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The following was received from the South Carolina Department of Health and Environmental Control (Department) via phone and email: The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 0930 EST on 11/10/23 that a medical event had been discovered by the licensee on 11/09/23 at approximately 1700 EST. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 45 percent of the prescribed 500 Gray (Gy) dose. MUSC estimates that the patient received 276 Gy of the intended 500 Gy dose. The licensee reported that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control. 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 3/19/24 AT 1508 EDT FROM KORINA KOCI TO OSSY FONT * * *

The following update was received from the South Carolina Department of Health and Environmental Control (Department) via phone and email: The licensee provided their 15-day written report dated 11/17/23, which was received on 11/18/23. The written report indicated that at the time of the Y-90 radioembolization procedure no leaking was present, and after three flushes were performed the dose vial (originally containing the TheraSpheres) was measured again. Surveys of the vial and procedure room indicated radiation doses to be at background levels. Additionally, the licensee reported that measurements of the Nalgene container contents demonstrated high levels of residual activity and based on these readings the licensee ascertained that 55 percent of the prescribed dose was administered to the patient. Upon further investigation, the licensee stated that the microcatheter passing through the Y-fitting ruptured allowing the TheraSpheres to escape and collect in the fitting. The licensee's corrective actions included: communicating the details of this event with the manufacturer and inquire on whether this event has previously occurred, and requested from the manufacturer to provide refresher training to staff on the set-up of administration lines. Finally, the licensee reported that no adverse effects to the patient are expected to occur as a result of this event, since only 55 percent of the intended dose was delivered. Department inspectors were dispatched to the facility on 12/06/23. The details of the event were consistent with the licensee's 15-day written report. This event and investigation are considered closed. Notified R1DO (Ford) and NMSS Events Notification via email.

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number 10065 Texas NMED Number: TX230051

• * * UPDATE ON 11/9/23 AT 1529 EST FROM ART TUCKER TO KERBY SCALES * * *

The following update was provided by the Texas Department of State Health Services via email: On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location. Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico via 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

The following is a synopsis of information provided by the licensee via email: Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative. This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place. This issue has been entered into the licensee's corrective action program as IR-2022-9728.

• * * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHANE SUBOSITS TO THOMAS HERRITY * * *

The following is a synopsis of information provided by the licensee via email: On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done. This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition. Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953. Notified R2DO (Endress) and NMSS_EVENTS via email.

Peach Bottom Atomic Power Station Control Room was notified of a loss of greater than 25% of sirens after severe storms in the area associated with Hurricane Sandy. Thirty-one (31) of 97 Emergency Planning Zone (EPZ) sirens are currently unavailable in Lancaster, York, Cecil and Harford Counties. Actions are currently being taken to restore unavailable sirens. The licensee notified the NRC Resident Inspector.

• * * UPDATE AT 0515 EDT ON 10/31/12 FROM SCOTT RUCKER TO S. SANDIN * * *

Currently 12 of 97 sirens remain inoperable. The licensee will inform state and local agencies and the NRC Resident Inspector. Notified R1DO (Caruso).

It was discovered at approximately 1700 EDT on 6/19/2012 that the moderation control in the gadolinia pellet press operation had been degraded. An operator error allowed a can containing approximately 14 kg of uranium powder to be processed without the required material move transaction, a process control that ensures the container and material type are allowed at the designated location. This resulted in a temporary degraded item relied on for safety (IROFS) condition involving a criticality control. The press moderation control is one of four IROFS to prevent a criticality accident. The gadolinia press station material control system functioned as designed and prompted the operator of an error. The other criticality controls on geometry were maintained at all times. At no time was an unsafe condition present. The gadolinia pellet press operation has been shut down and additional corrective actions, extent of condition, and extent of cause are being evaluated. This event is being conservatively reported pursuant to 10 CFR 70, Appendix A (b) (2).

• * * RETRACTION FROM SCOTT MURRAY TO HOWIE CROUCH AT 1359 EDT ON 7/11/12 * * *

On 6/20/12, GNF-A conservatively made a 24 hour event notification (EN 48038) due to a single missed Fuel Business System (FBS) transaction on 6/19/12 at the gadolinia press operation. After further review of the identified condition, it has been determined to be not reportable to NRC and the event notification can be retracted. Notified R2DO (Blamey) and NMSS EO (Silva).

At 1355 hrs. EDT, an event was recorded by the seismic monitoring system. The seismic monitoring system classified the event as less than Operating Basis Earthquake (OBE) and less than Safe Shutdown Earthquake (SSE). The seismic monitoring system additionally classified the event as Seismic: NO At 1405 hrs., SSES (Susquehanna Steam Electric Station) declared an Unusual Event (under EAL OU5) after confirmation by outside agencies that an actual seismic event had occurred and reports from numerous personnel that they had detected ground motion. At time of transmittal there is no indication of equipment damage, personnel injuries and no automatic initiations of any ECCS or ESF systems or RPS actuations occurred. Assessment of any equipment damage is ongoing. The licensee has notified the NRC Resident Inspector and state and local authorities.

• * * UPDATE FROM FRITZ OHLSEN TO JOHN KNOKE AT 2110 EDT ON 8/23/11 * * *

The licensee has terminated the Notification of Unusual Event. The licensee has notified the NRC Resident Inspector and state and local authorities. Notified R1DO (Krohn), IRD (Morris), DHS (Bean) and FEMA (Via).

At 1403 hrs. EDT, North Anna Power Station declared an Alert due to significant seismic activity onsite. The Alert was declared under EAL HA6.1. Both units experienced automatic reactor trips from 100% power and are currently stable in Mode 3. All offsite electrical power to the site was lost. All four emergency diesel generators (EDG) automatically started and loaded and provided power to the emergency buses. While operating, the 2H EDG developed a coolant leak and was shutdown. As a result, the licensee added EAL SA1.1 to their declaration. All control rods inserted into the core. Decay heat is being removed via the steam dumps to atmosphere. No personnel injuries were reported.

• * * UPDATE FROM ROBERT RINK TO HOWIE CROUCH AT 1116 EDT ON 8/24/11 * * *

The licensee has downgraded the Alert to a Notification of Unusual Event based on equipment alignments and inspection results. The licensee notified R2 IRC. Notified IRD (Marshall), NRR (Thorp), FEMA (Hollis), DHS (Inzer), USDA (Ferezan), HHS (Willis) and DOE (Parsons).

• * * UPDATE FROM ROBERT RINK TO HOWIE CROUCH AT 1317 EDT ON 8/24/11 * * *

The licensee has exited the Notification of Unusual Event at 1315 EDT. The exit criteria was that all inspections and walkdowns were completed and plant conditions no longer meet the criteria for a NOUE. Notified R2DO (Widmann), IRD (Marshall), NRR (Thorp), FEMA (Hollis), DHS (Inzer), USDA (Ferezan), HHS (Willis) and DOE (Jackson).

• * * UPDATE FROM DON TAYLOR TO DONALD NORWOOD AT 1405 EDT ON 8/26/11 * * *

This notification is to report new information identified post event that a condition existed which met the emergency plan criteria but was not declared. On August 23 at 1403 EDT, North Anna Power Station declared an Alert due to seismic activity onsite. The Alert was declared under Emergency Action Level (EAL) HA6.1 "Other conditions existing which in the judgment of the SM warrant declaration of an alert. Initial review of seismic response data from the earthquake on 8/23/11 (1348 hours) indicates that design spectrum input assumptions (i.e. Design Basis Earthquake (DBE) limits) may have been exceeded above 5 HZ. This would have resulted in classification of an Alert under EAL HA1.1. No significant equipment damage to safety related systems (including class I structures) has been identified through site walk-downs nor has equipment degradation been detected through plant performance and surveillance testing following the earthquake. The licensee notified the NRC Resident Inspector. The licensee also plans on notifying the State Emergency Operations Center and the Louisa County County Administrator. Notified R2DO (Widmann) and NRR EO (Bahadur).

The following information was obtained from the State of California via email: At 0530 PDT on 8/6/2011, a Model 4640 Troxler material density gauge belonging to Pavement Engineering of Redding, CA was lost at a construction site between McAllen Road and Olivehurst on Highway 70 south of Yuba City, CA. The operator set the gauge down by the side of the road and returned to find it missing. It was reported missing at 1105 PDT on 8/6/2011 to the California Emergency Management Agency who contacted the California Department of Public Health, Radiological Health Branch (RHB) at 1126 PDT. Sutter County Sheriff's office has responded and is investigating. Also contacted was Sutter County Fire Dept. A health physicist has been deployed from RHB to assist in the search with a variety of radiation survey instruments in case the gauge was misplaced by the side of the road. The gauge contains 9 mCi of Cs-137.

• * * UPDATE ON 08/06/2011 AT 1936 PDT FROM JOHN FASSELL (VIA EMAIL) TO ERIC SIMPSON * * *

A survey by RHB staff over 0.6 miles of highway margin assisted by licensee personnel failed to recover the gauge. A reward will be posted by the licensee. Notified R4DO (Hagar) and FSME EO (McKenney) via 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

At the request of NRC Region I, Camden-Clark Memorial Hospital reassessed records from a prostate radioactive seed implantation procedure that had been performed on February 25, 2011. The record review indicated that the patient had received roughly 80 percent of the prescribed dose. The effect on the patient has been minimal as the desired response was achieved. The long term effect will be under constant follow-up. The entire implant process will be reviewed with special attention to real time seed placement and subsequent thirty day image evaluation with respect to NRC regulatory guidelines. The attending physician, based on medical judgment, felt that notifying the patient would be harmful. The patient is under the care of oncologic physicians and will be followed appropriately as per his disease type.

• * * UPDATE AT 1636 EST ON 12/03/12 FROM DAN BERKLEY TO S. SANDIN * * *

The licensee is updating the report with the following information: That (1) the dose received by the target was less than 80% of the prescribed dose and (2) a small volume of tissue outside of, and adjacent to, the treatment site received a dose that was greater than 10 Gy and more than 50% greater than the prescribed dose to that location." The licensee discussed this update with R1 (Weidner). Notified R1DO (Jackson) and FSME Events Resource via 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.

A Troxler moisture density gauge being used at Fort Meade (Maryland) was found to be stolen along with other industrial equipment at 1400 on 12/2/10. The Troxler gauge was last seen on Monday afternoon, 11/29/10, when it was secured in a temporary storage location inside a lock-box and chained to a sea container. Other items stolen included crane mats, a generator and miscellaneous tools. The nuclear gauge is a Troxler Model 3430, S/N 37672, which contains two radioactive sources. One source is 44 mCi of Am-241/Be (S/N 78-2430). The other source is 9 mCi of Cs-137 (S/N 77-4907). The licensee will notify base police to begin an investigation into the theft. The licensee has notified the State of Maryland of the theft.

• * * UPDATE FROM DREW THOMAS TO JOE O'HARA AT 0948 ON 12/14/10 * * *

On 12/10/10, FT. Meade U.S. Army base police officers informed the licensee that the stolen container had been "dumped" back onto the jobsite. The licensee responded to the site and discovered the missing gauge inside the container. The source was in the locked and shielded position inside the gauge and the gauge doesn't appear to have been damaged. The gauge has been recovered and is now in the custody of the licensee. A leak test of the gauge is scheduled to be performed. Notified R1DO(Holody), FSME(Reis) and ILTAB. 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

Oyster Creek has declared an Unusual Event (MU7) due to Reactor Coolant System leakage greater than 10 gpm. Leakage has been determined to be from the 'B' reactor recirculation pump seals. The 'B' Reactor Recirculation Loop was isolated and leakage stopped. The plant remained in the normal electrical lineup and no safety systems actuated during this evolution. The licensee notified the NRC Resident Inspector.

• * * UPDATE FROM ERIC SWAIN TO ERIC SIMPSON AT 1548 ON 12/1/10 * * *

At 1537 EST, "Oyster Creek has terminated from an Unusual Event. Event terminated due to isolating leakage from the 'B' Reactor Coolant Loop. The licensee notified the NRC Resident Inspector. Notified R1DO (Schmidt), IRD (Gott), NRR EO (Nelson), DHS and FEMA.

On 10/22/10, at 1058 EDT, a troubleshooting of Independent Spent Fuel Storage Installation (ISFSI) Cask TN-50-A indicated that a leak existed in the cask lid sealing area at a rate greater than allowed by ISFSI Cask Technical Specification (TS) Section 3.1.3, Cask Helium Leak Rate. TS 3.1.3 limits the Cask Helium Leak Rate to 1.0 E-05 ref-cc/sec. The cask is currently in unloading operations and is located within the Peach Bottom Atomic Power Station Unit 3 containment building. Preliminary review indicates that a leak exists at the weld plug that provides sealing of the drilled interseal passageway associated with the drain port penetration of the cask lid. This leak effectively provides a bypass of the main lid outer confinement seal. This report if being submitted pursuant to 10CFR72.75(c)(1) as a result of a material defect in a weld in the cask main lid. This report is also being submitted pursuant to 10CFR72.75 (c) (2) as a result of a resolution in the effectiveness of the cask confinement system. The Certificate of Compliance for this cask is 1027 (Amendment 1). The NRC Resident Inspector has been informed of this notification.

• * * UPDATE AT 1515 EDT ON 10/27/10 FROM JEREMY HITE TO DONG PARK * * *

On 10/27/10, at 1107 (EDT), troubleshooting of Independent Spent Fuel Storage Installation (ISFSI) Cask TN-68-01 identified that a helium leak exists in the cask lid sealing area at a leak rate greater than allowed by ISFSI Cask Technical Specification Section 3.1.3, Cask Helium Leak Rate. TS 3.1.3 limits the Cask Helium Leak Rate to 1.0 E-O5 ref-cc/sec. The cask was in LOADING OPERATIONS and is currently located within the (Peach Bottom Atomic Power Station) PBAPS Unit 2 containment building. Preliminary review indicates that a leak exists in the Cask Main Lid Outer Closure Seal. The cask will be repaired and tested prior to returning the cask to the Independent Spent Fuel Storage Installation (ISFSI). No release of radiation occurred as a result of this issue. This report is being submitted pursuant to 10CFR 72.75(c)(2) as a result of a reduction in the effectiveness of the cask confinement system. The Certificate of Compliance for this cask is 1027 (Amendment 0). The NRC Resident Inspector has been informed. Notified R1DO (Caruso), NRR EO (Thorp), NMSS EO (Lorson), and IRD (Grant).