Semantic search

Jump to navigation Jump to search
 Entered dateEvent description
ENS 574124 November 2024 09:02:00The following information was provided by the licensee via phone and email: At 0500 CST, on November 4, 2024, the Monticello Nuclear Generating Plant was notified by Wright County dispatch of a spurious actuation of one emergency response siren that lasted approximately ten minutes. The cause of the actuation has not been determined and the vendor is investigating. The siren is no longer actuating. There was no impact to the health and safety of the public as a result of this event and the offsite response capabilities remain functional. No press release by the licensee is planned at this time. This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified.
ENS 5738817 October 2024 12:02:00

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On October 17, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 gauge had been stolen from the back of one of the company's pickup trucks. The gauge contains a 40 millicurie americium-241:beryllium source and an 8 millicurie cesium-137 source. The RSO stated the technician went to the truck at 0545 CDT this morning and found that the chains holding the gauge in the truck had been cut and the gauge and transport case were missing. The RSO stated that because the gauge had not been used this day, the cesium source rod should have been locked in the fully shielded position. The City of Fort Worth's police department was notified of the theft. The RSO is traveling to the office where the gauge was normally stored to interview the technician involved in the event. Additional information will be provided as it is received in accordance with SA-300. Texas NMED #: TX240039 Texas Incident #: 10138

  • * * UPDATE ON 10/17/2024 AT 1435 EDT FROM ART TUCKER TO NATALIE STARFISH * * *

The Department has sent a notice of this event to the City of Fort Worth Emergency Management Office. 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 5738014 October 2024 15:11:00The following information was provided by the licensee via phone: On October 14, 2024, at 1233 EDT, a brush fire started in the Oyster Creek Unit 1 switchyard due to an electrical failure. The station contacted local 911 and fire company for response. At approximately 1247 EDT, the fire company arrived at the switchyard. At approximately 1300 EDT, the fire company began extinguishing efforts. The fire was officially put out at 1449 EDT. There was no radiological or fuel storage impact from this event. The NRC Resident Inspector and the State of New Jersey have been notified.
ENS 573644 October 2024 14:33:00

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via phone and email: On 10/4/2024, at 1244 EDT, QSA Global, Inc. (license number 12-8361) was notified that a package containing a 109.1 Ci Ir-192 sealed source in a type B package was missing in transit and notified the Agency at 1315 EDT on the same day. The following information was provided at the time of notification: Isotope: Ir-192 Source Serial Number: 97855M Form: Sealed source Activity (at time of shipment): 109.1 Ci Container Model Number: 650L Container Serial Number: 1063 Transportation Index: 0.6 Shipping Date: 9/13/24 Last Known Location: (Common carrier) hub in Memphis, TN The reporting requirement is immediate and is required by 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. The Agency considers this event to be open. The following additional information was obtained from the Agreement State in accordance with Headquarters Operations Officers Report Guidance: The last physical scan was on 9/17/24, at 1403 EDT, in Memphis, TN. The recipient reached out to the common carrier on 10/1/24 asking to track the package. The response from the common carrier was that they were experiencing high volume and the package was waiting to be cleared in customs. The recipient followed up again on 10/4/24, at 0928 EDT, asking for an update, and received an update at 1108 EDT stating that they could not locate the package. The Agency has contacted the State of Tennessee regarding this event. Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).

  • * * UPDATE AT 1308 EDT ON OCTOBER 8, 2024 FROM BOB LOCKE TO BRIAN P. SMITH * * *

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email: At 1108 EDT on October 8, 2024, the missing package was delivered undamaged to the intended recipient. The Agency considers this event closed. Notified R1DO (Arner), IR (Grant), NMSS (Fisher), ILTAB (Brown), INES (Smith), NMSS Events Notification. Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email). THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 573603 October 2024 14:55:00The following information was provided by the licensee via phone and email: At 1000 CDT, on October 3, 2024, Kewaunee Power Station was informed that the Wisconsin Department of Health Services (WDHS) was notified of an asbestos worker qualification issue specific to several workers at the Kewaunee Solutions Decommissioning Project. This notification was made by a subcontractor performing asbestos abatement work at the site and involves a lack of documentation of the worker qualifications. The NRC Regional Inspector has been notified.
ENS 5732617 September 2024 04:48:00The following information was provided by the licensee via phone and email: At 0127 EDT on 9/17/2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped due to the passive residual heat removal heat exchanger outlet flow control valve failing open. A manual safeguards actuation was initiated due to the lowering pressurizer water level resulting from the reactor coolant system cooldown that was caused by the passive residual heat removal heat exchanger outlet flow control valve failing open. 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 failure of the control valve does not inhibit the residual heat removal system from functioning as it is passive. The reactor coolant system maximum allowable cooldown rate was exceeded (Technical Specification 3.4.3). The limit is 100 degrees F per hour above 350 degrees F. The maximum observed cooldown rate was 226 degrees F per hour. At time 0458 EDT, reactor coolant system temperature is 369.1 degrees F, reactor pressure is 900 psig. Currently, the plant is cooling down and proceeding toward placing shutdown cooling online.
ENS 5729830 August 2024 18:30:00The following information was provided by the licensee via phone and email: At 1051 CDT on 8/30/2024, during transfer of 4KV shutdown bus 1 to support Unit 1 shutdown activities, the alternate feeder breaker failed to close resulting in 4KV shutdown boards 'A' and 'B' experiencing an under voltage condition. This resulted in 'A' and 'B' diesel generators automatically starting and tying to their respective boards. This condition also caused a loss of reactor protection system (RPS) channel 'A' on Units 1 and 2, resulting in invalid actuation of primary containment isolation system Groups 2, 3, 6, and 8. The failure of the board to transfer was identified during preparation for the evolution, contingency actions were prepared and implemented as planned. The breaker failure to close has been corrected and 4KV shutdown bus 1 is energized on alternate. 4KV shutdown boards 'A' and 'B' have been restored to offsite power supplies and the diesel generators are secured. All systems responded as expected for the loss of voltage. This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The change in reactor power from 70 percent to 40 percent was not as a result of the failed breaker, rather Browns Ferry Unit 1's change in reactor power was due to a scheduled reactor shutdown which was in progress. In regards to the Unit 2 loss of channel 'A' RPS, this was not a specified system actuation. The actuation of the 'A' and 'B' diesel generators were the specified system actuation. Although the 'A' and 'B' diesels are common to both Units 1 and 2, only Unit 1 credits these specific diesel generators for accident mitigation. As such, this event is only reportable from Unit 1. Unit 2 did not experience a specified system actuation.
ENS 5728423 August 2024 09:02:00The following information was provided by the licensee via phone and email: At 0500 CDT on 8/23/24, Wolf Creek entered technical specification limiting condition for operation (LCO) 3.7.5 required action D.1 which requires shutdown to mode 3 within 6 hours. The turbine driven auxiliary feedwater pump discharge valve to the 'B' steam generator was not successfully restored to operable prior to expiration of the 72 hour completion time. At 0800 CDT, the shutdown to mode 3 was initiated, which is being reported in accordance with 10CFR50.72(b)(2)(i). The NRC Resident Inspector has been notified.
ENS 5727316 August 2024 16:37:00The following information was provided by the Virginia Department of Health, Office of Radiologic Health (RMP) via email: At approximately 1100 EDT on 8/16/2024, RMP was notified of an incident involving a portable nuclear gauge. At approximately 0900, at a deep trench construction site in Fairfax, a CPN International gauge model MC-1, containing 10 mCi Cs-137 and 50 mCi Am-241, was dropped approximately 15 feet when a rope pulley system slipped. The authorized user notified the radiation safety officer (RSO) who arrived on site and then they notified the RMP. Per the RSO, the gauge fell onto dirt at the bottom of a trench. The device landed flat onto the base of the gauge. The gauge functions and is operational. The rod handle was retracted and locked at the time, and the source remained retracted in the shielded position. The RSO obtained survey readings of 0.4 mR/h at 1 meter from the gauge. The gauge was placed in its transportation box, secured in the back of a pickup truck, and transported back to the licensee's office for secure storage. A leak test was obtained and analysis indicates there is no leakage. The gauge will be sent for assessment by an authorized dealer. RMP will follow up with an investigation. Event Report ID No.: VA240004 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 5727115 August 2024 13:25:00The following information was provided by the licensee via phone and email: On August 13, 2024, Diablo Canyon Power Plant (DCPP) determined that a manufacturing non-conformance associated with snubber valve assemblies identified with ALCO part number 2402466 is reportable under 10 CFR Part 21. Pacific Gas and Electric Company's (PGE) evaluation has determined the upper body of these valves did not meet material and heat treatment requirements (AISI 1117 resulfurized carbon steel vs. AISI 8620/8630 low alloy steel). Similar Part 21 reports regarding issues associated with the material and heat treatment requirements of ALCO snubber valves have been previously reported by others. The subject parts were procured as commercial grade items and dedicated by PGE solely for use at DCPP. Therefore, although previously reported, and potentially not required per the provisions of Part 21.21 (d)(2), DCPP is conservatively making this notification. There is no impact to the operability of any safety related systems or impact to the health and safety of the public. All spare valve assemblies have been removed from PGE's warehouse. The NRC senior resident inspector has been notified, and a written report will be submitted within 30 days. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No other nuclear power plants were affected.
ENS 573634 October 2024 11:38:00The following is a synopsis of information provided by MPR Associates, Inc. (MPR) via fax: On August 9, 2024, MPR received information that electrical contactors (Models AF80 and AF116) provided by Asea Brown Boveri Ltd. (ABB) contain a microcontroller. The fact that these contactors contain a microcontroller was not included in MPR's analysis during their commercial grade dedication process. Two contactors were supplied to Beaver Valley Power Station (ABB AF116-30-11-13) where one was installed in the excitation system for one emergency diesel generator. Five contactors were supplied to Davis-Besse Nuclear Power Station (ABB AF116-30-11-13), but none were installed. MPR is currently working to provide information to support continued use of the installed contactors. MPR is also working to identify a replacement contactor that is suitable for the application. Responsible MPR officer: Robert Coward, Principal Officer MPR Associates, Inc. 320 King Street Alexandria, VA 22314 703-519-0200
ENS 5725330 July 2024 18:52:00The 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.
ENS 5724225 July 2024 09:49:00The following was provided by the Illinois Emergency Management Agency (the Agency) via email: On 7/16/2024, the Agency was notified that the licensee found a box with seven calibration rod sources stored in the previous radiation safety officer's desk. The licensee had previously been cited for poor source accountability. The replacement of the radiation safety officer (RSO) and the use of a consultant were implemented as corrective actions. Locating and reporting these sources is a result of those efforts. The New England Nuclear gamma reference rod source set (Catalog No. NES-100T) contains a Co-57, Co-60, Cd-109, Ba-133, Cs-137, Mn-54, and Na-22 source - each with a nominal activity of 7 microcuries. While the sources were labeled as exempt when distributed in 1977, the Co-60 and Cd-109 sources appear to no longer be exempt under current regulations (10 CFR 30.71 Schedule B), nor does any exemption exist that grandfathers these sources. Wipe tests were performed and indicated no leakage. In accordance with SA-300, section 5.6.2, 'found sources' are to be reported when they exceed 10 times the value specified in Appendix C to 10 CFR Part 20. The Cd-109 source contained 12.9 microcuries when assayed 9/6/77, so, it remains reportable. The sources were placed on the licensee's sealed source inventory. Corrective action is adequate, and this matter is now considered closed. IL Event Number: IL240016 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 5722916 July 2024 11:18:00The 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
ENS 572148 July 2024 18:24:00The 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.
ENS 572104 July 2024 14:27:00

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

  • * * UPDATE ON 7/15/2024 AT 1050 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *

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.

  • * * RETRACTION ON 7/18/2024 AT 1407 EDT FROM PA DEP BEREAU OF RADIATION PROTECTION TO JORDAN WINGATE* * *

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 PA wishes to formally retract the submission. Notified R1DO (Schroeder), NMSS Events Notification (email).

ENS 5719627 June 2024 14:20:00The following information was provided by the licensee via phone and email: On June 27, 2024, at 1037 EDT, the North Carolina State University (NCSU) PULSTAR reactor was shutdown due to channel failure of the N-16 detector. This channel is required during operations over 500 kW by TS 3.4a. The reactor was operating at 950 kW at the time of channel failure. The reactor operator promptly shutdown and secured the reactor. Due to the nature of an unscheduled shutdown, investigation as to the source of channel failure and remedy will be commenced. At this time, failure has been isolated to just the N-16 channel. As such, operations may continue with approval for restart by the director of the NCSU PULSTAR reactor at powers below 500 kW. To resume full operations, channel maintenance, required surveillances, and additional approval by the director of the NCSU PULSTAR reactor are required. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The N-16 channel provides a reference power level indication while adjustments are being made to other power level channels.
ENS 5719727 June 2024 18:38:00The 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
ENS 5719226 June 2024 09:49:00The 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.
ENS 5719125 June 2024 16:57:00

The following information was provided by the licensee via phone and email: In accordance with Technical Specification (TS) 6.7.2.1, a report is required to be made within 24 hours by telephone, confirmed by digital submission or fax to the NRC Operations Center if requested, and followed by a report in writing to the NRC, Document Control Desk, Washington, D.C. within 14 days that describes the circumstances associated with eight different specifications, one of which, (h), is abnormal and significant degradation in reactor fuel, cladding, or coolant boundary. At approximately 0900 MDT this morning, abnormal and significant degradation in reactor cladding was observed on fuel element 681E, an aluminum-clad element being inspected for removal from service. The degradation was in the form of an L-shaped hole, approximately 0.25 inches long in the upper section of the fuel element body approximately one inch from the top edge, where the upper aluminum pin and upper graphite section meet internally. It is unknown how long this damage has existed, as there is no visual record of any of this fuel since first inspected in 2003 at the VA Omaha TRIGA reactor before USGS took possession. At that point, it did not have this damage. According to the records, it was dropped during handling in 2003 when it was being unloaded from the shipping cask here at the GSTR (Geological Survey TRIGA Reactor), but no record of further inspection appears to exist. Therefore, this element may have been in the operating core for as long as 18 years in this condition, as USGS was first licensed to use it in 2006. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No fission products were detected in the primary, pool, or on an air particulate detector. The damaged element remains in its storage location in the pool with no other mitigating measures planned in the near term.

  • * * UPDATE ON 07/03/2024 AT 0927 EDT FROM JONATHAN WALLICK TO JORDAN WINGATE * * *

The following is a summary of information provided by the licensee via phone and email: After continued fuel inspections, four additional damaged fuel elements were identified (Fuel Element 3007, Fuel Element 5952, Fuel Follower Control Rod 5767, and Fuel Follower Control Rod 5768). The damaged elements will be moved to dry storage and will not be considered for further use. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Inspections are approximately one third complete. Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).

  • * * UPDATE ON 7/15/2024 AT 1005 EDT FROM JONATHAN WALLICK TO ERNEST WEST * * *

(The licensee has) additional elements to report, under license technical specification 6.7.2.1 (h): Fuel element 3361, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has a severe scratch approximately one eighth of an inch wide along most of the element, and two other substantial scratches. The top of the main scratch terminates in what appears to be a cracking pattern, though likely not fully through the cladding, as no fission product release was detected. The element also exhibits apparent rust on the triangular spacer, covering approximately 10 percent of the serial number face surface. It will not be used in the future. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was transferred to our facility after previous use at Michigan State University in 1989, also having been previously used at General Atomics in San Diego. Estimated manufacture (date) in 1964. Fuel element 7932, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has multiple deep scratches, disconnected at the ends, though running in parallel for lengths down a side of the element for nearly the entire length. (The element) gives the appearance of potential separation, but no fission product release was detected. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1974. Fuel element 9473, stainless-steel clad: Multiple deep scratches on several sides with little to no light reflection. Scratches are typical on elements, however, the appear to threaten the integrity of the cladding and further use may result in release, though none has been detected yet. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1980. Fuel element 5888, stainless-steel clad: Several concerning scratches and a large, repeatedly damaged scratch, indicating improper handling and threatening cladding integrity. No fission product release detected, but further handling may result in even minor damage sufficient enough to enable a release. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. Inspection records show small amounts of damage; however, (the records were) not fully indicative of the degree (of damage) observed during this inspection. The element has not been in service at this facility. It was obtained from the fuel repository at Idaho National Lab in 2016, which transferred the element from General Atomics, originally used starting in 1970. Fuel element 5671, stainless-steel clad: Appears to have oddly spaced and shaped bands of rust around the fuel section of the element. Coloration and lack of light reflection strongly suggest an abnormal corrosion, prominent on all sides of the element in varying degrees. Gently rubbing with a soft cloth resulted in minimal transfer of material, only some coloration but no discernable particulate, indicating the defects are integrated into the cladding and not freely releasable. No obvious mechanism exists to explain the features, though other elements on site have a similar pattern, none exhibit the degree of discoloration or loss of luster. The element was in storage at the facility but had been previously used. It will not be used in the future. It was originally purchased new from General Atomics in 1968. (The licensee is) still working through fuel inspections. There will likely be future updates. Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).

  • * * UPDATE ON 7/25/2024 AT 0903 EDT FROM JONATHAN WALLICK TO SAMUEL COLVARD * * *

(The licensee has) an additional element to report, under license technical specification 6.7.2.1 (h): Fuel element 6551 (stainless-steel clad): Corrosion of top fitting and upper canister weld, but not an apparent breach as no fission product release was detected. It will not be used in the future. This is the first close inspection that the element has undergone at our facility other than briefly viewing upon its arrival. It was in storage prior to this inspection. This element was transferred to our facility after previous use at the VTT FiR-1 reactor in Finland in 1/2021. Estimated manufactured in 9/1970, and delivered to the Finland reactor in 11/1970. (The licensee is) still working through fuel inspections. There will likely be future updates. Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).

  • * * UPDATE ON 08/08/2024 AT 0918 EDT FROM JONATHAN WALLICK TO ROBERT THOMPSON * * *

(The licensee has) an additional element to report, under license technical specification 6.7.2.1 (h): Fuel element 5708, stainless-steel clad: Was found to have a small bolt bonded to the top of the element, approximately 1/2" long, machine size 10. The bolt appears to have galvanically corroded to the top of the element and cannot be removed, suggesting it has been in place for decades. Top-down views show significant corrosion that is spreading to the upper weld of the element, but not an apparent breach, as no fission product release was detected. It will not be used in the future. Previous inspections did not note any problems with the element. It was in storage prior to this inspection, last in core in 2007. This element was procured new from General Atomics in 1969 by our facility. (The licensee is) still working through fuel inspections. There will likely be future updates. Notified USGS PM (Sutherland), NPR Event Coordinator (Waugh).

ENS 5719326 June 2024 12:52:00The 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
ENS 5719024 June 2024 17:46:00The 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
ENS 5715731 May 2024 16:40:00The following information was provided by the licensee via phone: On May 31, 2024, a moisture density gauge (InstroTek Xplorer, model: 3500, serial number: 5130, 10 mCi Cs-137, 40 mCi Am-241:Be) could not be found when an authorized user went to retrieve it from storage for calibration at their Dexter, MI office. The gauge was last inventoried on November 16, 2023, at the licensees Ann Arbor office location and then relocated in January, 2024, to their Dexter location. The licensee inspected their former Ann Arbor location and verified that the space was empty. The licensees Radiation Safety Officer is currently directing ongoing search efforts. 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 5713016 May 2024 20:53:00The following information was provided by the licensee via email: On May 16, 2024 at 0840 EDT, operations declared the reactor water cleanup (RWCU) leak detection instruments related to the high differential flow signal inoperable. Technical specification (TS) 3.3.6.1, primary containment and drywell isolation instrumentation, conditions `A and `B were entered as one required channel of instrumentation was inoperable, and an automatic function with isolation capability was not maintained. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C) and 10 CFR 50.72(b)(3)(v)(D). All other RWCU primary containment isolation instrumentation functions remained operable. At 1210 EDT, the affected leak detection instruments were declared operable, and the TS limiting condition for operation 3.3.6.1 was declared met. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5712714 May 2024 12:05:00

The following was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on 5/13/24 concerning one lost iodine-125 brachytherapy seed with an activity of approximately 0.267 millicuries. On 5/13/24, Bard Brachytherapy received a package from Northside Hospital - Gwinnett (Lawrenceville, GA), and initially identified a total of seven of the nineteen iodine-125 brachytherapy seeds were missing. Five seeds were found shortly thereafter in the packing material. The common carrier was called to return to the Bard facility and an additional seed was located within the delivery vehicle. Additional searches of the local Schaumburg, IL (common carrier) hub and OHare airport facility were unsuccessful in locating the final seed. The Agency was notified that the final seed was considered lost. The package is reported as having left Lawrenceville, GA and then Norcross, GA before arriving at the Schaumburg, IL facility. Reportedly, the package had no indication of damage from transit. The cause of the loss seed appears to be inadequate packaging when shipped. Illinois event number: IL240013.

  • * * UPDATE ON 5/22/2024 AT 1058 EDT FROM GARY FORSEE TO SAMUEL COLVARD * * *

The licensees written report was received 5/22/23 and provided no additional information. Exposures to the carrier and other members of the public are not expected to exceed reportable limits. Due to the small size and the proximity required to accumulate a reportable exposure, this incident is not expected to result in public exposures exceeding regulatory limits. The Illinois licensee followed reporting timelines and package receipt procedures. Provided no new information becomes available that would allow identification of the seed, reasonable search efforts have been undertaken and this matter is considered closed. Notified R3DO (Ziolkowski), R1DO (Carfang), NMSS Events Notification (email), ILTAB (email). THIS MATERIAL EVENT CONTAINS A Less than Cat 3 LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 571159 May 2024 11:48:00The following information was provided by the licensee via phone and email: At 0800 EDT on May 9, 2024, it was identified during leak rate testing that through-wall flaws existed on reactor plant river water piping inside the containment building. This determination resulted in a containment bypass condition such that a gaseous release could have occurred at a location not analyzed for a release in the loss of coolant accident dose consequence analysis. This condition is not bounded by existing design and licensing documents. Evaluation of the condition of the piping is ongoing to support repair prior to startup. With the plant currently in cold shutdown, the containment, as specified in Technical Specification 3.6.1, is not required to be operable. There was no impact on the health and safety of the public or plant personnel. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A), 10 CFR 50.72(b)(3)(ii)(B), and 10 CFR 50.72(b)(3)(v)(C). The NRC Resident Inspector has been notified.
ENS 571033 May 2024 11:56:00The following information was provided by the licensee via email: At 0411 EDT on 5/03/2024, it was determined that primary containment did not meet TS (Technical Specification) 4.6.1.2 (surveillance) requirement due to a primary containment leak rate test exceeding `La (allowable leakage rate). This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The final observed leak rate is still being calculated as the test is still within the stabilization period. Testing is allowed within the stabilization period for an unspecified amount of time. Short term corrective actions are to identify and repair any leak paths. No mode changes are required due to this event.
ENS 571053 May 2024 17:16:00The following information was provided by the licensee via phone and email: At 1630 EDT on 5/3/2024, the supervisor of nuclear site safety contacted the Area Director of OSHA to notify them of a workers foot injury requiring removal of a toe to the first joint. This was a 24 hr notification in accordance with 29 CFR 1904.39. The NRC Residents have been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The individual was not contaminated or working in a radiological area at the time of injury.
ENS 5707112 April 2024 12:05:00The following is a summary of information received from the Alabama Office of Radiation Control via email: On April 11, 2024, at 1500 CST, a device (Ohmart/Vega, SH-F1, Model A-2102, Source SN 9254GK, 100 mCi Cs-137) was discovered to have a stuck open shutter during routine shutter checks. The device is in place and operational. The area around the vessel on which the device is mounted has been barricaded and marked for no entry. The licensees plan is to replace the source holder with a new one. The licensee is getting a quote for replacement and installation with an estimated repair date of May 10, 2024.
ENS 5707615 April 2024 12:28:00The following information was received from the Colorado Department of Public Health and Environment via email: This letter is serving as notification of an equipment failure under (Colorado Regulation) Section 4.52.2.3 and 5.38.1.3. A QSA Global 880 Delta camera was received from Source Production and Equipment Company, Inc. (SPEC), after being resourced. During the check-in procedure and mechanism check, it was discovered that the lock that controls access to the pigtail attachment was broken in the locked position. The camera was tagged out until it could be sent to Industrial Nuclear Company (INC), for repairs on 04/04/2024. The lock was repaired at INC, and the camera was returned to the licensee on 04/10/2024 with no issues. Colorado Event Report ID: CO240011
ENS 5703317 March 2024 17:59:00The following information was provided by the licensee via phone and email: On March 17, 2024, at 1515 CDT, the Comanche Peak Unit 2 reactor was manually tripped due to an anticipated automatic trip due to lo-lo steam generator (SG) water levels. Prior to the trip, main feedwater pump '2B' tripped and an auto runback to 700 MW (60 percent power) was in progress. Both motor driven auxiliary feedwater pumps and the turbine driven auxiliary feedwater pump started due to lo-lo level in all SGs. Unit 2 is being maintained in hot standby (Mode 3) in accordance with integrated plant operating procedures IPO-007B. The emergency response guideline network has been exited. Decay heat is being rejected to the main condenser via the steam dump valves. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The cause of the '2B' main feed pump trip was due to loss of primary and redundant power to the servo control valve. The loss of power to the servo control valve is under investigation.
ENS 5702412 March 2024 12:16:00The following information was provided by the licensee via phone and email: On March 12, 2024, at 0816 CDT, Comanche Peak Unit 2 reactor automatically tripped on lo-lo level in the 2-03 steam generator (SG). Prior to the trip, main feedwater pump (MFP) 2A speed reduced and a manual runback to 700 MW (60 percent) was in progress. Both motor driven auxiliary feedwater pumps and the turbine driven auxiliary feedwater pump started due to lo-lo level in all SGs. Concurrent with the loss of speed on MFP 2A, a servo filter swap was in progress on MFP 2A. Unit 2 is being maintained in hot standby (Mode 3) in accordance with integrated plant operating procedure IPO-007A. The emergency response guideline network has been exited. Decay heat is being rejected to the main condenser via the steam dump valves. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The cause of the loss of the MFP is under investigation. Unit 1 was unaffected.
ENS 5702512 March 2024 12:29:00The following summary of information was provided by the licensee via phone and email: During an inventory which began the week of March 4, 2024, the licensee discovered one lost tritium exit sign (Isolite SLX-60, 4.4 Ci). The sign was at a location undergoing renovation. All other tritium exit signs that were on site have been accounted for. An investigation ensued to attempt to determine the disposition of the missing sign. This sign was declared lost on March 12, 2024. 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 5702111 March 2024 15:46:00The following information was provided by the licensee via phone and email: On March 11, 2024, at 1337 EDT, with Unit 1 in Mode 1 at 35 percent power performing power ascension activities, the reactor was manually tripped due to the 'A' reactor feed pump (RFP) tripping on low suction pressure. Due to the power level at the time, the 'B' RFP had not been placed in service. Closure of containment isolation valves (CIVs) in multiple systems and actuation of high-pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) occurred as a result of reaching the actuation setpoint on reactor water level as designed. The trip was not complex, with all safety systems responding normally post-trip. Operations responded and stabilized the plant. The 'B' RFP was placed in service and is controlling reactor water level. Decay heat is being removed by discharging steam to the main condenser using turbine bypass valves. Unit 2 is not affected. Due to the emergency core cooling system (ECCS) discharging into the reactor, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). Also, the Reactor Protection System actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, it is reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of CIVs, RCIC and HPCI. There was no impact on the health and safety of the public or plant personnel. The 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 'A' RFP is under investigation. The reactor electric plant remains in a normal lineup with both emergency diesel generators available. There were no temperature or pressure technical specification limits approached.
ENS 570021 March 2024 17:27:00The following information was provided by the licensee via email: At 1330 CST, on March 1, 2024, an equipment vendor was coordinating with Wright County performing maintenance on an emergency siren when the county operator mistakenly sent an alarm signal instead of cancel signal, activating all Wright County emergency sirens for approximately 17 seconds. At 1345 CST, the Monticello Nuclear Generating Plant (MNGP) emergency planning coordinator received a notification from the vendor and notified the duty shift manager (of the inadvertent activation). Wright County officials are planning to make a public notification via social media to local residents. No press release by the licensee is planned at this time. This event is reportable per 10 CFR 50.72(b)(2)(xi), 'News Release or Notification of Other Government Agencies.' This is a 4-hour Reporting requirement. The NRC Resident has been notified.
ENS 570001 March 2024 12:48:00The following summary of information was provided by the Florida Bureau of Radiation Control (the Bureau) via email: On March 1, 2024, at 1121 EST, the Bureau received a call from Universal Engineering Scientists to report that a Troxler gauge (Model: 3430P, Serial: 86000, 8 mCi Cs-137, 40 mCi Am-241:Be) was run over on a work site. The Cs-137 source rod was extended 12 inches into the ground. The licensee radiation safety officer (RSO) responded and determined that the source rod could not to be retracted. The gauge was placed in a container and shielded for transport to a storage facility in Port St. Lucie where it will be held for evaluation. The Bureau inspector has been notified and will respond. Florida Incident No.: FL24-015
ENS 5702311 March 2024 15:28:00

The following summary of information was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email: On March 1, 2024, the Department was notified of a medical misadministration that occurred on February 28, 2024. The misadministration was that of Ga-68 Dotatate (5.24 millicuries) being administered instead of F-18 FDG (Fludeoxyglucose). The licensee proceeded with the scan having an incomplete scan description on an outside physician's order. The signed order received only asked for "PET-CT Scan (Base of Skull to Thigh)." An unsigned order/history form, clearly designating a Ga-68 Dotatate scan, was filled out by the outside clinic's medical staff and included with the physician's order. The licensee proceeded with scan as directed using the elaboration of the unsigned order/history form as designation of the specific scan ordered. The patient was notified of the incident and will receive the appropriate scan the following week. Investigation in to how this situation can be avoided in the future has been conducted by the licensee. WA Event Number: WA-24-0007 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.

  • * * UPDATE ON 3/14/24 AT 1538 EDT FROM BORIS TSENOV TO ADAM KOZIOL * * *

The following was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email: The licensee provided a written report to the Department identifying root causes and corrective actions. The report also calculated an effective dose estimate of 498 mrem and the highest expected effective organ dose to the spleen of 5.47 rem. Notified R4DO (Werner) and NMSS Events (email)

ENS 5699024 February 2024 09:27:00The following information was provided by the licensee via phone and email: At 0219 CST on February 24, 2024, Browns Ferry Unit 3 was shut down in a refueling outage, while closing 4 kV shutdown board breaker 3EB-9, the 4 kV shutdown board normal feeder breaker tripped open resulting in a valid 4 kV bus under-voltage condition. Due to the under-voltage condition, the 3B emergency diesel generator (EDG) auto started and tied to the board. The cause of the breaker tripping open is unknown and an investigation is in progress. All systems responded as expected for the loss of voltage. This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No other safety related equipment was affected. The 3B EDG continues to supply the shutdown board pending further investigation.
ENS 5697316 February 2024 18:10:00The following information was provided by Texas Department of State Health Services (the Department) via email: On February 16, 2024, the Department was contacted by the licensee's radiation safety officer (RSO) that the source in a Mark 1 irradiator could not be raised or lowered. The device contains a 10,000-curie cesium-137 source (original activity manufactured 6/25/1986). The source problem was discovered when a researcher was attempting to irradiate a few mice and the source would not raise. The RSO stated they inspected the device and found a fuse that controlled the source's movement both up and down had failed. The RSO stated they had contacted a service company to repair the device. The source is in the fully shielded position. No individuals received any exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas NMED number: TX240006
ENS 5707715 April 2024 14:38:00The following information was provided by the licensee via email: At 2224 EST on February 15, 2024, with both units 1 and 2 in Mode 1 at 100 percent power, an invalid start of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The 1A-A, 1B-B, and 2B-B EDGs started and functioned successfully. The start signal for the 1A-A, 1B-B, and 2B-B EDGs was generated from the common emergency start of the 2A-A EDG. The signal was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design (basis) safety function. The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system. This event was originally reported under EN 56970 on February 16, 2024, at 0205 EST in accordance with 10 CFR 50.72(b)(3) (iv)(A) as an event that results in a valid actuation of the emergency diesel generator system. This EN was retracted on February 21, 2024, at 1549 EST. This event is being reported in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the emergency diesel generator system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5697216 February 2024 14:29:00The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email: On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided. PA NMED Event Number: PA240005 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 5699427 February 2024 06:42:00The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email: On January 6, 2024, the Department was notified by the licensee, that on January 3, 2024, a nuclear medicine technologist was performing routine leak testing of sealed sources in preparation of returning the sources to the manufacturer. The leak test indicated one of the sealed sources (Co-57, 21.12 microcuries as of 2/1/2023, manufacturer: Eckert and Ziegler, model: PHI-0124, serial number: V6-599) had more than 0.005 microcuries of removable Co-57 contamination. The sealed source was secured, the radiation safety officer (RSO) was notified, and decontamination protocol was followed. Post-decontamination surveys and wipe tests of the staff and department indicated that there was no detectable contamination in the department or on staff members. The sealed source and the waste generated during the decontamination process were placed in leakproof containers and marked as containing Co-57. All items are currently stored in the nuclear medicine hot lab. Disposal with a waste disposal company has been arranged. Georgia NMED event number: 76 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 5686419 November 2023 00:53:00The following information was provided by the licensee via phone and email: At 2138 EST on November 18, 2023, Harris Nuclear Plant notified the National Response Center of a biodegradable oil leak that entered the Harris Lake. The North Carolina Department of Environmental Quality will also be notified of this condition on November 19, 2023. The oil leak was less than one gallon and came from a temporary pump. The leak has stopped, and spill cleanup is underway. This condition did not violate any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a notification to another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5686318 November 2023 02:51:00The following information was provided by the licensee via phone and email: On November 17, 2023, at 2215 CST, River Bend Station (RBS) was operating at 30 percent reactor power performing plant startup activities when an isolation of low-pressure feedwater string `A' occurred. The team entered applicable alternate operating procedures and inserted control rods to exit the restricted region of the power to flow map. Feedwater temperature continued to lower until it challenged the prohibited region of the AOP-0007 graph requiring a reactor scram. The team inserted a manual reactor scram at 2355 from 24 percent reactor power. All control rods fully inserted and there were no complications. All systems responded as designed. Currently RBS Unit 1 is stable with reactor level being maintained 10 to 51 inches with feed and condensate, and pressure being maintained 500 to 1090 psig using steam drains. This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the Reactor Protection System (RPS) when the reactor is critical and 10 CFR 50.72(b)(3)(iv)(A) Specified System Actuation as result of Group 3 isolations. The NRC Senior Resident inspector has been notified. No radiological releases have occurred due to this event from the unit. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The electric plant is in a normal lineup for current plant conditions with all emergency diesel generators available. The cause of the initial isolation of low-pressure feedwater string "A" is still under investigation.
ENS 568418 November 2023 13:27:00The following information was provided by the licensee via phone and email: At 0645 EST, on November 8, 2023, with Unit 2 in Mode 3 at zero percent power, a manual actuation of the auxiliary feedwater system (AFW) occurred during a planned plant cooldown. The reason for the AFW manual-start was a trip of the 22 steam generator feed pump due to a high casing level. The 23 AFW motor driven pump was manually started in accordance with implementation of AOP-3G, Malfunction of Main Feedwater System to restore steam generator levels. There was no impact to Unit 1. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No other systems were affected. No other compensatory or mitigation strategies implemented. Plant cooldown was the only significant evolution in progress. No impact to other technical specifications or limiting conditions for operation. All systems functioned as required. The electric plant is being supplied by offsite power with all diesel generators available. No significant increase in plant risk. There was nothing unusual or not understood.
ENS 568397 November 2023 18:42:00The following information was provided by the licensee via email: At 1617 on 11/7/2023, Calvert Cliffs Unit 2 experienced an automatic trip from a Reactor Protection System (RPS) based on reactor trip bus under voltage (UV). At that time a loss of U-4000-22 caused a loss of 22, 23, and 24 4kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV condition. The loss of 22 and 23 4kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser. RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4-hour report. ESFAS actuation (2B DG start on UV) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report. ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report. Site Senior NRC resident inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Unit 1 was unaffected. Estimation of duration of shutdown is 24 hours.
ENS 5679113 October 2023 11:48:00The following was reported by the Illinois Emergency Management Agency (the Agency) via email: The Agency was notified October 12, 2023, by GE Healthcare in Arlington Heights, IL to advise that a radiopharmaceutical package was missing (during shipment). The last known location was a shipping facility in Fort Worth, TX when it was last scanned by shipping personnel on October 10, 2023, at 0035 CDT as 'arrived.' This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. The 16 cm cubed package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10 mL shielded vial. The activity of indium-111 was 1.535 mCi at the time of shipment but has since decayed to approximately 0.6 mCi. It was reportedly offered for shipment on October 9, 2023, for delivery to a customer in Carrollton, Texas on October 10, 2023. Upon failure to arrive, the licensee initiated a search, and after a review of online tracking data and conversations with shipping personnel, GE Healthcare logistics were informed that the shipping facility has initiated a search for the package and that it is currently unaccounted for in their system. The shipping facility's tracking system last showed the package as 'arrived' as of 0035 CDT on October 10, 2023. Illinois Incident Number: Il230029 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 5676729 September 2023 18:43:00The following report summary was received by email from Virginia Radioactive Materials Program (VRMP): On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr. According to the RSO, no public exposure occurred. The licensee has fitted a lead pig (lead shielded container) around the source for transport to a licensed nuclear gauge service company. Virginia Event Report ID Number: VA230002
ENS 5676328 September 2023 13:35:00The following information was provided by the licensee via phone: On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.
ENS 5681425 October 2023 14:52:00The following was received from the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS)) via email: IEMA-OHS was contacted the morning of October 25, 2023, by GE Precision Healthcare (a Wisconsin-licensed service provider) to advise of a Ge-68 source that had been improperly shipped to Illinois. Reportedly, a positron emission tomography-computed tomography (PET/CT) unit, still containing the Ge-68 source, was removed from a medical facility in Washington state and shipped to an unlicensed Illinois facility (MAK Healthcare). The parties involved are seeking the proper removal and return of the source to the Washington licensee. It is our understanding that GE Healthcare intends to send a technician to the Illinois facility on Friday, October 27 to remove or retrieve the sources under reciprocity. Thereafter, the source will be packaged and returned to the licensee in Washington state. Illinois staff contacted Washington staff and advised them of the available details. In accordance with SA-300, section 5.6.2, this report is being filed with the Nuclear Regulatory Commission as a 'found source'. The matter may also be reportable under the Illinois equivalent of 10 CFR 20.2203(a)(3)(ii). IEMA-OHS staff will monitor the activities in Illinois to verify source integrity and proper return to appropriately licensed individuals. This report will be updated as details become available. At this time, the Ge-68 sealed source is estimated to have a maximum activity of 11 mCi and is either an IPL-model number HEGL-0132 or 0019 or 0020. Illinois report number: IL230031 See NRC Event Notification number 56818 for a parallel report made by Washington. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Retrieved from "https://kanterella.com/Special:Ask/-5B-5BNRC-20officer::Sam-20Colvard-5D-5D-20-5B-5BCategory:ENS-20Notification-5D-5D/-3FEntered-20date/-3FEvent-20description/mainlabel%3D/order%3Ddescending/sort%3Dstart-20date/offset%3D0/format%3Dtable/searchlabel%3DNRC-20Officer:/default%3DNRC-20Officer*:"