN Revision Imported Date: 7/8/2024
EN Revision Text: 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."
The following information was provided by the licensee via email and phone:
"At 0338 CDT, with the unit 1 in mode 2 at 3 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 10CFR50.72(b)(3)(iv)(A) for an actuation of the auxiliary feedwater system, eight-hour notification.
"Operations responded using procedure 1BwEP-0 and stabilized the plant in mode 3. Decay heat is being removed by steam dumps via the main condenser. 1A and 1B auxiliary feedwater pumps were actuated manually prior to 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."
Notified R3DO (Hartman)
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Saint Francis Medical Center - Cape Girardeau MO
Report Date 05/07/2024 14:56:00
Event Date 05/06/2024 11:00:00
EN Revision Imported Date: 7/11/2024
EN Revision Text: 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.
The following summary was provided by the licensee via telephone:
After further assessment of the event, it was discovered that the patient also received an unintended dose of 360 Gy Y-90 TheraSpheres to the lungs. No health effect or permanent functional damage is expected.
Notified R3DO (Nguyen), NMSS Events Notification (email), NMSS Regional Coordinator (Sun)
The following information was provided by the licensee via telephone and email as a clarification to the July 9, 2024, update:
"The patient's Y-90 TheraSphere treatment resulted in an unintended dose to an organ/tissue other than the treatment site. The estimated intended dose was 0.9 Gy to the lungs. The estimated dose given the lungs was 3.29 Gy. The estimated overage was 2.39 Gy, which is 165 percent over the intended lung dose.
"This administration occurred on May 6, 2024, and was the second administration of the patient's regime. The previous treatment was on April 16, 2024, and was completed as intended. The patient's cumulative lung dose from both treatments was 4.2 Gy. The planned lung dose for the regime was 1.8 Gy, again showing the approximately 2.4 Gy overage from the May 6, 2024, administration."
Notified R3DO (Nguyen), NMSS Events Notification (email), and NMSS Regional Coordinator (Sun)
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Snyder and Associates, Inc - Maryville MO
Report Date 06/10/2024 8:31:00
Event Date 06/10/2024 4:15:00
EN Revision Imported Date: 7/26/2024
EN Revision Text: LOST RADIOACTIVE SOURCE
The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:
At 0415 CDT, on 6/10/2024, the Radiation Safety Officer's (RSO) truck, which contained a Troxler 3440 nuclear gauge (serial number 66812), was stolen (loss of control). The RSO left the truck running with the keys in the ignition and the nuclear gauge secured inside when an individual decided to get in the drivers seat and drive away. When the RSO realized the truck was stolen, they immediately contacted Missouri local law enforcement. The nuclear gauge contains 44 mCi of Am241:Be.
The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:
At 0902 CDT, on 6/10/2024, the truck was located and returned to the RSO with the Troxler gauge secure in its locked case. There was no indication of tampering with the case or the locks used to secure the Troxler gauge.
The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:
After reviewing security footage, it was determined that the truck was not left running, but the keys were left in the ignition which allowed the truck to be started.
Notified R3DO (Feliz-Adorno)
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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NV Div of Rad Health - Carlin NV
Report Date 06/24/2024 11:48:00
Event Date 06/18/2024 0:00:00
AGREEMENT STATE REPORT- STUCK SHUTTER
The following information was provided by the Nevada Division of Radiation Health via email and phone:
"On June 18, 2024, Nevada Goldmines - Elko, discovered a failed shutter while conducting required 6-month shutter checks on a Berthold LB 7440 fixed gauge in the open position. In place radiation surveys were conducted to verify safety until a contractor would be available to remove the gauge and move it to storage. All readings were normal. The licensee coordinated with Radiation Technology Inc., (RTI) to remove the gauge and move it to the authorized storage area pending decision to repair or dispose of the gauge.
"RTI conducted onsite leak checks and results were less than 0.005 microcuries. A second set of leak check samples were taken to be returned to RTI lab for verification. A radiation survey following deinstallation confirmed them to be background.
"The gauge was removed from service, plates placed over the open window to provide shielding, and the device with plates covering the window was placed in storage. Surveys of the storage area show increase in radiation consistent with adding a new gauge to the job box, with the highest radiation level being 79 microR/hour at 12 inches."
Gauge Information: Model: Berthold LB 7440 Serial number: 3015 Activity: Cs-137 (150 Ci)
Nevada Item Number: NV240004
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Utah Division of Radiation Control - Ogden UT
Report Date 06/24/2024 17:46:00
Event Date 06/04/2024 0:00:00
AGREEMENT STATE REPORT - LOST I-125 SEED
The following information was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Department) via email:
"On June 24, 2024, the Department was notified that on June 4, 2024, an I-125 seed for breast localization was not recovered during routine tissue processing of the tissue sample at the grossing bench or within the histology lab. The seed was verified in the tissue sample at the time of removal from the patient through both survey of the patient and a radiograph of the tissue sample. The seed was most likely disposed of either in the biohazard waste or in the non-biohazard waste.
"Upon discovery of the lost source, a survey of the lab with a low energy gamma detector was performed in an attempt to locate the source. The source was not found.
"Exposure to the public is expected to be very low or minimal. The low energy X-rays associated with I-125 decay are likely to be attenuated due to overlying waste, minimal time around the waste, and the given low exposure rate associated with the source. The material is encapsulated."
Utah Event Report ID: 240004
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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Carl Vinson VA Medical Center - Dublin GA
Report Date 06/26/2024 9:49:00
Event Date 06/26/2024 6:50:00
REMOVABLE CONTAMINATION LIMITS EXCEEDED
The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program via phone and email:
"Per 10 CFR 20.1906(d), VHA National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.
"The package was received Wednesday, June 26, 2024, at about 0650 EDT, at the Carl Vinson VA Medical Center, 1826 Veterans Blvd, Dublin, Georgia. This facility operates under VHA permit number 10-09569-01 issued in accordance with master materials license number 03-23853-01VA.
"The package was checked in and surveyed upon receipt around 0650 EDT. A wipe performed on the external surface of the package indicated a removable contamination level that exceeded the regulatory limit of 240 dpm/cm^2 for beta-gamma emitters. The measured contamination was 26,679 dpm/100cm^2. After adjusting for a 10 percent wipe efficiency and converting units, this equals 2668 dpm/cm^2 or about 10 times the reporting limit. The contamination was isolated primarily to the package handle.
"The package contained four dosages of Tc-99m with a total activity of about 90 mCi (nominal). Analysis of the wipe test confirmed a gamma peak consistent with Tc-99m. Wipe tests of the interior of the delivery package resulted in levels below the exterior level of around 2800 dpm. The dosages themselves appeared to be unimpacted and able to be used. The container was isolated and is being stored in a designated, shielded area for decay.
"The facility Nuclear Medicine Technologist (NMT) notified the delivery carrier by phone about the contaminated package at around 0910 EDT. VHA National Health Physics Program, who manages the master materials license, was alerted to the incident around 0710 CT (0810 ET)."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
HOO follow up calls with the licensee and the radiopharmaceutical delivery company confirmed no spread of contamination. The receipt area at the licensee indicated no spread of contamination. The delivery driver clothes and hands were surveyed clean. There is no indication of spread of contamination to the public.
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Illinois Emergency Mgmt. Agency - Carol Stream IL
Report Date 06/26/2024 12:52:00
Event Date 06/25/2024 0:00:00
AGREEMENT STATE REPORT - BROKEN BRACHYTHERAPY SEED
The following information was provided by Illinois Emergency Management Agency, Radioactive Materials Branch (the Agency) via email:
"The Agency was contacted on 6/25/24 by Bard Brachytherapy in Carol Stream, IL to advise that they received a package which contained an applicator device with a broken brachytherapy seed. The applicator device was found to be contaminated and was placed in the licensee's hood for decontamination, recovery, and proper disposal. The licensee indicated there was no staff or area contamination as a result. The South Carolina licensee, having shipped the seed, similarly reported no contamination or adverse impacts. Due to the condition of the damaged seed, the radionuclide (Pd-103 or I-125) as well as the model and lot number are still pending. The activity remaining is likely beneath 0.5 mCi. This matter is reportable under 32 Ill. Adm. Code 340.1220(c)(1) and was transmitted to the NRC. Updates will be provided as they become available.
"Bard Brachytherapy is a manufacturer and distributor of brachytherapy seeds (IL-02062-01). Their client, West Hospital in Charleston, SC, returned the damaged seed in proper packaging. There is no indication of a public health or contamination concern."
Illinois Report #: IL240015
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Colorado Dept of Health - Greeley CO
Report Date 06/27/2024 18:38:00
Event Date 06/27/2024 0:00:00
AGREEMENT STATE REPORT - LOST ELECTRON CAPTURE DETECTOR SOURCE
The following summary of information was provided by Colorado Department of Public Health and Environment, Radioactive Materials Unit (the Department) via phone and email:
On June 27, 2024, the Department was notified by the licensee (IEH-WAL Laboratories) of a missing source from an electron capture detector for gas chromatography (ECD-GC) (Agilent Technologies, ECD, Model: 1923369576, 15 mCi Ni-63). The discovery of the lost source was through an inventory check earlier in the day. The last record of the device was on February 21, 2024, at a location in Littleton, CO, where similar units were repaired or dispositioned. Searches at both the Greeley and Littleton locations were performed. This notification is being made to the NRC in accordance with Colorado Regulations Section 4.51.1.1.
Colorado Event Report ID: CO240015
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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Monticello - Monticello MN
Report Date 06/28/2024 16:28:00
Event Date 06/28/2024 1:10:00
BOTH DIVISIONS OF LPCI INOPERABLE
The following information was provided by the licensee via email:
"This condition is being reported in accordance with 10 CFR50.72(b)(3)(v) as a condition that could have prevented fulfillment of a safety function. On 6/27/2024 at 2158 CDT, [technical specification] TS 3.5.1 condition 'D' (both divisions of [low pressure coolant injection] LPCI inoperable) was entered for surveillance testing. On 6/28/2024 at 0110 CDT, MO-2012 [residual heat removal] RHR Division 1 LPCI injection outboard valve was attempted to be cycled. It was discovered to be inoperable resulting in an inability to exit TS 3.5.1 'D'. Initial review of this condition for immediate reportability under 50.72(b)(3)(v) event or a condition that could have prevented fulfillment of a safety function, concluded the condition was not reportable based on the operability of other emergency core cooling systems (ECCS). Specifically, core spray and high pressure coolant injection were both operable to perform the function of emergency core cooling. Subsequent reviews determined that the reportability decision under 50.72(b)(3)(v) as an event or condition that could have prevented fulfillment of a safety function should be based on the safety function at the LPCI system level, rather than at the ECCS system level. The decision to report the inoperability of LPCI under 50.72(b)(3)(v) was made at 1030 CDT on 6/28/2024. The NRC Resident Inspector has been notified."
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MA Radiation Control Program - Worcester MA
Report Date 06/28/2024 15:33:00
Event Date 06/27/2024 14:30:00
AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 06/28/24 at 1430 EDT, the licensee reported a medical event under license 60-0096 for BWXT Medical Ltd. TheraSpheres Model TheraSphere Y-90 Glass Microsphere System (Sealed Source and Device Registry: NR-0220-D-131-S) for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more.
"The medical event was reported to the radiation safety officer (RSO) at 1430 EDT on 6/27/2024. The prescribed dose to the patient was 106.4 mCi over two fractions. The dose received by the patient was 68.5 mCi (60.4 mCi on the first fraction, and 8.1 mCi on the second fraction). This resulted in an under dose of 35.6 percent. The authorized user and prescribing physician have been notified. The licensee has not reported whether the patient has been notified.
"The Agency will follow up with licensee RSO to determine the event cause and corrective actions.
"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
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South Texas - Wadsworth TX
Report Date 06/30/2024 16:13:00
Event Date 06/30/2024 12:22:00
OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"At 1222 CDT on 06/30/24, South Texas Project notified the Texas Commission on Environmental Quality (TCEQ) and the National Response Center regarding an oil spill of 280 gallons to the ground inside the protected area. This event was recorded as TECQ Event number: 20242394 and Incident Response Center incident number: 1403420.
"The spill occurred due to the overflow of an oily waste sump. The influent to the sump was stopped. The spill was confined to a 15 feet by 15 feet area on the ground and did not enter any waterway.
"This notification is being made solely as a four-hour, non-emergency notification for a notification to another government agency. This was determined to be reportable as required by 10CFR50.72(b)(2)(xi).
"There was no impact to the health and safety of the public or plant personnel. The NRC resident inspector has been notified."
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San Onofre - San Clemente CA
Report Date 07/01/2024 14:13:00
Event Date 07/01/2024 7:34:00
OFFSITE NOTIFICATION FOR REPORTED LEAK
The following information was provided by San Onofre Nuclear Generating Station (SONGS) via email:
"At 2200 PDT on June 30, 2024, the California Office of Emergency Services (CAL OES) received a hazardous material spill report from BNSF Railway. BNSF reported a leak from a rail car that was transporting 'radioactive material surface contaminated objects'. BNSF contacted the local fire department to investigate the leaking material. This rail car was transporting the decommissioned Unit 2 pressurizer.
"Informational surveys conducted by a third party have determined that the leaked material did not involve contamination above background levels. Currently, there are SONGS radiation protection personnel en-route to investigate the reported leak.
"At 0734 PDT on July 1, 2024, SONGS personnel identified through the CAL OES website that BNSF had reported a hazardous spill to CAL OES. This is a 4-hour report due to a notification made to a government agency.
"Notification has been made to Region IV due to SONGS not having a NRC resident."
The following information was provided by the licensee via phone and email:
"Additional radiological surveys performed by SONGS radiation protection personnel have confirmed that there is no detectable contamination in the leaked material."
Notified R4DO (Agrawal)
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Oconee - Seneca SC
Report Date 07/01/2024 15:11:00
Event Date 07/01/2024 9:42:00
POSITIVE FITNESS FOR DUTY TEST
The following information was provided by the licensee via phone and email:
"At 0942 EDT on July 1, 2024, it was determined that an individual had a confirmed positive test as specified by the fitness-for-duty testing program. The individual's authorization for site access has been terminated.
"The NRC Resident Inspector has been notified."
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Colorado Dept of Health - Kersey CO
Report Date 07/01/2024 18:51:00
Event Date 07/01/2024 15:30:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email:
"Five Rivers Cattle Feeding, LLC reported eight missing tritium (H-3) exit signs. The initial registration received on June 26, 2012, indicated that each tritium exit sign contained 6.2 Ci (49.6 Ci total)."
Colorado State Event Report Number: CO240016
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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Agilent Technologies - Wilmington DE
Report Date 07/02/2024 7:45:00
Event Date 06/05/2024 7:00:00
LOST SOURCE
The following information was provided by Agilent Technologies (the licensee) via phone:
A single electron capture device (ECD) containing 15 mCi of Ni-63 was reported to be lost. The ECD was one of ten in a package being transferred by a customer on June 5, 2024. The licensee believes that the ECD was erroneously discarded by a licensee operator. The licensee attempted to recover the ECD without success.
The licensee's root cause analysis determined the event occurred due to the employee not following the established procedure. In addition, employee training was inadequate due to failure to update the training program. Corrective action to update the training program has been undertaken by the licensee.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee believes that the ECD was discarded in the facility's normal waste stream.
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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River Bend - St Francisville LA
Report Date 07/02/2024 10:08:00
Event Date 05/13/2024 19:28:00
EN Revision Imported Date: 7/9/2024
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID PARTIAL CONTAINMENT ISOLATION
The following information was provided by the licensee via phone and email:
"At 1928 CDT on May 13, 2024, River Bend Station (RBS) was operating in Mode 1 at 100 percent power when an invalid isolation signal actuated multiple containment isolation valves in more than one system. The invalid isolation signal was caused by voltage perturbations on the offsite power distribution system due to multiple lightning strikes in the vicinity of RBS.
"The event caused one containment isolation valve to isolate in the floor and equipment drains system, and two containment isolation dampers to isolate in the auxiliary building ventilation system.
"This event was a partial system isolation for the affected systems and did not result in a full train actuation.
"This event meets the reportable criteria for 10 CFR 50.73(a)(2)(iv)(A) and is being reported as any event or condition that resulted in manual or automatic actuation of any systems listed in paragraph (a)(2)(iv)(B). This notification is being provided in lieu of a Licensee Event Report as indicated in 10 CFR 50.73(a)(1)."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The valve and dampers were immediately re-opened. The standby gas treatment system automatically initiated due to the closure of the containment isolation dampers in the auxiliary building ventilation system.
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Univ Of Maryland (MARY) - College Park MD
Report Date 07/03/2024 11:29:00
Event Date 07/03/2024 9:07:00
NONCOMPLIANCE WITH TECHNICAL SPECIFICATION
The following information was provided by the licensee via phone and email:
"On July 3, 2024, at 0907 EDT, a reactor operator (RO) was in the process of commencing a routine startup. During the startup, the RO switched on the ventilation fans for less than 1 second with the key in the console.
"[With the key in the console] the reactor did not meet the definition of 'reactor secured' and thus the confinement requirements of technical specification (TS) 3.4.2 were still required to be met. [Ventilation fans running in this condition violates the confinement requirements of TS 3.4.2.]
"The RO notified the director of radiation facilities and logged the action. Throughout the duration of the event all control rods were fully inserted.
"The director notified the NRC project manager."
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Midwest Subsurface Testing - Osage Beach MO
Report Date 07/03/2024 13:26:00
Event Date 07/03/2024 11:46:00
DAMAGED DENSITY GAUGE
The following information is a summary of the information provided by the licensee via phone:
At 1146 CDT on 7/3/2024, the radiation safety officer at Midwest Subsurface Testing reported a gauge was damaged on a construction site. An InstroTek MC1 Elite moisture density gauge containing 10 millicuries of cesium-137 and 50 millicuries of americium-241/beryllium was backed over by a skid loader. The source was stuck in the shielded position. A radiological survey was conducted, which verified there was no contamination. The damaged gauge was recovered and transported to a vendor facility to conduct a leak test.
This event was reported under 10 CFR 30.50 (b)(2).
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Utah Division of Radiation Control - West Jordan UT
Report Date 07/04/2024 1:31:00
Event Date 07/03/2024 16:20:00
AGREEMENT STATE REPORT - LOST GAUGE
The following information was provided by the Utah Division of Radiation Control (the Department) via email:
"On July 3, 2024, a technician for American Testing Services, Inc. (ATS), completed a job at a temporary jobsite. They placed the gauge on the tailgate while they completed the paperwork. Then, they left the jobsite but failed to put the gauge in the transportation box and secure the gauge for transport. Reportedly, the gauge was in the shielded position when on the tailgate. It is unknown if was locked in the safe position or not.
"The technician drove away from the site and made a stop down the road. When they left that location, they noticed that the gauge and the transportation case were no longer on the vehicle, but the chains were still on the truck. They retraced the route but did not find the gauge. Afterwards, the technician reported the gauge missing to the radiation safety officer (RSO).
"The RSO reported the incident to the Department. The only information given at that time was that a gauge was lost. There was no information regarding where the incident occurred, what isotopes and activity were involved, information regarding what happened, etc. The RSO was informed to get more information regarding the details for the incident and provide the information to the Department as soon as possible."
Utah Event Report ID number: UT240005
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PA Bureau of Radiation Protection - Philadelphia PA
Report Date 07/04/2024 14:27:00
Event Date 07/03/2024 0:00:00
EN Revision Imported Date: 7/22/2024
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Pennsylvania Department Bureau of Radiation Protection (the Department) via email:
"On July 3, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres [Y-90 resin microspheres].
"A patient was about to undergo a treatment with SirSpheres when the physician noticed a globule on the vial septum. They cleared the globule and began the treatment. At the beginning of treatment, the tube became occluded immediately, resulting in the patient receiving only 0.2% of the prescribed dose. The procedure was stopped. The physician and patient have been informed. No harm to the patient is expected from this event."
PA Event Report ID: PA240014
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"On July 11, 2024, the Authorized User (AU) for the event was interviewed and provided the following additional information:
"The treatment used Y-90 SirSpheres administered through the `SIROS' apparatus. The treatment location was the right lobe of the liver. When the vial was placed into the apparatus the `C' and `D' lines were not in the right location and no spheres were at the bottom of the dose vial where they usually are. The AU saw the spheres clumped at the top of the dose vial, so they agitated the vial to try to suspend the spheres. The vial was then connected to the `SIROS' unit. The AU started the procedure by trying to push a 20 mL syringe of saline solution through the `D-Line' which connects to the dose vial. After many attempts the AU could not get any solution through the `D-line' which he thought may be occluded. The AU then checked the patient's catheter line with contrast and tried to slightly move the catheter. The AU then connected a 3 mL syringe to the `D-line' to create more pressure to try to push the solution to the dose vial, but the line remained occluded. The treatment was then terminated. The patient was retreated on July 10th, 2024, successfully.
"The Department will perform a reactive inspection."
Notified R1DO (Schroeder), NMSS Events Notification (email).
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:
"After the licensee's physicists performed all calculations and consultation with the NRC, it was determined that no dose was delivered and since no material was administered the dose threshold would not be met and there would not be a radiation protection concern to the patient. Therefore, this is not considered a medical event and DEP wishes to formally retract the submission."
Notified R1DO (Schroeder), NMSS Events Notification (email).
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Byron - Byron IL
Report Date 07/07/2024 23:12:00
Event Date 07/07/2024 14:40:00
BOTH TRAINS OF CONTROL ROOM VENTILATION TEMPERATURE CONTROL SYSTEM INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1440 CDT on 7/7/2024, it was discovered that both trains of the control room ventilation temperature control system were simultaneously inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).
"There was no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified.
"One train of control room ventilation temperature control was restored to operable status at 1634 CDT on 7/7/2024."
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Harris - Raleigh NC
Report Date 07/08/2024 11:04:00
Event Date 07/08/2024 7:48:00
INADVERTENT SIREN ACTIVATION
The following information was provided by the licensee via fax and email:
"On July 8, 2024, at 0748 EDT, six emergency response sirens were inadvertently actuated. Four sirens are located in Chatham County and two sirens are in Wake County. The first notification was made to Wake County at 0754. Investigation is ongoing to determine the cause of the actuation. Duke Energy notified the state and all counties within the emergency planning zone (EPZ). A press release was issued by Wake and Chatham Counties.
"This is a four-hour notification, non-emergency for the notification of another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact to the health and safety of the public or plant personnel.
"The NRC resident inspector has been notified."
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Watts Bar - Spring City TN
Report Date 07/08/2024 18:24:00
Event Date 07/08/2024 15:21:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 1521 EDT on July 8, 2024, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The [reactor] trip was not complex with all systems responding normally post trip.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the steam dump system and the auxiliary feedwater (AFW) system. Unit 2 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 AFW 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."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The specific cause of the turbine trip is under investigation by the licensee.
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Vogtle 3/4 - Waynesboro GA
Report Date 07/09/2024 1:11:00
Event Date 07/08/2024 21:25:00
MANUAL REACTOR TRIP AND AUTOMATIC SAFEGUARDS ACTUATION
The following information was provided by the licensee via email:
"At 2125 EDT on 07/08/2024, with Unit 3 in Mode 1 at 100 percent power, the reactor was manually tripped due to main feedwater pump `A' miniflow valve failing open, which resulted in lowering steam generator water level. Additionally, an automatic safeguards actuation occurred due to the cooldown of the reactor coolant system. The trip was not complex, with all safety systems responding normally post-trip.
"Operations responded and stabilized the plant. Decay heat is being removed by the passive residual heat removal heat exchanger. Units 1, 2, and 4 are not affected.
"Due to the core makeup tank actuation, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). The reactor protection system actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is reportable per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid containment isolation actuation and a valid passive residual heat removal heat exchanger actuation.
"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 cause of the main feedwater pump 'A' miniflow valve failing open was unknown and under investigation at the time of the notification of this event to the NRC.
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American Centrifuge Plant - Piketon OH
Report Date 07/09/2024 9:30:00
Event Date 07/09/2024 7:46:00
CRITICALITY ACCIDENT AND ALARM SYSTEM OUT OF SERVICE FOR TESTING
The following information was provided by the licensee via fax or email:
"The American Centrifuge Plant (ACP) criticality accident and alarm system (CAAS) is designed to detect a nuclear criticality accident and provide audible and visual alarms that alert personnel to evacuate the immediate area, as required by 10 CFR 70.24, criticality accident requirements.
"The CAAS will be temporarily disabled (declared inoperable in accordance with approved plant procedures) to perform periodic CAAS testing activities. The planned CAAS outage is expected to last for approximately 48 hours, commencing at approximately 0800 EDT, on Wednesday, July 10th, 2024. The planned maintenance activities will affect the CAAS in the X-3001 North.
"Essential personnel will be present inside the controlled access area during the maintenance activities. Compensatory measures will be implemented in accordance with section 5.4.4 of the License Application for the American Centrifuge Plant. These measures include the following: evacuation of non-essential personnel from the area of concern and the immediate evacuation zone (IEZ) before removing CAAS equipment from service; limiting access into the area; restricting fissile material movement; and the use of personal alarming dosimeters for personnel that must access the area during the CAAS outage. These measures will be implemented until CAAS coverage is verified to be operational and the CAAS is declared operable in accordance with approved plant procedures.
"American Centrifuge Operating, LLC (ACO) will notify the NRC when CAAS coverage is returned to normal operation.
"The licensee has notified the NRC Project Manager."
ACP condition notification #11933
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NV Div of Rad Health - Elko NV
Report Date 07/09/2024 8:40:00
Event Date 07/08/2024 0:00:00
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER The following information was received from the state of Nevada via email:
"Nevada Gold Mines LLC - Goldstrike, [Nevada license] 05-11-13545-01, reported a stuck open shutter on a Berthold LB 7440, serial number 1459. The fixed gauge remains installed pending the arrival of a contractor to replace the failed shutter. Radiation surveys of the installed gauges are as expected for a gauge in service giving 0.11 mR/hour 1 foot back from the gauge (in walkway). Gauge is installed in a location where there is occasional foot traffic, providing no additional exposure mine/mill staff until it can be repaired. Licensee [was] reminded to report the failure to the manufacturer in accordance with the operations and maintenance manual for the gauge."
The gauge contains 50 mCi of Cs-137. The state of Nevada considers this event closed.
Nevada Item Number: NV240005
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Louisiana Department of Environmental Quality - Garyville LA
Report Date 07/09/2024 13:27:00
Event Date 07/02/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following report was received from the Louisiana Department of Environmental Quality via email:
"A nuclear gauge was stuck in the open shutter position. This event is considered an equipment failure. The failure occurred while BBP (Bonds Barton Pilcher) tried to remove a screw on the rotor on July 2, 2024.
"Marathon Petroleum brought in a third party to work on the nuclear gauge. BBP was the third party. Marathon Petroleum plans on having BBP replace the nuclear gauge with another one as soon as possible."
Device information is as follows:
Model: Ohmart SH-F1A
Serial number: 13524941
Isotope: Cs-137 with an activity of 15 mCi
Source serial number: 65511
The device was acquired in June 2006.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: There were no reports of exposures and the licensee has taken measures to prevent future potential exposures.
Louisiana Event Report ID No.: LA20240007
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Cooper - Brownville NE
Report Date 07/10/2024 9:32:00
Event Date 07/09/2024 4:55:00
LOSS OF COMMUNICATIONS CAPABILITIES
The following information was provided by the licensee via email:
"On July 09, 2024, at 0455 CDT the National Weather Service reported to Cooper Nuclear Station that the National Warning System radio tower near Shubert, Nebraska was not working. The Shubert Tower transmitter activates the Emergency Alert System/Tone Alert Radios used for public notification. Additional information from the National Weather Service received July 10, 2024, at 0455 CDT determined that the Shubert Tower transmitter was not able to be repaired within 24 hours and is still non-functional. A backup notification system has been verified to be available during this period.
"This is considered to be a major loss of the Public Prompt Notification System capability. Due to the unplanned loss of the primary notification system for greater than 24 hours, this condition is reportable under 10CFR50.72(b)(3)(xiii), since the backup alerting methods do not meet the primary system design objective. A backup notification system is available to use for notifications if needed.
"The NRC Senior Resident Inspector has been informed."
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Peach Bottom - Philadelphia PA
Report Date 07/10/2024 11:15:00
Event Date 07/10/2024 7:28:00
EN Revision Imported Date: 7/11/2024
EN Revision Text: AUTOMATIC REACTOR SCRAM DUE TO MANUAL TURBINE TRIP
The following information was provided by the licensee via phone and email:
"At 0728 EDT on July 10, 2024, with Unit 2 in Mode 1 at 24 percent power, the reactor automatically scrammed due to a manual turbine trip. The [reactor] scram was not complex with all systems responding normally. Reactor vessel level reached the low-level set-point following the scram, resulting in valid Group 2 and Group 3 containment isolation signals. 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 2 and Group 3 isolations.
"Operations responded using 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 3 was not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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NJ Dept of Environmental Protection - Cherry Hill NJ
Report Date 07/10/2024 16:32:00
Event Date 07/10/2024 0:00:00
AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
Kennedy Memorial Hospital University Medical Center (the licensee) was scheduled to administer a Nordion TheraSphere therapy (116 mCi of Y-90) to a patient. The target organ was the right hepatic lobe of the liver. There was a tubing failure in the delivery system and the administration was suspended. It is estimated that only 2.62 mCi (17 percent) of the prescribed dosage was administered.
The patient and referring physician were notified. The patient has been re-scheduled for treatment.
No release of licensed material or contamination was reported.
The licensee will follow-up with a full written report. The licensee is sending the equipment that failed to the manufacturer for detailed analysis.
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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Arizona Dept of Health Services - Mesa AZ
Report Date 07/11/2024 0:24:00
Event Date 07/10/2024 0:00:00
AGREEMENT STATE - LOST TROXLER GAUGE
The following is a summary of the information provided by the Arizona Department of Health Services (the Department) via email:
On July 10, 2024, a truck carrying a portable gauge was involved in a car accident. The driver was transported to the hospital. The location and the extent of damage to the gauge and truck are currently unknown. The portable gauge is a Troxler 3440, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be.
The Department has requested additional information and continues to investigate the event.
Arizona Incident: 24-008
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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Washington State Dept of Health - Ritzville WA
Report Date 07/12/2024 18:53:00
Event Date 07/12/2024 9:30:00
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following is a summary of information provided by the Washington State Department of Health (DOH) via email:
A portable gauge (PG) was ran over by a roller around 0930 PDT. The main body was crushed and the gauge source rod broke off but appeared to be intact.
The PG user used a shovel to pick up the source and placed it in the transport box. The PG user stayed with the PG until the radiation safety officer (RSO) arrived. The RSO confirmed [an] intact source rod and gathered the remaining damaged PG parts into the transport box. It was then transported to the licensee storage location.
The RSO and local fire department did not have a survey meter for radiation and contamination surveys.
Three DOH representatives were sent for radiation and contamination survey data collection. The highest on-contact radiation level on the PG container was 1.7 mR/hr. No indication of contamination outside of the PG container was detected. A direct frisk of the RSO and PG user's hands found no indication of contamination.
DOH will take survey data including wipes and verify they are negative. Once verified, the RSO will contact the manufacturer or a waste broker for PG disposal. A leak test will be performed prior to transport. The damaged PG will remain secured in the transport box until disposal.
Washington state event number: WA-24-016
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McGuire - Cornelius NC
Report Date 07/12/2024 19:37:00
Event Date 07/12/2024 13:37:00
TECHNICAL SUPPORT CENTER VENTILATION SYSTEM NON-FUNCTIONAL
The following information was provided by the licensee via email and phone:
"On July 12, 2024, at 1337 EDT, operations discovered that the technical support center (TSC) ventilation system was non-functional, which resulted in an unplanned loss of the TSC that could not be restored within seventy-five minutes.
"If an emergency had been declared requiring TSC activation during this period, the TSC would have been staffed and activated using existing emergency planning procedures. If relocation of the TSC had been necessary, the emergency coordinator would have relocated the TSC staff to an alternate location in accordance with applicable site procedures.
"This is an eight-hour, non-emergency notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because loss of the TSC ventilation system affected the functionality of an emergency response facility.
"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 TSC ventilation system remains out-of-service at the time of the notification. In the event of an emergency, the licensee will use the alternate TSC facility per applicable site procedures until the ventilation system is restored. Repair of the ventilation system is being worked around-the-clock.
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Maryland Dept of the Environment - Joppatowne MD
Report Date 07/15/2024 10:33:00
Event Date 07/15/2024 8:59:00
EN Revision Imported Date: 7/26/2024
EN Revision Text: AGREEMENT STATE REPORT - SUSPECTED RADIOACTIVE MATERIAL FOUND
The following information was provided by the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:
"On July 15, 2024, at about 0859 [EDT], the MDE/RHP was contacted by the Maryland Emergency Response Division (ERD) that a bolted container [marked with] Russian [text] and red paint [located on] the middle part of the container with a trefoil symbol that was suspected of containing [radioactive material] was found dropped off at [a salvage] site in Joppatowne, MD. The scrap yard does not know the source(s) of these items and who [deposited] them. [Personnel at the scrap yard] did not detect radiation with available instruments.
"MDE/RHP will follow up and investigate the case today."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Two MDE/RHP inspectors were enroute to the scrap yard to investigate at the time the notification of this event to the NRC was made.
The following information was provided by the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:
"RHP inspectors responded to the site on the same day (7/15/2024) and investigated the case. RHP inspectors surveyed the area and took wipe samples of the outside of the containers. The survey results and wipe analysis report indicated no elevated radiation other than natural background. On July 17, 2024, the containers were rejected by Joppa Salvage as suspect of containing hazardous material (RAM), and returned back to Aberdeen Proving Ground, a federal site, by the hauler that dropped them. There are no health or safety concerns related to this event.
"MDE/RHP closed this event."
Maryland Event ID Number: 56594.
Notified R1DO (Lilliendahl), NMSS Events (email), ILTAB (email), NMSS Day (Brenneman)
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Colorado Dept of Health - Berthoud CO
Report Date 07/15/2024 18:09:00
Event Date 07/01/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of information received from the Colorado Department of Public Health via email:
The state of Colorado reported the loss of two exit signs.
Manufacturer: SRB Technologies Model Number: BX-20-WH Isotope and Activity: H-3, 17.51 Ci each
Colorado Event Report ID Number: CO240017
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Texas Dept of State Health Services - Kingwood TX
Report Date 07/15/2024 20:16:00
Event Date 07/14/2024 0:00:00
AGREEMENT STATE - STOLEN GUAGE
The following information was provided by the Texas Department of State Health Services (the Department) by email:
"On July 15, 2024, the Department was notified by the licensee that a moisture density gauge had been stolen from the back of one of its trucks. The radiation safety officer (RSO) reported that the technician had taken the gauge to their apartment after completing work on Friday, July 12, 2024. On July 14, 2024, the technician found the chains that secured the gauge in the back of the pickup truck had been cut and the gauge was missing. The gauge is an InstroTek Xplorer 3500, containing a 40 millicurie americium-241 source and a 11 millicurie cesium-137 source. The RSO stated local law enforcement has been notified of the theft. The RSO stated they have been in contact with local pawn shops in the area. The licensee is watching online marketplaces for the gauge. The RSO stated the gauge does not present an exposure hazard to an individual.
"Additional information will be provided as it is received in accordance with SA-300."
Texas incident number: I-10112
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following summary was provided by the Texas Department of State Health Services (the Department) by phone and email:
On July 16, 2024, the licensee reported to the State that they confirmed that the cesium-137 source rod was locked in the fully shielded condition. This updated information is pertinent in that the dose risk to the public is minimal. The condition does not present an exposure hazard to the public.
Notified R4DO (Taylor), NMSS Events (email), ILTAB (email), CNSNS (Mexico) (email)
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Colorado Dept of Health - Denver CO
Report Date 07/16/2024 11:18:00
Event Date 07/15/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following is a summary of information received from the Colorado Department of Public Health via email:
The state of Colorado reported the loss of one exit sign.
Manufacturer: Isolite Corporation Model Number: SLX60 Isotope and Activity: H-3, 7.5 Ci
Colorado Event Report ID Number: CO240018
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Colorado Dept of Health - Colorado Springs CO
Report Date 07/16/2024 12:29:00
Event Date 07/01/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of information received from the Colorado Department of Public Health and Environment via email:
Two Isolite Corporation exit signs (model number: DH/SL201 RW) containing 11.5 curies of tritium each (23 curies total) were determined to be lost by the licensee.
Colorado event number: CO240019
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 - Sun City AZ
Report Date 07/17/2024 12:56:00
Event Date 07/16/2024 0:00:00
AGREEMENT STATE REPORT - LOST I-125 SEED
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with (1) approximately 0.150 mCi I-125 seed on July 15, 2024. The patient returned to the hospital on July 16, 2024, to have the tissue, including the seed, removed. When the surgeon attempted to locate the seed, they were unable to detect it. The operating room and patient were surveyed but the seed was not located. 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: 24-009
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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PA Bureau of Radiation Protection - Harleysville PA
Report Date 07/18/2024 11:39:00
Event Date 07/17/2024 18:30:00
AGREEMENT STATE REPORT - STOLEN TROXLER DENSITY GAUGE
The following information was provided by the Pennsylvania Department Bureau of Radiation Protection (the Department) via email:
"On July 18, 2024, the Department was notified of a stolen nuclear density gauge. This event is reportable within 24-hours per 10 CFR 20.2201(a)(1)(i).
"On July 17, 2024, an employee of the licensee reported to police that a nuclear density gauge was stolen from their vehicle between 1830-2250 EDT. Local police are aware of the incident. The Department has been in contact with the licensee and will update this event as soon as more information is provided.
"Manufacturer & Model Number: Troxler Electronic Laboratories "Model Number: 3440 "Serial Number: 87955 "Isotope & Activity: Cs-137, 9 millicuries; Am-241:Be, 44 millicuries"
Pennsylvania Incident Number: 240016
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Calvert Cliffs - Lusby MD
Report Date 07/18/2024 18:33:00
Event Date 07/18/2024 15:24:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 1524 [EDT] on 07/18/2024, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a 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 by discharging steam to the main condenser using the turbine bypass valves.
"Unit 1 implemented AOP-7K (abnormal operating procedure), overcooling event, due to a grid transient. Operations responded and stabilized Unit 1 in Mode 1 at 100 percent power.
"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).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All rods fully inserted. There were no other specified system actuations.
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New York State Dept. of Health - Stony Brook NY
Report Date 07/22/2024 13:02:00
Event Date 07/18/2024 0:00:00
AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"The NYSDOH received an email from the radiation safety officer (RSO) on July 22, 2024, to report a lost Fe-55 source. The make and model of the missing source was not disclosed; however, NYSDOH is requesting additional information and will provide this information once available. The source serial no. is 55-1.1-8 and was last assayed 10/1/2015. At the time of manufacture and distribution, this source was 10 mCi.
"The source in question was last seen during routine inventory on January 5, 2023. Following this inventory, this source was not accounted for on March 23, 2023. It was believed that this source may have been utilized by an authorized user between January 5, 2023, and March 23, 2023. However, after many discussions between the authorized user and Stony Brook University's radiation safety office, it was confirmed that the source in question was officially lost on 7/18/2024. Decay calculations suggest that the missing Fe-55 source is approximately 1.07 mCi to date. As this source was last inventoried on January 5, 2023, it is estimated that the Fe-55 source was approximately 1.58 mCi at the time it was last confirmed as present in the storage area. This activity is approximately 15.8 times the quantity for Fe-55 requiring labeling as stated in Appendix C to 10 CFR 20. The loss of this source meets the reportability criteria in 10 CFR 20.2201(a)(1)(ii).
"It is not believed that this source may cause any incidental doses which may exceed the limits in Subparts C or D of 10 CFR 20. Furthermore, the loss of this source would not be expected to have any negative implications on public health. NYSDOH is monitoring this incident and has assigned incident number 1493 to track this event. Additional information will be provided to NMED once available."
Event Report ID No. NY-24-06 NYSDOH Incident Number: 1493
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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Texas Dept of State Health Services - Friendswood TX
Report Date 07/22/2024 13:21:00
Event Date 07/22/2024 0:00:00
AGREEMENT STATE REPORT - ATTEMPTED THEFT OF CATEGORY 2 MATERIAL
The Texas Department of State Health Services reported an apparent attempted theft of Category 2 radioactive material from the licensee. Local law enforcement was informed.
Texas Incident Number: 10113 SID-03254
Notified DHS SWO, FEMA Ops, USDA Ops, HHS Ops, DOE Ops, CISA Central, EPA EOC, FDA EOC, Nuclear SSA, FEMA National, CWMD Watch Desk
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
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Louisiana Radiation Protection Div - Jefferson LA
Report Date 07/23/2024 17:25:00
Event Date 07/23/2024 6:30:00
AGREEMENT STATE REPORT - FIRE IN EQUIPMENT CONTAINING RADIOACTIVE MATERIAL
The following information was provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:
"This event is considered [an] equipment fire. The licensee had a vent hood equipment electrical fire. The fire occurred at 0630 [CDT] on July 23, 2024. The event was not reported until 1445 on July 23, 2024.
"The vent contained radioactive material waste. The majority of the waste was radioactive iodine. This event is under investigation and [LA DEQ] will have an inspector sent out.
"According to the licensee, there was no release. All material in the vent hood remained intact.
"The local fire department was called out to the location to put out the fire."
LA DEQ Event Report Number: LA20240008
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South Texas - Wadsworth TX
Report Date 07/24/2024 9:31:00
Event Date 07/24/2024 7:02:00
EN Revision Imported Date: 7/30/2024
EN Revision Text: NOTIFICATION OF UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
A Notification of Unusual Event was declared by South Texas Project Unit 1 at 0718 CDT for emergency action level (EAL) SU.1, loss of all offsite power for greater than 15 minutes, following a fire in the switchyard. Unit 1 tripped following the loss of power and is stable in Mode 3. Unit 2 reduced power to 90 percent but was otherwise unaffected by this event. Offsite services responded to the switchyard fire. The fire was extinguished at 0925 CDT.
There is no radioactive release and no threat to public safety.
The licensee notified state and local authorities and the NRC senior resident inspector.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
* * * UPDATE ON 7/24/2024 AT 1154 EDT FROM CHRIS VAN FLEET TO ERNEST WEST * * *
The following information was provided by the licensee via phone and email:
"At 0702 CDT on 7/24/2024, with Unit 1 in Mode 1 at 100 percent power, the Unit 1 reactor automatically tripped due to loss of offsite power. The trip was not complex, with all systems responding normally post-trip. No equipment was inoperable prior to the event that contributed to the event or adversely impacted plant response to the scram.
"Operations responded and stabilized the plant. Decay heat is being removed by steam generator power operated relief valves (PORV). Unit 2 was reduced in power to approximately 90 percent power due to conditions in the switchyard.
"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).
"There was no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified."
Notified R4DO (Azua)
The following is a summary of information provided by the licensee via phone:
At 1146 CDT, South Texas Project Unit 1 terminated the previously declared Notification of Unusual Event due to restoration of an offsite source of electrical power.
Notified R4DO (Azua), NRR EO (McKenna), IR MOC (Crouch), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
The following information was provided by the licensee via phone and email:
For the 10 CFR 50.72(b)(3)(iv)(A) reporting requirements:
"At 0702 CDT on 7/24/2024, with both Unit 1 and 2 in Mode 1 at 100 percent power, the South Texas Project (STP) north and south switchyard electrical buses were de-energized.
"In Unit 1, all emergency diesel generators (EDGs) 11, 12, and 13 automatically started in response to loss of offsite power on train `A', `B', and `C' engineered safety feature (ESF) buses.
"Also in Unit 1, trains `A', `B', and `C' of the auxiliary feedwater (AFW) system automatically started.
"In Unit 2, EDG 22 automatically started in response to loss of offsite power on the train `B' ESF bus.
"Also in Unit 2, train `B' of the AFW system automatically started.
"This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in the valid actuation of a pressurized water reactor auxiliary feedwater system (50.72(b)(3)(iv)(B)(6)) and emergency alternating current (AC) electrical power system (50.72(b)(3)(iv)(B)(8)). There was no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified."
For the 10 CFR 50.72(b)(2)(xi) reporting requirement:
"A news release was completed at 1140 CDT on 7/24/2024, by South Texas Project on the declaration of the Unusual Event. This media release is being reported in accordance with 10 CFR 50.72(b)(2)(xi): Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made."
Notified R4DO (Azua)
The following information was provided by the licensee via phone and email:
"After a review of station logs, it was determined that there was not a loss of all offsite AC power to Unit 1 related to the event that occurred on July 24, 2024. An offsite AC power source was available through the 138 kV transmission line.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At this time the licensee is not retracting the declaration of emergency action level 'SU.1'.
Notified R4DO (Werner)
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Perry - Perry OH
Report Date 07/24/2024 13:22:00
Event Date 07/24/2024 10:46:00
OFFSITE NOTIFICATION
The following information was provided by the licensee via phone and email:
"At 1046 EDT on 7/24/2024, fourteen Ashtabula County emergency response sirens were inadvertently activated during system maintenance. Ashtabula County Emergency Management Agency was contacted and made aware of the situation. This notification is being made solely as a four-hour, non-emergency notification for a notification of other government agencies in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact to the health and safety of the public or plant personnel. The NRC resident inspector has been notified of the issue."
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Missouri U of Science & Tech (MIST) - Rolla MO
Report Date 07/24/2024 17:46:00
Event Date 07/24/2024 14:10:00
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via phone and email:
"Minimum staffing [was] not met under Missouri University of Science and Technology Reactor (MSTR) Technical Specification (TS) 6.1.3.1(a) [for approximately one hour].
"At 1400 CDT, on July 24, 2024, the MSTR conducted a planned shutdown from 40 kW in support of a thermal power calibration. At approximately 1410, the control room operator left the control room for the reactor bay to perform additional power calibration data collection. At approximately 1510, the radiation safety officer (RSO) passed by the control room and observed that the magnet key remained in the console. The operator was promptly notified and secured the key. The operator notified the reactor manager and senior reactor operator on duty (shift supervisor) by approximately 1530, who discussed the issue with the facility director.
"During the time period of 1410 to 1510, the MSTR did not meet the TS definition for reactor secured, as the magnet key remained in the console. As such, without an operator in the control room, the minimum staffing requirements of TS 6.1.3.1(a) were not met, as this specification states: `1. The minimum staffing when the reactor is not secured shall be: a) A certified reactor operator in the control room.' It is noted that the reactor was shut down and the control rods remained inserted for the duration of the event.
"The event has been entered into the facility corrective action program as CAP-2024-001, and the NRC project manager will be notified."
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Saint Francis Hospital - Hartford CT
Report Date 07/24/2024 17:49:00
Event Date 07/24/2024 10:30:00
LOST AND RECOVERED SOURCE
The following information was provided by the licensee via phone and email:
"A Class 7 package (approximately 10 Ci of Ir-192 for use in a high dose rate remote afterloader for radiation oncology) was delivered to Saint Francis Hospital, [in] Hartford, CT. The package was delivered to hospital shipping/receiving and signed for at 1030 [EDT]. The package was then routed to [the] oncology department. When reaching oncology, it appears the package was mistaken for a 'chemotherapy' package instead of a 'radiation oncology' package and placed in storage in the chemotherapy department. Later, a medical physicist anticipating delivery of the package today inquired about the package with the delivery service and was informed that the package had been delivered. The physicist then began searching for the package and was able to locate it in the chemotherapy department. The physicist retrieved the package and began the check-in process at about 1500 per standard operating procedures. The physicist stated that the package was unopened, undamaged, and still sealed.
"The RSO received notification from radiation oncology that the package was missing prior to when the package was eventually found. The package was stored in a secured area, but its location was unknown to trained staff for the interim period, so the decision was made to make notification of the incident.
"This is an initial assessment. The radiation safety staff along with management will be conducting an investigation to determine more precise timelines, details, and evaluating corrective action options to prevent recurrence."
THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL
Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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South Texas - Wadsworth TX
Report Date 07/24/2024 20:58:00
Event Date 07/24/2024 13:23:00
POSITIVE FITNESS FOR DUTY TEST
The following information was provided by the licensee via email:
"On July 24, 2024, a licensed operator violated the station's fitness for duty (FFD) policy. The employee's unescorted access to South Texas Project has been terminated. The event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).
"The NRC resident inspector has been notified."
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RSSC dba Marmon - East Granby CT
Report Date 07/25/2024 11:05:00
Event Date 07/23/2024 0:00:00
EN Revision Imported Date: 8/26/2024
EN Revision Text: PART 21 REPORT - NON-COMPLIANT INSULATED CONDUCTOR
The following is a synopsis of information received via fax:
A reel of insulated conductor was found non-compliant due to failure of insulation tensile and elongation at break test following air oven aging. Wire from the non-compliant reel was delivered to nine plants.
Affected plants: Wolf Creek, Dresden, LaSalle, Limerick, Peach Bottom, Arkansas Nuclear One, Waterford, Susquehanna, and Davis Besse.
Reporting company point of contact: RSSC Wire and Cable LLC dba Marmon Industrial Energy and Infrastructure 20 Bradley Park Road East Granby, CT 06026
Phillip Sargenski - Quality Assurance Manager Phone: 860-653-8376 Fax: 860-653-8301 Phillip.sargenski@marmoniei.com
* * * UPDATE ON 08/23/24 AT 1315 EDT FROM PHILLIP SARGENSKI TO JOSUE RAMIREZ * * *
The vendor provided the final report for this event listing corrective actions and the estimated completion dates.
Notified R1DO (Lilliendahl), R3DO (Skokowski), R4DO (Vossmar), and Part 21 group (Email).
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Browns Ferry - Decatur AL
Report Date 07/25/2024 20:48:00
Event Date 07/23/2024 13:00:00
EN Revision Imported Date: 8/23/2024
EN Revision Text: PART 21 - HPCI RUPTURE DISC NOT WITHIN TECHNICAL REQUIREMENTS
The following information was provided by the licensee via phone and email:
"Tennessee Valley Authority (TVA) completed an engineering evaluation for a Fike Metal Products 16-inch rupture disc, part number 16-CPV-C, which had failed in March 2024 during an event previously reported to the NRC as Event Notification 57036 and Licensee Event Report 260/2024-002-00.
"The evaluation determined that the failure of the rupture disc constituted a failure to comply by a basic component which resulted in a substantial safety hazard.
"The rupture disc was procured as a non-safety related item from Fike Corporation and commercially dedicated by Paragon Energy Solutions. The disc was supplied to TVA in a satisfactory condition meeting all acceptance criteria. During a routine flowrate surveillance test, the high-pressure coolant injection (HPCI) inner rupture disc developed a hole which caused the Unit 2 HPCI turbine to trip. This resulted in [Browns Ferry Unit 2] entering Technical Specification (TS) Limiting Condition for Operation (LCO) 3.5.1 Condition `C', which is a 14-day shutdown LCO. Per HPCI system design criteria, turbine casing protection disc rupture pressure shall be at 175 psig plus 1 or minus 10 psig and the rupture discs shall be sized for a flow capacity of 600,000 pounds per hour at 200 psig, minimum. The failed HPCI inner rupture disc did not experience pressures above 45 psig since being installed; therefore, the HPCI turbine inner rupture disc did not meet its technical requirements.
"On July 23, 2024, the Browns Ferry Nuclear Plant Site Vice President was notified of the requirement to report this event under 10 CFR 21.21. This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Both Fike Corporation and Paragon Energy Solutions have been informed of the HPCI inner rupture disc not meeting technical requirements. Known potentially affected plants include Browns Ferry Units 1, 2, and 3.
The following information was provided by the licensee via phone and email:
"The purpose of this notification is to retract a previous event notification, EN 57245, reported on 7/25/24. "Continued evaluation has concluded that the failure of the disc was not the result of a failure to comply by a basic component, therefore, the NRC non-emergency 10 CFR 21.21 (d) report was not required and the NRC EN 57245 can be retracted. "The licensee has notified the NRC Resident Inspector."
Notified R2DO (Masters) and Part 21/50.55 Reactors group (Email).
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Louisiana Energy Services - Eunice NM
Report Date 07/26/2024 10:53:00
Event Date 07/26/2024 8:44:00
EN Revision Imported Date: 7/29/2024
EN Revision Text: ALERT DECLARATION DUE TO SEISMIC ACTIVITY FELT ON SITE
The following information was provided by the licensee via fax and phone call:
"On July 26, 2024, at 0844 MDT, Urenco (Louisiana Energy Services) declared an Alert following a magnitude 5.0 earthquake in Snyder, Texas, which was felt onsite. No release on site was detected."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The earthquake was felt from within the Urenco control room. Three centrifuges were taken out of service due to the seismic event, however, there were no leaks found on the equipment. No public protective actions are recommended at this time.
The licensee notified State and local authorities.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)
On 7/26/2024, at 1430 MDT, Urenco USA terminated the Alert. Urenco USA met conditions for event termination. No damage was found upon completion of site walkdowns and seismic aftershock magnitude continues to decrease. The licensee will notify State and local authorities.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Coovert), IR MOC (Crouch), NMSS (Helton)
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Univ Of New Mexico (NEWM) - Albuquerque NM
Report Date 07/26/2024 19:08:00
Event Date 07/26/2024 16:54:00
EN Revision Imported Date: 7/29/2024
EN Revision Text: NON-POWER REACTOR - UNPLANNED HIGH POWER TRIP
The following information was summarized from the licensee via phone and email:
At the time of the trip, the reactor was being operated by an authorized operator trainee under direct supervision of a reactor operator with a senior reactor operator present. The reactor was at a steady state power of 5 watts as planned by the supervisor. The reactor tripped unplanned as a result of high power trip signal. The trip was uncomplicated, the event was not an emergency, and involved no damage to the facility. The reactor is shut down and secured at this time.
The safety channels of the AGN-201M are set to operate near 120 percent of the licensed power limit of 6 watts. The high-power trip observed today was unplanned but does not appear to have occurred because of an actual exceedance of the trip setpoints on the redundant safety channels, or the licensed power limit. Both trip setpoints and safety channels were measured during monthly surveillances on 7/23/24, and were within the normal and expected range.
In the past, there have been protection system trips caused by static electrical discharge from the operator to the console however the cause of the trip is still under investigation.
Monthly surveillances relating to the safety channels are planned to be repeated to verify that they are operating in the normal range before resuming reactor operations.
The University of New Mexico is making this notification to the NRC in accordance with technical specification '6.9.2.a.7', which requires notification for unplanned events causing a reactor shutdown (i.e. high-power trip).
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Saint Lucie - Ft. Pierce FL
Report Date 07/28/2024 21:58:00
Event Date 07/28/2024 18:37:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 1837 EDT on 7/28/24, with Unit 1 in mode 1 at 100 percent power, the reactor automatically tripped due to inadvertent closure of a main steam isolation valve. During the trip, auxiliary feedwater actuated. All other systems responded normally post-trip. Operations stabilized the plant in mode 3. Decay heat is being removed by atmospheric dump valves and auxiliary feedwater. Unit 2 is not affected.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)."
The NRC resident inspector has been notified.
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River Bend - St Francisville LA
Report Date 07/30/2024 15:10:00
Event Date 06/07/2024 1:46:00
EN Revision Imported Date: 8/6/2024
EN Revision Text: CONTROL ROOM ENVELOPE FAILED SURVEILLANCE
The following information was provided by the licensee via email:
"At 0146 CDT on June 7, 2024, River Bend Station (RBS) was operating at 100 percent power when a loss of control room envelope (CRE) was declared due to failing to meet Technical Specification (TS) 3.7.2, Surveillance Requirement (SR) 3.7.2.4, during surveillance testing. Mitigating actions were established which included the ability to issue potassium iodide to control room staff. With mitigating actions in place, the dose consequence to control room staff continued to be less than the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event.
"The CRE is considered a single train system at RBS, therefore, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function.
"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 failed surveillance (SR 3.7.2.4) was for unfiltered air in-leakage greater than 300 cubic feet per minute.
"This event was initially reported under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function. The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that there was no adverse impact on the control room emergency ventilation system or the control room envelope (CRE) boundary's ability to perform its safety function. The CRE would not have been challenged to meet the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event. Consequently, this condition is not reportable as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC resident inspector has been notified."
Notified R4DO (Vossmar).
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Sequoyah - Soddy-Daisy TN
Report Date 07/30/2024 18:52:00
Event Date 07/30/2024 16:41:00
AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP
The following information was provided by the licensee via phone and email:
"At 1641 EDT, with Unit 2 in Mode 1 at 94 percent power and increasing in power after a forced outage, the reactor automatically tripped due to an electrical trouble 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 by the auxiliary feedwater (AFW) 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) and in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified."
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