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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
Texas A&M University (TAMN) - College Station TX
Report Date 12/19/2023 16:15:00
Event Date 12/15/2023 11:00:00
EN Revision Imported Date: 12/16/2024
EN Revision Text: TECHNICAL SPECIFICATIONS VIOLATION
The following information was provided by the licensee via phone and email:
"At approximately 1100 CST on December 15, 2023, the facility was discovered to be in violation of a Limiting Condition of Operation (LCO) according to Technical Specification 3.3.2.2, which requires that the static pressure measurement in the confinement exhaust system measure -0.1 inches of water or less during operation. It was discovered that this plant variable was not tied to the PANALARM trip for 'Building Pressure', nor was the sensor output value available in the control room to be checked by operators. The PANALARM trip for 'Building Pressure' was set to a different variable not related to the LCO required value. This condition has existed since 2006.
"The reactor was not in operation at the time of the discovery, and the situation creating this LCO violation is being corrected prior to the next reactor startup."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The issue was discovered by the vendor when a controller board was being replaced after damage from a power outage.
The following information was provided by the licensee via email:
"This event report is hereby withdrawn. The reactor was not operated in contravention with the LCO. The confinement pressure was maintained."
Notified NRR (Boyle) and NRR (Waugh)
Beaver Valley - Shippingport PA
Report Date 11/12/2024 1:21:00
Event Date 11/11/2024 17:31:00
EN Revision Imported Date: 12/31/2024
EN Revision Text: MSIV FAILED TO CLOSE DURING SURVEILLANCE
The following information was provided by the licensee via phone and email:
"At 2250 EST on November 11, 2024, a technical specification required shutdown was initiated at Beaver Valley Power Station Unit 2. The following technical specification limiting conditions of operation (LCOs) were entered at 1939 EST on November 11, 2024:
"LCO 3.6.3, containment isolation valves, condition C, one or more penetration flow paths with one containment isolation valve inoperable; required action C.1, isolate the affected penetration flow path by use of at least one closed and de-activated automatic valve, closed manual valve, or blind flange.
"LCO 3.7.2, main steam isolation valves (MSIVs), condition C, one or more MSIVs inoperable in mode 2 or 3; required action C.1, close MSIV within 8 hours.
"These technical specification required actions will not be completed within the completion time; therefore, a technical specification required shutdown was initiated, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i).
"With one main steam isolation valve inoperable, this condition is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The failure occurred during planned surveillance testing in preparation for reactor startup.
The following information was provided by the licensee via phone and email:
"On 11/12/2024 an 8-hour notification was made describing the failure of one main steam isolation valve (MSIV) to close during testing while the plant was in MODE 3. This notification was made pursuant to 10 CFR 50.72(b)(3)(v) as a condition that could have prevented the fulfillment of a safety function. Further engineering evaluation has determined that this condition was not reasonably expected to prevent the fulfillment of a safety function based on a review of the accident analyses and the redundant equipment which is known to have been capable of performing the safety functions. Therefore, this does not result in a reportable condition under this criterion.
"At the same time, a 4-hour notification was made pursuant to 10 CFR 50.72(b)(2)(i) as an initiation of a shutdown required by plant technical specification due to initiating a transition to MODE 4 to exit TS applicability. The plant was in hot standby (MODE 3) at the time of the event and negative reactivity was not added in order to move to MODE 4, therefore, this event is not reportable under this criterion.
"The NRC Resident Inspector has been notified."
Notified R1DO (Lilliendahl)
Utah Division of Radiation Control - Clive UT
Report Date 11/25/2024 13:48:00
Event Date 11/14/2024 0:00:00
AGREEMENT STATE REPORT - EXCLUSIVE USE TRANSPORT VEHICLE EXCEEDED EXPOSURE RATES
The following information was provided by the Utah Division of Radiation Control via email:
"Shipment 1072-07-0875, consisting of demolition debris from the Fort Calhoun Nuclear Generating Station decommissioning project, destined for direct disposal as low level radioactive waste, was moved into the restricted area and the [waste] generator was notified. The radiological acceptance survey from railcar FURX322364 performed in the field yielded results with the highest [on] contact exposure rate as 765 mR/hr with instrument model L-3078 (serial number 25023333), and a confirmatory [on] contact exposure rate at 744 mR/hr was taken with model L-78 (serial number 234101). The Department of Transportation limits in 49 CFR 173.441 and NRC limits in 10 CFR 71.47 prohibit exposure rates in exceedance of 200 mR/hr at any point on the external surface of the package."
Utah Event Report ID No: UT 240008
NJ Rad Prot And Rel Prevention Pgm - Camden NJ
Report Date 11/25/2024 14:28:00
Event Date 01/01/2018 0:00:00
EN Revision Imported Date: 1/15/2025
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New Jersey Bureau of Environmental Radiation (BER) via email:
"On 11/22/2024, BER staff called the licensee for an update on their termination process for device serial number 13823, and was informed that the device was transferred to a sister company that was looking to start a site in New York State in 2018. While the device was in New York, it was either lost or stolen. The licensee did not notify BER staff that the device was lost or stolen until 2024, when staff was requesting more information for their request to terminate their general license registration."
Source Information: Manufacturer: Thermo NITON Analyzers LLC Model: XLP Series Serial Number: 13823 Isotope and Activity: Am-241, 30mCi
State Event Report ID Number: TBD
The following information was provided by the New Jersey Bureau of Environmental Radiation (BER) via email:
BER would like to close this event. The device was not found and is unlikely to be recovered.
Notified R1DO (Carfang), NMSS Events Notification (email), 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
Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 11/25/2024 16:15:00
Event Date 11/21/2024 0:00:00
AGREEMENT STATE REPORT - LOST PACKAGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"The Agency was contacted November 21, 2024, by GE Healthcare, to report that a [radioactive] Yellow-II package containing a radiopharmaceutical had been damaged in transit and was now missing its contents. GE Healthcare (Illinois license #IL-01109-01) reported shipping a shielded vial of In-111 on November 15, 2024, from their Arlington Heights facility to Heartlight Pharmacy Services in Lima, OH. The 10 mL vial had an assayed activity of 3.201 mCi at the time of shipment. On November 16, 2024, the package was scanned in San Francisco. Tracking details identified that the package was received at the Memphis, TN sort facility but after no movement, GE Healthcare contacted [the carrier] to determine the new delivery date. On November 21, 2024, [the carrier] confirmed that the package was being held in their over goods department as it appeared that damage allowed the contents to escape the outer package. A photo of the GE Healthcare product container was provided to [the common carrier] and a search for the missing product container is ongoing at the Memphis sort facility.
"Tennessee program staff were notified the same day and are working with the carrier. Updates will be provided as they become available."
Illinois Item Number: IL240028
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
California Radiation Control Prgm - San Diego CA
Report Date 11/25/2024 20:00:00
Event Date 11/22/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the California Radiologic Health Branch via email:
"On 11/22/24, an exit sign containing tritium was discovered missing from an Ikea warehouse located in San Diego. Site personnel were not sure when it went missing. A search of the facility and questioning of warehouse employees did not locate the missing sign."
Information on the exit sign: Make and Model: SRB Technologies, Betalux-E Series, Model 171. NC License No.: 034-0534-2. Maximum Tritium activity: 21.6 Ci, 799.2 GBq.
California 5010 Number: 112524
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
Texas Dept of State Health Services - Brookshire TX
Report Date 11/26/2024 17:56:00
Event Date 11/26/2024 0:00:00
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION
The following report was received by the Texas Department of State Health Services (the Department):
"On 11/26/24, the Department was notified by the licensee of a malfunction that occurred with one of its cameras during an industrial radiography procedure. The licensee stated that a technician, while operating a SPEC 150 camera containing a 56 curie source of Ir-192, heard grinding noises during the crank-out process. The technician then retracted the source and conducted a source survey to confirm that it had returned to the shielded position. Upon inspection, the technician observed that the source was still extended at the end of the guide tube. The technician contacted the radiation safety officer (RSO), who responded to the scene, conducted an inspection, and was unable to determine if the source had become disconnected. The RSO subsequently covered the source with lead shielding and contacted the manufacturer who advised the licensee to transport the camera and source to the manufacturer for further examination and repair.
"The licensee stated no members of the public were exposed to radiation because of the incident.
"Additional information will be provided in accordance with SA-300."
Texas Incident Number: 10147 Texas NMED Number: 240046
Illinois Emergency Mgmt. Agency - Chicago IL
Report Date 11/27/2024 14:13:00
Event Date 11/26/2024 0:00:00
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:
"The Agency was contacted the evening of 11/26/24 by the radiation safety officer for Princeton Technical Services to advise that a Troxler 3430 moisture density gauge had been hit by a vehicle while in use at the airport. Reportedly, the authorized user (AU) set the portable gauge next to his vehicle and forgot to properly secure it prior to moving. The vehicle struck the gauge and broke off the face plate and the electronic keypad. The AU stated that there was no damage to the source housings and the cesium source rod was fully retracted. These statements were confirmed by on scene Chicago Fire Department (CFD) personnel. The CFD used a Thermo RadEye device to measure the exposure rate at one meter which was compared to the shipping papers. The reading at one meter was 189 microR/hour and the listed transport index was 0.3 which supports the fact that the source rod was properly shielded. The gauge was then packaged in the undamaged case and transported back to the licensee's location.
"Agency inspectors conducted a reactive inspection the morning of 11/27/24 and corroborated the details above. The licensee's written report is pending and will be used to update this event with a root cause and corrective actions. The licensee attributes the cause of the event to human error and the failure to follow their procedure."
Illinois Item Number: IL240029 Source Number: 1 Source/Radioactive Material: Sealed Source Gauge Manufacturer: AEA Technologies Model Number: NR Serial Number: 750-9439 Radionuclide: Cs-137 Activity: 0.008 Ci (8 mCi or 296 MBq) Source Number: 2 Source/Radioactive Material: Sealed Source Gauge Manufacturer: Isotope Products Lab Model Number: NR Serial Number: 47-6362 Radionuclide: Am-Be Activity: 0.04 Ci (40 mCi or 1.48 GBq)
New Mexico Rad Control Program - Jal NM
Report Date 11/27/2024 14:51:00
Event Date 11/27/2024 8:00:00
AGREEMENT STATE REPORT - DAMAGED DENSITOMETER
The following report was received by the New Mexico Radiation Control Program (the Program) via email and phone:
"The Program reported that a Berthold densitometer, model number 'LB8010', serial number '12133', Cesium-137 source with an activity of 20 mCi, had a shutter handle failure while on a fracking operation near Jal, New Mexico. The pad name is the Matador Firethorn. The device was not physically damaged, but the shutter handle became detached from the device. The failure is being considered a design failure on the Berthold device. The shutter is in the open position and cannot be closed. The vendor in Houston, Texas, has been requested to come to the location and change out the device for one that is operable. The vendor has been requested to transport the device back to Houston in preparation for disposal.
"There were no unnecessary exposures to any persons as a result of this incident."
Illinois Emergency Mgmt. Agency - Oak Lawn IL
Report Date 12/02/2024 16:26:00
Event Date 12/02/2024 0:00:00
AGREEMENT STATE - SOURCE FAILED TO RETRACT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email and phone:
"The Agency was contacted on 12/2/24 by radiation oncology staff at Advocate Christ Hospital to advise a 4.3 Ci Ir-192 source for a high dose rate afterloader (HDR) was stuck in the exposed position. The source was extended for daily quality assurance checks and is within a shielded vault. There were no staff or patient exposures. The manufacturer has been contacted to dispatch a service technician to the site and is expected 12/3/24. Agency staff conducted a reactive inspection on 12/2/24 to verify public exposure rates were within limits, verify adequate room security could be maintained, and determine the resources made available by the licensee to prevent any radiation exposures. After investigation, inspectors found the licensee had effectively restricted access by installing a secondary key-pad controlled door outside the vault door. Appropriate signage had been installed and survey readings in all areas were confirmed to be below public exposure limits (max 40 microrem per hour). The fault appears to be electrical and updates will be provided once obtained from Varian staff."
Equipment information: Device name: Remote afterloader HDR Model number: GammaMed Plus iX Serial number: H641313 Manufacturer: Varian
Illinois item number: IL240030
Colorado Dept of Health - Greeley CO
Report Date 12/03/2024 14:12:00
Event Date 11/20/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
Eight tritium exit signs were determined to be lost by the licensee.
Manufacturer: Safety Light Corp. Number of signs: 2 Model: 2040 Activity = 11.5 Ci each, H-3
Manufacturer: Best Lighting Products Number of signs: 6 Model: SLXTU1GB10 Activity: 7.03 Ci each, H-3
Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))
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
South Texas - Wadsworth TX
Report Date 12/03/2024 17:32:00
Event Date 12/03/2024 15:15:00
FALSE NEGATIVE QUALITY ASSURANCE TEST
The following information was provided by the licensee via phone and email:
"Contrary to the requirements in 10 CFR 26.137(b), a Health and Human Services (HHS) certified laboratory returned a blind specimen result that was inconsistent with what was expected.
"On November 14, 2024, blind specimens from the same lot number were sent to the two contracted HHS laboratories. On November 27, 2024, one of the labs reported unexpected results while the other laboratory reported the expected results (positive for opiates). At approximately 1415 CST on December 3, 2024, the lab report was reviewed by the fitness-for-duty medical review officer (MRO) staff at the South Texas Project and the inaccurate result was identified. At approximately 1510 CST on December 3, 2024, MRO staff contacted the laboratory to discuss the testing discrepancy and directed the lab to retest the specimen. The MRO staff also requested that the laboratory initiate an investigation to determine the reason for the inaccurate result.
"10 CFR 26.719(c)(3), reporting requirements state, 'If a false negative error occurs on a quality assurance check of validity screening tests, as required in 26.137(b), the licensee or other entity shall notify the NRC within 24 hours after discovery of the error.'
"The licensee has notified the NRC Resident Inspector."
Turkey Point - Miami FL
Report Date 12/04/2024 13:24:00
Event Date 12/04/2024 10:33:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone or email:
"At 1033 EST on December 4, 2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped in response to a reactor protection system channel failure while planned maintenance was in progress on a redundant channel. The plant is currently in mode 3. Decay heat is being removed by steam dumps to atmosphere. Unit 4 is unaffected. An actuation of the auxiliary feedwater system occurred and started as designed. An actuation of the emergency core cooling system (ECCS) occurred and started as designed. 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 ECCS actuation included safety injection, residual heat removal, and emergency containment cooling. The cause of the trip and the ECCS actuation are under investigation. There are no indications of primary to secondary leakage.
Brunswick - Southport NC
Report Date 12/04/2024 19:01:00
Event Date 12/04/2024 16:40:00
SECONDARY CONTAINMENT INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1640 EST, on December 4, 2024, secondary containment was declared inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function.
"Secondary containment was declared inoperable due to a small hole discovered in the service water piping within secondary containment. The effective safety function was restored at 1730 EST by installation of a temporary repair and secondary containment has been restored to operable.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Notified R2DO (Suber)
NJ Rad Prot And Rel Prevention Pgm - Newfield NJ
Report Date 12/05/2024 11:32:00
Event Date 12/02/2024 0:00:00
EN Revision Imported Date: 12/18/2024
EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST IN TRANSIT
The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
"The licensee reported to NJDEP on December 3, 2024, that a Ge-68 pin source that they sent for disposal has been lost in transit on December 2, 2024. The source is a Eckert & Ziegler model HEGL-0132, with current approximate activity of 0.267 mCi. The shipping container arrived at its destination damaged and empty. The licensee has filed a claim with the shipper. If the source is not located within the 30 days, the licensee will follow-up with a full written report to include root cause(s) and corrective actions.
"This event is reportable under 10 CFR 20.2201(a)(1)(ii)."
New Jersey Event Report ID number: To be determined
"The missing Ge-68 pin source was found by the common carrier, repackaged, and returned to the supplier (Sanders Medical in Knoxville, TN). The source was located and shipped on December 10, 2024. The NJDEP is in possession of evidence of receipt by the supplier.
"This incident is closed."
NMED Report: 240435
Notified R1DO (Lally), NMSS Events (email), 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
NJ Rad Prot And Rel Prevention Pgm - Linden NJ
Report Date 12/06/2024 12:55:00
Event Date 12/05/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the New Jersey Department of Environmental Protection via email:
"On December 5, 2024, the licensee became aware of a shutter that could not fully close but was able to return to the fully open, operative position. The shutter failure was identified while performing a routine six-month fixed gauge shutter check. The fixed gauge is located eight feet above a walking platform which is only accessible to licensee staff via ladder, scaffolding or other means. No members of the public have access to this location.
"The shutter is currently in its normal, open position. No maintenance activities are scheduled which would require closure of the shutter.
"The licensee has a contract with the manufacturer and has scheduled them to assess this situation and make any necessary repairs.
"The shutter holder contains a Cs-137 sealed source (model A-2102) with maximum activity of 300 mCi.
"This event is reportable under 10 CFR 30.50(b)(2) [NJAC 7:28-51.1]"
Equipment information: Model number: SH-F2 Serial number: 0362CG Manufacturer: Vega Americas, Inc.
New Jersey Event Report ID number: To be determined
Illinois Emergency Mgmt. Agency - Alton IL
Report Date 12/06/2024 15:51:00
Event Date 12/05/2024 0:00:00
AGREEMENT STATE REPORT - STUCK SOURCES
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"On December 5, 2024, two 1.53 mCi Co-60 sources were removed from their casting molds for an outage and placed into shielded source holders. At that time, it was discovered that one source could not be fully placed into its shielded configuration. The cause was believed to be a bend or steel prohibiting the source from being fully inserted. The active portion of the source was shielded, but the inactive portion extended beyond the shutter. It was also discovered that the shutter for the second source was inoperable.
"The sources were oriented to minimize exposure rates and secured in the licensee's source storage room. Exposure rates within the source storage room were 2 mR per hour and the exterior wall (unrestricted area) was maximumly 1.6 mR/hour. These measurements were confirmed by Chase Environmental consulting staff on December 6, 2024.
"The Agency staff will respond to the facility and assess the sources and shields when being removed for use on Monday, December 9, 2024.
"There are no anticipated exposures in excess of regulatory limits as a result of this incident. The matter is reportable to the Agency under 32 Ill. Adm. Code 340.1220(c)(2)."
Equipment information: Device: Gauge shutter Manufacturer: Berthold Model number: LB 300 IRL ML
Illinois Item Number: IL240031
Illinois Emergency Mgmt. Agency - Peoria IL
Report Date 12/06/2024 15:51:00
Event Date 12/04/2024 0:00:00
EN Revision Imported Date: 12/17/2024
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"On December 4, 2024, while administering Y-90 microspheres to a patient for radioembolization of the liver, a portion was shunted to the gastrointestinal tract. The shunting was not identified in the licensee's pre-administration macroaggregated albumin (MAA) mapping. The shunting is estimated to have resulted in approximately 100 cGy (rem) to the patient's stomach. The patient and physician have been notified. The licensee has not been reachable for additional details and a site visit is being coordinated."
"The Agency conducted a reactive inspection on 12/11/24. Inspectors spoke with the authorized user (AU) to determine if shunting to non-treatment sites had been assessed in advance of the administration in accordance with the manufacturer's instructions. Proper shunting calculations had been performed for the lung and no additional non-treatment sites were identified. The licensee had performed an angiogram to evaluate GI flow on the day of procedure with nothing unique noted. Specifically, no GI flow was observed. The AU continued with administration to segment 4 of the liver using a Progreat 2.4Fr by 130 cm microcatheter, lot numbers: 240701 (exp. 6/30/26) and 240619 (exp. 5/31/26). No pressure, blockage or other abnormalities were encountered during administration. Nothing new or unique about the target or delivery was reported or identified. However, upon performing post-administration PET scans, uptake to the stomach was observed. The Agency has seen an increased number of licensees performing post administration PET scans and as a result, licensees are now able to visualize shunting to other organs. For example, in this case, without the post administration scan, the uptake to the stomach would not be known.
"The inspector's reactive inspection memorandum is pending and this report will be updated with additional details. However, at this point, both the physician and the inspectors believe the shunting to the stomach was due to the vasculature of the patient and not improper catheter placement. As a result, this medical event is being requested for retraction. This report is being kept open pending addition of the inspector's detailed findings."
Notified R3DO (Stoedter), NMSS (Allen), and NMSS Events Notification (Email)
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Brunswick - Southport NC
Report Date 12/06/2024 17:00:00
Event Date 12/05/2024 23:58:00
EN Revision Imported Date: 12/13/2024
EN Revision Text: EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE
The following information was provided by the licensee via phone and email:
"At 2358 Eastern Standard Time (EST) on December 5, 2024, emergency diesel generator (EDG) '1' was declared inoperable due to a failure in the standby lube oil temperature control circuit. At this time, EDG '2' was already inoperable due to failure of a relay in the starting air circuity. As a result, both EDGs were simultaneously inoperable; therefore, this condition is being reported as a non-emergency notification per 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function.
"Offsite power, EDG '3', and EDG '4' were operable during the entire time period that EDGs '1' and '2' were inoperable. The effective safety function was restored at time 0148 on December 6, 2024, when lube oil temperature was restored and EDG '1' was declared operable. EDG '1' was inoperable concurrently with EDG '2' for approximately 1 hour and 50 minutes.
"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 inoperability of two EDGs placed the plant in LCO 3.8.1.
"The purpose of this Notification is to retract EN 57459 which was made on December 6, 2024, at 1700 EST.
"At 2358 EST on December 5, 2024, emergency diesel generator (EDG) '1' was declared inoperable due to low lube oil temperature. At this time, EDG '2' was already inoperable. The condition of EDG 1' and EDG 2' being inoperable at the same time was reported as a non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).
"Subsequent to this, it was determined that the identified EDG 1' low lube oil temperature reading was not representative of the temperature of the lube oil in the crankcase and sump, and therefore had no impact on EDG 1' operability. A component failure in the standby lube oil flow control circuit resulted in lube oil flow bypassing the lube oil circuit leg where temperature is sensed, allowing this uncirculated oil in the temperature sensing leg to stagnate and cool. Lube oil flow continued to recirculate through the heater circuit leg to the EDG and remained above the operability limit.
"The operability determination for EDG 1' has been updated indicating that EDG 1' operability was never lost for this event. As a result, there was not a condition that could have prevented the system from fulfilling the safety function. Offsite power, EDG `1', EDG '3', and EDG '4' were operable during this time.
"The NRC Resident Inspector has been notified."
Notified R2DO (Franke)
Utah Division of Radiation Control - Orem UT
Report Date 12/06/2024 17:33:00
Event Date 09/16/2024 0:00:00
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following report was received by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:
"On September 16, 2024, one of the licensee's portable gauge users was performing a measurement on asphalt using a Troxler 3430 moisture density gauge (serial number 25688) containing a cesium-137 source (serial number 75-8566, presumably 8 mCi) and an americium-241 source (serial number 47-22058, presumably 40 mCi). The operator had his back to the paving vehicle, and the vehicle did not have a functioning back-up alarm. The vehicle struck the operator in the shoulder, and the vehicle's right rear tire impacted and damaged the gauge. The operator sustained minor injuries, but the gauge suffered serious damage. The licensee's radiation safety officer (RSO) surveyed the vehicle's right rear tire using a calibrated instrument and found no evidence of contamination. The highest exposure rate reading from the damaged gauge was approximately 1 mR/hr at 1 meter from the gauge. The RSO was able to return the source rod to the shielded position, secure the damaged source rod from moving using duct tape, and place the gauge in the transportation case. The transport index of the transport case with the damaged gauge inside was 0.3. The RSO contacted Troxler for instructions to return the gauge to Troxler and to order a replacement gauge.
"This event was discovered during a routine license inspection by the Division on December 6, 2024. At the time of the inspection the transport case with the damaged gauge was still in the licensee's possession."
Acuren - Prudhoe Bay AK
Report Date 12/09/2024 20:39:00
Event Date 11/07/2024 0:00:00
BROKEN RADIOGRAPHY SOURCE CABLE
The following information was provided by the licensee via email:
"On 11/07/2024, a radiographic crew was performing radiographic testing (RT) on a lease in Prudhoe Bay, AK (about 15 minutes from the Prudhoe Bay field station), when they noticed their camera (Sentinel 880 Delta, serial number: D3963, Ir-192 source model # A424-9, serial number: 96639M, 65.9 Ci) did not lock the source into the safe position. After attempting to check the lock with the same result, they initiated the proper notifications to the site radiation safety officer (RSO), management and drill site operator.
"At 1030 YST, the crew contacted management after extending and verifying their boundaries. They were instructed to wait for retrieval personnel and monitor their boundaries. The retrieval personnel consisted of a trained and certified retrieval RSO and experienced retrieval employees.
"The retrieval crew arrived on-site at 1100. The scene was immediately assessed, boundaries verified, dosimetry checked, and no one was over exposed to radiation. A short meeting with the RT crew and retrieval personnel followed. It was determined that the exposure device was hanging about six feet off the ground on ropes attached to a pipe above it, and the collimator was pointing upward of the building where their exposure was being taken. Once the initial information was gathered, a conference call was initiated with offsite RSO, and management began to form a plan for locating the source.
"The collimated guide tube and camera were safely lowered to the floor. Once the collimator was on the floor it was shielded. The team determined that the source may have disconnected. To verify, the crew cranked the cable all the way in to see if they could confirm the connector either came off or broke off into the pigtail. They attempted to unscrew the back of the camera but were unable to loosen one of the screws. It was decided to disconnect the safety connector off the cranks from the crank cable housing unit. In doing so, it was found that the 550 connector had broken. A plan was formulated to retrieve the source.
"The drive cable connector broke on the shoulder of the connector between the ball and the crimp, closer to the crimp. How or why is under investigation with QSA. This prevented the retrieval personnel from removing the drive cable from the camera in their attempts to retract the source. The safety connector of the cranks from the crank housing unit had to be removed before moving forward.
"QSA Global has the equipment involved in this incident and are investigating the cause of the mechanical failure.
"Event exposures: Radiation worker 1: 50 mR film badge, 211 mR ring finger. Radiation worker 2: 67 mR film badge, 47 mR ring finger. Radiation worker 3: 43 mR film badge, minimal reading ring finger. Radiation worker 4: 68 mR film badge, ring finger not used."
MA Radiation Control Program - Billerica MA
Report Date 12/10/2024 16:14:00
Event Date 12/10/2024 15:00:00
AGREEMENT STATE REPORT - MISSING TC-99M GENERATOR PACKAGE
The following report was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 12/10/2024, at around 1500 EST, Lantheus Medical Imaging, Inc. (license number 60-0088) was notified that a package containing a 1 Ci Mo-99/Tc-99m generator in a type B package was missing in transit and notified the Agency at 1545 on the same day.
"The reporting requirement is immediate per 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
Generator Model: Technelite-LEU 37.0 GBq Domestic Generator Serial Number: B338411A04 Shipped to Southwest Health Systems in Cortez, Colorado. Deemed lost by common carrier on 12/10/2024. The most recent reported location was Memphis, TN. Activity: 37 Gbq, Mo-99/Tc-99m Calibration date: 12/03/2024 Shipped as Yellow III, TI of 1.3
"At 1318 EST on 12/11/2024, the licensee reported that the missing package had been delivered to its intended destination. The Agency considers this event closed."
Notified R1DO (Jackson), NMSS Events Notification (email), 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
Illinois Emergency Mgmt. Agency - Morris IL
Report Date 12/10/2024 16:26:00
Event Date 12/09/2024 0:00:00
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"The Agency was contacted on 12/10/2024 by representatives for Equistar Chemicals, LP (IL-01737-01) in Morris, IL, to report a fixed gauge shutter stuck in the open position [that was discovered on 12/9/2024]. The gauge is installed on the side of a process vessel and is normally in the open position. The shutter will remain in its normally open position and there will be no vessel entry. There are no changes in radiation levels except [expected levels resulting from] not being able to close the shutter. Entry to [the vessel] requires complete shutdown of the process line, and none are currently scheduled. The manufacturer's representative is on site today, 12/10/2024, to troubleshoot and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue.
"Agency inspectors are coordinating a site visit to determine the root cause and corrective action. The licensee has provided a preliminary assessment that moisture can enter the housing and cause corrosion in the shutter. This report will be updated when additional information is available."
Arkansas Nuclear - Russellville AR
Report Date 12/10/2024 18:02:00
Event Date 12/10/2024 10:30:00
SECONDARY CONTAINMENT INOPERABLE
The following information was provided by the licensee via phone and email:
"At 0930 CST on 12/10/2024, Arkansas Nuclear One, Unit 1, discovered both isolation valves open in a one-inch breathing air line containment (reactor building) penetration. This resulted in inoperable reactor building isolation valves in a required mode of applicability per Unit 1 Technical Specification 3.6.3 and an inoperable reactor building per Unit 1 Technical Specification 3.6.1. Unit 1 had recently entered the modes of applicability for both Technical Specifications at 0556 CST on 12/8/2024 following a planned maintenance outage.
"The outside isolation valve was locked closed at 0950 CST on 12/10/2024, restoring operability of the reactor building. The inside valve was locked closed at 1345 CST on 12/10/2024, restoring operability of both isolation valves.
"This condition is being reported under 10 CFR 50.72(b)(3)(ii)(B) as an event or condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety. This condition is also being reported under 10 CFR 50.72(b)(3)(v)(C) and (D) 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: (C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The cause of the out-of-position valves is under investigation. No evolutions were in progress besides a plant startup at the time of the event.
Colorado Dept of Health - Greenwood Village CO
Report Date 12/10/2024 18:30:00
Event Date 03/05/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
Two tritium exit signs were determined to be lost by the licensee.
Manufacturer: Isolite Corporation Number of signs: 2 Model: BX-10-BK Activity: 9.21 Ci each, H-3
The signs were discovered missing during an annual fire inspection on 03/05/2024.
Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))
Colorado Event Report ID Number: CO240030
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
Colorado Dept of Health - Fort Collins CO
Report Date 12/11/2024 16:00:00
Event Date 06/01/2024 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
One tritium exit sign was determined to be lost by the licensee.
Manufacturer: Isolite Corporation Number of signs: 1 Model: 880-12-6 Activity: 12.57 Ci, H-3
Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))
Colorado Event Report ID Number: CO240031
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
Vermont Department of Health - Burlington VT
Report Date 12/11/2024 18:06:00
Event Date 12/10/2024 16:03:00
AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the Vermont Department of Health via email:
A patient was prescribed 49.2 mCi of Y-90 TheraSphere microspheres, but received 33.6 mCi. This is a 30 percent difference in the prescribed dose and is reportable in accordance with 10 CFR 35.3045.
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.
Texas Dept of State Health Services - El Paso TX
Report Date 12/12/2024 10:45:00
Event Date 12/06/2024 0:00:00
AGREEMENT STATE REPORT - AUTOCLAVE CONTAMINATION
The following report was received by the Texas Department of State Health Services (the Agency):
"On December 11, 2024, the Agency received an email from the licensee requesting information on reporting a contamination incident that occurred in their biosafety level 3 (BSL-3) laboratory involving 200 microcuries of C-14. The incident occurred on Friday, December 6, 2024, and was discovered on December 7, 2024, when the sample had cooled and access could occur.
"The licensee's researcher had labeled a sample of the material they were using with the C-14. After the use was concluded, the researcher doused the material with a fluid to kill the bacteria.
"The sample was placed in a `red bag' for disposal, but [the sample] was inadvertently placed on a tray that was moved to the autoclave. The sample was put through the autoclaving process where the plastic container it was in ruptured due to the heat and pressure. Some material spilled onto the tray, and some material was in the drain of the autoclave. It was not until December 7, 2024, when the material cooled, that any assessment could confirm the presence of radioactive material and any evaluation for contamination could be made. The drain [exposure rate] was four times background, and the tray contained most of the contamination and material. The BSL-3 laboratory and vivarium have been closed until such time as decontamination can be completed.
"There was no contamination of personnel, no contamination outside of the autoclave, and no contamination in the actual BSL-3 laboratory. Additional information will be provided in accordance with SA-300."
Texas Incident Number: I-10150
Texas NMED Number: TX240048
Florida Bureau of Radiation Control - Tampa FL
Report Date 12/12/2024 11:33:00
Event Date 04/04/2024 0:00:00
AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"[The licensee] contacted the Florida BRC to notify them about a lost source of Cs-137 [with a remaining activity of 127 microcuries of Cs-137 as of 4/4/2024]. The source was last seen in April, 2024. West Coast Nuclear Pharmacy is no longer operating and has been purchased by RLS Pharmacy (4688-2). The source was not located during the transport of material from West Coast Nuclear Pharmacy to RLS Pharmacy. The last BRC inspection of West Coast Nuclear Pharmacy occurred on November 20, 2024. This incident was referred to materials for further action."
Device Type: Cs-137 E-vial Manufacturer: NAS Model number: MED 3550 Serial number: 13767
FL Incident Number: FL24-114
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
Brunswick - Southport NC
Report Date 12/12/2024 12:22:00
Event Date 11/03/2024 19:17:00
INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES
The 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 1917 Eastern Standard Time (EST) on November 3, 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.
"The group 6 isolation resulted from a spurious signal from the reactor building ventilation radiation monitor `A' channel. No manipulations associated with the isolation or reset logic were ongoing at the time, and no abnormalities were noted in the reactor building ventilation radiation values. The readings for both reactor building ventilation radiation monitor channels remained consistent with each other, with no readings approaching the isolation setpoint.
"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."
Colorado Dept of Health - Fort Collins CO
Report Date 12/12/2024 18:23:00
Event Date 07/02/2024 0:00:00
AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:
One static eliminator was declared lost by the licensee. The licensee believes the device was lost during shipment back to the manufacturer on 07/02/2024.
Licensee: Avago Tech Manufacturer: NRD, LLC Quantity: 1 Device: Static Eliminator Model: P-2042 Isotope: Po-210 Original activity: 5 mCi as of 4/27/2023 Decayed activity: 0.254 mCi as of 12/12/2024
Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))
Colorado Event Report ID Number: CO240032
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
Westinghouse Electric Corporation - Hopkins SC
Report Date 12/13/2024 10:23:00
Event Date 12/12/2024 10:30:00
EN Revision Imported Date: 1/17/2025
EN Revision Text: DEGRADATION OF SAFETY ITEM
The following information was provided by the licensee via phone and email:
"At approximately 1030 EST, on 12/12/2024, Nuclear Criticality Safety (NCS) staff were notified that the polyvinyl chloride (PVC) piping of a passive overflow item relied on for safety (IROFS, SGD-147) for Uranium Recovery and Recycle Services (URRS) vessel V-756A was in a deformed condition. V-756A and V-756B are interconnected URRS dissolver product hold tanks. The V-756B redundant passive IROFS overflow (SGD-130) is constructed of steel. NCS staff reviewed the condition of the PVC overflow piping and determined the overflow was deformed into a position that would restrict flow to the point that it could not provide its intended safety function. The safety function of the IROFS is to prevent backflow of uranium bearing material into water and nitric acid systems by providing an overflow path below the height of the water and nitric acid inputs into V-756A/B. The SGD-130 passive overflow was available to perform its intended safety function. The issue was entered as a red-book item in the corrective action program (CAP) as IR-2024-13041.
"Per criticality safety evaluation, CSE-4A, and supporting calculation note, CN-SB-11-031, with the passive overflow IROFS SGD-147 in a failed condition, the overall likelihood index (OLI) for the fault tree scenario increased from -6 to -3 which does not meet the OLI of -4 necessary to meet 10 CFR 70.61 performance requirements. The result is reportable per 10 CFR Part 70 Appendix A(b)(2), 'Loss or degradation of items relied on for safety that results in failure to meet the performance requirements of 10 CFR 70.61.'
"Operations for the dirty dissolver process are down pending further investigation and development of compensatory actions. A causal analysis will be performed and corrective actions to prevent recurrence will be documented in the CAP.
"Further investigation determined that on 12/12/2024, during third shift URRS, while dirty dissolver operations were down, a centrifuge malfunction occurred that necessitated spill clean up of the centrifuge platform area in the ground floor level below the platform. Based on interviews of URRS personnel, it was determined that to clean up the two spill locations, two separate steam-driven eductors with suction wands were utilized to transfer spill solutions to V-756A in roughly the same timeframe. The apparent cause of the PVC overflow piping deformation is excessive steam vapor influx into V-756A from the simultaneous spill cleanup activities.
"A review of the site maintenance database identified one completed maintenance work order for the replacement of V-756A overflow piping for PVC pipe deformation. Additional review of previous maintenance activities for the V-756A will be performed to determine if there were other instances of deformation of the overflow piping for V-756A. This occurrence in September 2024 was not brought to the attention of management or engineering staff to ensure comprehensive follow-up and corrective actions. The occurrence was not captured as red-book CAP item for a degraded or failed IROFS."
"Number and types of controls necessary under normal operating conditions: For scenario 4.3 of CSE-4-A supporting Calculation Note, CN-SB-11-031, two passive overflow IROFS controls (SGD-130 and SGD-147) are necessary under normal operating conditions to prevent a backflow condition into the nitric acid supply.
"Number and types of controls which functioned properly under upset conditions: Passive overflow IROFS (SGD-130) on V-756B is constructed of metal and will not deform when exposed to steam. Criticality safety staff reviewed the SGD-130 overflow for V-756 A/B and determined it could perform its safety function.
"Number and types of controls necessary to restore a safe situation: The PVC overflow IROFS SGD-147 for vessel V-756A was replaced on 12/12/2024. An extent of condition review for process vessels with PVC/plastic pipe passive overflows with potential exposure to excess heat has been initiated.
"Safety significance of events: Passive overflow IROFS SGD-130 remained available and a review of tank level data logging confirmed there was no overflow of V-756 A/B and there was no backflow condition into the deionized water and nitric acid systems.
"Safety equipment status: The passive overflow IROFS control SGD-147 for V-756A/B was replaced on 12/12/2024. The IROFS controls necessary to meet 10 CFR 70.61 performance requirements are in place.
"Status of corrective actions: Operations for the dirty dissolver are down pending further investigation and development of compensatory actions. A causal analysis will be performed and corrective actions to prevent recurrence will be documented in the corrective action program."
The following information was provided by the licensee via phone and email:
"Following review of pertinent integrated safety analysis risk assessment information, Westinghouse reevaluated the nuclear criticality safety scenario utilized as the basis for reporting event notification (EN) 57472 on December 13, 2024. The scenario for a backflow condition into the nitric acid header did not consider initiating and enabling conditions in the accident sequence for a potential backflow of uranyl nitrate solution into Uranium Recovery and Recycle Services (URRS) vessels V-756 A/B. The reevaluation determined the overall likelihood index of the scenario with a failure of the SGD-147 passive overflow meets the performance requirements of 10 CFR 70.61.
"Westinghouse is retracting EN 57472 based on the reevaluation of the scenario. 10 CFR 70.61 performance requirements were met to ensure a nuclear criticality remained highly unlikely for the backflow scenario."
Notified R2DO (Suggs), and NMSS Events Notification (email).
SC Dept of Health & Env Control - Spartanburg SC
Report Date 12/13/2024 16:10:00
Event Date 08/13/2024 0:00:00
EN Revision Imported Date: 1/10/2025
EN Revision Text: AGREEMENT STATE REPORT - IRRADIATOR EVENT
The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:
During a routine inspection conducted by the Department on December 3, 2024, inspection and maintenance records indicated that a float switch for a panoramic pool irradiator had failed on August 13, 2024. Between December 3, 2024, and December 13, 2024, the licensee evaluated the event for reporting applicability. On December 13, 2024, the licensee reported the event to the Department. The licensee is reporting that the float switch on a Nordion (model JS8900) continuous panoramic pool irradiator (serial number IR97) failed on August 13, 2024, during routine maintenance and inspection checks. The float switch was replaced on August 13, 2024. Specifically, the float did not operate the full length to the hard stop. The licensee is reporting no current health and safety concerns. This event is under investigation by the Department.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The float switch alarms radiation workers of low water levels which would result in higher radiation levels.
The following information was provided by the South Carolina Department of Environmental Services (the Department) via email:
"The licensee submitted a 30-day written report on December 29, 2024. The details of the 30-day written report were consistent with the initial reports. The licensee reported that the cause of the event to be attributed to the wiring harness securing nut being loose, allowing the wiring harness to move which could have caused the low water wire to move out of the intended position. The licensee reported that the new float switch assemble was sealed with an epoxy at the top to ensure that the wiring harness does not move out of position. The licensee's corrective actions included replacing the pool water float assembly and ensuring that all future pool water float assemblies are sealed with epoxy to ensure that wiring does not move from the tested position.
This event/investigation is considered closed."
Notified RDO1(Dimitriadis); NMSS_EVENTS_NOTIFICATION
Global Nuclear Fuel - Americas - Wilmington NC
Report Date 12/17/2024 15:05:00
Event Date 12/16/2024 16:55:00
CONCURRENT REPORT
The following information was provided by the licensee via phone and email:
"Global Nuclear Fuel - Americas (GNF-A) is making a concurrent report to the NRC for an OSHA (Occupational Safety and Health Administration) reportable event under 29 CFR 1904.39.
"At approximately 1655 EST, on December 16, 2024, the North Carolina Department of Labor was notified that an employee was injured while operating an electric powered pallet jack resulting in a partial amputation of the left thumb soft tissue. The employee was inside the airborne controlled area but was surveyed and free released with no contamination. Root cause investigations and corrective actions were begun. Because the North Carolina Department of Labor was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."
Wisconsin Radiation Protection - Milwaukee WI
Report Date 12/17/2024 17:13:00
Event Date 09/19/2024 0:00:00
AGREEMENT STATE REPORT - LOST SOURCE
The following information was received from the Wisconsin Department of Health Services (the department) via email:
"On September 19, 2024, a licensee reported that a package they shipped containing a Co-57 flood source had been lost by a common carrier and its whereabouts are unknown. The package was shipped on September 3, 2024, identified as missing on September 19, 2024, and reported to [the department] on the same day. The source was originally 20 millicuries and was approximately 2.98 millicuries at the time of shipment. [The source] was shipped as an excepted package containing a limited quantity of Co-57. The source serial number is: BM552022201101.
"The department considers this event closed."
WI Event Report ID No: WI240004.
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
Wisconsin Radiation Protection - � WI
Report Date 12/17/2024 17:13:00
Event Date 10/18/2024 0:00:00
AGREEMENT STATE REPORT - DISCOVERY OF CO-60 SCRAP MATERIAL
The following information was received from the Wisconsin Department of Health Services (WI DHS) via email:
"On October 18, 2024, WI DHS identified Co-60 [material] in a rejected scrap load using a portable radionuclide identification device. The scrap material was determined to be from a nearby manufacturing facility.
"On October 25, 2024, WI DHS performed a site visit at the manufacturing facility where the scrap material originated. Multiple metal castings and a bin of metal swarf were identified as contaminated with Co-60. Exposure rates on contact with most items ranged from approximately 100-200 microR/hr, with the highest reading of approximately 950 microR/hr.
"The manufacturing facility purchased the metal castings from a WI foundry. It was determined that contaminated metal castings were purchased from a single WI foundry that had imported the castings from a foundry in India. The WI foundry only sold the casings to one manufacturing facility. On October 30 and November 27, 2024, WI DHS performed site visits at the WI foundry and confirmed the presence of Co-60 in additional metal castings from the same foundry in India. The WI foundry did not perform any manufacturing processes on the imported items. The WI foundry is continuing to screen items from the India foundry for elevated radiation levels.
"Preliminary dose assessments by WI DHS indicate that public dose limits have not been exceeded at any of the facilities nor while in transportation. No removable contamination has been identified. WI DHS continues to monitor as additional items are identified and a final disposition of the radioactive material is determined."
WI Event Report ID No: WI240005.
Comanche Peak - Glen Rose TX
Report Date 12/18/2024 20:38:00
Event Date 12/18/2024 14:30:00
LOSS OF OFFSITE EMERGENCY NOTIFICATION SYSTEM CAPABILITY
The following information was provided by the licensee via phone and email:
"Comanche Peak Nuclear Power Plant (CPNPP) experienced an unplanned loss of the alert and notification system (ANS) method of outdoor warning primary siren capability for 30 hours from 12/17/24, 0900 CST to 12/18/24, at 1500.
"The capability to activate the sirens was lost during a planned activity to upgrade CPNPP radio system components. The loss of the capability to activate the sirens was not anticipated as part of the planned modification.
"The condition was discovered on 12/18/24, at 1430 while performing periodic testing on the ANS. The siren capability was restored at 1500 when the back-up radio repeater was powered on. The FEMA approved back-up alerting method (route alerting) was available during the loss of ANS siren capability.
"The CPNPP ANS system is currently functional on the back-up radio repeater. There were no plant activities that would have required siren activation during the loss of capability period."
The NRC Resident Inspector has been notified.
Arkansas Department of Health - Oceola AR
Report Date 12/19/2024 10:04:00
Event Date 12/18/2024 0:00:00
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was received from the Arkansas Department of Health, Radiation Control (the Department) via email:
"On 12/18/2024, at 1530 CST, Exploratory Ventures LLC. notified the Department via phone that an IMS-5420-XX profile thickness gauge experienced a stuck open shutter. This gauge contains a 50.5 curie Cs-137 source, Eckert & Ziegler NuX.N27_A, serial number NR-1120-D-101-S, listed in the sealed source and device registry.
"An IMS technician arrived on-site at 1615 and was able to close the shutter at 1630. The gauge was moved from the in-line position to allow the technician to close the shutter; the technician opened the access panel on the gauge and placed an adjustable wrench on the pointer to manually close the shutter. As they started to turn the pointer, the spring of the shutter activated and closed the shutter. The technician closed the access panel then surveyed the area for radiation and found none.
"The gauge is currently locked-out and not in use. It will remain locked-out until an authorized service technician arrives to service the unit. The estimated date of service is pending.
"The investigation is ongoing and the report will proceed in accordance with SA-300."
Arkansas Event Number: AR-2023-005
Franciscan Health Munster - Munster IN
Report Date 12/20/2024 14:01:00
Event Date 10/28/2024 0:00:00
MEDICAL EVENT
The following is a summary of information provided by the licensee via phone:
The licensee's radiation safety officer (RSO) was notified on 12/20/2024, at approximately 1130 CST of a medical event that occurred at Franciscan Health Munster in Munster, IN on 10/28/2024. A patient was prescribed a Y-90 TheraSphere treatment with a prescribed dose of 23.5 Gbq. The calculated administrated dose was 18.32 Gbq. This indicates an approximate 22 percent underdose. The licensee is continuing to investigate.
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.
The following information was provided by the licensee via phone:
The event is being retracted due to the following reasons. The activity initially documented as prescribed corresponded to the quantity requested from the manufacturer. This activity is intended to decay to a specific dose by the time the procedure occurs. On the day of the procedure, the prescribed dose was 110 Gy, while the dose delivered was 89.1 Gy. The difference between these amounts is less than 20 percent, thus not subject to reporting.
Notified R3DO (Nguyen), and NMSS Events Notification (email).
Colorado Dept of Health - Englewood CO
Report Date 12/23/2024 19:05:00
Event Date 12/22/2024 0:00:00
AGREEMENT STATE REPORT - LOST SOURCES
The following information was provided by the Colorado Department of Public Health and Environment via email:
[Eight tritium exit sign were determined to be lost by the licensee.]
"Manufacturer: Safety Light Corp "Model Number: 880-12-6 [Quantity: 2] "Model Number: 2040 [Quantity: 6] "Isotope and activity: H-3, 11.5 Ci each
"Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))"
Colorado Event Report ID No.: CO240033
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
Ametek Solidstate Controls - Columbus OH
Report Date 12/28/2024 11:01:00
Event Date 10/29/2024 0:00:00
PART 21 - INTERIM REPORT FOR REGULATING TRANSFORMER
The following is a synopsis of information provided by AMETEK Solidstate Controls Inc. (AMETEK) via email:
During regulating transformer system operations, the transformer may be experiencing short circuiting between coils to ground.
Visual inspection for severe darkening or charring of coils, magnetic shunts, or core, and/or the use of thermal probes or infrared guns monitoring for excessive temperatures greater than 180 degrees Celsius or 355 degrees Fahrenheit may detect affected regulating transformer systems.
Affected systems exhibit signs of transformer insulation system deterioration, increased audible noise from the units, blackening on any areas of the transformer, or signs of electrical shorting between windings or coil to core.
The cause of the short circuiting is unknown. Component failure impact analysis and regulating transformer system electrical testing are in progress.
Recommend all units currently in service with internal components, which include but are not limited to capacitors, wire harnesses, and transformer materials, with temperatures in excess of 180 degrees Celsius or 355 degrees Fahrenheit be removed from service.
COMPONENT DESCRIPTION: The AMETEK SCI model numbers listed are for regulating transformers that are intended to take in AC power at 460 VAC plus or minus 10 percent and output AC power at 120 VAC plus or minus 2 percent with low harmonic distortion.
Models: 85-IS0075-12 and 85-IS0150-14
AFFECTED PLANTS: Southern Nuclear Company - Vogtle Constellation Energy - Ginna
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