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 Entered dateEvent description
ENS 5702613 March 2024 02:29:00

The following information was provided by the licensee via phone and email: On March 12, 2024, at 2111 EDT, a valid containment ventilation isolation train 'A' and 'B' signal was received due to a spurious loss of power to 1EMF-38 (containment particulate radiation monitor) and 1EMF-39 (containment gas radiation monitor). The power to 1EMF-38 and 1EMF-39 was restored. 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: There were no plant evolutions ongoing at the time of the event and the cause of the loss of power is under investigation. There was no impact to Unit 2.

  • * * RETRACTION ON 3/13/2024 AT 1436 EDT FROM JASON MOORE TO SAM COLVARD * * *

After further review of the event, it was determined the actuation of the associated containment ventilation isolation train 'A' and 'B' was not valid. This is due to the loss of power being associated with the control room modules for 1EMF-38 and 1EMF-39, and not a result of an actual sensed parameter or plant condition. Therefore, this event notification is being retracted. The NRC Resident Inspector has been notified. Notified R2DO (Miller)

ENS 5702713 March 2024 10:42:00The following information was received by the Minnesota Department of Health (MDH) via email: On March 12, 2024, at 1539 CDT, the licensee contacted MDH to report a gauge with a missing shutter. During their routine semiannual inventory and shutter check, the licensee discovered a Texas Nuclear model 5190 fixed gauge that was missing its shutter. The gauge contained a 100 mCi Cs-137 source (decayed to 35 mCi). The gauge was equipped with a removable shutter, and the licensee assumes that it had become loose and detached from the device due to normal operating vibration. The event was discovered at approximately 1420 on March 12, 2024. The licensee stated that they had a spare shutter and were able to install it on the gauge. The gauge was installed and operating when the missing shutter was discovered. Therefore, no abnormal radiation field or exposure occurred due to the missing shutter. At the time of the call, the licensee had not yet located the missing shutter. This gauge is used for density measurements on their tailings clarifier underflow pump. Minnesota State Event Report Number: MN240002
ENS 570137 March 2024 02:30:00The following information was provided by the licensee via email: On March 6, 2024, at 1635 PST, with Columbia Generating Station operating at 100 percent power in Mode 1, there was a malfunction in the halogenation/dehalogenation system. This system is used for continuous control of the biological growth in the circulating water and plant service water systems as well as to prevent discharge of halogens to the Columbia River during continuous blowdown. The result of this malfunction was exceeding the established limits of 0.1 milligrams/liter (mg/L) for total residual halogen (TRH) in the station's national pollutant discharge elimination system (NPDES) permit. At the time of discovery, the local indication for TRH was 3.20 mg/L. This was confirmed via a local grab sample. This maximum daily effluent limit is the highest allowable daily discharge, measured during a calendar day. The station NPDES permit requires notification to the Energy Facility Site Evaluation Council (EFSEC). The automatic isolation function of the system failed to isolate the continuous blowdown line as did the emergency trip push button. The system was manually secured, and the continuous blowdown line to the Columbia River was isolated. The cause of the issue is under investigation. Notification was made to EFSEC on March 6, 2024, at 2303 PST. This event is being reported as a four hour report made in accordance with 10 CFR 50.72(b)(2)(xi) due to a "News Release or Notification of Other Government Agency" related to protection of the environment. The NRC Senior Resident Inspector has been notified.
ENS 570116 March 2024 09:14:00The following information was received from the Georgia Radioactive Materials Program via email: The licensee reported on 3/5/24 about an incident at Piedmont Hospital with Y-90. They underdosed a patient when the catheter was put in the artery. There were vein convulsions which caused only about 30 percent of it to be administered. The licensee stated it did not cause stasis. A follow up with a report will be submitted to the Georgia Environmental Protection Division within 15 days. Georgia Incident Number: 79 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 5699124 February 2024 18:08:00The following information was provided by the licensee via email: At 1546 EST, with unit 2 at 100 percent power, the reactor was manually tripped due to the '22' steam generator feed pump tripping. The trip was uncomplicated with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Operations responded using emergency operation procedure EOP-0, Post Trip Immediate Actions and EOP-1, Uncomplicated Reactor Trip and stabilized the plant in mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected. ESFAS (engineered safety features actuation systems) actuation (auxiliary feedwater manual actuation) is reportable under 10 CFR 50.72(b)(3)(iv)(A) 8-hour report. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5697016 February 2024 02:05:00

The following information was provided by the licensee via email: At 2224 EST on February 15, 2024, with both units 1 and 2 in mode 1 at 100 percent power, an actuation of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The reason for the emergency diesel generator system auto-start was clearance removal sequencing errors. The emergency diesel generator system automatically started as designed when the common emergency start signal was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the emergency diesel generator system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

  • * * RETRACTION ON 2/21/2024 AT 1549 EST FROM TYSON JONES TO KAREN COTTON * * *

The following information was provided by the licensee via email: In accordance with NUREG-1022, Section 2.8 and Section 4.2.3, Watts Barr is retracting the previous report EN 56970 pursuant to 10 CFR 50.72(b)(3)(iv)(A). The start signal for the 1A-A, 1B-B, and 2B-B emergency diesel generators (EDG)s was from activation of the common emergency start of the 2A-A EDG. The actuation was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design safety function. The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system. Since the starts were not initiated via an automatic signal from a LOOP, SI, or traditional operator action, the signal is not a valid actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A). Therefore, EN 56970 is being retracted. The NRC Resident Inspector has been notified of this retraction. Notified R2DO (Miller)

ENS 569485 February 2024 20:26:00The following is a summary of information received from the Tennessee Division of Radiological Health via email: A fire on a truck involving a super sack containing low level waste consisting mostly of personal protective equipment and other small items occurred on Interstate 40 in Nashville. The licensee believes there may have been batteries in the sack that could have caused the fire. With the fire out there were no airborne or exposure hazards associated with the material involved. The exposure rates at the trailer were approximately 15 microR/hr. The licensee has dispatched health physicists and a truck with overpack materials to re-pack the load for transport back to their facility in Oak Ridge. No personnel exposures were reported. Tennessee Event Report Identification Number: TN-24-015 National Response Center Incident Report Number: 1390886
ENS 569472 February 2024 15:00:00The following information was received from the Illinois Emergency Management Agency (the Agency) via email: The Agency was notified 2/2/24, by G.E. Healthcare in Arlington Heights, IL, (RML IL-01109-01) to advise two radiopharmaceutical packages were missing at the Memphis, TN, (common carrier) hub. The first package contained two shielded vials of iodine-123 (I-123), accounting for 66.8 mCi at the time of shipment. The second package contained 1.0 mCi of indium-111 (In-111); but was located in the (common carrier) facility damaged with the contents missing. (Common carrier) staff advise they are actively searching the facility. The first radiopharmaceutical package containing two vials of I-123 (and believed to be intact) was shipped 1/29/24 from Arlington Heights, IL, to Nuclear Diagnostic in Budd Lake, NJ. It was last reported at the (common carrier) hub in Memphis, TN, on 1/29/24. The second package believed to be damaged and within the (common carrier) facility was shipped 1/13/24 from Arlington Heights, IL, to RLS USA in Pittston, PA. Missing is a vial of In-111 Oxyquinoline Solution within a 6-mm thick lead-shielded container. The current activity is estimated to be 19.0 microcuries. If unshielded, this vial would present an exposure rate of approximately 1 millirem per hour at three inches. GE Healthcare has been provided photos and a description of the container and inner product. (Common carrier) staff are currently surveying with radiation detection equipment. Illinois Item Number: IL24004 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 569462 February 2024 14:01:00

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email: The licensee's Assistant Director of Radiation Safety contacted the Department on February 1, 2024, at 1700 EST, to report a missing source. He stated he was notified that morning that a germanium-68 Phantom, for use with a PET/MRI (positron emission tomography/magnetic resonance imaging) machine was reported missing. It has a reference activity of 55 MBq / 1.5mCi. During a follow up call from the Department, the Assistant Director stated the source was delivered and accounted for Monday, January 29, 2024, then reported missing February 1, 2024. The source was in a restricted area and locked in the hot lab. The Assistant Director stated they have created a police report and are awaiting surveillance footage. The licensee believes it may have been thrown away accidentally, therefore they are also searching their dumpsters. Georgia Incident Number: 77

  • * * UPDATE ON 02/06/24 AT 1428 EST FROM STACY ALLMAN TO NATALIE STARFISH * * *

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email: The Assistant Director of Radiation Safety contacted the Department on 02/02/24 to provide an update on the steps being taken to find the lost source. They had informed the police department and opened an investigation. Security was also assisting in the investigation. The radiopharmacy that supports Emory University, called on 02/05/24 and reported their driver accidentally removed the source. The source was returned on 02/05/24 and the Assistant Director of Radiation Safety completed the check in and the leak test on the source. Notified R1DO (Lilliendahl), NMSS Events Notification, and ILTAB 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 5699325 February 2024 21:00:00The following is a summary of the information provided by Fairbanks Morse Engine via email: Arkansas Nuclear One (ANO) Unit 2 had a failure of a mini-gen signal generator on the opposed piston emergency diesel generator. Bench testing after removal from the engine showed an erratic signal, and this was confirmed by Fairbanks Morse. Fairbanks Morse destructive analysis revealed wear of the dynamic surface on the stator bushing inside diameter. The cause of the worn stator bushing is most likely due to inadequate lubrication on the dynamic surfaces, outside diameter of the shaft and inside diameter of the stator bushing. Possible causes of inadequate lubrication could be failure to apply enough lubrication to the dynamic surfaces during the manufacturing process or deterioration/evaporation over time. Fairbanks Morse has implemented corrective actions to address this issue, and they are estimated to be completed by May 23, 2024. Affected plants with potentially defected parts: Arkansas Nuclear One, Edwin I. Hatch Nuclear Plant, Joseph M. Farley Nuclear Generating Station, Limerick Generating Station, and Prairie Island Nuclear Generating Plant. Point of Contact: Martin Kurr Quality Assurance Manager Fairbanks Morse 608-364-8247 Martin.Kurr@fmdefense.com Fairbanks Morse Notification Report Number: 23-02
ENS 5699225 February 2024 20:47:00The following is a summary of the information provided by Fairbanks Morse Engine via email: Prairie Island Nuclear Generating Plant (PINGP) was conducting a planned replacement of emergency diesel generator air start solenoid valves when it discovered that the bottom stem appeared to be bent and observed air leakage. PINGP returned five valves to Fairbanks Morse, and they returned them to the manufacturer, ASCO. ASCO reassembled one valve and confirmed there was air leakage through the valve. The leakage path was from the air supply port to the exhaust port when the valve was in the de-energized normally open state. ASCO functionally tested the remaining four valves and found a second valve that also leaked. ASCO and Fairbanks Morse have implemented corrective actions to address this issue. Fairbanks Morse will notify PINGP and Limerick Generating Station. Affected plants with potentially defected parts: Prairie Island Nuclear Generating Plant and Limerick Generating Station. Point of Contact: Martin Kurr Quality Assurance Manager Fairbanks Morse 608-364-8247 Martin.Kurr@fmdefense.com Fairbanks Morse Notification Report Number: 23-01
ENS 5692312 January 2024 11:12:00

The following information was received from the Illinois Emergency Management Agency (the Agency) via email. On Thursday, January 11, 2024, the Agency received written notification from the radiation safety officer (RSO) at a nuclear pharmacy of an elevated dosimetry badge report for a worker in Romeoville, IL. The whole body dose reported would exceed the occupational limits in 32 Ill. Adm. Code 340.210. The information provided indicates the worker received 162,926 mrem during the week of December 11, 2023, which exceeds the annual limit of 5,000 mrem. This is a reportable incident under 32 Ill. Adm. Code 340.1230, and will be reported to NRC and NMED. While an investigation is underway to determine the cause of this overexposure, after speaking with the RSO, it is likely the result of a spill/splash event. If this spill resulted in an occupational exposure in excess of the limits, it is also reportable under 32 Ill. Adm. Code 340.1220(b) and will be reported to the NRC today. In the next week, Agency inspectors will perform a reactionary inspection to inspect the adequacy of the licensee's investigation, compliance with the Agency's regulations, and determine the root cause. NMED Item Number: IL240002

  • * * UPDATE ON 1/24/2024 AT 1557 EST FROM GARY FORSEE TO KAREN COTTON * * *

A reactive inspection was conducted on 1/19/24. Reportedly on 12/11/2023, the technician noted a pressure issue within an F-18 synthesis cell. While containing approximately 9.9 Ci of F-18, the technician opened the synthesis cell to diagnose the issue. The magnitude of the resulting whole-body exposure is an unknown component of the reported 162 rem. Extremity badges reported only 447 mrem for this wear period. Movement of the synthesis tubing resulted in an undetermined quantity of F-18 contaminating the upper chest, neck and underarm of the technician. The technician reports feeling `wetness' as a result of the contamination event. Licensee staff estimated 3-5 minutes passed before decontamination efforts were initiated. Initial survey readings on the technician were 12 mR/hour from the neck and chest after shirt and lab coat were removed. No assessment of uptake/intake was performed, nor were any bioassays performed. No medical assessment was performed for blood changes or impacts to the skin. The corporate Radiation Safety Officer (RSO) was not notified until the dosimetry report was returned nearly 30 days later. At the time of the inspection, no medical conditions had emerged that were indicative of radiation exposure. The technician's badge was not evaluated for contamination, simply assumed to be contaminated and sent for reading. The badge did not show evidence of contamination when received by the dosimetry processor - however, that may have been due to decay. The licensee did not cease or limit any work with radioactive materials assigned to the individual. The employee has continued work in 2024, as the elevated exposure was attributed to the 2023 annual limit. Inspectors believe there is some portion of the exposure recorded on the optically stimulated luminescence (OSL) (dosimeter) that was not a true whole-body exposure (resulting from contamination and storage in the bunker). However, the lack of adequate records or timely assessment makes any quantification impossible. While an undetermined fraction of the recorded 162 rem was likely not a whole-body dose to the technician; there are certainly exposure avenues which could have led to at least 5 rem whole body. Until data is presented which indicates otherwise, this matter is being treated as an occupational exposure in excess of the 5 rem limit. While 16 mL containing 9.9 Ci of F-18 was in the synthesis cell, there is no accurate account on the amount of activity deposited on the technician's skin/clothing. (The syringe containing the F-18 was not used and allowed to decay within the cell. No volume or activity assessment performed). The only data allowing an estimate is the initial 12 mR/hour exposure rate, which would be close to 13 microcuries of activity incident to the detector active surface area. I.e., if the badge was surveying 12 mR/hour at one inch, that would equate to approximately 13 microcuries of F-18 incident to the probe. The exposure to the OSL over the mean life of this F-18 is estimated at 20 Rem. No data is available to estimate committed dose. While a VARSKIN+ analysis is pending, initial estimates indicate skin dose is likely less than 10 percent of the occupational limit. If the entirety of the 162-rem exposure was suspected to have come from contamination, the initial contamination of the badge would have needed to exceed 100 microcuries. This would have an exposure rate in excess of 100 mR/hour - inconsistent with the recorded exposure rates. Occupational whole body dose year to date, prior to this incident, was recorded at 974 mrem. Average weekly whole-body dose was 19 mrem. The area was isolated due to the spill and this incident is likely also reportable under 32 Ill. Adm. Code 340.1220(b), equivalent to 10 CFR 20.2202(b). The investigation is still in process. Notified R3DO (Orlikowski), NMSS Event Notifications (Email), and NMSS/MSST Division Director (Williams)

  • * * UPDATE ON 3/18/2024 AT 1440 TO FROM GARY FORSEE TO SAM COLVARD * * *

A notice of violation was issued on 2/6/2024. A response was received on 3/6/2024 and included proposed corrective actions and steps to prevent recurrence. The licensee contracted a qualified consultant to perform skin dose calculations, and to further evaluate likely whole-body doses. The consultant calculated a skin dose of 89 rem from contamination, and a total whole-body dose of 100 mrem resulting from this incident. The licensee submitted information to indicate a 2023 proposed adjusted (deep-dose equivalent) (DDE) of 1.278 rem and a proposed adjusted (shallow-dose equivalent) (SDE) of 90.2 rem as detailed in the consultant report. The Agency has reviewed and concurs with the licensee's calculations for skin dose resulting from this incident. This matter will remain reportable, but on the basis of a skin dose exceeding the regulatory limit. Pending no further developments and appropriate enforcement action, this matter is considered closed. Notified R3DO (Hills), NMSS Event Notifications (Email), NMSS Regional Coordinator (email) (Rivera-Capella), NMSS/MSST Division Director (Williams), Director, Division of Radiological Safety and Security, R3 (email) (Curtis)

ENS 5687529 November 2023 17:02:00The following information was provided by the licensee via email: This notification is being made per 10 CFR 50.72(b)(2)(xi), as a result of notifications made to State and local government agencies for the discovery of an oil sheen in the discharge canal outside Unit 3. The New York State Department of Environmental Conservation and Westchester County Department of Health were notified. No sheen was observed in the river or at the southern end of the discharge canal near the outfall gates. Clean up efforts are underway. The licensee will notify the NRC Project Manager.
ENS 568828 December 2023 16:47:00

The following is a synopsis of information that was provided by Tioga Pipe Incorporated via fax: On November 15, 2023, nine pieces of one-inch buttweld long radius 90 degree elbows were determined not to meet correct thickness requirements. Three of the nine fittings were installed in the plant. The supplier requested that the uninstalled material be quarantined and tagged as nonconforming. The supplier doesn't know where the fittings were installed in the plant. Brunswick Nuclear Generating Station is the only plant affected. For questions concerning this 10 CFR 21 issue, please contact: Bryan Nichols Director of Quality Assurance Tioga Pipe Incorporated (484) 546-5613 bnichols@tiogapipe.com

  • * * UPDATE ON 12/11/23 AT 0959 EST FROM SHANNON ECHOLS TO ERIC SIMPSON * * *

Duplicate Part 21 notification made by Mackson Nuclear, LLC. This notification is identical to the Part 21 notification made by Tioga Pipe Incorporated via fax to NRC on Friday, December 8, 2023. No additional information was provided. Brunswick Nuclear Generating Station is the only plant affected. Notified R2RDO (Miller) and Part 21 Group via email.

  • * * UPDATE ON 02/02/24 AT 1001 EST FROM WILLIAM KOTCHER TO ERIC SIMPSON * * *

The following is information that was provided by Tioga Pipe Incorporated via fax: The licensee, Duke Energy - Brunswick Nuclear Plant, evaluated the installed elbows for acceptability in accordance with their corrective action program. Brunswick inspectors performed UT thickness evaluations of the installed nonconforming elbows (Fitting IDs: 16836-1-3, -14, and -20) and the results were used to confirm that the subject system remained operable. The remaining six nonconforming elbows (Fitting IDs: 16836-1-1, -6, -7, -11, -15, and -21) have been returned to the manufacturer, Flowline, and are being processed and controlled under Flowline's nonconforming items program. The faxed information includes an attached E-mail chain of seven E-mails related to the Tioga Part-21 notification. Questions are directed to William Kotcher, (713) 512-35699, or Bryan Nichols, (484) 546-5613. Notified R2RDO (Miller) and Part 21 Group via email.

ENS 568303 November 2023 15:27:00The following information was provided by the licensee via email: A press conference is being held by the Oconee County Sheriff's office today at 1530 EDT in which Duke Energy will be present and may participate regarding the facts pertaining to an event that occurred outside the Oconee Nuclear Power Plant. The NRC Resident Inspector was notified. This is a four-hour report per 10 CFR 50.72(b)(2)(xi) for any event or situation for which a news release is planned or notification to other government agencies has been or will be made which is related to heightened public or government concern. The event is not significant with respect to the health and safety of the public.
ENS 5680218 October 2023 15:18:00The following information was provided by the licensee via email: On October 18, 2023, at 1116 (EDT), with Unit 1 in Mode 5, an automatic actuation of the 1A auxiliary feedwater motor driven pump occurred when an incorrect action resulted in an automatic start signal. 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 auxiliary feedwater system. Feedwater is not needed for plant conditions, and the 1A auxiliary feedwater pump did not feed the steam generators. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5687328 November 2023 16:10:00The following information was provided by the Texas Department of State Health Services (the Department) via email: A Houston police officer was driving by a scrap yard on October 16, 2023, when his (personal radiation detector) PRD alarmed. He contacted his office, and another officer with radiation detection equipment went to the location and determined the radionuclide to be cesium-137. This officer contacted the Department, and on October 17, 2023, a Department investigator went to the location and located a box in a remote section of the scrap yard. The 4 foot by 4 foot by 4 foot box had several devices that appeared to be nuclear gauges in it. A service provider was contacted by the Department and put in contact with the property owner. The service provider responded to the location to remove the gauges and determine the source of radiation. Access to the area was restricted and controlled by the property owner. It does not appear that any individual would have exceeded an exposure limit. The service provider was able to determine that there was one source in the box. The source was placed in the back of a trash truck and shielded with all of the empty source holders stacked around it. The source holders all had the radioactive materials information removed. On October 19, 2023, a second service provider went to the site to retrieve the source. While there, they found three more shields in another area of the facility that were suspected to have sources that were very well shielded. All four sources (shields) were taken to the service provider's facility. The service provider removed the 4 sources. The service provider reached out to other individuals in an attempt to identify the manufacturer. It was determined that the sources were made by 3M and sold to Ronan Engineering, who then sold them to a DuPont plant in Wilmington, NC in 1992. The North Carolina program was contacted, and they reported that license was terminated in April of 2014. The sources were sent to a facility in South Carolina. The South Carolina program was contacted, and they provided a document showing the sources had been transferred to a Texas licensee in Sugar Land, Texas. The Texas licensee closed its facility and shipped all the sources they had for disposal. The last shipment of sources with this activity level was shipped from that facility in March of 2019. The contractor used to dispose of the sources has been contacted and will attempt to determine how the sources could have ended up at the scrap yard. The Department will provide updated information as it is received. Texas Incident Number: 10058 Texas NMED Number: TX230055 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 567806 October 2023 13:00:00The following is a summary of information provided by the licensee via phone and email: Two trespassers were observed by the central alarm station operator via site security cameras on the southeast end of the Maine Yankee property. Both trespassers observed to be carrying equipment to conduct manual digging for fish bait. Local law enforcement was called and responded to the Maine Yankee site. Law enforcement officers from Wiscasset Police and Lincoln County Sheriffs Department contacted both individuals and advised they had trespassed onto Maine Yankee property. Both trespassers apologized for their actions and were fully compliant with the officers. They were both advised and agreed to remain off Maine Yankee Property in the future. Their conduct was not deemed suspicious.
ENS 5674318 September 2023 14:48:00The following information was provided by the licensee via email: On 09/17/2023 at 2218 (EDT), Operations identified that the bearing cooling (BC) tower basin was overflowing. Earlier in the day, the BC tower was isolated as part of a planned maintenance evolution and the overflow condition was due to isolation valve leak-by. At 2255, the leak-by was corrected and stopped the overflow. Approximately 75 gallons may have been discharged to the lake from the overflow. The BC water was sampled by Chemistry and all chemical parameters were within VP DES (Virginia Pollutant Discharge Elimination System) limits. At 1420 on 09/18/23, a 24-hour notification was made to the Virginia Department of Environmental Quality (DEQ) in accordance with the North Anna VPDES permit. This issue is being reported per 10CFR50.72 (b)(2)(xi) due to the notification of other government agency. The NRC Resident Inspector was notified.
ENS 5673915 September 2023 11:50:00The following information was received from the New Jersey Department of Environmental Protection (NJDEP) via email: On 9/15/2023, NJDEP staff was notified of a potential overexposure of an authorized user (AU) at a radiopharmacy. This licensee states that a whole body badge from June was submitted late and results were just received. This AU's June badge results were 4632 mrem. The badge was processed twice to ensure the reading was correct. This brings the AU's annual readings to 5351 mrem. As a result, the licensee has been put on work restrictions while an investigation is done. The licensee has also requested Landauer reprocess the badge. Staff was also told that the ring badges had the exact same reading as the whole body badge. Records of instant read out dosimeters are kept by this licensee and all recorded readings were no higher than 2 mR per day for June and July. More information to follow as the licensee's investigation is completed. New Jersey Event Number: To Be Determined
ENS 5674215 September 2023 18:00:00The following information was provided by Alabama Radiation Control via email: The licensee's representative called an Alabama Radiation Control staff member to report that an RT (radiographic testing) crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS (Applied Technical Services) office in Marietta, Georgia to respond. Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged. Alabama Radiation Control will provide more information as the investigation continues. Alabama Incident Number: To Be Determined
ENS 5674015 September 2023 13:34:00The following information is a summary provided by the licensee via phone and email: On September 7, 2023, a Senior Reactor Operator (SRO) noted that power indication channel 1 and channel 2 initially responded abnormally during preoperational checks. It was determined that the data acquisition system (DAS) system had been de-energized possibly by a power outage the night before. The DAS was re-energized and channel 1 and channel 2 both returned to normal. Preoperational checks were able to be completed but the reactor start up was not completed due to time. On September 14, 2023, the licensee was concerned regarding the initial abnormal response of the power indications when the DAS was de-energized, and it was determined that further investigation was needed to fully understand the potential effects on the reactor power channel indications. A plan was developed and approved by the Reactor Administrator to perform applicable steps of OP-1 to perform pre-operational and rod-drop tests with DAS energized and with DAS de-energized. All indications and pre-operational checks were normal with DAS energized. A rod drop test was performed while de-energizing DAS to determine the effect if any on reactor power and scram functionality. Safety rod 1 and 2 were raised (reactor not critical), data recorded, then the power to DAS was removed. The power readings after DAS was de-energized were as follows: channel 1 - 150 cps (counts per second), channel 2 - off scale high on meter and chart recorder, channel 3 - 33 percent of 10 mW. The SRO noted that reactor did not scram when channel 2 indicated off scale high. The SRO manually scram the reactor, power to DAS was restored, and all indications returned to normal. An attempt to perform the pre-operational checks with DAS de-energized was aborted due to channel 1 and 2 indicating abnormally. The licensee contacted the NRC Project Manager.
ENS 5674418 September 2023 17:53:00The following information was received from the California Department of Public Health via email: On 09/13/23, Tesla Corporation contacted (Radiation Health Branch) RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source. 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 5669424 August 2023 08:24:00The following information was provided by the licensee via email: A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated. The NRC Resident Inspectors have been notified
ENS 5668015 August 2023 15:00:00The following is a summary of information provided by the licensee via phone: A patient underwent an eye plaque procedure where they were to receive 85 Gy of Iodine-125 over a seven day period. The patient received an estimated dose of 57 Gy. The total dose delivered differs from the prescribed dose by greater than 20 percent. The licensee believed the seed could have shifted during the 7 days. A written report will be forwarded when complete. 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 567816 October 2023 18:12:00The following information was provided by the licensee via phone and email: This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A). On August 8, 2023, at 1107 hours pacific daylight time (PDT) with Unit 1 in Mode 1 at 100 percent power, an invalid actuation occurred when Unit 1 4-kV vital bus 'G' was automatically transferred from auxiliary power to startup power due to an invalid bus under voltage signal, which occurred during planned maintenance activities. As a result of the actuation signal, auxiliary salt water and containment fan cooling units transferred automatically and started as designed. Plant systems responded as expected. This event was entered into the Diablo Canyon Power Plant corrective action program for resolution. There was no plant or public safety impact. The NRC Senior Resident Inspector has been notified.
ENS 566501 August 2023 15:53:00The following information was provided by the licensee via email: On 08/01/2023 at 0955 EDT, the Fermi 2 active seismic monitoring system provided indication of a potential seismic activity event. Plant abnormal procedures were entered, and compensatory measure were met and remain in place. Neither the (United States Geological Survey) (USGS) nor the next closest nuclear power plant could confirm or validate the readings obtained at Fermi. The seismic monitoring system was declared nonfunctional to validate the calibration of the system. Femi 2 has two active seismic monitors: one on the reactor pressure vessel pedestal and one in the high-pressure core injection (HPCI) room. Only the HPCI room accelerometer was declared inoperable. The HPCI accelerometer is the sole 'trigger' for the seismic recording system, which outputs peak accelerations experienced during a seismic event. This is used in assessment of the magnitude of an earthquake for EAL HU 2.1. The loss of the active seismic monitoring system is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii). No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area. The NRC Resident Inspector has been notified.
ENS 5662012 July 2023 12:49:00

The following information was provided by the licensee via email: At 0449 (EDT) on 7/12/2023, Millstone Unit 3 declared the 'B' train of the emergency core cooling system (ECCS) inoperable due to a degraded damper associated with the ventilation support system for the 'B' charging pump. At the time of this event, the 'A' train of service water was already inoperable due to planned maintenance on a breaker that would have prevented an 'A' service water valve powered from this breaker from closing on a safety signal. This configuration resulted in the possibility that the 'A' train of ECCS would not have been available to fulfill its design function under all postulated accident conditions. This event is being reported under 10 CFR 50.72(b)(3)(v)(B), '(any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (B) remove residual heat).' Subsequently, the 'A' train of service water was restored to operable at 0548 on 7/12/2023. Repairs and investigation continue on the 'B' train ECCS damper. The NRC resident has been notified. This event did not impact Millstone Unit 2. There was no impact to the public.

  • * * RETRACTION ON 7/31/2023 AT 1400 EDT FROM JAMES KELLY TO JOHN RUSSELL* * *

The following information was provided by the licensee via email: The condition was reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(B), via an 8-hour report as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat. A subsequent engineering review of the conditions that existed at the time determined that, based on area temperature response, any impact on ventilation flows into and out of the `B' charging pump cubicle did not generate an observable change in the temperature trend. Based on this, it is concluded with reasonable assurance that the functional requirement of the support system was maintained and the `B' charging pump would have continued to perform its safety function until the `A' train of service water was restored to operable and as a result safety function was not lost. Therefore, this condition is not reportable and NRC Event Number 56620 is being retracted. The basis for this conclusion has been provided to the NRC Resident Inspector." Notified R1DO (Bicket).

ENS 5662112 July 2023 19:25:00The following information was received from the Texas Department of State Health Services (the Agency) via email: On July 12, 2023, the Agency was notified by the licensee's service company that during routine shutter checks, the shutter on a Vega Americas model SH-F2 (gauge) could not be shut. The gauge contains a 200 millicurie (original activity) Cs-137 source. Open is the normal operating position for the shutter. The licensee has made plans to repair the gauge in the next seven days. The service company stated there is no risk of radiation exposure to members of the general public or radiation workers due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10036
ENS 5661811 July 2023 17:42:00The following information was provided by the licensee via email: At 1530 (EDT) on 7/11/2023, North Anna Power Station notified the Virginia Department of Environmental Quality (DEQ) that a small volume of filtered/purified water potentially discharged into Lake Anna from a leak from a reverse osmosis unit. The leak did not follow the normal release path for discharge through outfall 013. No environmental impact associated with this leak was observed or would be expected because the water in question is cleaner than the lake water, and would have met all discharge requirements for outfall 013. The NRC Resident Inspector was notified. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
ENS 5661511 July 2023 14:56:00The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: The licensee (QSA Global, Inc., License No. 12-8361) reported at 1015 (EDT) today (July 11, 2023), that it discovered yesterday (July 10, 2023) at 1553 that one of two packages destined for delivery to AMCOL Ingenieria LTDA of Bogota, Columbia was missing. Each of the two packages was a single QSA Global, Inc. model 650L source changer containing an iridium-192 sealed source(s) shipped on June 26, 2023. One of the two packages was received by AMCOL Ingenieria LTDA of Bogota, Columbia on July 10, 2023. The missing package was a QSA Global, Inc. Model 650L source changer, serial number 120 containing two sealed sources of iridium-192, 104.2 curies (3.86 TBq) and 104.3 curies (3.86 TBq), respectively. The licensee reported that the missing package was last known to be at the carrier's sorting facility in Memphis, TN, on July 1, 2023. The carrier package tracking number was provided by the licensee. The licensee then reported at approximately 1300 on July 11, 2023, that the missing package was found by the carrier at the carrier's Memphis, TN facility, and that the package will likely be moved forward by the carrier to the Bogota, Columbia destination. The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C and of 105 CMR 120.077(B). The Agency considers this event to be open. THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
ENS 5661711 July 2023 16:01:00The following information was provided by the Florida Department of Health, Bureau of Radiation Control (BRC) via email: The BRC received a call on Monday 7/10/2023 at 1335 (EDT) from Miami-Dade Police reporting they found two Troxler gauges in an empty lot next to the incident location address. One gauge belonged to the licensee (CTI Construction Testing and Inspection, Inc.), the other gauge belonged to another company (see FL23-103) (NRC EN 56616). Miami-Dade Police on the scene said they had contacted the owner of the gauge and someone was en route to retrieve it. Miami-Dade Police sent pictures of the gauge, and the gauge appeared to be intact. An attempt was made to contact the (company) RSO on 7/11/2023, and a voice mail was left to return the call. Another company RSO (on license #3298-1) was contacted, who said the gauge is back in their possession with no damage. The BRC Inspector is to conduct a more thorough investigation with each licensee. Florida Incident Number: FL23-104 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 5661611 July 2023 16:01:00The following information was provided by the Florida Department of Health, Bureau of Radiation Control (BRC) via email: The BRC received a call on Monday, 7/10/2023, at 1335 (EDT), from Miami-Dade Police reporting they found two Troxler gauges in an empty lot next to the incident location address. One gauge belonged to the licensee (Sacyr Construction), the other gauge belonged to another company (see FL23-104) (NRC EN 56617). Miami-Dade Police on the scene said they had contacted the owner of the gauge and someone was en route to retrieve it. Miami-Dade Police sent pictures of the gauge, and the gauge appeared to be intact. The RSO (Radiation Safety Officer) was contacted on 7/11/2023, and he said one of his employees called him yesterday morning (and stated) that their construction site was broken into over the weekend, and several pieces of equipment were stolen. The RSO stated that the gauge was found before he was able to report it stolen, the gauge is back in their possession, and that there is no damage to the gauge. The BRC Inspector is to conduct a more thorough investigation with each licensee. Florida Incident Number: FL23-103 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 5653019 May 2023 16:11:00The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: A telephone call received by the Agency from the (Radiation Safety Officer) RSO of Invicro, LLC, at 1054 EDT on 5/19/2023. A package was received on 5/19/2023 at approximately 1000 EDT at the licensee's site that exceeded the dose rate limit of 200 mrem/hr on the external surface of the package. The radionuclide was fluorine-18 (F-18) in liquid form enclosed in a glass vial. The assayed dose was 499 mCi at 0930 at PETNET Solutions, Inc. in Woburn, MA, the distributor of the F-18. The package was labeled Yellow II and the maximum surface dose rate should therefore not exceed 50 mrem/hour for a Yellow II labeled package. The package upon shipment was measured by the shipper to have a surface dose rate of 7 mrem/hour and a transport index (TI) of 0.4. The licensee reported that 5 wipe samples were taken on the external surface of the package with no resultant removable contamination observed. It was reported that the glass vial contained approximately 350 mCi of F-18 at the time the package was opened. The external dose rates on all external surfaces continued to exceed 200 mR/hr, even with the vial removed from the package. Surveys of areas where the package was opened, and where the vial was transported, are undergoing. The vial is currently stored in a hot cell. The external package is being stored in a shielded location. Personnel are being surveyed for contamination. At this time there is no indication of external contamination of the shipping package. The Agency, Invicro LLC, and PETNET Solutions, Inc. are in communication working the details of the scenario and potential personnel exposer. The Massachusetts Radiation Control Program considers this to be an open reportable event.
ENS 5652719 May 2023 12:33:00The following information was provided by the licensee via email: At 0852 (EDT) on May 19, 2023, with Unit 2 in Mode 3 at zero percent power, an actuation of the auxiliary feedwater system (AFW) occurred. The reason for the AFW auto-start was a failed start attempt of the 'B' main feedwater pump. The 'A' and 'B' motor driven auxiliary feedwater (MDAFW) pumps automatically started as designed when the 'Loss of Both Main Feedwater Pumps' signal was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5652919 May 2023 13:49:00The following was received from the Colorado Department of Public Health and Environment via email: On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation. Colorado Event Report Number: CO230012 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 565658 June 2023 09:37:00The following information was provided by the licensee via email: On 05/06/2023, at 1552 (EDT) with Seabrook Unit 1 in Mode 3 at zero percent power, while performing digital rod position indication system surveillance testing, shutdown bank 'E' stopped withdrawing. In response, the reactor trip breakers were manually opened, initiating a valid actuation of the reactor protection system (RPS). Subsequently, at 2253 while continuing to perform digital rod position indication system surveillance testing, shutdown bank 'C 'stopped inserting. Reactor trip breakers were manually opened, initiating a valid actuation of the RPS. The RPS responded as designed during both events, and both actuations are being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified.
ENS 5649630 April 2023 23:14:00The following information was received from the Florida Bureau of Radiation Control via email: (The Florida Bureau of Radiation Control) received a call from the (Radiation Safety Officer) RSO at Atkins North America, reporting the theft of five Troxler gauges from their facility in Tampa, FL. Tampa Police report number 23-18111075. 1) Model 3440, serial number 27848, source serial number Cs 750-1764, AmBe 47-24477 2) Model 3440, serial number 23089, source serial number Cs 75-4899, AmBe 47-18903 3) Model 3430, serial number 27128, source serial number Cs 750-846, AmBe 47-23647 4) Model 3440, serial number 32293, source serial number Cs 750-7450, AmBe 47-10058 5) Model 3440, serial number 29466, source serial number Cs 750-3720, AmBe 47-26413 Activity for each gauge: Cesium-137 8mCi Am-Be 40mCi Florida Incident Number: FL23-061 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 5674115 September 2023 14:38:00The following information was received from the state of Illinois via email: During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP (accredited medical practitioner) wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of (prescribed)'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event. On 9/15/23, the authorized user (AU) physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending. Illinois Item Number: IL230026 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 565648 June 2023 09:37:00The following information was provided by the licensee via email: On April 12, 2023, with Seabrook Station Unit 1 in Mode 6 at zero percent power, a valid actuation of the 'B' emergency diesel generator (EDG) emergency power sequencer occurred due to a loss of power to the 'B' train emergency bus. The 'B' EDG was removed from service for scheduled maintenance during this time. This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) for a valid actuation of the 'B' EDG emergency power sequencer. The NRC Resident Inspector has been notified.
ENS 5652619 May 2023 12:03:00The following information was received from the Pennsylvania Department of Radiation Protection via email: On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed. Event Report Identification Number: PA230015 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 5641416 March 2023 01:26:00The following information was provided by the licensee via email: At 2157 EDT on 03/15/2023, with Unit 3 in Mode 1 at 18 percent power, the reactor automatically tripped due to the loss of two reactor coolant pumps when their electrical buses failed to transfer after a main generator excitation protective relay tripped. Operations responded and stabilized the plant. Decay heat is being removed by steam generator power operated relief valves. Units 1, 2, and 4 are not affected. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
ENS 5641115 March 2023 04:27:00

The following information was provided by the licensee via email: At 2257 (CDT) on 3/14/2023 during the 2R22 refueling outage on Browns Ferry Nuclear Plant Unit 2, it was determined there was RCS boundary leakage from five of eight sensing lines that pass through containment penetrations X-30 and X-34 that did not meet the requirements of Section XI, of the ASME Boiler and Pressure Vessel Code. The condition will be resolved prior to plant startup. 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.

  • * * RETRACTION ON 03/28/2023 AT 1059 EST FROM CASEY CARTWRIGHT TO THOMAS HERRITY * * *

The following information was provided by the licensee via email: The purpose of this notification is to retract a previous Event Notification, EN 56411 reported on 3/14/23. Following the initial notification, further analysis of the condition was performed. It was determined that the leaking pipe weld was ASME Section XI Code Class 2 piping which falls under the requirements of ASME Section XI Subsection IWC and not Subsection IWB. Therefore, this condition does not represent a serious degradation of the nuclear power plant, including its principle safety barriers. Based upon the above, the leaks identified on the ASME Section XI Code Class 2 equivalent Main Steam sense lines are not reportable under 10 CFR 50.72(b)(3)(ii). Therefore, the NRC non-emergency 10 CFR 50.72(b)(3)(ii) report was not required and the NRC report 56411 can be retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(ii) is required to be submitted. Notified R2DO (Miller)

ENS 563842 March 2023 17:28:00The following information was received from the Texas Department of State Health Services (the Department) via email: On March 2, 2023, a licensee notified the Department that they were unable to retract a 79.6 Ci iridium-192 source to a Delta 880 camera at a temporary job site on March 1, 2023. After an exposure, the cable was cranked in but would not lock. The technicians cranked the cable back to the collimator and called a radiation safety officer (RSO). The RSO arrived at the site and found that both technicians had extended the boundary to 1-1.5 mR/hr. He then checked the dosimetry for both technicians and found both had received about 20 mR. The RSO investigated the source and determined that it had become disconnected from the wire at the point where the wire connects to the pig tail. The source was determined to still be in the collimator. A lead blanket was then used to cover the collimator. The crank-out and guide tubes were then replaced. The end of the pig tail was slowly exposed so that the wire could be connected by hand. The source was then retracted successfully back into the camera. The RSO wore a direct reading dosimeter on his hand while doing this and reported that his hands received around 600 mR. His whole-body dosimeter measured around 400 mR. His badge has been sent in for analysis. The technicians and public did not receive additional dose from this incident. Texas Incident Number: I-9997
ENS 5638123 February 2023 16:36:00

The following was received from the state of South Carolina via email: The South Carolina Department of Health and Environmental Control was notified on 02/23/23 at 1546 (EST) via telephone that a Humboldt Model 5001 device (serial number 4686) portable moisture density gauge was lost or missing. The Humboldt Model 5001 device contains a maximum activity of 11 millicuries (407 MBq) of Cs-137 and 44 millicuries (1628 MBq) of Am-241:Be. The licensee is reporting that the Humboldt Model 5001 device was lost or missing while in transit via a common carrier. The Humboldt Model 5001 device was picked up by the common carrier at a temporary jobsite in South Carolina on 01/18/23 and was intended to be delivered to the manufacturer in Raleigh, NC. The licensee is reporting that the Humboldt Model 5001 device was delivered to a common carrier facility in Durham, NC on 01/19/23. The licensee is reporting that the Humboldt Model 5001 device has not been delivered to the intended destination and the licensee is reporting that the common carrier has indicated that the shipment cannot be located. This event is under investigation by the South Carolina Department of Health and Environmental Control.

  • * * UPDATE ON 2/24/23 AT 1112 EST FROM SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL TO KAREN COTTON * * *

The South Carolina Department of Health and Environmental Control was notified on 02/24/23, at 1056 EST via telephone that the Humboldt Model 5001 device (serial number 4686) has been found by the common carrier and retrieved by the licensee from the common carrier facility in Durham, NC. This event is still under investigation by the South Carolina Department of Health and Environmental Control. Notified R1DO (Carfang), NMSS Events Notification, 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

ENS 5637922 February 2023 18:34:00The following was received from the Texas Department of State Health Services (the Agency) via email: On February 22, 2023, the Agency was notified by the licensee's service company that the shutter on a Vega SH-F2B was found stuck in the open position during routine testing. Open is the normal operating position. The gauge contains a 200 millicurie (original activity) cesium-137 source. The gauge does not present an exposure risk to members of the general public or plant workers. The manufacturer has been contacted to conduct the repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9992
ENS 5637821 February 2023 22:25:00The following was provided by the Utah Division of Waste Management and Radiation Control: On 2/21/23, at 1700 (MST), the Intermountain Heart Institute, Cardiac Molecular Imaging (CMI) Coordinator reported to the RSO (Radiation Safety Officer) that around 1630 a technologist, removing a Rb-82 generator from service, found liquid radioactive contamination in the bottom of the well chamber of the infusion system. A syringe was used to remove the saline from the well of the infusion system and the liquid was placed in the liquid radioactive waste storage. Decontamination procedures were followed. The infusion system well was wiped dry with paper towel(s). All radioactive waste was placed in approved radioactive waste storage. Wipe test(s) were performed. This incident has no impact on patient treatment. All quality control procedures passed while the generator was in use which verifies that patient treatments were within all requirements. The manufacturer was contacted for assistance, and it is planned that the generator will be shipped back for investigation. We will follow the manufacturer's instructions for the shipment. A new generator has been placed in the infusion system so that patient care can continue today. Utah Event Report Number: UT23-0003
ENS 5637721 February 2023 21:35:00

The following information was provided by the Texas Department of State Health Services (the Group) via email: On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9991

  • * * UPDATE ON 02/22/23 AT 2049 EST FROM ART TUCKER TO KERBY SCALES * * *

The following update was received from Texas Department of State Health Services (the Agency) via email: On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL (Optically Stimulated Luminescence) dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information.

  • * * UPDATE ON 02/23/23 AT 1307 EST FROM ART TUCKER TO IAN HOWARD * * *

The following update was received from Texas Department of State Health Services (the Agency) via email: On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.

  • * * UPDATE ON 02/28/23 AT 2250 EST FROM ART TUCKER TO ERNEST WEST * * *

The licensee's radiation safety officer provided the following additional information: `(The teletherapy unit that had a stuck source) is a Theratron 780C, and it was the Numatics Mark 8 solenoid valve that failed.' Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Vossmar) and NMSS Events Notification via email.

ENS 5637521 February 2023 13:57:00The following information was received from the state of Ohio via email: On Monday 2/20/2023, radiographers from the licensee's Akron, Ohio office experienced a source that would not retract. There were two radiographers working on the job site when they realized that their source was not locking into the safe position. They contacted management at 1013 (CST) and were instructed to move their boundaries out and use physical barriers to prevent unauthorized access. When the licensee's source retrieval team arrived on site, they discussed the situation with the crew and began to form a plan for locating the source. The retrieval team located the source in the collimator and then developed a plan for a way to shield and retract the source. The retrieval team made 16 moves to shield the source before attempting retrieval. The source was locked in the safe, shielded position inside the camera at 1510. The source retrieval team found that the drive cable connector had broken just above the crimp causing the source and pigtail to become disconnected from the cable. The licensee reports that the connector lot number is FW-21, and it was put into service on 12/18/2022. Ohio Item Number: OH230001
ENS 5631820 January 2023 09:18:00

The following is a summary of information provided by the licensee via email and phone: A patient, accompanied by her daughter who is the patient's preferred translator, was receiving the first of four Lutathera infusions. The physician, registered nurse, nuclear medicine personnel and radiological safety team members were present for the infusion. The Lutathera infusion was performed per protocol without any issue. Post infusion it was determined through the patient's daughter that the patient had had a lanreotide injection last week on 1/12/23. Per protocol Lutathera is to be given four weeks after a lanreotide/octreotide injection has been administered. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

  • * * RETRACTION ON 2/1/23 AT 1040 EST FROM SANDRA PHILLIPS TO ADAM KOZIOL * * *

The following information was provided by the licensee via telephone: Further review from hospital staff in coordination with NRC Medical Health Team determined this is not a medical event. Notified R1DO (Lally) and NMSS (email).