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| Entered date | Event description | |
|---|---|---|
| ENS 57188 | 24 June 2024 10:32:00 | The following information was received from the Georgia Radioactive Material Program (the Department) via email: A report was received from the radiation safety officer (RSO) at Applied Technical Services, LLC. on June 21, 2024, concerning the most recent dosimeter badge report which indicated a whole body dose of over 5,000 mrem for the month of April 2024 for an employee. The RSO has notified their upper management and the employee is suspended from all radiation work as of June 20, 2024, until further investigation. The employee is in the process of writing a detailed statement. The licensee is currently reviewing all utilization logs and will notify the Department once the investigation is complete. Further investigation is ongoing to determine root cause and a follow-up report will be provided within 30 days. Georgia Incident Number: 85 |
| ENS 57186 | 22 June 2024 08:02:00 | The following is a synopsis of information provided by Framatome, Inc. (Framatome) via email: During startup testing at the affected plant, unexpected high reactor peaking factor readings resulted from an incorrect boron concentration of Al2O3-B4C pellets in two burnable poison rod assemblies (BPRAs). The cause of the issue was due to 0.2 percent boron concentration Al2O3-B4C pellets inadvertently combined with the intended 2.0 percent boron concentration Al2O3-B4C pellets, which were then placed back into inventory labeled as 2.0 percent. This issue was determined to be a 10 CFR 21 Defect on June 21, 2024. Corrective actions are that Framatome replaced the two affected BPRAs with BPRAs fabricated correctly and a root cause analysis has been initiated by Framatome which is scheduled for completion by July 31, 2024. The affected plant is Oconee Unit 3. The name and address of the individual reporting this information is: Gayle Elliott Director, Licensing & Regulatory Affairs Framatome Inc. Office 434 832-3347 Mobile 434 841-0306 3315 Old Forest Road Lynchburg, VA 24501 gayle.elliott@framatome.com |
| ENS 57183 | 19 June 2024 18:00:00 | The following information was provided by the licensee via phone and email: At 1537 CDT on June 19, 2024, the shift manager was informed that a contract company to Xcel Energy would be notifying the Occupational Safety and Health Administration (OSHA) pursuant to the requirements of 29 CFR 1904.39. Notification to OSHA is required due to a contract employee who suffered a personal health condition while at an offsite facility for training and was declared deceased following emergency medical service departure to the medical facility. The NRC Resident Inspector has been notified of this event. |
| ENS 57181 | 19 June 2024 15:07:00 | The following information was provided by the licensee via phone and email: At 1640 EDT on 06/18/2024, the division 3 diesel generator was declared inoperable. This condition could prevent the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). All other emergency core cooling systems were operable during this time. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The division 3 diesel generator was declared inoperable due to potential water intrusion into the electrical generator. Inspection of the generator is in progress. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: This event resulted in Perry Unit 1 entering a 72 hour limiting condition for operation (LCO) in accordance with Technical Specification 3.8.1. condition 'B'. |
| ENS 57180 | 18 June 2024 16:19:00 | The following information was provided by the licensee via email and phone: During investigation related to licensee event report (LER) number 24-001, a noncompliance with technical specification 3.10.d was discovered. During the period from July 2022 to April 2024, three filters operating at greater than 99 percent efficiency were not in service. The limiting condition of this technical specification is associated with operation of an I-131 processing suite, rather than with operation of the reactor. The University of Missouri Research Reactor's iodine suite ventilation includes a series of seven filter trains, each of which were in service during this period at an efficiency greater than 98 percent. Filter banks '2' and '3' were operating at greater than 99 percent efficiency. Filter '3-3' was also credited as greater than 99 percent efficiency, however, the bypass between the two banks of filter '3-3' consisted of dampers rather than valves. Therefore the total efficiency, when bypass was taken into account, was less than 99 percent. Processing of iodine was generally performed weekly during the referenced period. Processing of iodine was suspended in May 2024 in association with LER 24-001, and remains suspended until compliance is achieved. Several detectors were monitoring the suite and downstream effluent from the suite during the referenced period, including the off-gas (stack) radiation monitor per technical specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room (derived air concentration) monitors, and the remaining three I-131 processing hot cells radiation monitors. No in-service monitors indicated abnormal rises in iodine levels during the period in question. |
| ENS 57176 | 17 June 2024 15:05:00 | The following information was provided by the Oregon Department of Health Radiation Protection (the Department) via email: During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT. The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee." Oregon Event Report ID Number: OR-24-0030 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 57159 | 3 June 2024 08:06:00 | The following information was provided by the licensee via phone and email: At 0051 EDT on June 3, 2024, with Unit 3 in Mode 3 at 0 percent power, an actuation of the emergency feedwater system (EFW) occurred as main steam pressure was being lowered as part of reactor coolant system (RCS) cooldown for a planned shutdown. The reason for the EFW auto-start was lowering levels in the 3A and 3B steam generators following loss of the operating main feedwater pump. The main feedwater pump automatically tripped when main steam pressure was lowered below the automatic feedwater isolation system (AFIS) actuation setpoint before AFIS channels were taken to bypass. The 3A and 3B motor driven emergency feedwater pumps automatically started as designed when the low steam generator level signal was received for the 3A and 3B steam generators. 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 EFW system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 57124 | 12 May 2024 20:46:00 | The following information was provided by the licensee via email and phone: At 1641 CDT on May 12, 2024, with Unit 2 in Mode 1 at 15 percent power, the reactor automatically tripped due to a unit auxiliary transformer lockout. During the trip, all control rods fully inserted. The cause of the transformer lockout is currently unknown. Emergency diesel generator (EDG) 21 and 23 actuated and all three engineered safety feature (ESF) busses were energized. All equipment responded as expected except for steam generator power operated relief valve (PORV) 2C which failed to open when required in automatic, and the load center (LC) E2A output breaker which failed to close automatically but was closed manually. Steam generator PORV 2C did open when placed in manual, although it subsequently failed to full open and was then closed. Primary system temperature and pressure are currently being maintained at 567 degrees/2235 psig following start of reactor coolant pumps 2A and 2D. Due to the reactor protection system actuation (RPS) while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the emergency diesel generators. There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: South Texas Project Unit 2 was in Mode 1 at 15 percent power due to performance of testing and analysis on the main turbine prior to the RPS actuation.
The following information was provided by the licensee via email and phone: South Texas Project is submitting the following correction to the event notification: The steam generator (SG) power operated relief valve (PORV) 2C did not fail to open automatically. System pressure during this event did not reach the automatic setpoint for the PORV (1225 psi), and there was no demand for it to open automatically. During the event, SG PORV 2C was taken to manual and it went full open when the up button was pushed slightly. It went closed when the down button was pressed to close it manually. In addition, the load center E2A output breaker initially failed to close automatically, however, after operations placed it in pull-to-lock and returned the hand switch to automatic, it closed automatically. Notified R4DO (Dixon). |
| ENS 57122 | 11 May 2024 22:49:00 | The following information was provided by the licensee via phone and email: At 1655 CDT, Waterford Steam Electric Station, Unit 3 was in Mode 3 with all control rod element assemblies (CEA) fully inserted with reactor trip circuit breakers closed and individual CEA disconnects open for plant startup. During the performance of emergency feedwater surveillance testing, reactor protection system (RPS) trip set point and emergency feedwater actuation system (EFAS) initiation set point for steam generator level low was exceeded for steam generator 1. Preliminary evaluation indicates that all plant systems functioned normally. The unit is currently stable in Mode 3. All control rods remain fully inserted. This event is being reported as a eight-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the RPS and emergency feedwater systems. The NRC Resident Inspector has been notified. |
| ENS 57125 | 13 May 2024 14:21:00 | The following information was provided by the licensee via phone and email: During a routine source check on 5/10/2024, it was noted that three of the six iodine-131 processing hot cell radiation monitors were located incorrectly. Upon investigation, it was discovered that on 4/19/2024 the filter banks were switched between bank A and bank B. During this filter bank switch, the detectors monitoring the filter banks were also not changed. This led to processing iodine three times between 4/19/2024 and 5/10/2024 without meeting the conditions of Technical Specification 3.10.c regarding monitoring requirements. The event was corrected on 5/10/2024. Several detectors were monitoring the suite during the period from 4/19/2024 and 5/10/2024, including the off-gas (stack) radiation monitor per Technical Specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room DAC monitors, and the remaining three iodine-131 processing hot cell radiation monitors. No in-service monitors indicated abnormal rises in iodine levels. After the detectors were returned to service in the correct location, it was noted that the readings on the filter banks were very low. These readings provide supporting evidence that they were not being loaded while the detectors were incorrectly located. |
| ENS 57107 | 5 May 2024 08:11:00 | The following information was provided by the licensee via email and phone: At 0338 CDT, with the unit 1 in mode 1 at 6 percent power, the reactor automatically tripped due to lowering steam generator water level. The trip was uncomplicated with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for an actuation of the auxiliary feedwater system. Operations responded using procedure 1BwEP-0 and stabilized the plant in mode 3. Decay heat is removed by steam dumps via the main condenser. 1A and 1B auxiliary feedwater pumps were actuated manually prior to the reactor trip in an attempt to restore steam generator water level. Unit 2 is not affected. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
The following information was provided by the licensee via email and phone: At 0338 CDT, with the unit 1 in mode 2 at 3 percent power, the reactor automatically tripped due to lowering steam generator water level. The trip was uncomplicated with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A) for an actuation of the auxiliary feedwater system, eight-hour notification. Operations responded using procedure 1BwEP-0 and stabilized the plant in mode 3. Decay heat is being removed by steam dumps via the main condenser. 1A and 1B auxiliary feedwater pumps were actuated manually prior to reactor trip in an attempt to restore steam generator water level. Unit 2 is not affected. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. Notified R3DO (Hartman) |
| ENS 57083 | 20 April 2024 13:51:00 | The following information was provided by the licensee via phone and email: At 0704 CDT on 4/20/24 with Unit 1 in Mode 1 at 100 percent power, an actuation of the emergency AC power system, specifically the Division 1 and Division 3 emergency diesel generators (EDGs) occurred during an unexpected loss of the Unit 1 system auxiliary transformer (SAT). The cause of the emergency AC power system auto-start was an unexpected loss of the Unit 1 SAT during switchyard maintenance. Bus 141Y did not fast transfer as designed resulting in the actuation of the Division 1 EDG. Division 3 EDG actuation is expected for this condition. The Division 1 and Division 3 EDGs automatically started as designed when the emergency AC power system valid actuation signal was received. 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 emergency AC power 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: Division 1 and Division 3 EDGs will remain in operation and loaded until the Unit 1 SAT is restored. This event resulted in the plant entering an unplanned 72 hour limiting condition for operation (LCO) in accordance with technical specification 3.8.1. The licensee is investigating the cause of the unexpected loss of the Unit 1 SAT and the failure of the bus 141Y fast transfer. |
| ENS 57066 | 4 April 2024 19:35:00 | The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 4/4/2024 at 1618 MST, a Notification of Unusual Event, HU4.2 was declared based on an unverified fire alarm in the containment building greater than 15 minutes. Palo Verde, Unit 3 was operating in Mode 1 at 91 percent power due to end of cycle coast down to a refueling outage. There is no known plant damage at this time. Offsite assistance cannot enter the containment building, therefore, offsite assistance was not requested. The plant is stable in Mode 1. The licensee notified State and local authorities and the NRC Senior Resident Inspector. Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).
The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: At 2013 MST, Palo Verde Unit 3 terminated the notification of unusual event. The basis for termination was that a containment entry was performed. All levels were inspected, and no fires were found. The NRC Resident Inspector has been notified. Notified R4DO (Deese), IR-MOC (Crouch), 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). |
| ENS 57050 | 25 March 2024 17:38:00 | The following information was provided by the licensee via email and phone call: At 1027 CDT on 3/25/24, it was determined that a contract supervisor tested positive in accordance with the fitness for duty testing program. The individuals authorization for site access has been terminated. The NRC Resident Inspector has been notified. |
| ENS 57049 | 25 March 2024 15:48:00 | The following information was received from the California Department of Public Health, Radiological Health Branch (RHB) via email: On 3/24/24, the alternate radiation safety officer phoned the RHB to report a medical event associated with a yttrium-90 (Y-90) therapy. A patient receiving Y-90 therapy was underdosed by more than 20 percent from the planned dose. RHB will investigate. California Report Number: 032424 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 57017 | 8 March 2024 13:59:00 | The following information was provided by the licensee via email and phone call: A non-licensed supervisor had a confirmed positive fitness for duty test. Unescorted access for the individual has been denied at all Dominion Energy sites. The NRC Senior Resident Inspector has been notified. |
| ENS 57064 | 4 April 2024 14:36:00 | The following information was received via email by the Illinois Emergency Management Agency (the Agency): Annual self-inspection request was sent to all generally licensed entities on February 15, 2024. This registrant e-mailed back on February 21, 2024, indicating that he was no longer associated with the company, the company was no longer in business in Illinois, and the radioactive material was lost. The company was sold and the radioactive material was sold with the other assets. However, the sources were in place as recently as January 3, 2020, when they submitted their last self-inspection. The registration had three 10 mCi nickel-63 (Ni-63) sealed sources on their inventory. After continued research, the Agency was unable to track down the sources. The Agency contacted the manufacturer, Shimadzu, who did not have any records of any service work on the 3 sources or disposal paperwork. The new company could not be found. These sources do not pose a health or safety risk to the public. Pending any new information, this matter is considered closed. Illinois Item Number: IL240005 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 57063 | 4 April 2024 12:24:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On March 4, 2024, the Agency received a notification from G.E. Healthcare in Arlington Heights, IL to advise of one missing radiopharmaceutical package at the Memphis, TN (common carrier) hub. The package contained one vial of I-123 with 14.268 mCi at the time of shipment. G.E. Healthcare was notified on March 4, 2024 by (common carrier) in Memphis, TN that a radiopharmaceutical package was missing with no indication of the contents being separated from the package. The package was originally shipped out of G.E. Arlington Heights, IL facility on February 29, 2024. The lead shielded package contained 14.268 mCi of I-123 in one 10 mL vial at the time of shipment. The destination was Spokane, WA. The last measured activity was 0.094 mCi. The last scan was at the (common carrier) hub in Memphis on February 29, 2024 and (common carrier) confirmed the package could not be found on March 4, 2024. This matter will continue to be tracked until an update is available or the package has decayed to background levels. As of April 3, 2024, the licensee indicates there are no changes to the status of the package or contents of the package. The package content has decayed to background levels. This does not pose a threat to the health and safety of the public. Provided there are no changes, this matter is considered closed. Item number: IL240007 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 57048 | 25 March 2024 14:04:00 | The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email: The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected. The discovery was made during a quarterly review of their written directive on March 20, 2024. The Agency is awaiting further information from the licensee.
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email: The discovery was made during a quarterly review of their written directive on March 12, 2024 (Corrected date). The authorized user prescribed an activity of 2.6 GBq (70 mCi) on February 7, 2024. The technologist drew up 3.17 GBq (85.8 mCi) which was 122 percent of the prescribed activity and delivered the syringe to the authorized user. The authorized user performed the administration within 30 minutes of the dose being drawn. The administered activity was estimated to be 84.5 mCi, 120 percent of the prescribed activity. The authorized user contacted the patients referring physician and both were satisfied with the activity delivered as the goal was to ablate the entire segment of diseased liver. The absorbed doses to all other tissues were below the targets for treatment with Y90. Personnel interviews were conducted by the department on April 2, 2024, aimed at gaining insight into the incident and engaging in discussions regarding the procedures involved. The event is considered closed. Notified R4DO (Warnick) and NMSS Events Notification (email) Arkansas Event #: AR-2024-2 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 57051 | 25 March 2024 18:54:00 | The following information was received from the Washington State Department of Health, Office of Radiation Protection (the Department) via email: Action Towing LLC transported a car to the Schnitzer Steel Industries scrap metal facility, and it triggered the scrap yards radiation detectors. The scrap yard staff measured about 35 micro roentgen/hour on the outside of the car. Officials at Schnitzer Steel Industries contacted the Department which resulted in an evaluation of the concern and issuance of a DOT special permit so that the radioactive car could be returned to Action Towing LLC for proper handling. The Action Towing office manager was informed that the staff had seen some sort of radiation equipment in the car, so the Department requested pictures of the equipment. The pictures showed an old military Geiger-Mueller (GM) survey meter and other items. The Department went to Action Towing to investigate the radioactivity. In addition to the old military GM survey meter, which was not radioactive, the Department found two glass tubes containing radioactive material, which measured about 2 milliroentgen/hour on contact. One of the tubes was labeled as radium-226. The Department took the radioactive tubes for disposal, then surveyed the car and found no elevated radioactivity remaining in the car, and therefore released the car for unrestricted use." WA State Item Number: WA240001 |