Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57141 | 24 May 2024 02:08:00 | The following information was provided by the licensee via email: At 2223 CDT on May 23, 2024, with Quad Cities Unit 2 at 38 percent power, the reactor automatically tripped due to a turbine trip signal resulting in main stop valve closure, creating a valid reactor protection system signal. Reactor vessel level reached the low-level set-point following the scram, resulting in valid Group II and Group III containment actuation signals. The trip was not complex with all systems responding as expected post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group II and Group III isolation. Operations responded using their emergency operating procedures and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 remains at 100 percent power. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Unit 2 was at a reduced power for maintenance. |
| ENS 57109 | 7 May 2024 10:29:00 | The following information was provided by the licensee via telephone: During an inspection in early March 2024, the licensee could not locate ten tritium exit signs. On May 7, 2024, after searching for the signs, the licensee declared the signs lost. The licensee does not know when the signs were lost. The total activity was 118.7 curies. The licensee notified the NRC Region 4 inspectors. THIS MATERIAL EVENT CONTAINS A Less than Cat 3 LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 57101 | 3 May 2024 10:27:00 | The following was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on 5/2/24 to advise that a patient who was administered Y-90 TheraSpheres on 5/1/24 received an underdose of approximately 23.6 percent. Both the patient and the referring physician were notified. There is no anticipated adverse impact to the patient and retreatment will not be necessary. The root cause has yet to be identified, and Agency inspectors will perform a reactive inspection the week of 5/6/24. This report will be updated as additional information becomes available. IL Event Number: IL240011 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 57090 | 25 April 2024 02:22:00 | The following information was provided by the licensee via email: On 4/24/2024 at 2215 CDT, Browns Ferry Unit 1 experienced an automatic reactor scram. The cause of the scram is currently under investigation. The main steam isolation valves (MSIVs) remain open with the main turbine bypass valves controlling reactor pressure. The reactor feedwater pumps are in service to control reactor water level. Primary containment isolation systems (PCIS) Groups 2, 3, 6, and 8 isolation signals were received. Upon receipt of these signals, all components actuated as required. Following the reactor scram, due to reactor water level reaching minus 45 inches, both high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) initiation signals were received, and both initiated as designed. All safety systems operated as expected. This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(A), `Any event that results or should have resulted in emergency core cooling system (ECCS) discharge into the reactor coolant system as a result of a valid signal except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(B), `Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A), `Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B): 1) Reactor protection system (RPS) including: reactor scram or reactor trip. 2) General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs). 4) ECCS for boiling water reactors (BWRs) - high-pressure coolant injection (HPCI). 5) BWR reactor core isolation cooling system (RCIC). All safety systems operated as expected. At no time was public health and safety at risk. The NRC resident inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Units 2 and 3 were not affected. |
| ENS 57080 | 17 April 2024 10:34:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On April 16, 2024, the Department was notified by the licensee that they had removed a Natco model B-20-06 nuclear gauge containing a 175 millicurie (original activity) Cs-137 source from a vessel to allow work on the vessel. The gauge shutter was in the closed position and was functioning normally. Dose rates taken at the gauge before removal were normal at 0.65 millirem per hour. After the gauge was removed from the vessel, it was placed on a pallet with other gauges that had been removed from the vessel. At this time, the licensee performed additional radiation surveys, and the dose rate taken within a foot at the top of the gauge shutter was now reading 8.65 millirem per hour. The gauges were all moved to a locked storage location. The licensee has contacted a service company to inspect the gauge and determine the cause for the increased dose rates. The licensees radiation safety officer (RSO) stated the shutter may have been damaged as the gauge was being moved to the pallet. The RSO stated no overexposures had occurred. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10099 Texas NMED No.: TX240012 |
| ENS 57047 | 25 March 2024 00:48:00 | The following information was provided by the licensee via email: At 1634 MST on March 24, 2024, an engineered safety features (ESF) service transformer deenergized resulting in a loss of power to the Unit 2 Train B 4.16 kV Class 1E Bus. The Unit 2 Train B emergency diesel generator (EDG) automatically started and energized the Unit 2 Train B 4.16 kV Class 1E Bus. As a result of the loss of power on the Unit 2 Train B 4.16 kV Class 1E Bus and subsequent load sequencing after the Unit 2 Train B EDG started, the Unit 2 Train B auxiliary feedwater (AFW) pump automatically started as designed. The Train B AFW pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The Train B AFW Pump did not supply feedwater to the steam generators. All systems operated as designed. Per the emergency plan, no classification was required due to the event. Units 1, 2, and 3 remain in Mode 1 at 100 percent power. The 4.16 kV Class 1E Buses in Units 1 and 3 were not affected by the deenergization of the ESF service transformer. The cause of the ESF service transformer being deenergized is under investigation. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems and auxiliary feedwater system. The NRC Resident Inspectors have been informed. |
| ENS 57042 | 22 March 2024 01:17:00 | The following information was provided by the licensee: A Notification of Unusual Event, HU4.4 (see note below) was declared based a fire in the protected area requiring off site assistance to extinguish. The fire was in the main transformer yard. The fire was detected at 2328 CDT on March 21, 2024, and the fire was declared out at 0009 CDT on at March 22, 2024. An automatic reactor trip was initiated due to a loss of offsite power to the "B" train and a failure to automatically transfer from unit auxiliary transformer "B" to startup transformer "B. The licensee notified State and local authorities and the NRC Resident Inspector. The NRC remained in Normal. 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). NOTE: Due to a typographical error initiating condition HU4.1 was initially recorded for the event. The correct initiating condition is HU4.4 as now shown.
The licensee terminated the Notification of Unusual Event at 0221 CDT on 3/22/24. The licensee notified the NRC Resident Inspector. Notified R4DO (Gepford), IR-MOC (Grant), NRR-EO (Felts), DHS-SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
RPS ACTUATION The following information was provided by the licensee via email: On March 21, 2024, at 2328 CDT, Waterford 3 Steam Electric Station, Unit 3 was operating at 98 percent power when an automatic reactor trip was initiated due to a loss of offsite power to the B train and a failure to automatically transfer from unit auxiliary transformer B to startup transformer B. Emergency feedwater actuation signal 2 (EFAS), safety injection actuation signal (ECCS), containment isolation actuation signal and emergency diesel generators automatically actuated. The unit is currently stable in Mode 3. All control rods fully inserted and all other plant equipment functioned as expected. Forced circulation remains with one reactor coolant pump per loop running. Decay heat removal is via the main condenser. A train safety bus is being supplied by off-site power, and B train safety bus is being supplied by emergency diesel generator B. Following the loss of offsite power to the B train, it was reported that main transformer B and startup transformer B were both on fire. The Emergency Director declared an Unusual Event at time 2337 CDT. The fire was reported extinguished at 0009 CDT on March 22, 2024, and the Unusual Event was terminated at 0221 CDT on March 22, 2024. Offsite assistance was requested. The local fire department responded to the site but the fire was extinguished by the on-shift fire brigade. NRC Region IV management was contacted regarding the emergency plan entry at 0030 CDT on March 22, 2024. This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system, ECCS, Containment Isolation and Emergency Diesel Generators. The NRC Resident Inspector has been notified. Notified R4DO (Gepford)
The initial notification in event notice #57042 by Waterford Steam Electric Station, Unit 3, reported a Notice Of Unusual Event (NOUE) emergency declaration due to a fire in the protected area requiring off site support to extinguish. The basis for retraction of the initial emergency notification is that this event did not meet the definition of a fire in the protected area that requires off site support to extinguish. Guidance provided in Nuclear Energy Institute (NEI) 99-01, Rev. 6 and implemented in Waterfords Emergency Plan procedure, initiating Condition HU4.4 states, The dispatch of an offsite firefighting agency to the site requires an emergency declaration only if it is needed to actively support firefighting efforts because the fire is beyond the capability of the Fire Brigade to extinguish. (NOTE: The Initial Notification Form sent from the Control Room at 2341 CDT on March 21, 2024, requested by and provided to the NRC Headquarter Operations Center via e-mail at 0302 CDT on March 22, 2024, stated that the Emergency Classification had been made on Initiating Condition HU4.4 rather than HU4.1)" When the event occurred on March 21, 2024, the Emergency Director declared an Unusual Event at 2337 CDT and requested offsite support based on the information available at that time including the initial assessment by the fire brigade leader and expected need for offsite support to extinguish the fire. As reported in the 0420 EDT update on March 22, 2024, the fire was reported extinguished at 0009 CDT on March 22, 2024, by the Waterford Fire Brigade without the need of offsite support." Notified R4DO (Kellar).
The initial notification in EN 57042 by Waterford Steam Electric Station, Unit 3, reported an emergency declaration of an Unusual Event due to a fire in the protected area requiring off site support to extinguish. The basis for the update to the initial notification is that this event did not meet the definition of a Fire in the Protected Area that requires offsite support to extinguish. As provided in NEI 99-01, Rev. 6 and implemented in Waterfords emergency plan procedure, initiating condition HU4.4 states, The dispatch of an offsite firefighting agency to the site requires an emergency declaration only if it is needed to actively support firefighting efforts because the fire is beyond the capability of the Fire Brigade to extinguish. Additionally, EAL 4.1 for a fire not extinguished within 15 minutes of detection in any Table H-1 fire area was not applicable because the fire did not occur in a Table H-1 fire area. When the event occurred on March 21, 2024, the Emergency Director declared an Unusual Event at 2337 CDT and requested offsite support based on the information available at that time including the initial assessment by the fire brigade leader and expected need for offsite support to extinguish the fire. As reported in the 0420 EDT update on March 22, 2024, the fire was reported extinguished at 0009 CDT on March 22, 2024, by the Waterford Fire Brigade without the need of offsite support. (NOTE: The Initial Notification Form sent from the Control Room at 2341 CDT on March 21, 2024, requested by and provided to the Headquarters Operation Center via e-mail at 0302 CDT on March 22, 2024, stated that the emergency classification had been made on initiating condition HU4.4 rather than HU4.1) In accordance with NRC Approved guidance in FAQ 21-02 (ML21117A104), Waterford 3 is retracting the initial event notification made at 0117 EDT on March 22, 2024. The remaining events that were reported in EN 57042 as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW (emergency feedwater) system, ECCS (emergency core cooling system), containment isolation and emergency diesel generators are still applicable and require no additional update at this time. The licensee also provided a site map. Notified R4DO (Kellar) |
| ENS 57043 | 22 March 2024 01:46:00 | The following information was provided by the licensee via email: At 2056 on 3/21/24, Callaway Plant was in Mode 1 at approximately 100 percent power when an automatic start of the turbine driven auxiliary feedwater pump occurred. The event occurred while restoring inverter NN12 from maintenance. NN12 is the normal in-service inverter for the group 2 120-VAC instrument bus (NN02). The actuation occurred while swapping from the swing inverter (NN18) to the normal in-service inverter (NN12). All safety systems responded as expected. At 2334, the turbine driven auxiliary feedwater pump was secured. The plant is being maintained in a stable condition, in mode 1. The NRC Resident Inspector was notified The licensee is investigating the cause of the automatic start.
Event Notification (EN) 57043, made on 03/21/2024 pursuant to 10 CFR 50.72(b)(3)(iv)(A), is being retracted based upon further investigation into the cause of the turbine driven auxiliary feedwater pump (TDAFP) actuation. The TDAFP received an invalid manual initiation signal caused by a voltage transient that was generated on the NK02 125-VDC bus upon closure of downstream breaker NK0211 (while restoring inverter NN12 from maintenance). This actuation signal was due to degradation of a 48-VDC power supply (PS1) within engineered safety features actuation system (ESFAS) logic cabinet SA036C. This degradation likely prevented the power supply from sufficiently filtering the transient that occurred on the 125-VDC bus associated with the NN12 inverter. Notified R4DO (Warnick) |
| ENS 57044 | 22 March 2024 08:35:00 | The following information was provided by the licensee: At around 1700 CDT on March 21, 2024, the Detroit Army Arsenals radiation safety officer (RSO) noticed a picture of two Army M58 Aiming Post Lights, which typically contain 5 Ci of tritium each, on a Reddit sub-group. The post indicated that the devices were a "going away gift" from the Army, and that the individual was no longer in the Army. The sealed sources appeared to be intact, but the RSO could not see the serial numbers. The RSO plans on reporting this to his chain of command and to the Army Criminal Investigative Service. 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 |
| ENS 57005 | 4 March 2024 10:25:00 | The following is a summary of the information provided by the Louisiana Department of Environmental Quality (LDEQ) via email: At 2152 CST on March 3, 2024, a lost source was found along Corporate Blvd., Baton Rouge, LA. The device is a Model IC-51 Calibrator with 1000 mCi of Cs-137 as of August 25, 1980. The label on the device indicates the manufacturer was Gulf Nuclear, Inc., of Webster, Texas. LDEQ took possession of the device on March 4, 2024, and has it at the time of this report. Event Report ID No.: LA20240003 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 |
| ENS 56971 | 16 February 2024 05:34:00 | The following information was provided by the licensee via email: At 0048 CST on February 16, 2024, with Unit 2 in mode 1 at 100 percent power, the reactor was manually tripped due to a loss of 2A 125V DC distribution panel. The trip was complex due to the loss of components associated with A-train DC power. Operations responded and stabilized the plant. Decay heat is being removed by the atmospheric relief valves. Unit 1 is not affected. An automatic actuation of the auxiliary feedwater system (AFW) occurred due to low-low steam generator levels. The AFW auto-start is an expected response with low-low steam generator levels from the reactor trip. AFW is still currently controlling steam generator levels. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW System. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56968 | 15 February 2024 05:45:00 | The following information was provided by the licensee via email: At 0247 CST on 2/15/2024, Callaway Plant was in mode 1 at approximately 100 percent power when a turbine trip and reactor trip occurred. All safety systems responded as expected with the exception of an indication issue on the feedwater isolation valves, which were confirmed closed. A valid feedwater isolation signal and auxiliary feedwater actuation signal were also received as a result of the reactor trip. The plant is being maintained stable in mode 3. All control rods fully inserted from the reactor trip signal and decay heat is being removed via the auxiliary feedwater system and steam dumps. The NRC Resident Inspector was notified. |
| ENS 57079 | 16 April 2024 23:29:00 | 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). |
| ENS 56969 | 15 February 2024 09:49:00 | The following information was provided by the New York State Department of Health (the Department) via fax: The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at (the Plainview facility), RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause. Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements. New York State Event Report Number: NY-24-01 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 |
| ENS 56950 | 7 February 2024 07:50:00 | The following is a summary of a report received from the North Carolina Department of Health and Human Services via email: At 1542 EST on February 3, 2024, Forsyth Memorial Hospital Inc., doing business as Novant Health, Forsyth Medical Center Mobile PET/CT Services notified the North Carolina Department of Health and Human Services of a contaminated PETNET Solutions, Inc. transport case. The transport case, containing fludeoxyglucose (FDG) (46.9 mCi of F-18), was received onboard a mobile coach lab while stationed at Novant Health Huntersville Medical Center. Immediately upon arrival, the technologist performed incoming package surveys. The survey at the surface read 6 mR/hr, and a removable contamination wipe read 33,000 dpm/100 sq cm. Two confirmatory wipes were then taken; both showing similar results. The technologist was able to pinpoint the contaminated spot on the transport case before securing the case onboard the mobile coach hot lab. The technologist then notified the PET/CT supervisor of the results. The supervisor contacted PETNET Winston-Salem who stated they would forward the event details to the PETNET location that dispatched the contaminated transport case, PETNET Columbia, SC. NC Item number: NC240001 |
| ENS 56935 | 27 January 2024 23:39:00 | The following information was provided by the licensee via email: At 2141 EDT, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being removed using the auxiliary feedwater and steam dump systems. Unit 1 is not affected. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72(b)(3)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. All control rods are fully inserted. The cause of the turbine trip is being investigated. The licensee notified the NRC Resident Inspector. |
| ENS 56917 | 9 January 2024 17:10:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On January 9, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that during routine checks, the shutters on three Vega America SH-F2 source holder failed to close. Open is the normal operating position for the gauges. Each gauge contains a 200 millicurie cesium-137 source. The gauges do not create an exposure risk to any individual. The RSO stated they have contacted a service provider for repairs to the gauges. Additional information will be provided as it is received in accordance with SA300. Texas Incident Number: I-10076 NMED Number: TX240001 |
| ENS 56918 | 9 January 2024 20:10:00 | The following information was provided by the California Department of Public Health, Radiation Health Branch via email: On January 8, 2024, the licensee's radiation safety officer contacted the California Office of Emergency Services to report a moisture/density gauge was stolen from a vehicle (Honda Pilot SUV) that was parked at the operator's residence. The gauge transport case was locked, as was the gauge inside the case, and the case was secured to the frame of the locked vehicle with a lock and chain. The gauge was a CPN model MC-3, serial number M339028680 containing 10 mCi Cs-137 (nominal) and 50 mCi Am:Be-241 (nominal). A police report was submitted to the Orange County Sherriff's Department. An advertisement has been submitted to the Orange County Register with a reward for return of the gauge. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 56890 | 15 December 2023 10:09:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On December 14, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN (common carrier) hub where it was scanned on December 12, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 3 mL shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.154 millicuries. It was offered for shipment on December 8, 2023, for delivery to a customer in Clovis, CA on December 11, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Item Number: IL230035 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
As of 1/11/2024, the package is now back at the pharmacy and in storage for decay. The package did eventually arrive at its intended location but was then sent back to the pharmacy. The inner packaging was damaged but the vial containing radioactive material was undamaged. This matter is now considered closed. Notified R3DO (Orlikowski), and NMSS via email. |
| ENS 56956 | 9 February 2024 10:55:00 | The following information was received from the Georgia Radioactive Material Program via email: On or about 9/21/23, a Filtec model FT-50C, containing 100 mCi of Am-241, was mistakenly placed into a scrap dumpster on-site by an employee of Shasta Beverages, Inc. The gauge was taken off-site in the scrap dumpster by a scrap collection company. The scrap company is unsure of which of two locations the dumpster was taken, a recycling facility or a scrap yard. This report serves as initial notification and will be followed up with additional information. Georgia Incident Number: 78
The Filtec unit was located at a scrap yard and returned to the licensee. The licensee has contacted the manufacturer to verify the device serial number and to perform a source leak test. The device and source appear intact. Notified R1DO (Arner), NMSS Events (email), and ILTAB (email). THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 56731 | 9 September 2023 15:35:00 | The following information was provided by the licensee via email: On 9/9/23 at 1143 EDT, with the Unit 1 in Mode 1 at 100 percent power, all 4 turbine control valves closed resulting in a reactor protection system (RPS) automatic reactor trip on over temperature differential temperature. All control rods inserted as expected. The trip was not complex and all systems responded normally post-trip. The cause of the control valve closure has not been determined. Following the SCRAM, operators responded and stabilized the plant. Decay heat is being removed by the main steam system through the atmospheric relief valves and auxiliary feed water systems. Due to the RPS actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for a valid specified system actuation. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 56711 | 2 September 2023 10:06:00 | The following information was provided by the licensee via email: On 09/02/2023, Honeywell declared a 'Plant Emergency' at 0815 CDT and upgraded to an 'Alert' at 0835 CDT in accordance with the Honeywell Emergency Response Plan due to a uranium hexafluoride leak on the kinney pump system. Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center, HHS Operations Center, EPA Emergency Operations Center, USDA Operations Center, FDA EOC (email), FEMA NWC (email), and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
The 'All Clear' was declared at 2115 CDT on 09/02/2023. There were no injuries related to this incident. This statement constitutes the NRC notification related to the incident. Honeywell is currently investigating the cause of the event. Notified R2DO (Miller), NMSS/DFM Division Director (Helton), NMSS Events Notification (email), IRMOC (Grant), 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). |
| ENS 56710 | 2 September 2023 09:46:00 | The following information was provided by the licensee via email: On 9/2/2023 at 0632 EDT, a feedwater transient occurred resulting in an reactor protection system (RPS) automatic reactor scram on low level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 recirculation sample system isolation, Group 3 traveling in-core probe (TIP) isolation valve isolation, Group 6 and 7 reactor water cleanup isolation, and Group 9 containment purge isolations. All control rods inserted as expected. High pressure core spray and reactor core isolation cooling initiated and injected as expected. ECCS systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable and in Mode 3. These 4 hour and 8 hour non-emergency reports are being made in accordance with 10 CFR 50.72(b)(2) (iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident was informed. There was no impact on Unit 1. |
| ENS 56652 | 3 August 2023 16:58:00 | The following information was provided by the licensee via email: A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Senior Resident Inspector was notified. |
| ENS 56653 | 3 August 2023 17:05:00 | The following information was provided by Paragon Energy Solutions, LLC via email: Pursuant to 10 CFR 21.21(d)(3)(i), Paragon Energy Solutions, LLC is providing this initial notification of a potential defect with Eaton/Cutler Hammer size 4 and 5 freedom series contactors that have been modified to include either a special coil and/or to improve the securing of shading coils. These contactors may have been supplied integral to a motor control center (MCC) cubicle or as spare parts. This condition, if left uncorrected, could potentially cause a substantial safety hazard. Paragon completed an initial evaluation of a failure of a size 4 freedom series contactor (PN: NLI-CN15NN3A-T16-MOD-M) supplied to Perry Nuclear Power Plant. The reported failure occurred 26 days following installation into its associated MCC Cubicle. Perry identified the screws holding the contact bar to the push bars had fallen out and were laying in the bottom of the molded base. This allowed the movable contact bar to sit on the stationary contacts and significantly degrade due to arcing and then fail in the energized position. This condition could prevent the contactor from performing its safety function to either energize or de-energize the attached load. The loose hardware is most likely a workmanship error since the contactor must be disassembled to complete the special coil and RTV modifications to the shading coils. In the fully re-assembled condition, inspection of this hardware for tightness is not possible. Affected plants: North Anna, Turkey Point, Harris, and Perry.
Paragon Energy Solutions submitted their final report in accordance with 10 CFR 21.21(d)(4). Paragon reported completion of corrective actions including revising the test inspection procedure to ensure hardware tightness during contactor reassembly, identifying all projects containing the affected contactors and verifying appropriate inspections have been completed, restricted use of test inspection procedures issued prior to 8/2/2023 until a formal review is completed, and issued a technical bulletin (TB-Starter-2023-01 Rev 0) for use by affected clients. Paragon recommends affected licensees perform the steps contained in Technical Bulletin TB-Starter-2023-01 Rev 0 to verify this condition is not present as part of their next routine maintenance outage associated with the affected in use equipment, and at the earliest opportunity for stock spares. Affected plants: North Anna, Turkey Point, Harris, and Perry. Notified R2DO ( Miller), R3DO (Skokowski), and Part 21/50.55 Group via email. |
| ENS 56649 | 1 August 2023 14:30:00 | The following is a summary of the information provided by the Oregon Health Authority via email: At 0830 PDT on August 1, 2023, during the 6-month shutter check and 3-year wipe test on the number 1 digestor level source, the licensee discovered a corroded shear pin that allowed the lever to detach from the source, leaving the source in the closed position. The current state of the source was verified closed with a survey meter. The licensee repaired the sheer pin and tested the mechanism. The source was working correctly and returned to service by 0922 PDT. |
| ENS 56655 | 3 August 2023 20:09:00 | The following report was received by the California Department of Public Health , Radiation Health Branch (RHB) via email: On 08/01/23, a portable moisture density gauge containing radioactive materials (Humboldt Model 5001C082, Serial number HIS 1767, containing 10 mCi Cs-137 and 40 mCi Am-241/Be) was run over by a piece of heavy equipment, on a construction site. The licensee cordoned off the area where the gauge was damaged and contacted Pacific Nuclear Technology (PNT) for assistance. The top shell of the gauge was crushed and found in several pieces, the source rod was bent, and there was no damage to the area where the Cs-137 source was contained. PNT was able to place the rod containing Cs-137 into its original shielding position. The Am-241/Be source was found undamaged in its original position attached to the base. PNT had surveyed the area using a Ludlum model 3, 44-9 detector, and no radiation levels above background were detected. The gauge was placed in the undamaged transit case (transportation index measured 0.2 mR/hr) and transported to the PNT facility where the gauge was leak tested. The leak test performed on the damaged gauge did not indicate any contamination. Currently, the gauge is in storage awaiting approval for disposal. RHB will be following up on this investigation. California incident number: 080123 |
| ENS 56648 | 1 August 2023 11:48:00 | The following information was provided by the licensee via email: At 1506 EDT on July 31, 2023, it was determined that a contractor supervisor failed a test specified by the fitness for duty testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56730 | 8 September 2023 15:15:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On July 12, 2023, the Agency received an e-mail from Tesla stating they had lost a generally licensed NRD device model number P-2021 Z705. The device contains a 10 millicurie polonium-210 source. The source is sealed inside an air tool used to blow off dust from cars prior to painting. The company performed searches for the device, but was unable to locate the device. The device was discovered missing when the company was getting ready to return them to the manufacturer. The company stated that due to the remaining activity (purchased on June 8, 2022) and the design of the device, it does not pose an exposure risk to any individual. Texas Incident Number: 10038 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 |
| ENS 56729 | 8 September 2023 15:15:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On July 12, 2023, the Agency received an e-mail from Tesla stating they had lost a generally licensed NRD device model number P-2021 Z705. The device contains a 10 millicurie polonium-210 source. The source is sealed inside an air tool used to blow off dust from cars prior to painting. The company performed searches for the device, but was unable to locate the device. The device was discovered missing when the company was getting ready to return them to the manufacturer. The company stated that due to the remaining activity (purchased on March 30, 2021) and the design of the device, it does not pose an exposure risk to any individual. Texas Incident Number: 10037 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 |
| ENS 56654 | 3 August 2023 19:19:00 | The following information was provided by the Washington State Office of Radiation Protection via email: During the semi-annual routine shutter tests on a fixed gauge, the gauge was found to be stuck in the 'ON' position. This malfunction did not pose any additional risk to personnel in the 'ON' position; it only inhibited the ability to lock the gauge in the 'OFF' position for maintenance. The gauge manufacturer was contacted, and a service engineer was able to move the source tube assembly to the 'OFF' position by applying lubricant to the handle rod and gently twisting and pulling on it. This event appears to have occurred due to a lack of lubricant on the handle rod, or from the dust conditions that the gauge is located in, resulting in the source tube assembly becoming stuck inside the source housing. Going forward, a few drops of lubricant will be added during the semi-annual shutter checks to prevent the source tube assembly from becoming stuck again. There were no personnel overexposures due to this event. Device/Source Details: VEGA Americas, Inc., model number: HLG-2, serial number: 13570676, containing a 2 Ci (original activity) Cs-137 source. Reference Document Number: WA-23-013. |
| ENS 56587 | 22 June 2023 16:36:00 | The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email: The South Carolina Department of Health and Environmental Control was notified via telephone at 1515 EDT on 06/22/23, that during the commissioning of a new device (at their Gaston S.C. facility) the strip source of the fixed gauging device was stuck between the source housing and dip-tube. The licensee is reporting that the fixed gauge is a Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device, housing a Cs-137 Berthold Technologies USA, LLC., sealed source Model BT-MPLM. The licensee is reporting that no immediate health and safety concerns have been identified. The licensee is reporting that a consultant has been contacted to perform the repair. A department inspector will be dispatched to the facility to conduct an on-site investigation. This event is still under investigation by the Department.
A Department inspector was dispatched to the facility on June 23, 2023. The licensee submitted their 30-day written report on July 14, 2023. The licensee is reporting that the serial number of the Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device is 40876-01-10009. The licensee also reports that the serial number of the sealed source containing 0.74 GBq (20 mCi) of Cs-137, (Model BT-MPLM) is G0990_22. The device was removed from service by a licensed contractor and will remain in the site's radiation storage room until the licensee and manufacturer determine the best option moving forward. The licensee reports that no regulatory exposure limits were exceeded as a result of this event, and that the sealed source remained housed for the duration of this incident. This event is still under investigation by the Department. Notified R1DO (Carfang) and NMSS Events Notification via email.
The licensee disposed/transferred the model BT-MPLM sealed source (serial number G0990_22) on 12/13/23. The Berthold Technologies USA, LLC., LB 300 IRL Type III Series source holder (serial number 40876-01-10009) was also disposed. This event is considered closed. Notified R1DO (Jackson) and NMSS Events (email) |
| ENS 56571 | 13 June 2023 13:00:00 | The following information was provided by the the Colorado Department of Health via email: On June 12, 2023, as the semi-annual leak tests/inventory were being performed at Sky Ridge Medical Center (RAML 1053-01), a leaking Co-57 Benchmark mini flood source (SN BM552021321103) was found. The exact timing of when the source started leaking is unknown. The source was last inventoried in December 2022, and was at background. (A staff member) from the Colorado Associates in Medical Physics (CAMP) found the source had 185 Bq (0.005 micro-Ci) or more removable contamination in excess of the regulatory limits. The initial removable contamination resulted in a wipe count of 3835 cpm (0.00525 micro-Ci) of removable contamination. The source was cleaned with paper towels and dish soap and when re-wiped had a lower count (1900 cpm), but remained above background even after additional wipes. All paper towels used for cleaning surveyed at background (0.03 mR/hr) and were disposed of in the hot trash in the hot lab. The source was wrapped in a thick trash bag, secured with tape and was placed in the shielded decay cabinet. The activity of the source on 6/12/2023 was 5.02 milli-Ci. The storage container, the cardiac single-photon emission computed tomography camera, and the hot lab counters were all wiped and surveyed, and all readings were at background (0.03 mR/hr). The source did not appear damaged or broken. CAMP will dispose of the source, and they have initiated a disposal inquiry. In the meantime, the source will remain in the shielded decay cabinet. Colorado event report ID number: CO230016 |
| ENS 56544 | 30 May 2023 08:34:00 | The following information was provided by the licensee via email: At 0446 EDT on 5/30/2023, with Millstone Power Station Unit 3 operating at approximately 100 percent reactor power, an automatic reactor trip occurred due to a turbine trip caused by electrical protection. The reactor trip was uncomplicated and decay heat is being removed via steam dumps to the condenser. All systems responded as expected to the trip. Auxiliary feedwater actuated automatically as expected following the trip due to low-low levels in the steam generators. There was no risk to the public. There was no impact to Millstone Unit 2. This event is being reported as a four hour report under 10CFR50.72(b)(2)(iv)(B) as a condition that resulted in actuation of the reactor protection system while the reactor was critical, and as an eight hour report under 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B) for actuation of the auxiliary feedwater system. The NRC Resident Inspector has been notified. |
| ENS 56528 | 19 May 2023 12:23:00 | The information below was provided by the Georgia Department of Natural Resources via email: During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal. GA Incident Number: 65 |
| ENS 56516 | 11 May 2023 00:18:00 | The following information was provided by Arizona Department of Health Services (the Department) via email: The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. Arizona incident number: 23-008 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. |
| ENS 56485 | 22 April 2023 21:35:00 | The following information was provided by the licensee via email: At 1942 EDT on April 22, 2023, during the Beaver Valley Power Station, Unit No. 2 refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that one penetration could not be dispositioned as acceptable per ASME Code Section XI. The reactor vessel vent line penetration will require repair prior to returning the vessel head to service. The indication was not through-wall as there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified |
| ENS 56484 | 21 April 2023 16:24:00 | The following information was provided by the licensee via email: The plant is in a safe condition. On April 21, 2023, Urenco, USA (UUSA) was staging a construction crane to be used the following week and failed to maintain procedural compliance while implementing IROFS50f and IROFS50g. The crane was properly permitted and placed inside the Controlled Access Area but was not properly permitted for operation. At all times the required spotters for IROFS50f and IROFS50g were in place and the movement of the crane was sufficiently controlled to restrict its movement to not swing into an area where damage could occur. However, visual indicators (reference markers) were not established as required by procedure. Spotters were in place and exercised appropriate control. IROFS50f/g are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Work has been stopped and the crane has been demobilized. UUSA is conservatively reporting this event under 10 CFR 70 Appendix A (a)(4). The licensee will notify Region 2.
This issue has been entered into the corrective actions program as EV 160170. Following a more detailed review, IROFS50g was determined to be operable and adequately implemented. As a result, the appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (b)(2). Notified R2DO (Miller) and NMSS Events Notification (email).
2nd Update: The operation of the crane has stopped and it remains south of SBM 1001. Contrary to the initial report, the required spotters were not present and controlling the movement of the boom. As a result, IROFS50f/g have been determined not to be available and reliable. The appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (a)(4). The stop work involving the use of construction vehicles and IROFS50 remains in place. All work performed by site projects has been stopped. The licensee has notified Region 2. Notified R2DO (Miller) and NMSS Events Notification (email). |
| ENS 56483 | 21 April 2023 15:55:00 | The following information was provided by the Texas Department of Health Services (the Department) via email: On April 21, 2023, the Department was notified of a gauge with a shutter that could not be moved into the closed position because the lever which moves the shutter broke off. The owner of the gauge reports the lever broke because of corrosion and vibrations. The gauge is a Texas Nuclear 5204 with 8 curies of cesium-137. It is on the side of a dredging vessel that is dredging the entrance channel in Corpus Christi in a 24 hours of work per day operation. During dredging operations, the gauge is normally in the open position and the beam is directed inwards towards the ship. The crew of the vessel normally avoid that side of the vessel and will continue to do so. A survey of the gauge was performed and there is no change. The owner of the gauge reports that they expect the gauge to be repaired by a servicing company on May 9, 2023. The Department discussed the possibility of the vessel being docked with the gauge still in the open position and will continue to monitor the situation. Further information will be provided per SA-300. The Department will also forward this to the Florida Radiation Control Program as this is a Florida licensee operating in Texas under reciprocity. Texas incident number: 10013 |
| ENS 56474 | 18 April 2023 03:56:00 | The following information was provided by the licensee via email: At 1112 EDT on 4/15/23, it was determined that the (reactor coolant system) RCS pressure boundary does not meet ASME Section XI, Table IWB-341 0-1, `Acceptable Standards,' due to through wall leak of the flux mapper seal table guide tube H-6. Corrective actions have been scheduled. `This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A). A follow-up review of the condition revealed that 10 CFR 50.72 notification was applicable within 8 hours of the time of discovery on 04/15/23. The NRC Resident Inspector has been notified. |
| ENS 56517 | 12 May 2023 10:07:00 | The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email: The licensee (Bethune Nonwovens, Inc., d/b/a Suominen Nonwovens) notified the Department in writing on April 21, 2023, that a generally licensed fixed gauging device had a failed shutter which had been repaired by the manufacturer on April 3, 2023. The licensee discovered that the event occurred on March 31, 2023, and reported that upon discovery of the stuck shutter, that the manufacturer arrived on site on the same day and placed the device out of service until repaired. The event involved a Mahlo fixed gauging device (model number: 11-200933, serial number 11-011985-AH-5783), which housed an Isotope Product Laboratories, krypton-85 sealed source (model number KAC.D3, serial number: AH-5783), with an activity of 9.62 GBq (260 mCi). The licensee reported that the cause of this equipment failure was attributed to corrosion around the shutter assembly. On May 2, 2023, a Department inspector was dispatched to the facility to conduct an on-site investigation. All dose measurements were consistent with the Sealed Source Device Registry certificate for the device. Based on the resulting dose rate surveys conducted by the Department and the manufacturer, interviews with licensee representatives, and the removal of the device from service at the time that the failure was discovered, it does not appear that any radiation exposure to workers, or any other individual members of the public has occurred. This event is considered closed. Internal ID number: SC230009 |
| ENS 56449 | 31 March 2023 16:54:00 | The following information was provided by the Florida Bureau of Radiation Control (BRC) via email: BRC Tallahassee received notification this afternoon from QC Laboratories, Inc. that tracking has been lost on a 16.8 curie (below Cat 2) Iridium 192 sealed source. The source was shipped out of country (St. Thomas, Virgin Islands) and was on return shipment. Per (the common carrier): 'Our records reflect that this package was tendered to (the common carrier) on March 16 with the expectation of delivery by 1030 EDT on March 17, barring delays in Customs. These records indicate that this shipment arrived at our port of entry at our central sorting facility in Memphis on March 17 and went into the customs clearance process. After Customs delays resulting from clearance paperwork issues, the paperwork was resolved. Customs clearance was completed on March 27, and the package was removed from the cage; however, we are unable to verify its status past that point.' Florida Incident Number: FL23-045 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 |
| ENS 56444 | 31 March 2023 13:31:00 | The following information was received from the Louisiana Department of Environmental Quality via email: On February 17, 2023, the (Alpha-Omega) Radiation Safety Officer (RSO) shipped a high dose rate (HDR) source through (a common carrier) for shipment to Radiation Oncology, Elk Grove Village, IL 60007. The shipment's last known location was the (common carrier's) Memphis Hub. Alpha-Omega contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a HDR Ir-192 source was lost in transit with (a common carrier) on March 30, 2023. The source serial number is 02-01-1027-001-021523-11023-87. The activity of the Ir-192 source on 2/17/23 was 400 GBq when it was shipped. The current activity on 3/31/23 is 7.292 Ci (269.8 GBq).The (common carrier's representative) in Dangerous Goods Administration stated that, '(the common carrier's) position is that an exhaustive manual search was completed and the parcel is no longer in our control.' Louisiana Event Report ID No.: LA20230006 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 |
| ENS 56448 | 31 March 2023 15:35:00 | The following information was provided by the New York State Department of Health via email: New York State Department of Health received a phone call from United Memorial Medical Center to report a Co-57 flood source that was sent to International Isotopes on January 11, 2023. This flood source was picked up by (the common carrier) and never arrived at International Isotopes. The technologist that shipped this source back checked the status of the delivery and noticed that the shipment had been delayed and noted that the location of the package was at the Rochester NY (common carrier) hub for several weeks. The technologist called (the common carrier) on March 30, 2023, and was informed that the package was determined as lost. Information on the source is below: Make: International Isotopes Model: BM01L10 (SSDR: NR-1235-S-104-S) S/N: BM01L1021298203 Isotope: Co-57 Est Activity (as of 3/30/2023): 2.66 mCi NYS Department of Health contacted (the common carrier) independently on March 31, 2023, and was also informed that the package was lost and unlikely to be recovered. 10 CFR 20 Appendix C states a value of 100 microCi for Co-57, therefore this loss is 26.6 times this value, requiring a 30-day notification in accordance with 10 CFR 20.2201(a)(l)(ii). United Memorial Medical Center has been instructed to contact New York State Department of Health with any updates regarding this package. New York State continues to monitor this event under Incident No. 1434. Provided the estimated activity as of March 31, 2023, unshielded exposure rate at one meter from the package is expected to be approximately 147.8 microR/hr, which does not constitute any immediate risks to (the common carrier) staff or workers. No further information on the device, source or incident is available at this time. Any updates to this event will be provided as soon as available. New York Event Report number: NY-23-02 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 |
| ENS 56445 | 31 March 2023 15:36:00 | The following information is a summary of the information provided by the licensee via email: On March 22, 2023, the subcontractor was performing grading and compaction of crushed concrete aggregate on the west half of the proposed building pad. The subcontractor had several active pieces of heavy equipment on the jobsite at the time, including a large excavator, a bulldozer, a skid steer loader, a large smooth drum roller, and dump trucks. While waiting to perform the compaction testing, the gauge operator stepped forward (east) approximately 10 feet to inspect a small excavation where the subcontractor had removed wet soils. At this time, the foreman operating the bulldozer had turned facing the south and began reversing the dozer north along the west edge of the pad. The gauge operator heard the dozer moving closer along the west edge of the building pad and turned to retrieve the gauge. Due to concerns for his safety, the gauge operator was not able to retrieve the gauge prior to the bulldozer's back left track making contact with the gauge. At the time of contact, the gauge's source rod was in the locked and shielded position. The gauge operator contacted the GME Testing's Radiation Safety Officer (RSO) and was instructed to follow operating and emergency procedures. The gauge operator responded immediately and had the foreman drive the bulldozer 15 feet north of the area to begin establishing the 15 foot perimeter around the gauge. The gauge sustained visible damage, with the yellow plastic shell cracking and the source rod falling over sideways onto the ground while in the locked and shielded position. The gauge operator quickly inspected the gauge and noted that the source rod remained in the locked position and undamaged inside the lead housing within the gauge, as well as the lead housing showing no signs of damage. The gauge operator remained with the gauge while securing the 15 feet perimeter and contacting the on-site foreman for the subcontractor, the superintendent for the contractor, and GME Testing's RSO. Readings were taken at the edge of the 15 foot radius around the gauge, the 3 foot radius, the 1 foot radius, and on the surface of the gauge. All readings gathered were within the acceptable range when compared to the the radiation profile of the gauge, as provided by the manufacturer. The damaged gauge was securely locked in its shipping case and transported to the GME Testing office. |
| ENS 56415 | 16 March 2023 13:23:00 | The following information was provided by the licensee via email: At 0845 EDT on March 16, 2023, it was determined that a contract employee supervisor failed a for-cause FFD test. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified. |
| ENS 56416 | 16 March 2023 17:04:00 | The following is a summary of the information provided by the New Mexico Radiation Control Bureau via telephone: A Berthold Model LB7440 density gauge (serial number 2110) installed in a mine was discovered to have a shutter stuck in the open position while removing the gauge from service. The gauge contains a 20 millicurie Cs-137 source. The licensee installed shielding on the gauge and placed it in a storage container. Radiation surveys around the container are between 0.032 and 0.0525 millirem. An authorized service company is scheduled to repair the gauge on March 27, 2023. |
| ENS 56410 | 14 March 2023 22:50:00 | The following information was provided by the licensee via fax: On March 14, 2023, at 2000 EDT, in accordance with 10 CRFR 50.72(b)(3)(xiii). Yankee Nuclear Power Station Independent Spent Fuel Storage Installation (ISFSI) determined that the impacts of a severe winter storm have resulted in a major loss in off site response capability. Since approximately 0200, very heavy snow has fallen and greater than two feet has accumulated on site. All security related equipment has remained functional, and there have been no impacts to methods of offsite communications or emergency assessment capability. The concrete cask heat removal systems have remained operable in accordance with the NAC International multi-purpose container system (NAC-MPC) technical specifications. From approximately 0550 until 1840, offsite power was lost, and the site was powered by the security diesel generator. Periodically throughout the day, the Security Shift Supervisor was in contact with State and local police to ensure response capability. At the 2000 hours update, the law enforcement agencies reported that there were recent reports of trees and power lines being downed by the weight of the snowfall causing road closures and significantly impacting routes and response times to the site. The site remains fully staffed.
On March 14, 2023, at 2000 EDT, in accordance with 10 CFR 50.72(b)(3)(xiii), Yankee Nuclear Power Station Independent Spent Fuel Storage Installation determined that the impacts of a severe winter storm resulted in a major loss in offsite response capability. Downed trees and power lines in conjunction with up to thirty-six (36) inches of snow prevented vehicle passage on normal response routes. On March 15, 2023, at approximately 1700 EDT, these roadways were passable, and employees and emergency vehicles regained normal access to the site. However, the Town of Rowe, Massachusetts police chief informed the site that the town remained in an emergency status and the roadways may need to be intermittently closed in order for utility workers to restore power lines and continue to clear tree limbs. On March 16, 2023, 1815 EDT, the Town of Rowe, Massachusetts police chief secured from the emergency. Therefore, this update is to inform the NRC that the Yankee Nuclear Power Station Independent Spent Fuel Storage Installation has similarly returned to baseline operations. NRC Region I management has been updated throughout the progression of the storm and recovery. A press release is not anticipated. Notified R1DO (Bickett) |
| ENS 56409 | 14 March 2023 15:52:00 | The following information was provided by the licensee via email: At 1000 EDT on March 14, 2023, during valve diagnostic testing, the high pressure core injection (HPCI) lube oil cooling water supply isolation valve did not stroke open. This failure resulted in the Unit 2 HPCI system being inoperable. This is being reported as a loss of an entire safety function condition in accordance with 10CFR50.72(b)(3)(v)(D). The licensee notified the NRC Resident Inspector.
The following information was provided by the licensee via email: The purpose of this notification is to retract event notification (EN) 56409 reported on 03/14/2023. On March 09, 2023, Susquehanna Unit 2 entered a routine high pressure core injection (HPCI) maintenance outage. In support of this system outage, Technical Specification (TS) 3.5.1, Condition D was entered for an inoperable HPCI system. On March 14 as reported in EN 56409, the HPCI lube oil cooling water supply isolation valve did not electrically stroke open following engagement of manual clutch lever. Specifically, to support the maintenance evolution, electricians declutched the valve actuator to move it from the motor/electric operational mode to the manual operational mode as part of planned valve diagnostic data collection. In this testing configuration (i.e., manual operational mode), an attempt to electrically stroke the valve was made, resulting in the valve failure to stroke. Prior to this maintenance evolution, the HPCI lube oil cooling water supply isolation valve was found in the expected full-closed position with the motor/electric operational mode enabled, meaning prior to the HPCI maintenance outage, the affected valve was operating as designed and capable of performing all design functions. The described condition was therefore determined to be the result of the maintenance activity. NUREG-1022, Section 3.2.7, states: 'reports are not required when systems are declared inoperable as part of a planned evolution for maintenance or surveillance testing when done in accordance with an approved procedure and the plant's TS (unless a condition is discovered that would have resulted in the system being declared inoperable).' Following completion of investigation and repair, Susquehanna determined that, per NUREG-1022, Section 3.2.7, the event was not reportable. HPCI was declared inoperable as part of a maintenance evolution which was done in accordance with an approved procedure and the TS. The described condition was not a pre-existing condition that would have resulted in the system being declared inoperable prior to the planned maintenance activity. Notified R1DO (Schroeder) |
| ENS 56412 | 15 March 2023 13:17:00 | The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email: While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report. NJ Event Report ID number: NJ-23-0001
Additional information has been obtained related to the initial notification provided on 3/15/23. The dose administered to the patient was only approximately 2.9 percent of the dose prescribed. The prescribed dose was 15 Gy. The unit malfunctioned after only 3 of the planned 13 shots was completed. 14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred. This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a). Notified R1DO (Bickett) and NMSS Events Notification. 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 |