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 Entered dateEvent description
ENS 5698321 February 2024 10:33:00The following is a synopsis of information that was provided by the licensee via email and phone call: A non-licensed supervisor had a confirmed positive during a fitness for duty test. The supervisor's access to the plant has been terminated.
ENS 5697819 February 2024 06:32:00The following information was provided by the licensee via phone and email: On February 19, 2024, at 0236 EST, with VC Summer Unit 1 in Mode 1 at 100 percent power, an actuation of the `B' emergency diesel generator (EDG) occurred. The reason for the `B' EDG auto-start was the trip of 1 `DB' normal incoming breaker. The `B' EDG automatically started as designed when the undervoltage signal was received. The `B' emergency feedwater pump started due to the undervoltage signal and ran for approximately 1 minute and was secured by operations per procedure. Other plant equipment and systems also responded as expected. 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 `B' EDG and a valid actuation of the `B' emergency feedwater pump. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The `A' Emergency Diesel Generator was tagged out for maintenance earlier in the shift, but maintenance has not started. The plan is to restore the `A' emergency diesel generator to an operable status and investigate the cause of the 1 `DB' normal incoming breaker trip. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: This event resulted in the plant entering a 12 hour limiting condition for operation (LCO) in accordance with technical specification (TS) 3.8.1.1.C. due to having one operable EDG and a loss of offsite power.
ENS 5697719 February 2024 03:34:00The following information was provided by the licensee via phone and email: At approximately 2325 EST on February 18, 2024, with Unit 1 in Mode 5 at 0 percent power and Unit 2 in Mode 1 at 100 percent power, emergency diesel generator 2 automatically started due to the unexpected loss of AC power to emergency bus E2 during a planned transfer of E2 DC control power from normal to alternate for the 1B-1 battery. In addition, the unexpected loss of AC power to E2 resulted in Unit 1 primary containment isolation system (PCIS) partial Group 2 (i.e., drywell equipment and floor drain, residual heat removal (RHR), discharge to radioactive waste, and RHR process sample), Group 6 (i.e., containment atmosphere control/dilution, containment atmosphere monitoring, and post accident sampling systems), and partial Group 10 (i.e., air isolation to the drywell) isolations. Emergency diesel generator 2 automatically started and re-energized the E2 bus as designed when the loss of E2 signal was received. The PCIS actuations were as expected for the outage plant line up on Unit 1 at the time. The cause of the loss of electrical power to emergency bus E2 is under investigation at this time. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency diesel generator 2 and PCIS. 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: This event will be entered into the plant's corrective action program.
ENS 5693123 January 2024 18:07:00The following information was provided by the Louisiana Department of Environmental Quality (LDEQ) via email: On January 22, 2024, at approximately 1400, Central Standard Time (CST), an unidentified nuclear gauge of roughly cylindrical dimensions and less than 30 cm in length and 12 cm in width was detected by the entrance gate radiation monitor at the Louisiana Scrap Metal facility (LA Scrap) located in Gibson, LA in Terrebonne Parish. Facility scrap surveyors were immediately dispatched to more close survey the suspected gauge using Ludlum Model 3 survey instruments with external probes. During this time an additional suspected nuclear gauge, similar in design and overall dimensions to the first, was discovered by the facility's scrap surveyors. Surface radiation readings of approximately 0.9 to 1.2 mR/hr were observed at the surface of both devices. No identifying markings, labels or tags were noted on the gauges' surfaces, and both devices appeared to have sustained significant corrosion to their housings, which nonetheless appeared intact. The devices were believed by the reporting party to have originated with scrap from the disassembly of a 220-foot marine vessel purchased by LA Scrap from a Florida scrap broker. The above incident was reported via the LDEQ Radiation Hotline at approximately 1335 CST on January 23, 2024. The facility is awaiting identification of the devices' isotope(s) (to be provided by the LDEQ) prior to contracting with BBP Sales, Louisiana Radioactive Material License, LA-10799-L01, for inspection, leak testing, packaging, and disposal of the devices. The facility environmental health and safety (EHS) manager, stated that the gauges have been enclosed in a bucket of moist dirt and secured within an area on site with restricted access. Facility workers were advised by the EHS manager to stay clear of the area in the meantime. LA Event Report ID: LA240002
ENS 5692614 January 2024 19:21:00The following information was provided by the Louisiana Department of Environmental Quality (LA DEQ) via email: This medical event was reported (to the LA DEQ) on January 13, 2024, at 2259 (CST). On January 12, 2024, the licensee was performing a Y-90 brachytherapy medical procedure. A tubing failure (catheter) resulted in an incomplete dosing of the patient. The catheter became blocked up with the undelivered radiopharmaceutical Y-90. The Y-90 was contained within the administrating device's tubing. There was no spill involved. The Y-90 being used was TheraSphere from Boston Scientific. Approximately 23 percent of the radiopharmaceutical Y-90 was delivered to the patient. No effect on the individual was determined. The remainder of the prescribed dose will be administered to the patient at a later date. LA DEQ Event Report ID: LA20240001 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 5692412 January 2024 14:28:00The following information was provided by the Minnesota Department of Health (MDH) via email: The MDH was notified on 1/12/2024, by PPL Group LLC, a representative for ERP Iron Ore, LLC Plant 2, of a missing/lost fixed gauge from the licensee's location listed above. PPL Group LLC contracted a waste broker to dispose of the registered generally licensed devices located at the plant. The completed inventory indicates that one device is missing. The missing device is a Berthold model LB74400-CR, serial number 0240/12 containing a 50 mCi Cs-137 source (assay date of 3/20/2014). MDH will do an inspection next week and will continue to keep the NRC informed of the status of our investigation. 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 569145 January 2024 15:56:00The following information was provided by the licensee via phone and email: At 1552 (EST) on 01/05/2024, Perry Nuclear Power Plant reported elevated levels of tritium in the underdrain system to the state of Ohio as a non-voluntary reporting of tritium. An investigation is currently ongoing to identify the cause of the elevated tritium levels. The tritium levels in this location do not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a notification of other 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 569155 January 2024 18:18:00

The following information was provided by the licensee via phone and email: At approximately 1111 EST on 01/05/2024, a mechanical penetration room door was discovered unlatched. Based on security badge history, the door was last opened at 1040 EST. The unlatched door resulted in both trains of the station emergency ventilation system being inoperable due to being unable to maintain the shield building negative pressure area. With both trains simultaneously inoperable, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The door was closed and verified latched upon discovery to restore the systems to an operable status. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

  • * * RETRACTION ON 1/17/24 AT 1400 EST FROM CHRIS HOTZ TO ADAM KOZIOL * * *

The station emergency ventilation system (EVS) was tested with the mechanical penetration room door unlatched. The test results showed that the station EVS attained the required negative pressure in the shield building within the time required by the Technical Specifications. Therefore, the station EVS remained operable with the door unlatched, and this issue did not prevent the system from fulfilling its safety function to control the release of radioactive material and mitigate the consequences of an accident. The NRC Resident Inspector has been notified. Notified R3DO (Orlikowski)

ENS 5698722 February 2024 08:55:00The following information was provided by the licensee via phone and email: This 60-day optional telephone notification is being made in lieu of a Licensee Event Report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). At approximately 2333 EST on January 1, 2024, an invalid actuation of group 6 primary containment isolation valves (PCIVs) (i.e., containment atmospheric control/monitoring (CAC/CAM) and post-accident sampling system (PASS) isolation valves) occurred. Reactor building ventilation isolated and standby gas treatment started per design. No manipulations associated with the isolation or reset logic were ongoing at the time. Troubleshooting determined that the group 6 isolation signal resulted from spurious relay contact actuation in the main stack radiation high-high isolation logic due to relay contact oxidation. The main stack radiation monitor is a shared component that sends isolation signals to Unit 1 and Unit 2. There were no Unit 1 actuations. Only the relay contacts associated with Unit 2 actuated. The relay has been replaced. The actuation was not initiated in response to actual plant conditions. It was not an intentional manual initiation and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation. During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public. The NRC Resident Inspector had been notified.
ENS 5698822 February 2024 08:55:00The following information was provided by the licensee via phone and email: This 60-day optional telephone notification is being made in lieu of a Licensee Event Report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). At approximately 0815 EST on December 28, 2023, an invalid actuation of the four emergency diesel generators (EDGs) occurred. It was determined that this condition was likely caused by spurious operation of the undervoltage relay for the startup auxiliary transformer feeder breaker to the `1D' balance of plant bus which was being fed by the unit auxiliary transformer at the time, per the normal lineup. This non-safety related EDG actuation logic was disabled, and additional investigation is planned during the upcoming refueling outage. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation. During this event, the four EDGs functioned successfully, and the actuations were complete. All emergency buses remained energized from offsite power and, therefore, the EDGs did not tie to their respective buses. This event did not result in any adverse impact to the health and safety of the public. The NRC Resident Inspector had been notified.
ENS 5690822 December 2023 20:11:00The following information was provided by the California Department of Public Health, Radiation Health Branch (RHB) via email: On 12/22/2023, the (University of California, San Francisco) notified RHB that a shipment of F-18 radioactive materials received from SOFIE CO FKA ZEVACOR PHARMA (license number: CA-RML 7131-43) was contaminated. The licensee reported that their contamination wipe tests ranged from 65,000 counts per minute (cpm) to over 100,000 cpm per 300-centimeter squared wipe area using a wipe counter with an efficiency of 25 percent. This amount exceeds the non-fixed radioactive contamination limits specified in Department of Transportation regulations 49 CFR 173.443 of 240 cpm per cm squared for beta and gamma emitters and is reportable under 10 CFR 20.1906(d)(1). RHB is in contact with SOFIE and will be investigating this matter further.
ENS 5688713 December 2023 05:50:00The following information was provided by the licensee via phone and email: At 0102 CST, while operating at 100 percent (reactor) power, River Bend Station experienced an automatic reactor scram caused by a turbine trip signal. The cause of the turbine trip signal is not known at this time and is being investigated. At 0108, reactor core isolation cooling (RCIC) was initiated due to a loss of reactor feed pumps following feedwater heater string isolation. At 0114, reactor water level control was transferred back to feedwater and RCIC was secured. Reactor water level is being maintained by feedwater pumps and reactor pressure is being maintained by turbine bypass valves. The scram was uncomplicated and all other plant systems responded as designed. 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 expected post scram (reactor water) level 3 isolations and manual initiation of RCIC. No radiological releases have occurred due to this event from the unit. The NRC Senior Resident Inspector has been notified of this event. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The cause of the turbine trip, while still under investigation, was likely due to an electrical transient involving the main generator. Walkdowns in the switchyard post-scram identified damage to one of the output breaker disconnects.
ENS 5688813 December 2023 09:45:00The following information is a synopsis of information provided by the licensee via phone and email: On December 11, 2023, Tennessee Valley Authority Sequoyah Nuclear Plant completed an internal 10 CFR Part 21 evaluation concerning Siemens 6.9kV, 1200A vacuum circuit breakers, Model No. 7-HKR-50-1200-130. Three separate breakers were found with issues including loose wires terminated incorrectly and the mechanism-operated control switch clevis pin missing a cotter key. Additionally, the mastic insulating pads were found defective on all three lower primaries by way of separation. The affected breakers were never installed in a safety related application. The NRC Resident Inspector will be notified. A written notification will be provided within 30 days. The manufacturer, Siemens, was notified of the defects. The only plant known to be affected at the time of the report is the Sequoyah Nuclear Plant.
ENS 568807 December 2023 14:36:00

The following information was provided by the Texas Department of State Health Services (the Department) via email: On December 7, 2023, the Department was notified by a Texas licensee's radiation safety officer (RSO) that while testing an MDS Nordion, Model Eldorado 8, teletherapy unit, the 1,817 curie cobalt-60 source became stuck in the unshielded position. The RSO stated that the room was isolated and dose rates taken outside the room did not create an exposure risk to any individual. The RSO stated that a service contractor would likely repair the unit on December 9, 2023. Access to the room was posted to prevent inadvertent entry into the room. An update will be provided when the source is returned to the shielded position and then further information will be provided per SA-300. Texas Incident Number: I-10070 NMED Number: TX230056

  • * * UPDATE ON 12/9/23 AT 1137 EST FROM RANDELL REDD TO KAREN COTTON * * *

On December 9, 2023, the Department was notified that the cobalt-60 source had been returned to the shielded position by the licensed servicing company. The technician who returned the source received around 0.3 millirem. The source activity is likely around 1,000 curies and not 1,817 curies, as originally reported. The Department will wait for the licensee and service company reports for information regarding the cause of the incident and report this to NMED per SA-300. Notified R4DO (Dixon) and NMSS Events Notification via email.

ENS 568795 December 2023 20:37:00The following information was provided by the The Washington State Department of Health via email: The shutter on a fixed nuclear gauge (a Vega Americas Corp. Model No. SH-F1 gauge containing 53 millicuries of Cs-137) was unable to be closed when licensee staff attempted to lock it out. Licensee staff consulted with the manufacturer and, per the manufacturer's recommendation, installed four inches of steel plates in front of the fixed nuclear gauge to shield it. After installation of the steel plates, radiation levels were 0.2 mR/hour. The licensee is planning to replace the entire fixed nuclear gauge, per the manufacturer's recommendation, as the manufacturer has previously replaced the shutter on this gauge. The steel plates will remain installed until the fixed nuclear gauge is replaced. The Washington State Department of Health will gather additional information about this event and will submit an updated event report. An investigation may be conducted. WA Event Number: WA-23-031
ENS 568784 December 2023 19:01:00The following information was provided by the licensee via phone and email: (The following is a report of) reactor safety system component malfunction under Missouri University of Science and Technology Reactor (MSTR) Technical Specification (TS) 6.7.2.c)iii) At 1124 (CST), on December 1, 2023, with the MSTR at 180 kW, a `150 Percent Full Power' scram signal was received from one safety amplifier, and the reactor scrammed automatically. Based upon other nuclear instrumentation, at no point was reactor power at, above, or near the MSTR 300-kW Limiting Safety System Setting (LSSS), nor was any transient underway that could have yielded such a situation. Power was within the 2 percent automatic control setpoint window of 180 kW, and power dropped rapidly as expected following a scram. At the time of the event, the console operator observed that the affected safety amplifier went blank, and following an approximate 0.5 second delay, returned to a normal status tracking the decay power with a scram indicator illuminated. At no point was the health and safety of the public or MSTR in doubt. Due to ongoing reviews and replacement component sourcing, the MSTR has not operated since the event. Per MSTR TS 6.7.2.c)iii), `(the license shall make a report for) a reactor safety system component malfunction that renders or could render the reactor safety system incapable of performing its intended safety function unless the malfunction or condition is discovered during maintenance tests or periods of reactor shutdowns.' Following a thorough review of the scram logic and documented failure modes and effects analysis (FMEA) provided in the system's `Operation and Maintenance Manual' (Imaging & Sensing Technology Report 021-2103, Rev. 00), in the MSTR's opinion, the safety system malfunctioned but was able to complete its safety function. The event is being reported pending further review by facility staff and discussions with Nuclear Regulatory Commission facility project management. This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day. Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. Additional replacement parts will need to be secured and repairs performed to restore operability. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: This event has been entered into the licensee's corrective action program.
ENS 5686821 November 2023 21:20:00

The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 21, 2023, the licensee's radiation safety officer (RSO) advised the Department that one of its technicians had lost a Humboldt 5001EZ moisture density gauge (which contains a nominal activity of 40 mCi of Am-241:Be and 10 mCi of Cs-137). The technician had finished testing at a temporary job site and then took a phone call. After completing the call, he left the job site with the moisture density gauge sitting on the tailgate. When he realized what had happened, he called the project supervisor who sent workers out to search the testing area and surrounding areas. The technician notified the RSO and started driving back to the site while looking for the gauge. The RSO sent more technicians out to assist in the search and he also notified the local police department. The RSO reported the trigger lock was not on the insertion rod and it was only the gauge that was lost. It was not inside the transport case at the time. Search of the driving route will resume after daylight and the RSO will be checking with other construction workers at this and nearby sites. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: 10069 Texas NMED Number: TX230054

  • * * UPDATE ON JANUARY 29, 2024, AT 1842 EST FROM KAREN BLANCHARD TO KAREN COTTON * * *

The following updated information was provided by the Texas Department of State Health Services (the Department) via email: On January 22, 2024, the Department received information from a steel mill in Texas that it had discovered a radioactive source in a load of scrap metal from San Antonio. The investigation revealed the source to be the 40 millicurie Americium-241 source from the licensee's lost device. The source was still in its holder and secured to the device's structure, on which the device serial number was stamped. The cover, electronics, and the Cesium-137 source and source rod were not attached or located. The load of scrap the mill found the source in has been fully processed and none of their other radiation detectors indicated the presence of the Cesium source. The scrap yard is surveying the areas at their facility. The steel mill noted radiation readings of 400 microR/hr on contact. They have secured the source at their facility and the licensee is making arrangements for retrieval/disposal of it. There is no information or indication of any exposure exceeding regulatory limits. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Agrawal), NMSS Events Notification (Email), ILTAB (Email), CNSNS (Mexico). 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 5687122 November 2023 16:41:00

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On November 22, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN (common carrier) hub where it was scanned on November 21, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 10 milli-Liters shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.56 millicuries. It was offered for shipment on November 17, 2023, for delivery to a customer in Ontario, Canada on November 20, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Tennessee program officials were notified, and the matter was reported to the HOO (NRC Headquarters Operations Officer). This report will be updated with any available information. Illinois Item Number: IL230033

  • * * UPDATE ON 12/5/23 AT 1650 EST FROM GARY FORSEE TO ADAM KOZIOL * * *

On 12/5/23, the licensee advised that the package was delivered undamaged to the client site. This matter is considered closed. Notified R1DO (Werkheiser), R3DO (Szwarc), NMSS and ILTAB (email) THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5686620 November 2023 17:53:00The following information was provided by the licensee via email: At 0956 (CST) on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period. 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 licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.
ENS 5685314 November 2023 16:54:00The following information was provided by the Florida Department of Health via email: On 11/14/2023, a patient arrived in the nuclear medicine department for administration of their fourth cycle of Lutathera, a Lu-177 labeled radiopharmaceutical. The standard prescription of Lutathera for patients is 200 mCi in accordance with manufacturer's instructions for use and industry standard. The technologist assayed the vial and went through pre-administration procedures including a pre-treatment time out. 202 mCi of Lutathera was administered via IV in the right upper forearm over the course of thirty minutes. Start time of 1211 (EST) with an end time of 1241. Upon completion of the procedure, the technologist noticed that the patient had been prescribed a reduced activity of 150 mCi as opposed to the standard prescription of 200 mCi. Realizing this was a medical event, the technologist notified the radiation safety officer (RSO) at approximately 1330. The technologist also informed the nuclear medicine department supervisor. The RSO proceeded to inform the Authorized User (AU)/prescribing physician. The AU spoke with the patient explaining that the activity administered exceeded the prescribed amount. The physician explained that he did not expect any adverse effects from the higher than prescribed activity as the patient had received the standard activity of 200 mCi. The reduced activity of 150 mCi had been decided by the prescribing physician due to borderline renal function and the patient had tolerated all previous three administrations. Since the patient's renal function was not affected by the three previous administrations, the prescribing physician explained that the patient could have received the 200 mCi. The patient did not express concern upon being informed of this event. The AU also informed the referring physician. An initial report was made to (Florida) via telephone at 1529 in accordance with 64E-5.345(4)(a). Florida Incident Number: FL23-164 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 5685214 November 2023 14:36:00The following information was provided by the licensee via phone and email: At 1041 CST on 11/14/23 with Farley Unit 2 in Mode 1 at 10 percent power, the reactor was manually tripped due to rising steam generator levels. The trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Auxiliary feedwater (AFW) was manually initiated in accordance with plant procedures and is feeding the steam generators. Heat removal is being provided via the atmospheric relief valves. 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). This event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the auxiliary feedwater 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: All rods fully inserted. The licensee attempted to take manual control of the feedwater control valves to lower steam generator level but, due to reaching a steam generator level that requires a manual trip, the licensee manually tripped the reactor.
ENS 5685515 November 2023 16:40:00The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On November 15, 2023, the Department was notified by the licensee that a Troxler model 3440 moisture/density gauge had been lost. The gauge contains one 8 millicurie Cs-137 source and one 40 millicurie Am-241 source. The radiation safety officer (RSO) stated that on November 14, 2023, a licensee technician was performing work at a temporary job site where testing was being performed periodically. While sitting in their truck with the gauge on the tailgate of the truck, the technician realized they needed to go to a second job site about 20 minutes from where he was. When they reached the second job site, the technician realized they had left the gauge on the tailgate. The technician notified the licensee's RSO and the licensee conducted multiple searches for the gauge but did not locate the gauge. The RSO was advised to contact local law enforcement about the event. The RSO was advised to check local pawn shops and internet sites such as eBay and Craig's List to watch for the gauge. The RSO does not believe the gauge possesses an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10066 NMED Number: TX230052 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 5685415 November 2023 14:19:00The following information was provided by the Wisconsin Department of Health Services (the Department) email: On Wednesday, November 8, 2023, the licensee was treating an individual in their high dose rate (HDR) suite. During the treatment, while the Ir-192 source was exposed, it was noticed that the door to the suite was ajar. The treatment was immediately paused, and the physicist confirmed that the door was open and that the door interlock was not functioning as required. The staff closed the door, put up caution tape, and maintained constant visual surveillance to ensure no one entered. Treatment was reinitiated and completed according to the written directive. On Friday, November 10, 2023, the interlock had not yet been repaired, and the licensee performed another HDR treatment utilizing caution tape and constant surveillance. The licensee reported the event to the Department by phone on November 14, 2023. The licensee performed an event reconstruction and surveyed at the open door with the Ir-192 source exposed. The highest dose rate of 0.3 mR/hr indicates that no member of the public would have received a dose exceeding public dose limits from this event. The patients were unaffected. The Department will be performing a reactive inspection on November 20, 2023. WI Event Report ID Number: WI230022
ENS 568334 November 2023 23:16:00

The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 4, 2023, the Department was notified by the licensee that one of its technicians had lost a Troxler 3430 moisture/density gauge. The gauge contains one 40 millicurie Am-241 source and one 8 millicurie Cs-137 source. The licensee reported that a technician was waiting in their truck to perform a test at a temporary job site when they were told by the job supervisor that the work was done for the day. The technician drove home and when they reached their home, realized they had left the gauge, which was inside its transportation box, sitting on the tailgate of the truck and it was now missing. The licensee did not know if the cesium source rod or transport case was locked. The technician retraced their route twice, but it was already dark, and they did not see the gauge. The technician notified his radiation safety officer that they had lost the gauge. The licensee will notify local law enforcement of the event. The licensee stated they will begin searching for the gauge as soon as it is light out. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-10064 Texas NMED Number: TX230050

  • * * UPDATE ON 11/5/2023 AT 1052 EST FROM ART TUCKER TO ERNEST WEST * * *

On November 5, 2023, the Department contacted the licensee and requested the status of the gauge. The licensee stated that they had performed additional searches for the gauge this morning but did not find the gauge. The licensee stated they had contacted the Harris County, Texas, Sheriff's Department. The licensee stated they would offer a reward for the gauges return. The licensee was advised to contact local pawn shops and watch social media platforms like eBay and Craig's List. The licensee was advised to contact local fire departments about the gauge and provide its contact information. The licensee stated the gauge was labeled with its contact information. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Roldan-Otero), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email

  • * * UPDATE ON 1/6/2024 AT 1129 EST FROM ART TUCKER TO ERNEST WEST * * *

On January 4, 2024, the Department was notified by the licensee that a Troxler gauge identical to the one they had lost was on the Facebook Marketplace website. The Department contacted the Federal Bureau of Investigation Special Agent (FBISA) it has worked with previously and shared the information. On January 5, 2024, the FBISA worked with the licensee and was able to set up a meeting with the seller and was able to recover the gauge. (The FBISA confirmed by serial number it was the gauge that was stolen). The licensee returned the gauge to its secured storage location and will perform radiation and leak test on the gauge. The individual who had the gauge stated they did not know it contained radioactive material. They also stated they never manipulated the source rod. Additional information will be provided as it is received in accordance with SA300. Notified R4DO (Drake), NMSS Events Notification, ILTAB, and CNSNS (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

ENS 5685113 November 2023 15:13:00The following information was provided by the licensee via phone and email: Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report: On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter. On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, (November 13, 2023).
ENS 568367 November 2023 10:16:00The following is a synopsis of information provided by the Colorado Department of Public Health and Environment via email: On 10/30/23, the licensee discovered that 11 tritium exit signs were not able to be located. The exit signs were SRB Technologies (model number BX-10-BK) signs each containing 10 Ci of tritium (H-3). This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)). Event Report ID No.: CO230040 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 5681725 October 2023 17:38:00The following information was provided by the Tennessee Division of Radiological Health via email: During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was a normal operating position. A VEGA field technician has been scheduled to arrive onsite on November 7, 2023, to service the gauge. Manufacturer: Ohmart/VEGA Source holder model: SHLM-CR Source serial number: 4259CO Isotope: Cs-137, 37 mCi Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days. Tennessee Event Report ID Number: TN-23-079
ENS 5690722 December 2023 13:39:00The following is a synopsis of information received via facsimile: Valcor Engineering Corporation (VEC) identified a defect with Valcor solenoid valves with part number V52600-5890-1 on October 23, 2023. The defect identified is that stroke matching of internal components was not performed in accordance with internal procedures causing valve flow coefficient (Cv) to be only approximately 50 percent of the minimum required Cv of 2. Substantial safety hazard could be created if the flow rate through the solenoid valve exceeded a certain threshold. VEC has identified two of these solenoid valves at LaSalle County Nuclear Generating Station (LaSalle) with serial numbers 33 and 34. For corrective actions, VEC repaired and returned the valve with serial number 34 to LaSalle. To prevent recurrence, VEC intends to improve the training program for production personnel and, if needed, review and revise the stroke matching procedure including enhancing quality assurance oversight of that process. VEC estimates it will take 30 days to complete corrective actions. Currently, LaSalle is the only known affected facility. Valcor is in the process of identifying and notifying affected customers. For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223), email: mikeswirad@valcor.com
ENS 5681625 October 2023 16:16:00

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email: KY RHB was notified on 10/25/23 by the radiation safety officer (RSO) of University of Kentucky (UK) Broad Scope medical license, of an incident which occurred at the UK Chandler Medical Center on October 23, 2023. (The UK) RSO reports, 'During a high dose rate (HDR) treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user (AU) directed that the transfer tubing be replaced and treatment completed. The tubing used to complete the cycle was not the correct length, resulting in approximately 10 seconds of source exposure at the wrong dwell position(s). The source was outside of the body during this exposure period, therefore, there is uncertainty in the dose estimates to patient skin. Likely exposure in the treatment position (legs apart) is likely below the reporting thresholds in 10 CFR 35, while conservative estimates (assuming patient's legs were closed) lead to doses above reporting thresholds. Since the exact positioning is indeterminant, the licensee did not report a dose from this incident at this time. Upper bound worse case estimates place the skin dose below the level where patient harm is expected by the treating oncologist and no changes in plan of care are anticipated from this event. This incident remains under investigation.' RHB is following up with the RSO for additional information not included in the initial report. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The intended organ to be dosed was the cervix/uterus. Dose estimates were not available at the time the report was received from KY RHB.

  • * * UPDATE ON 12/6/2023 AT 1904 EST FROM RUSSELL HESTAND TO ERNEST WEST * * *

On 10/25/2023 the University of Kentucky (UK) reported a possible dose misadministration that occurred at the UK Chandler Medical Center on 10/23/2023. During a high dose rate (HDR) cervix/uterus treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user directed that the transfer tubing be replaced, and treatment completed. The tubing used to complete the cycle was not cut to the correct length. This resulted in the source being 12cm out of position for the 10 seconds remaining in the planned treatment. The source was outside of the patient's body during that exposure period, causing a potential radiation exposure to the skin of the thigh in excess of reporting requirements. The worst-case assessment assumes that the patient's thigh was in direct contact with the applicator for the full 10 seconds, resulting in a localized skin dose of 300 cGy. In the judgment of treating physician, the dose is below the level likely to cause injury. However, the dose is above the reporting threshold for a Medical Event. In the most likely scenario, the patient's thigh was at least 8 mm away, resulting in a significantly lower dose of less than 50 cGy. The patient and referring physician were informed in a timely manner. Corrective Actions: 1) A leak mitigation countermeasure is being trialed in an effort to prevent fluid from leaking down the catheter and potentially causing this issue in the future. 2) Current procedures are very specific about verification of transfer catheter length before starting a treatment. However, they have not until now directly addressed a process for interruption of a procedure to make adjustments to the patient set up. These procedures have been updated and training / education is being performed on the updated processes. Based on the investigation by the (Kentucky Department for Public Health and Safety) Radiation Health Branch in collaboration with the University of Kentucky, we find the corrective actions to be sufficient and consider this incident closed. NMED Item Number: 230461 Notified R1DO (Werkheiser), NMSS Division Director (Williams), and NMSS Event Notifications (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.

ENS 5681122 October 2023 16:40:00The following information was provided by the licensee via fax and phone: On October 22, 2023, at 1149 CDT, with the reactor at 100 percent core thermal power and steady state conditions, the Cooper Nuclear Station secondary containment differential pressure exceeded the Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.1.1 limit of -0.25 inches water gauge. The condition existed for approximately 80 seconds until the reactor building ventilation system responded to restore differential pressure to normal. Investigations identified a hinged duct access hatch found open. The hatch was closed and latched, and ventilation system parameters were returned to normal. There were no radiological releases associated with this event. Declaring secondary containment inoperable as a result of not meeting TS SR 3.6.4.1.1 is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material and mitigate the consequences of an accident. The NRC Senior Resident Inspector has been informed. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: At the time the licensee notified the NRC Headquarters Operations Officer, the cause of the hinged access duct being open had not been determined. This event has been added to the licensee's corrective action program.
ENS 5680319 October 2023 15:15:00

The following information was provided by the licensee via email: On 10/19/2023, at approximately 1110 (CST), with Unit 1 in mode 1 at 100 percent power, the reactor automatically tripped. All control rods fully inserted into the core following the trip. All safety functions operated as designed. The cause of the trip is being investigated. Operations responded and stabilized the plant. Auxiliary feedwater actuated as expected. Decay heat is being removed by the steam generator through the steam generator power operated relief valve. The trip was complex as non-safety related power was lost to both Unit 1 and Unit 2. Unit 1 is currently in mode 3 and on natural recirculation as both reactor coolant pumps are without power. Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was lost for approximately 70 minutes. No impacts to the SFP temperature were observed. 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). Due to the actuation of the auxiliary feedwater system following the reactor trip, this event is being reported as a specified system actuation in accordance with the reporting criteria of 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.

  • * * UPDATE ON 10/19/2023 AT 1646 EDT FROM MARTIN CABIRO TO ERNEST WEST * * *

The second paragraph of the original report is amended as follows to correct information regarding the spent fuel pool for Unit 2: Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was maintained at all times with one train of SFP cooling. The second train lost power and was restarted approximately 70 minutes (after power was lost). No impacts to the SFP temperature were observed. Notified R3DO (Orth) and IR MOC (Crouch) and NRR EO (Felts) via email

ENS 5680419 October 2023 19:58:00The following information was provided by the licensee via phone and email: Reporting due to loss of emergency preparedness capabilities. Seismic monitoring capability is non-functional due to loss of power. These monitors do not have a credited compensatory measure. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The NRC Resident Inspector has been notified. The licensee intends to notify state and local officials.
ENS 5680117 October 2023 15:46:00The following is a synopsis of information provided by the licensee via phone and email: On 10/17/23 around 1100 CDT, the licensee received two packages each containing technetium-99m. Swipe readings on the packages revealed gross counts of 19158 disintegrations per minute (DPM) for the first package and 6874 DPM for the second package. The licensee's radiation safety officer (RSO) and the supplier, Cardinal Health, were notified. The inside of the package was also wipe tested and was not contaminated. The nuclear medicine department was surveyed, including the hot lab and department hallway and no additional contamination was found. The licensee has placed the two cases in short term storage and intends to send them back to Cardinal Health when they are at background. The licensee also called and left a message with NRC Region 3 personnel.
ENS 5678510 October 2023 00:38:00The following information was provided by the licensee via email: On October 9, 2023, during the Palo Verde Nuclear Generating Station Unit 1 refueling outage, while performing a small nozzle inspection in support of boric acid walkdowns, boric acid leakage was found on the area of the weld of a pressurizer thermowell. At 1507 MST, non-destructive examination of the weld indicated leakage through the reactor coolant pressure boundary. The exam result constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 567691 October 2023 03:02:00The following information was provided by the licensee via email: At 2014 (PDT) on 09/30/2023, with (Diablo Canyon) Unit 1 in Mode 1 at 11 percent reactor power in preparation for a pre-planned manual reactor trip into a scheduled refueling outage, the reactor was manually tripped due to a failed secondary system dump valve. Auxiliary feedwater was manually started in accordance with plant procedures. This event is being reported in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A). There was no plant or public safety impact. The NRC Senior Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Diablo Canyon Unit 2 was unaffected.
ENS 567702 October 2023 10:19:00The following information was provided by the Pennsylvania Bureau of Radiation Protection via email: On September 28, 2023, staff from Magee Pathology department called the (University of Pittsburgh) radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for (10 CFR) 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative. PA event report ID: PA230028
ENS 5676027 September 2023 18:23:00The following information was provided by the Utah Division of Waste Management and Radiation Control via email: At approximately 1400 (CDT) on September 27, 2023, a Troxler 3440 portable gauge (serial number 37345) was run over by a water truck. The Troxler 3440 gauge has an 8 mCi Cs-137 source and a 40 mCi (Am-241/Be) source. The Utah radiation safety officer inspected the gauge at the job site and determined that the sources appeared to be undamaged and remained in the shielded position. The licensee took the gauge to another Utah licensee, Construction Materials Technologies (doing business as Precision Calibration) (with license number) UT1800143, for evaluation and repair. Utah Event Report ID: UT23-0008
ENS 5676127 September 2023 18:40:00

The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email: On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 (CDT). The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to (Radiation Emergency Assistance Center/Training Site) (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant. An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 (CDT) to discuss a dose estimate as well as get a narrative. The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the (NRC) Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300. Texas Incident Number: I-10055 Texas NMED Number: TX230046

  • * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *

The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email: On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident. It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive. The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot. Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event. Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv). This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report. Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email.

ENS 5675624 September 2023 19:12:00The following information was provided by the Texas Department of State Health Services (the Department) via email: On September 24, 2023, the Department was notified by the licensee that during a maintenance inspection, the shutter on a Ronan Engineering nuclear gauge failed to close. The gauge contains a 500 millicurie Cs-137 source. Open is the normal operating position for the gauge. The licensee stated that due to the location of the gauge it is not an exposure risk to any individual. The licensee is posting a sign at the access port to the vessel the gauge is attached to stating `NO ENTRY.' Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-10054
ENS 5673513 September 2023 07:28:00The following information was provided by the Texas Department of State Health Services (the Department) via email: On July 13, 2023, the Department was contacted by the Biomeric's quality assurance scientist, who stated she could not find two generally licensed devices. The devices are P-2024-1000 static eliminators. The devices were used to remove static electricity on small plastic parts. The devices were discovered missing during an inventory of devices that were to be replaced. The company stated the devices did not pose a risk of exposure to any individual. The company searched for the devices, but was unable to locate them. The company has implemented a monthly inventory program to keep better track of the devices. The devices will be centrally located when in storage from now on. Texas Incident Number: 10039 Texas NMED Number: TX230034 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 567267 September 2023 17:40:00

The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email: On or about 1715 (EDT), 9/7/23, (the licensee's) Assistant Radiation Safety Officer (RSO) notified (the Bureau) of a missing soil moisture density gauge. Operator (deleted) believed the gauge to be absent due to the storage/transport box 'feeling light' when the box was moved at 1700 EDT. Sanford Police Department (PD) was notified by the licensee. (A Bureau investigator) was notified. The NRC was notified. Upon a subsequent thorough search of job site with Sanford PD, (the licensee) called the (Bureau's) duty officer at approximately 1800 EDT to report the gauge was located in the storage/transport box, which was within a locked and fenced area. Florida Incident Number: FL23-141

  • * * UPDATE ON 09/08/23 AT 0930 EDT FROM ROBERT LATHAM TO TOM HERRITY * * *

Just to clarify, I talked to the RSO this morning and he said the gauge user assumed the gauge was left at the job site that morning because when he got back to the office that evening to remove his samples, he had to move the gauge case and it felt light. It wasn't until they went back to the job site to meet with the PD that someone actually looked in the case and then realized the gauge was still in there. So the gauge was never out of their possession or control, they just assumed it was. I will be submitting an investigation and incident report, but not a radioactive material license inspection report since there was no violation for loss of control. Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.

  • * * RETRACTION ON 09/08/23 AT 1037 EDT FROM MONROE A. COOPER TO TOM HERRITY * * *

On 9/8/23, at 1026 EDT, the Bureau spoke with Tierra and it was explained that the gauge was misidentified as missing. This occurred because a user determined the Troxler case felt light, and reported the object missing without ensuring the gauge was not present. Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.

ENS 567236 September 2023 19:24:00The following information was provided by the licensee via email: On 09/06/2023, at approximately 0830 (CDT), a bottle of vanilla extract, intended for use in cooking, with an alcohol content of greater than 0.5 percent by volume was found in the protected area. An immediate extent-of-condition search of other kitchen areas within the protected area identified four additional bottles of vanilla extract or imitation vanilla extract, for a total of five bottles identified. The alcohol content by volume (ABV) of these extracts ranged from an unlisted percentage (with ethyl alcohol as a listed ingredient) up to 41 percent ABV. The volume capacities of the bottles ranged from 2 to 8 fluid ounces, with varying volumes of remaining contents.
ENS 567155 September 2023 17:22:00The following information was provided by the licensee via email: A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.
ENS 567206 September 2023 17:50:00

The following is a synopsis of information from Paragon Energy Solutions, LLC received via email. On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023. Point of Contact: Richard Knott Vice President Quality Assurance Paragon Energy Solutions LLC 817-284-0077 Affected plants: Beaver Valley Limerick North Anna Sequoyah Susquehanna

  • * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *

The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows: Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence. Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory. Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation. To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check. These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities. Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors

ENS 567091 September 2023 18:53:00The following information was provided by the Arizona Department of Health Services (the Department) via email: The Department was notified by the licensee that on September 1, 2023, a patient was prescribed 1,800 centigray in 3 fractions using a 2.5 cm diameter vaginal cylinder. After the start of the first fraction of the treatment, the patient notified the Authorized User and Authorized Medical Physicist that she thought the cylinder was in the `wrong place.' The treatment was stopped at 111 seconds into the treatment and the licensee discovered that the cylinder was placed into the rectum instead of the vagina. The treatment utilized a Varian GammaMedplus iX with an approximate 5.2 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event. 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 5681825 October 2023 20:24:00The following information was provided by the Washington State Department of Health via email: A positron emission tomography-computed tomography (PET/CT) unit with a Ge-68 sealed source (11 millicurie) was removed improperly from a medical facility in WA (Radia Imaging Center) and shipped to an unlicensed facility (MAK Heathcare in Woodstock, IL). Leak tests are in process to verify no spread of contamination. Currently, the plan is to ship the PET/CT scanner back to source manufacturer, Eckhert & Ziegler, in Burbank, CA on Friday, 10/27/2023. WA Incident Report Number: WA-23-028 See NRC Event Notification number 56814 for a parallel report made by Illinois. 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 5667611 August 2023 08:03:00The following information was provided by the licensee via phone and email: At 0329 (CDT) on August 11, 2023, with Unit 2 in Mode 1 at 90 percent power, the reactor automatically tripped due to a turbine trip. The trip was uncomplicated with all systems responding normally post-trip. The cause and details of the event are under investigation. Containment isolation valves actuated closed in multiple systems on a valid Group II signal. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B), and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group II isolation. Operations responded using the emergency operating procedure and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 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.
ENS 5667310 August 2023 04:03:00The following information was provided by the licensee via email: At 0039 (EDT) on 8/10/23, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped during a reactor protection system (RPS) bus shift. All systems responding normally post-trip. There was no equipment inoperable at the time of the trip. Operations responded and stabilized the plant. Reactor water level being maintained via feedwater. Decay heat is being removed by cycling safety relief valves. An actuation of high-pressure core spray, division 3 diesel generator, and reactor core isolation cooling occurred during the scram and main steam line isolation closure. The reason for the auto-start was reaching Level 2 (130 inches in the reactor pressure vessel) during the transient. The systems automatically started as designed and injected to the reactor vessel when the Level 2 signal was received. The RPS actuation is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The emergency core cooling system (ECCS) injection is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). The ECCS actuation is being reported as a eight-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 566604 August 2023 20:51:00The following information was provided by the licensee via phone and email: At 1746 EDT on 08/04/2023, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to number 2 steam generator low low level. The trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being removed by using the auxiliary feedwater and steam dump systems. Unit 1 is not affected. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72 (b)(3)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. All control rods are fully inserted. The cause of the number 2 steam generator low low level is being investigated.
ENS 566584 August 2023 15:30:00The following information was provided by the licensee via email: At 1320 (EDT) on 08/04/2023, with the Unit 3 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering level in the 3C steam generator. The trip was uncomplicated with all systems responding normally post-trip. Decay heat is being removed via the auxiliary feed water system and the atmospheric steam dumps. Unit 4 is not affected. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The cause of lowering level in the 3C steam generator was unknown at the time of the notification and will be investigated by the licensee.
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