Event Notification Report for May 13, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/12/2024 - 05/13/2024
Power Reactor
Event Number: 57126
Facility: Watts Bar
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Paul Blakely
HQ OPS Officer: Thomas Herrity
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Paul Blakely
HQ OPS Officer: Thomas Herrity
Notification Date: 05/13/2024
Notification Time: 16:40 [ET]
Event Date: 05/13/2024
Event Time: 09:17 [EDT]
Last Update Date: 05/13/2024
Notification Time: 16:40 [ET]
Event Date: 05/13/2024
Event Time: 09:17 [EDT]
Last Update Date: 05/13/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
INOPERABILITY OF BOTH TRAINS OF UNIT 2 LOW HEAD SAFETY INJECTION
The following information was provided by the licensee via phone and email:
"At 0917 EDT on May 13, 2024, a control room operator erroneously rendered the `B' train of the Unit 2 residual heat removal (RHR) system inoperable. This occurred while the `A' train of the Unit 2 RHR system was out of service for preplanned maintenance. RHR serves as the low head safety injection (LHSI) subsystem for the emergency core cooling system (ECCS) and because of this, Unit 2 was without a required train of ECCS from 0917 EDT to 0921 EDT.
"No other equipment issues were identified.
"The LHSI subsystem is credited by the analysis for a large break loss of coolant accident at full power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC resident inspector has been notified.
"There is no release of radioactive material associated with this event."
The following information was provided by the licensee via phone and email:
"At 0917 EDT on May 13, 2024, a control room operator erroneously rendered the `B' train of the Unit 2 residual heat removal (RHR) system inoperable. This occurred while the `A' train of the Unit 2 RHR system was out of service for preplanned maintenance. RHR serves as the low head safety injection (LHSI) subsystem for the emergency core cooling system (ECCS) and because of this, Unit 2 was without a required train of ECCS from 0917 EDT to 0921 EDT.
"No other equipment issues were identified.
"The LHSI subsystem is credited by the analysis for a large break loss of coolant accident at full power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC resident inspector has been notified.
"There is no release of radioactive material associated with this event."
Agreement State
Event Number: 57127
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Sam Colvard
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Sam Colvard
Notification Date: 05/14/2024
Notification Time: 12:05 [ET]
Event Date: 05/13/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/22/2024
Notification Time: 12:05 [ET]
Event Date: 05/13/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/22/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Carfang, Erin (R1DO)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Carfang, Erin (R1DO)
EN Revision Imported Date: 5/23/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/13/24 concerning one lost iodine-125 brachytherapy seed with an activity of approximately 0.267 millicuries. On 5/13/24, Bard Brachytherapy received a package from Northside Hospital - Gwinnett (Lawrenceville, GA), and initially identified a total of seven of the nineteen iodine-125 brachytherapy seeds were missing. Five seeds were found shortly thereafter in the packing material. The common carrier was called to return to the Bard facility and an additional seed was located within the delivery vehicle. Additional searches of the local Schaumburg, IL [common carrier] hub and O'Hare airport facility were unsuccessful in locating the final seed. The Agency was notified that the final seed was considered lost. The package is reported as having left Lawrenceville, GA and then Norcross, GA before arriving at the Schaumburg, IL facility. Reportedly, the package had no indication of damage from transit. The cause of the loss seed appears to be inadequate packaging when shipped."
Illinois event number: IL240013.
* * * UPDATE ON 5/22/2024 AT 1058 EDT FROM GARY FORSEE TO SAMUEL COLVARD * * *
"The licensee's written report was received 5/22/23 and provided no additional information. Exposures to the carrier and other members of the public are not expected to exceed reportable limits. Due to the small size and the proximity required to accumulate a reportable exposure, this incident is not expected to result in public exposures exceeding regulatory limits. The Illinois licensee followed reporting timelines and package receipt procedures. Provided no new information becomes available that would allow identification of the seed, reasonable search efforts have been undertaken and this matter is considered closed."
Notified R3DO (Ziolkowski), R1DO (Carfang), NMSS Events Notification (email), 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
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/13/24 concerning one lost iodine-125 brachytherapy seed with an activity of approximately 0.267 millicuries. On 5/13/24, Bard Brachytherapy received a package from Northside Hospital - Gwinnett (Lawrenceville, GA), and initially identified a total of seven of the nineteen iodine-125 brachytherapy seeds were missing. Five seeds were found shortly thereafter in the packing material. The common carrier was called to return to the Bard facility and an additional seed was located within the delivery vehicle. Additional searches of the local Schaumburg, IL [common carrier] hub and O'Hare airport facility were unsuccessful in locating the final seed. The Agency was notified that the final seed was considered lost. The package is reported as having left Lawrenceville, GA and then Norcross, GA before arriving at the Schaumburg, IL facility. Reportedly, the package had no indication of damage from transit. The cause of the loss seed appears to be inadequate packaging when shipped."
Illinois event number: IL240013.
* * * UPDATE ON 5/22/2024 AT 1058 EDT FROM GARY FORSEE TO SAMUEL COLVARD * * *
"The licensee's written report was received 5/22/23 and provided no additional information. Exposures to the carrier and other members of the public are not expected to exceed reportable limits. Due to the small size and the proximity required to accumulate a reportable exposure, this incident is not expected to result in public exposures exceeding regulatory limits. The Illinois licensee followed reporting timelines and package receipt procedures. Provided no new information becomes available that would allow identification of the seed, reasonable search efforts have been undertaken and this matter is considered closed."
Notified R3DO (Ziolkowski), R1DO (Carfang), NMSS Events Notification (email), 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
Power Reactor
Event Number: 57206
Facility: River Bend
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Darren Farthing
HQ OPS Officer: Robert A. Thompson
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Darren Farthing
HQ OPS Officer: Robert A. Thompson
Notification Date: 07/02/2024
Notification Time: 10:08 [ET]
Event Date: 05/13/2024
Event Time: 19:28 [CDT]
Last Update Date: 07/02/2024
Notification Time: 10:08 [ET]
Event Date: 05/13/2024
Event Time: 19:28 [CDT]
Last Update Date: 07/02/2024
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Agrawal, Ami (R4DO)
Agrawal, Ami (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 7/9/2024
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID PARTIAL CONTAINMENT ISOLATION
The following information was provided by the licensee via phone and email:
"At 1928 CDT on May 13, 2024, River Bend Station (RBS) was operating in Mode 1 at 100 percent power when an invalid isolation signal actuated multiple containment isolation valves in more than one system. The invalid isolation signal was caused by voltage perturbations on the offsite power distribution system due to multiple lightning strikes in the vicinity of RBS.
"The event caused one containment isolation valve to isolate in the floor and equipment drains system, and two containment isolation dampers to isolate in the auxiliary building ventilation system.
"This event was a partial system isolation for the affected systems and did not result in a full train actuation.
"This event meets the reportable criteria for 10 CFR 50.73(a)(2)(iv)(A) and is being reported as any event or condition that resulted in manual or automatic actuation of any systems listed in paragraph (a)(2)(iv)(B). This notification is being provided in lieu of a Licensee Event Report as indicated in 10 CFR 50.73(a)(1)."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The valve and dampers were immediately re-opened. The standby gas treatment system automatically initiated due to the closure of the containment isolation dampers in the auxiliary building ventilation system.
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID PARTIAL CONTAINMENT ISOLATION
The following information was provided by the licensee via phone and email:
"At 1928 CDT on May 13, 2024, River Bend Station (RBS) was operating in Mode 1 at 100 percent power when an invalid isolation signal actuated multiple containment isolation valves in more than one system. The invalid isolation signal was caused by voltage perturbations on the offsite power distribution system due to multiple lightning strikes in the vicinity of RBS.
"The event caused one containment isolation valve to isolate in the floor and equipment drains system, and two containment isolation dampers to isolate in the auxiliary building ventilation system.
"This event was a partial system isolation for the affected systems and did not result in a full train actuation.
"This event meets the reportable criteria for 10 CFR 50.73(a)(2)(iv)(A) and is being reported as any event or condition that resulted in manual or automatic actuation of any systems listed in paragraph (a)(2)(iv)(B). This notification is being provided in lieu of a Licensee Event Report as indicated in 10 CFR 50.73(a)(1)."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The valve and dampers were immediately re-opened. The standby gas treatment system automatically initiated due to the closure of the containment isolation dampers in the auxiliary building ventilation system.
Agreement State
Event Number: 57250
Rep Org: Colorado Dept of Public Health
Licensee: Rose Medical Center
Region: 4
City: Denver State: CO
County:
License #: CO 229-03
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Josue Ramirez
Licensee: Rose Medical Center
Region: 4
City: Denver State: CO
County:
License #: CO 229-03
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Josue Ramirez
Notification Date: 07/29/2024
Notification Time: 09:44 [ET]
Event Date: 05/13/2024
Event Time: 15:24 [MDT]
Last Update Date: 07/29/2024
Notification Time: 09:44 [ET]
Event Date: 05/13/2024
Event Time: 15:24 [MDT]
Last Update Date: 07/29/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Brenneman, Kevin (NMSS)
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Brenneman, Kevin (NMSS)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was provided by the Colorado Department of Public Health and Environment via email:
"This event in Colorado was originally sent to the wrong NRC email address and it is now being provided to the NRC. This event is being tracked as NMED number 240183.
"A patient was administered a measured dose of 0.613 GBq Y-90 TheraSpheres on 5/13/2024, at 1524 MDT. The desired administration location in the liver received a dose of 0.582 Gbq. Post administration imaging analysis conducted on 5/15/2024, showed an uptake to the stomach wall of 1.5 Sievert."
Notification made per: 10 CFR 35.3045(a)(1)(iii)
Colorado event report ID No.: CO240013
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 Colorado Department of Public Health and Environment via email:
"This event in Colorado was originally sent to the wrong NRC email address and it is now being provided to the NRC. This event is being tracked as NMED number 240183.
"A patient was administered a measured dose of 0.613 GBq Y-90 TheraSpheres on 5/13/2024, at 1524 MDT. The desired administration location in the liver received a dose of 0.582 Gbq. Post administration imaging analysis conducted on 5/15/2024, showed an uptake to the stomach wall of 1.5 Sievert."
Notification made per: 10 CFR 35.3045(a)(1)(iii)
Colorado event report ID No.: CO240013
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.